breast and cervical cancer screening rates increased when women had a usual source of care and when they had a regular clinician at their usual source (O'Malley et al., 1997). One of the strongest predictors of whether a person will be screened for cancer is whether the physician recommends testing (Fox and Stein, 1991; Grady et al., 1992; Mickey et al., 1997; Zapka et al., 1991). Overall, physicians order fewer cancer screening tests than are recommended in preventive health care guidelines (Fox et al., 1988; Schwartz et al., 1991). Some researchers have looked into the reasons physicians may not recommend screening tests and have found the following:

  • Physicians are generally aware of guidelines, but they may not perceive screening tests to be beneficial in the absence of symptoms (Schapira et al., 1993).
  • Screening recommendations change, and some providers may not keep up with current standards, whereas others may be confused by conflicting guidelines.
  • Many individuals seek health care only when they have an acute illness and providers may miss opportunities to provide screening if they focus only on the presenting illness.
  • A lack of reimbursement for counseling about screening, time pressures, and health system infrastructure limitations (e.g., a lack of tracking or reminder systems) may also contribute to providers' underuse of cancer screening tests.

Screening practices also vary by physician specialty. Obstetrician-gynecologists are more likely than family practitioners to order cancer screening tests for women. Internists generally recommend screening at lower rates than other primary care providers, and subspecialists providing primary care tend to screen at the same, or lower rates than primary care providers (Albanes et al., 1988; Bassett, 1985; Bergner et al., 1990; Mann et al., 1987; Schwartz et al., 1991; Weinberger et al., 1991; Weisman et al., 1989; Zapka et al., 1992). Some studies suggest that women cared for by female physicians are more likely to be screened for cancer than women cared for by male physicians (Lurie et al., 1997).

The manner in which screening is presented by health care providers can affect whether a person actually has the test. A higher level of enthusiasm for the recommendation can influence the likelihood of screening (Mickey et al., 1997). Women who say that they participated in the initial decision to be screened for breast cancer were also more likely to adhere to the recommended follow-up mammography regimen than those who felt the doctor had made the decision for them (Phillips et al., 1998).

Interventions to Improve Screening Rates

A number of interventions have been demonstrated to increase cancer screening rates. Telephone and mailed reminders from providers, multimedia educational interventions, financial incentives, and peer counseling can all increase women's use of mammography (Clementz et al., 1990; Davis et al., 1997; Irwig et al., 1990; Janz et al., 1997; Kendall, 1993; Kiefe et al., 1994; King et al., 1994; Landis et al., 1992; Lantz et al., 1995; Mickey et al., 1997; Mohler, 1995; Taplin et al., 1994). Among women already screened for cancer, reminders to return for screening increase interval testing (Mayer et al., 1994; Schapira et al., 1992). Providing general information about cancer screening alone to those who are eligible, however, has not been effective in increasing test use (Champion, 1994b; Nattinger et al., 1989; Skinner et al., 1994).



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