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Cancers originally develop from normal cells that gain the ability to proliferate aberrantly and eventually turn malignant.These cancerous cells then grow clonally into tumors and eventually have the potential to metastasize.
M a y 2 0 10 PR MARY CARE Research Brief Research Institute The Role of Primary Care Providers in Cancer Screening Roberto Cardarelli, DO, MPH PREPARED BY Erin Carlson, MPH Graduate Research Assistant Center for Community Health Rachael Jackson, MPH Associate Director Center for Community Health ACKNOWLEDGMENTS Special thanks to Kimberly Fulda, DrPH, Anita Kurian, DrPH, MBBS, Vishwam Pandya, MD, Kristen Hahn, MPH, and Jennifer Thomas, MS for their contributions to this document. SUGGESTED CITATION The Role of Primary Care Providers in Cancer Screening. Primary Care Research Institute, 2010. The Role of Primary Care Providers in Cancer Screening INTRODUCTION Cancer is the second leading cause of death in the U.S. and accounts for approximately one out of four deaths. In 2009, an estimated 1,479,350 new cancer cases were expected to be diagnosed, and over a half‐million Americans were expected to die of cancer.1 Cancer is costly to Americans in terms of the reduction of quality and years of life, as well as the monetary costs to fight the disease and compensate for the disability it renders. The National Institutes of Health estimated overall costs of cancer in 2008 at $228.1 billion, including $93.2 billion for direct medical costs, $18.8 billion for cost of lost productivity due to illness, and $116.1 billion for cost of lost productivity due to premature death.1 Reducing the morbidity, mortality, and monetary costs of cancer through prevention and early detection has been a national goal for decades. Cancer screening, early detection, and prevention stand to improve population‐based health by protecting quality of life and reducing mortality. Lack of effective treatment for some cancers underpins the importance of prevention and early detection.2 As such, cancer screening is in the forefront of vital public health issues. The 5‐year relative survival rate for all cancers has improved from 50% between 1975‐1977 to 66% between 1996‐2004, largely due to earlier detection and diagnosis, as well as advancements in treatment.1 Despite widespread acceptance of the need for preventive and early detection strategies, there remains a gap between acceptance and implementation. Although overall screening has increased in recent decades, major disparities still exist among some populations. Individuals with no usual source of care, the uninsured, and recent immigrants experience a significant gap in screening utilization, and minorities are still less likely to receive cancer screening and have higher cancer death rates than non‐minority groups.3, 4 Thus, no striking achievements have been observed in reducing cancer disparities for the groups with greatest need. Reducing or eliminating health disparities was a critical goal set forth by Healthy People 2010. Addressing the need for widely‐spread accessible and patient‐accepted cancer screening is imperative to reducing disparities in accordance with Healthy People 2010 objectives. If the population benefits of cancer screening are to be achieved, we must identify barriers to cancer screening, as well as the means to overcome those barriers, for the groups that are least likely to get screened. In this research brief, we will explore some of the cancer screening barriers identified by researchers and ways that primary care providers can help to overcome these barriers. 1 NATIONAL CANCER SCREENING GUIDELINES The U.S. Preventive Services Task Force recommends routine, asymptomatic screening for three cancer sites—breast, colorectal, and cervix—as described in Table 1. These three cancers are among the most common and, in the case of breast and colon cancer, have high mortality rates when left undetected until the cancer has spread beyond the primary site. Breast cancer is the most frequently diagnosed cancer in women and is the second leading cause of cancer death in women. Colorectal cancers account for nearly 10% of all cancer deaths. Table 1. Cancer Screening Recommendations from the U.S. Preventive Services Task Force (USPSTF), 2009 Cancer Population Screening Method When Breast Women 50 years of age Mammography with or Biennially, beginning at Cancer5 and over* without a clinical breast age 50 exam Cervical Women who have been Cytologic screening Every year, beginning at Cancer6 sexually active and have a (Pap smear) age 21 or 3 years after cervix onset of sexual activity, whichever comes first. After 2‐3 normal annual Pap smears, screening can be performed every 3 years. Colon Average risk men and Colonoscopy Every 10 years, beginning Cancer7 women 50 years of age or at age 50 older Flexible sigmoidoscopy or Every 5 years, beginning at double‐contrast barium age 50 enema Fecal occult blood test Every year, beginning at age 50 * The updated breast cancer screening guidelines limit routine screening to women 50 years and older, but suggest