Testimony of JAMES S. MARKS, M.D., M.P.H.

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TESTIMONY OF

JAMES S. MARKS, M.D., M.P.H.

DIRECTOR

NATIONAL CENTER FOR CHRONIC DISEASE

PREVENTION AND HEALTH PROMOTION

CENTERS FOR DISEASE CONTROL AND PREVENTION

DEPARTMENT OF HEALTH AND HUMAN SERVICES

BEFORE THE

SENATE APPROPRIATION SUBCOMMITTEE

ON LABOR, HEALTH AND HUMAN SERVICES, AND EDUCATION

MAY 9, 2001

Mr. Chairman, members of the committee, I am especially pleased to be here today to talk with you about the Center for Disease Control and Prevention's (CDC) National Breast and Cervical Cancer Early Detection Program. Now in its 11^th year of providing free mammograms and Pap smears to low-income American women, this program has saved lives, and contributed to the increased awareness of many American women about the importance of screening and early detection in preventing deaths from cancer.

Today I will talk about why we are so committed to this program, why now is such an important time for this program, and what our vision for the future is.

Recognizing the value of appropriate cancer screening, Congress passed the Breast and Cervical Cancer Mortality Prevention Act of 1990 (Public Law 101-354) which enables CDC's National Breast and Cervical Cancer Early Detection Program to provide critical breast and cervical cancer screening services to underserved and uninsured women, including older women, women with low incomes, and women of racial and ethnic minorities. Breast health services are available for women aged 40 - 64. Appropriations have increased from $5 million in Fiscal Year 1990 to approximately $174 million in Fiscal Year 2001. There have been great successes and advances in detecting breast and cervical cancers with the help of this program, but challenges remain.

CDC supports early detection programs in all 50 states, six U.S. territories, the District of Columbia, and 12 American Indian and Alaska Native organizations. The program establishes, expands, and improves community-based screening services for women to reduce breast and cervical cancer mortality. The success of the breast and cervical cancer program depends on screening, education and outreach, partnership development, case management, and mechanisms to assure the quality of tests and procedures, all of which, are part of the program.

Through September 2000, more than 3 million screening tests have been provided to more than 1.8 million women. That number includes 1.6 million Pap tests and 1.4 million mammograms. Almost half of these screenings were to minority women, who have traditionally had less access to these services. More than 9,500 women have been diagnosed with breast cancer, more than 40,000 women were diagnosed with precancerous cervical lesions, and 715 women were found to have invasive cervical cancer.

CDC collects data from all funded programs to monitor and evaluate each clinical service program. For each woman enrolled in the program, information is collected on demographic characteristics, mammogram results, breast exams, Pap tests, diagnostic procedures and outcomes, cancer diagnoses, and, for women diagnosed with cancer, information on the onset of treatment.

The program's success is due in part to the dedication of a large network of professionals, coalitions and national organizations devoted to detecting breast and cervical cancer early.

An estimated 27,000 health professionals are involved in providing breast and cervical cancer screening services to underserved and uninsured women.
More than 18,000 health educators and outreach workers are educating women on the importance of early detection and helping them access critical screening and follow-up services. Many of these individuals are local employees and volunteers, most of whom are contracted with support from CDC.
More than 7,000 individuals are now members of a national network of coalitions that have joined together with State health departments in support of this program.

The percentage of women ages 40 and older who reported ever having a mammogram increased from 64 percent in 1989 to 85 percent in 1997, and the percentage of women who reported receiving a mammogram within the previous two years increased from 54 percent in1989 to 71 percent in 1997. Disparity rates for mammography utilization among most minority groups have either been eliminated or reduced, and overall, there has also been a recent decline in the rate of breast cancer mortality among all women. While much remains to be done, our most recent mortality data reflect that 19.4 women per 100,000 die of breast cancer, surpassing our Healthy People 2000 goal of reducing mortality from 23 to 20.6 women per 100,000.

Please refer to the maps that use CDC Behavioral Risk Factor Surveillance Survey data. These maps show trend in the states reporting women aged 50 years and older who had a recent mammogram in the years 1991, 1995, and 1999. The darker colors have the higher rates of recent mammography utilization. Although this is encouraging news, the maps show that we still have many more women to reach.

Breast and cervical cancers are very serious concerns for American women. During the past decade, almost one-half million women have died of breast and cervical cancer. In 2001, the American Cancer Society estimates that 192,200 women will be diagnosed with breast cancer and 40,600 will die of the disease.

Preventing or curing all cancers is our collective goal. But let me be clear. We know today how to prevent up to 30 percent of all deaths from breast cancer. It is not a new scientific breakthrough; it is mammography. This technology has been around since the late 1970s. Additionally, the Guide to Community Preventive Services has recommended routine mammography screening since the 1980s. Mammography is currently the single most effective method for diagnosing breast cancer early. The longer breast cancer remains undetected and untreated, the greater the likelihood it will spread. The five-year survival rate drops from 97 percent when breast cancer is diagnosed at the local stage, to 21 percent when it is detected after having spread.

