Mammography Screenng:

Lessons Learned from Across the US

UTAH Mammography Action Summit

November 8, 2012

Faye Wong, MPH, Chief

Program Services Branch

Division of Cancer Prevention & Control

Centers for Disease Conttol & Prevention

National Center for Chronic Disease Prevention and Health Promotion

Division of Cancer Prevention and Control

You will walk away knowing 3 things…

Mammography screening rates have room

for improvement

An organized public health cancer

screening model works

Using evidence-based interventions

enhances effectiveness

Adapted from Daily Pictures FB Page

Screening Infrastructure, capacity & PH expertise

Needs & Opportunities

Evidence-based Interventions

Connecting to partners and systems

Innovation

Needs and Opportunities

5

Cancer screening in the U.S. needs to be scaled up

7 million women aged 50–74 need to be screened for breast cancer

Overall, mammography screening rates in the United States have not improved since 2002.

Insured are almost twice as likely to get screened as uninsured

1/3 breast cancer cases in the U.S. are diagnosed at late-stages of the diseases

CDC. Surveillance of Screening-Detected Cancers (Colon and Rectum, Breast, and Cervix) US, 2004–2006. MMWR

2010;59(No. SS-9):[1-25].

Demographic Tsunami

National Breast and Cervical Cancer Early Detection Program (NBCCEDP)

CA

ID

OR

WA

MT

WY

UT CO

NM

TX

OK

KS

NE

SD

ND

MN

WI

IA

IL OH IN

KY

WV VA

NC

GA

FL

AL MS

MO

AR

LA

NV

MI

PA NJ

NY CT MA

VT NH

ME

TN

SC

RI

AZ

DC

DE

MD

HI HI

AK

AMERICAN SAMOA

NORTHERN MARIANA ISLANDS GUAM PUERTO RICO

REPUBLIC of PALAU

American Indian Initiative:

Arctic Slope Native Assn, Ltd – North Slope Borough, Barrow, AK

Cherokee Nation – Tahlequah, OK

Cheyenne River Sioux Tribe – Eagle Butte, SD

Kaw Nation – Kaw City, OK

Native American Rehabilitation Assn of the Northwest, Inc

South Puget Intertribal Planning Agency – Shelton, WA

Hopi Tribe – Kykotsmovi, AZ

Navajo Nation – Window Rock, AZ

Yukon-Kuskokwim Health Corp – Bethel, AK

Southeast Alaska Regional Health Consortium – Sitka, AK

Southcentral Foundation – Anchorage, AK

67 Screening Delivery Systems

Source: April 2012 MDE submission

Since 1991:

>4.2 million women screened

53% are of minority race or ethnic background

>10.4 million breast and/or cervical cancer screening examinations completed

54,276 breast cancers detected

3,113 invasive cervical cancers detected

The Affordable Care Act

is a Real Opportunity for

Public Health

and Cancer Screening

Affordable Care Act increases access to cancer screening to millions

Requires coverage of USPSTF recommended preventive health services, grades A and B, w/elimination of cost-sharing including breast, cervical and colorectal cancer screening

Required for…

New health insurance plans

State insurance exchanges

Medicare

New Medicaid Expansion clients

*For mammography, uses USPSTF recommendations prior to November 2009 updated guidelines

Screening Infrastructure, Capacity & Public Health

Expertise

CDC has well established & effective cancer

screening infrastructures across the US

Expansive

public, private

and community

partnerships

have been a

key to

success…

Tracking,

Surveillance

and evaluation

Professional

Education

QA/QI &

Systems

Change

Screening, follow-up

& case management

Public Awareness,

Education & Targeted

Outreach

PUBLIC

HEALTH

MODEL

Organized Public Health Model Cancer Screening System

NBCCEDP Performance 94% of women with an abnormal breast screening test

complete diagnostic evaluation; and 91% of those within 60 days

97% of women diagnosed with breast cancer initiate treatment; and 93% of those within 60 days

91% of women with an abnormal Pap test complete diagnosis evaluation; and 88% within 90 days

92% of women diagnosed with invasive cervical cancer or high-grade premalignant lesions initiate treatment; 87% of those with invasive cancer within 60 days

Evidence-based Interventions

Physician recommendation is a

significant motivator to participation in cancer

screening.

Beydoun HA, Predictors of colorectal cancer Screening. Cancer Causes Control; 2008

Increasing Population-Level Cancer Screening: Using Community Guide Evidenced-Based Strategies

Client Reminders

Reducing Structural

Barriers

Provider Reminders

Provider Assessment

and Feedback

Small Media Partnerships

Note: Out of pocket costs, one on one counseling and group education are also recommended interventions.

Innovation to Increase Screening

*Some groups may fit within multiple levels of this model.