that clinicians consider biennial screening mammography before the age of 50 years on an individual basis, taking into consideration patient context, including the patient’s values regarding the specific benefits and harms. The National Cancer Institute and the American Cancer Society continue to suggest routine mammography beginning at the age of 40. Breast, colorectal, and cervical cancer are each largely asymptomatic in the early stages but have at least a 90% 5‐year survival rate if detected and treated when the cancer is still localized. Unfortunately, these cancers often go undetected until the later stages when survival rates are dramatically lower. For example, only 40% of colorectal cancers are diagnosed in the early stages when there is a high chance of survival. Table 2 shows the estimated new cases, deaths, and 5‐year survival rates based on stage of diagnosis for each of these cancer sites. 2 Table 2. Incidence, Mortality, and Survival Information on Breast, Cervical, and Colorectal Cancer* Cancer Site Estimated New Estimated Deaths 5‐Year Relative Survival Rate, Cases in 2009 in 2009 1999‐2005 Localized Cancer Non‐Localized Cancer Breast 192,370 new 40,610 deaths 98% 27% to 84% cases Colorectal 106,100 colon 49,920 deaths 90% 11% to 68% cancer cases; 40,870 rectal cancer cases Cervical 11,270 cases of 4,070 deaths 92% Not available invasive cancer *Source: Surveillance Epidemiology and End Results (SEER) Stat Fact Sheets http://seer.cancer.gov. Rates and estimated cases are from the SEER 17 areas (San Francisco, Connecticut, Detroit, Hawaii, Iowa, New Mexico, Seattle, Utah, Atlanta, San Jose‐Monterey, Los Angeles, Alaska Native Registry, Rural Georgia, California excluding SF/SJM/LA, Kentucky, Louisiana and New Jersey). While lung, skin, and prostate cancers also have relatively high incidence and mortality rates, the U.S. Preventive Services Task Force guidelines state that there is not sufficient evidence to recommend or not recommend routine screening for these cancer sites. For these reasons, references to cancer screening in this brief are directed toward mammography, flexible sigmoidoscopy or colonoscopy, and Papanicolaou (Pap) testing for breast, colorectal, and cervical cancers, respectively. THE ROLE OF PRIMARY CARE PROVIDERS IN CANCER SCREENING According to the American Academy of Family Physicians, a primary care practice should serve as a patient’s first entry point into the health care system and a continual focal point for follow‐ up services. The care provided by such practices includes health promotion, disease prevention, health maintenance, counseling, patient education, and diagnosis and treatment of acute and chronic illnesses in a variety of health care settings (e.g., office, inpatient, critical care, long‐term care, home care, day care, etc.). These practices are designed to serve patients with undifferentiated and undiagnosed problems, making it an ideal setting in which to identify cancer cases. Primary care providers include primary care physicians, who are usually trained in the specialties of family medicine, general internal medicine, or general pediatrics, and non‐ physician primary care providers (such as nurse practitioners and physician assistants). These providers are patient advocates who coordinate the care of their patients, using the entire health care system, as needed, to treat their patients.8 Evidence indicates that primary care reduces obstacles to prevention and early detection, prevents mortality, and promotes health.9 Studies have shown that primary care providers are critical to providing high‐quality health care.10 Research has found that health is better in 3 geographic areas with more primary care providers (PCPs), that people who receive care from PCPs are healthier, and that the characteristics of primary care are associated with better health.10 Primary care providers play a particularly critical role in closing gaps to cancer prevention and early detection.9 The Institute of Medicine emphasizes the critical role of primary care in disease prevention and early detection, supported by numerous studies, with a special focus on primary care’s effect on cancer screening.11‐15 Receiving primary care has been positively associated with patients having up‐to‐date screenings and health habit‐counseling.16 Shappert found that over 85% of all mammograms are ordered by primary care providers,17 and numerous studies have demonstrated that a physician’s advice to have mammograms and colorectal cancer screenings enhances their receipt.18‐21 Access to primary care providers has been found to be predictive of adequate cancer screening.11, 12, 22‐26 Areas with larger supplies of family physicians are associated with an earlier detection of breast cancer, colon cancer, cervical cancer, and other cancers.18, 27‐29 Having at least one personal health care provider is significantly associated with adequate cervical,26 breast,26 and colorectal30 cancer screening behavior. Furthermore, a study by Ferrante, Gonzalez, Pal & Roetzheim found that for each tenth percentile increase in supply of primary care