with a series of recommendations that were accepted by the NCPB for cancer patients (Box 3.1). For more detail and context, the reader is referred to the complete IOM report.
A recent review examined outcome measures that have been used, or proposed for use in the clinical audit of palliative care of patients with advanced cancer. Identified measures met some, but not all of the objectives of measurement in palliative care, and fulfilled some, but not all of the criteria established for validity, reliability, responsiveness, and appropriateness (Hearn et al., 1997).
A persistent, vexing problem for many Americans is lack of health insurance or insufficient coverage to help defray the expense of a costly illness such as cancer. Although most individuals diagnosed with cancer are elderly and have Medicare coverage, an estimated 7 percent of those facing a new diagnosis of cancer lack health insurance. Health insurance offers some, but often incomplete, protection against the high costs of cancer care. High deductibles, copayments or coinsurance, and limits on coverage can all contribute to high out-of-pocket costs. Medicare was, for example, estimated to cover only 83 percent of typical total charges for lung cancer and 65 percent of typical charges for breast cancer in 1986. Some individuals have additional protection through other insurers (e.g., Medigap policies, Medicaid), but even then, the financial burden of cancer can be substantial. A particular problem for many with cancer involves limitations on prescription drug coverage, an expensive and widely used benefit.
Individuals who are poor, have low educational attainment, or are members of racial or ethnic minority groups tend to have less favorable outcomes with cancer than other groups. Limited access to primary care or cancer screening contributes to having cancer diagnosed at later stages when the prognosis is worse. Having health insurance coverage improves access, but does not guarantee that cancer screening tests are used. Other factors that can impede access to screening are culturally based attitudes and beliefs, not having services available in the local community, and health care providers not able to speak the language of the people they serve.
It is often health care providers who can be held accountable for the underuse of cancer screening tests. One of the strongest predictors of whether a person will be screened for cancer is whether the physician recommends testing, and evidence suggests that physicians order fewer screening tests than they should. The use of screening tests is improved in managed care plans, compared to fee-for-service plans.
Even when screening is used, many individuals fail to receive timely, or any, follow-up of abnormal screening results. Both screening and follow-up rates can be improved with interventions aimed at those eligible for screening (e.g., telephone and mailed reminders from providers, educational interventions) and health care providers (e.g., reminder systems).
Differences in treatment by race have been well documented. However, it appears that the effect may actually be related more closely to social class than to race. Another group that appears to be vulnerable in the cancer care system is the elderly. Older people are often less likely to get effective cancer treatments than are younger people, despite evidence that the elderly can tolerate and benefit from them. Some undertreatment is explained by provider attitudes toward treating the elderly, who are perceived as less willing or able to tolerate aggressive treatment.