Mammography, however, is not perfect. According to the Institute of Medicine, routine screening in clinical trials resulted in a 25 to 30 percent decrease in breast cancer mortality among women between the ages of 50 and 70. When research determines other methods to be more effective or accurate, CDC is prepared to move quickly to help women receive the benefits of new proven screening or diagnostic technologies. Our goal is that all women should have access to existing and future detection methods and treatments so that breast cancer could eventually no longer kill so many.

To that end, we are working with the National Cancer Institute and an independent non-Federal Task Force on Community Preventive Services, to develop a Guide to Community Preventive Services. This Community Guide provides an in depth review of community health care interventions that are shown to be effective at promoting health and preventing disease. We are examining the community-wide interventions to increase the appropriate use of screening for breast, cervical, and colorectal cancer and the evaluation of the effectiveness of interventions to improve use of cancer screening. The review will be completed within the next 18 months and will be a useful resource to our screening programs in states to guide them on the most effective strategies to increase screening utilization. CDC will also be funding several research projects this year that will be designed to test the effectiveness of interventions to increase use for screening of breast and cervical cancer.

In October 2000, the Breast and Cervical Cancer Treatment Act of 2000 became law. This new law gives states the option of providing full Medicaid benefits to uninsured women who are diagnosed with breast or cervical cancer by the CDC screening program. We commend Congress, this committee, the National Breast Cancer Coalition, and the American Cancer Society for this unprecedented legislation.

Much progress has been made in making the Medicaid option a reality for many women in need of treatment. CDC and the Health Care Financing Administration (HCFA) have developed and distributed the necessary materials and instructions for states to implement this Medicaid optional benefit. On January 4^th, 2001 a guidance letter was sent to health officials in all 50 states to encourage their participation through the submission of a Medicaid plan amendment. Detailed questions and answers regarding the new benefit have also been provided. CDC and HCFA have hosted conference calls with national organizations, state breast and cervical cancer programs and state Medicaid agencies to encourage all states to consider this Medicaid option. To date, more than half of the States have taken action, including the introduction or enactment of legislation, revision or enactment of regulations, or the submission of revised Medicaid plans. Three States, Maryland, New Hampshire, and West Virginia, have U.S. Department of Health and Human Services (DHHS) approved amended Medicaid Plans; Rhode Island's plan is currently under review. Information about the Medicaid Treatment Act and its progress toward implementation can be located on CDC's Web site. www.cdc.gov/cancer/nbccedp/law106-354.htm and on the HCFA web site cms.hhs.gov/bccpt/default.asp and an electronic mailbox BCCPT@cms.hhs.gov.

What's our vision for the future of the breast and cervical cancer early detection program? Quite simply, we want no woman to die because she lacked knowledge, access or finances for mammography screening. Identifying, educating and motivating women who have rarely or never been screened for breast cancer is an enormous challenge. To be successful in these cases, the outreach efforts of CDC's program in communities often become a door-to-door, one-on-one campaign to reduce community and individual barriers that impede a woman's ability or decision to obtain the lifesaving benefits of early detection. Barriers such as fear, lack of transportation and child care, linguistic and cultural differences, and lack of physician referral are all common hurdles that must be overcome. Many outreach strategies are employed to overcome these barriers.

More and more women every year are reaching the age for regular screening-in fact, every eight seconds a baby-boomer reaches the age of 50 - the age when the likelihood of developing breast cancer begins to increase rapidly - and a large number of these women are underserved or uninsured. To date, we have only been able to screen a fraction of the women in need of mammography services.

Let me end by telling you a story. It's Beth's story. Beth's husband David lost his job after 28 years. Before David lost his job, Beth made sure to get a mammogram every year. This time, Beth waited five years before she was checked. She might never have had another one if she hadn't found out about Ladies First, the Vermont breast and cervical cancer screening program. When Beth went in for her free mammogram, it was none too soon. Beth's mammogram showed a lesion that turned out to be cancer. The good news is that doctors caught Beth's cancer early enough to treat it successfully. With other help from Ladies First, the cancer treatment was not a financial burden for Beth or her husband. Beth credits Ladies First with saving her life.

There are many Beths out there, and we love to hear their stories. But what concerns us most are the women we don't hear about, the women who are not getting regular screening. Awareness of the program isn't the issue; not being screened is. We hope that we can reach more of these women and catch their cancer early. And when research provides us something even better than mammography, we will use the CDC-funded programs to get that science to women as quickly as possible. Thank you.

Last revised: July 11, 2003