providers, there was a 4% increase in the odds of a breast cancer diagnosis in an early, rather than late, stage.27 ACCESS TO CANCER SCREENING IN THE CONTEXT OF PRIMARY CARE While access to primary care and having a primary care provider are associated with higher rates of cancer screening, it is important to acknowledge the barriers to cancer screening that exist within the context of primary care. By identifying potential barriers to cancer screening, practices to overcome barriers can be put in place. Barriers to cancer screening in primary care often fall into one of three categories and may include the following obstacles:2 1) Patient‐level factors • Education • Ability to pay for tests • Acceptance of screening procedure • Trust in health care provider • Transportation • Comfort with gender of health care provider 4 2) Provider‐level factors • Gender of provider (concordance with patient) • Provider awareness of screening guidelines • Time constraints • Inadequate technical expertise in screening procedures (e.g., Pap tests and flexible sigmoidoscopy) • Inadequate knowledge of how to counsel patients about smoking cessation or the importance of screening interventions • Distraction by patient co‐morbidities 3) System‐level factors • Health insurance coverage for recommended screening procedure • Having one personal health care provider • Inadequate space or staffing • Time constraints that system‐level factors place on provider Overcoming barriers to cancer screening in the primary care setting is necessary to help providers channel awareness and desire to promote early cancer detection among their patients into routine practice. Below are some of the common barriers to cancer screening during the context of the primary care visit and suggestions for addressing those barriers, according to Wender.2 Lack of time: Most aspects of cancer screening require no more than 5 to 10 minutes of provider time. While increasing the amount of time allotted for a patient visit may not be realistic, given demands on provider time, efforts can be directed at helping providers use existing time efficiently to allow for preventive practices. Lack of expertise: Screening practices that require special technical expertise, such as Pap tests and flexible sigmoidoscopy, are now taught during residencies. However, those physicians who went through residency prior to the time those skills were commonly taught can call on those who have learned the skill for technical assistance. Provider forgetfulness: Reminder systems and improved quality assurance procedures within the clinical practice help to set a standard for care, prompt completion of the screening practice, and measure provider performance in adhering to the screening practice. 5 Table 3. Barriers to Screening for Breast, Cervical, and Colorectal Cancer* Level of Barrier Barrier to Screening in Primary Care Mammography referral and adherence Patient Forgetfulness2 Lower socioeconomic status2 Older age2 Lack of personal PCP31 Failure to receive other screenings31 Provider Lack of time2 Forgetfulness2 System Lack of health insurance coverage2, 31 PCP failed to recommend screening31 Flexible sigmoidoscopy Patient Low acceptance2 Older age32 Failure to receive other screenings32 Provider Lack of expertise2 Disagreement with recommendation2 Forgetfulness33 System Inadequate space for equipment2 Health insurance coverage2, 33 Inadequate reimbursement33 Lack of time to perform test33 Absence of performing providers33 Papanicolaou Test Patient Low acceptance2 Older age2 Socioeconomic status2 Low English proficiency34 Provider Lack of expertise2 *Based on table created by Wender (1993).2 Low patient acceptance: Patient education by providers is imperative to improving patient acceptance for cancer screening procedures. Overcoming forgetfulness and time constraints during the visit are the first steps to providing patient counseling. Further, providers should not allow themselves to be deterred from suggesting screening procedures perceived to have low patient acceptance. For instance, though Pap tests have been one of the most successful screening procedures in reducing cancer mortality and have relatively high patient acceptance, data indicate that providers often do not suggest the test to patients who do not request it.2, 35 6 POLICY IMPLICATIONS Policies to support primary care are imperative both to increasing cancer prevention and screening, as well as to strengthening health care overall. Policies to support and expand the supply of primary care providers, thus increasing access to primary care, on a macro‐level include the following: • Increase the number of PCPs in the medical field. We must encourage more providers to enter primary care practices. One way to do this may be to improve primary care reimbursement rates for both common conditions and for primary care characteristics like referrals (such as those for mammography or colonoscopy). • Encourage a more equitable distribution of PCPs. States can do this by tailoring licensing policies to health needs in different areas or by providing financial incentives