INTERPERSONAL

Comprehensive Cancer Control Coalitions

Community, state and regional organizations

Healthcare Systems/Academic Medical Institutions

Health Plans, Insurance

Companies (public/private)

Employers/ Worksites

Professional Organizations &

Associations

Community-Based Organizations

Provider

Friend Family

Patient Navigator

State/Local Health Departments

Health Disparities

Collaboratives

Media

Research Institutions

Community Health Worker/ Promotora

Survivorship Support

Organizations/Groups

Tribal Urban Health Clinics

INDIVIDUAL

Expand Focus to Embrace Population Screening

Medicare & Medicaid

FQHCs/CHCs Minority Health Clinics

Win-Win Partnerships to Increase Population-level Cancer Screening Among Insured and Uninsured

Other Government and Public, Non-Profit, Community-based organizations

Public Health

Private Sector Healthcare System

Tracking,

Surveillance

and evaluation

Professional

Education

QA/QI &

Systems

Change

Screening, follow-up

& case management

Public Awareness,

Education & Targeted

Outreach

PUBLIC

HEALTH

MODEL

Organized Public Health Screening Systems and Evidence-based Interventions

Client Reminders

Reducing Structural

Barriers

Provider Reminders Provider

Assessment and Feedback

Small Media

POLICY AND ENVIRONMENTAL INTERVENTIONS

HEALTH SYSTEMS

CHANGE

COMMUNITY-CLINICAL LINKAGES

SURVEILLANCE AND EPIDEMIOLOGY

Includes population-based approaches

Includes screening provision

Four Domains of Chronic Disease Prevention & Control Programs

Potential Strategies

Build on Cancer Screening Infrastructure and History of Collaboration

Extensive existing NBCCEDP & CRCCP provider

network & delivery system

Established Quality Assurance System

State/local Health Department Infrastructures

Existing Comprehensive Cancer Control

coalition and other partnerships

Provide Education, Outreach and Patient Support

Well designed, effective small media

materials & evaluated media campaigns

Community outreach worker models -

promote screening, target outreach

(rarely/never screened and high-risk

population sub-groups)

Patient navigators

Design and Support Practice Systems That Optimize Cancer Screening

Practice-wide screening registries

Systems to prompt provider action

Use of standing orders and expedited

screening referral

Automated mail-out or telephone

screening reminders for screening or

rescreening

Monitor and Assure Adequate Follow-up and Treatment

Expand existing CDC reporting system to all

patients who receive screening services

Adapt system for use across all Federally

Qualified Health Centers

Adapt system to Electronic Health Records

Implement Benchmarks and Performance Indicators

• Include mammography screening in

performance measures

• Adopt quality performance measures

• Develop payment systems that incentivize

delivery of screening and other preventive

services

Adapted from Daily Pictures FB Page

Screening Infrastructure, capacity & PH expertise

Needs & Opportunities

Evidence-based Interventions

Connecting to partners and systems

Innovation

Outcomes Impact

Daily Pictures FB Page

Thank You! fwong@cdc.gov

For more information please contact Centers for Disease Control and Prevention

1600 Clifton Road NE, Atlanta, GA 30333

Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348

E-mail: cdcinfo@cdc.gov Web: http://www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

National Center for Chronic Disease Prevention and Health Promotion

Division of Cancer Prevention and Control

NBCCEDP is a versatile infrastructure that connects women to comprehensive,

high-quality breast and cervical cancer prevention

and care services.

NBCCEDP has 20 years experience providing comprehensive, high-quality cancer prevention and care services.

NBCCEDP connects underserved women to care and screening services.

NBCCEDP will continue to play a

critical role after the rollout of health care

reform.

Partnerships are key in cancer

prevention and control .

NBCCEDP Message Box, 2011-2012 Target audience: Key stakeholders

• Partnerships with strong collaborations are needed to expand the reach of NBCCEDP and provide underserved women with access to life-saving breast and cervical cancer services.

• NBCCEDP’s national partners continue to play a vital role in assuring that underserved women receive vital services.

• Public health must work with the private sector more than ever to overcome barriers to screening.

• Partners are vocal at the state and Federal level to ensure that essential services are maintained.

• Individually and collectively, partners work with NBCCEDP’s network in developing, implementing, and promoting effective breast and cervical cancer prevention programs and practices.

• Early cancer detection leads to better treatment outcomes and decreased mortality.

• NBCCEDP programs educate providers, partners, and the public about screening recommendations and clinical protocols.

• Systems are in place to ensure women are rescreened at appropriate intervals .

• Quality assurance reviews ensure that diagnosis and treatment services are timely and appropriate.

• NBCCEDP’s 68 funded programs are more than a payment source. • NBCCEDP programs help women across the U.S. overcome

socioeconomic, geographic, language, literacy, cultural, and other barriers to accessing breast and cervical cancer services.

• Patient navigation, which guides women through comprehensive cancer prevention and care services, is an integral part of NBCCEDP programs.

• Patient navigation is a proven mechanism for helping women navigate cancer care, from initial screening to treatment.

• Health insurance is not enough to ensure underserved women get breast and cervical cancer screening services.

• Access barriers (language, literacy, fear, transportation, etc.) will continue and require attention.

• Underserved women will need assistance with understanding and navigating the health care system in order to obtain needed services.

• The need for education of providers, partners, and the public will become more important.

• NBCCEDP programs have proven systems for serving hard to reach populations, providing quality assurance and patient navigation, and ensuring patient follow-up.

QUALITY SERVICES

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ACCESS

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September 2, 2011