for practicing in underserved areas. • Encourage more incoming medical students to specialize in primary care. Federal funds supporting graduate medical training and expansion of loan forgiveness programs can be directed toward training primary care providers, especially those that serve in medically underserved areas. • Support primary care quality improvement and research. Allocate more research dollars toward quality improvement and research on primary care. In addition to increasing access to primary care providers, policies are needed that focus specifically on increasing cancer screening in the primary care setting. Research has shown that policies that effectively promote screening largely target organizational level interventions. Methods proven in randomized trials to increase screening in primary care settings include:36 • Use posters and brochures in the clinic setting to inform patients and remind providers. • Monitor patient screening rates using manual tracking systems to provide health care providers with accurate data. Providers’ perceptions of efficacy in screening their patients have been shown to be higher than actual screening rates. • Incorporate into office routines a centralized, systematic approach to track screenings. • Secure access to technical assistance for more specialized clinical screening practices (e.g., colonoscopy). Access to equipment alone has not been shown to affect change without facilitating technical training and assistance. • Structure patient charts to include physician reminders about cancer screening counseling. 7 • Synchronize clinic and physician screening policies with the latest screening practice recommendations set forth by the National Cancer Institute and U.S. Preventive Services Task Force. Studies have indicated that patients are not routinely screened at the intervals recommended by these organizations due to lack of physician awareness or due to physician confusion from conflicting guidelines published by other organizations. CONCLUSION Efforts to provide comprehensive cancer screening in the primary care setting are critical for early diagnosis and subsequent promotion of effective treatment. To facilitate and effectuate cancer screening in the context of routine primary care, patient‐, provider‐ and system‐level barriers must be identified and overcome with both macro‐level and organizational policies. Changes on multiple levels, such as increasing the number of primary care providers, examining primary care reimbursement policy, creating a clinic environment conducive to patient education and cancer screenings, and educating providers about current screening practices and guidelines will support life‐saving cancer screening as part of the primary care culture. 8 REFERENCES (1) American Cancer Society. Cancer Facts and Figures 2009. American Cancer Society website 2009;Available at: URL: http://www.cancer.org/downloads/STT/500809web.pdf. AccessedOctober 28, 2009. (2) Wender RC. Cancer screening and prevention in primary care. Obstacles for physicians. Cancer 1993 August 1;72(3 Suppl):1093‐9. (3) Swan J, Breen N, Coates RJ, Rimer BK, Lee NC. Progress in cancer screening practices in the United States: results from the 2000 National Health Interview Survey. Cancer 2003 March 15;97(6):1528‐40. (4) SEER Cancer Statistics Review, 1975‐2006. SEER website 2009;Available at: URL: http://seer.cancer.gov/csr/1975_2006/. AccessedNovember 8, 2009. (5) U.S. Preventive Services Task Force. Screening for Breast Cancer. U S Preventive Services Task Force web site 2009 November;Available at: URL: http://www.ahrq.gov/Clinic/uspstf/uspsbrca.htm. AccessedJanuary 11, 2010. (6) U.S. Preventive Services Task Force. Screening for Cervical Cancer. U S Preventive Services Task Force web site 2003 January;Available at: URL: http://www.ahrq.gov/Clinic/uspstf/uspscerv.htm. AccessedJanuary 11, 2010. (7) U.S. Preventive Services Task Force. Screening for Colorectal Cancer. U S Preventive Services Task Force web site 2008 October;Available at: URL: http://www.ahrq.gov/Clinic/uspstf/uspscolo.htm. AccessedJanuary 11, 2010. (8) American Academy of Family Physicians. Primary Care. American Academy of Family Physicians website 2010;Available at: URL: http://www.aafp.org/online/en/home/policy/policies/p/primarycare.html. (9) Starfield B, Shi L, Macinko J. Primary care impact on health outcomes: A literature review. Milbank Quarterly 1995;83(3):457‐502. (10) Ginsburg JA, Doherty RB, Ralston JF, Jr. et al. Achieving a high‐performance health care system with universal access: what the United States can learn from other countries. Ann Intern Med 2008 January 1;148(1):55‐75. (11) Gill JM, McClellan SA. The impact of referral to a primary physician on cervical cancer screening. Am J Public Health 2001 March;91(3):451‐4. (12) Selvin E, Brett KM. Breast and cervical cancer screening: sociodemographic predictors among White, Black, and Hispanic women. Am J Public Health 2003 April;93(4):618‐23. 9 (13) Klabunde CN, Frame PS, Meadow A, Jones E, Nadel M, Vernon SW. A national survey of primary care physicians' colorectal cancer screening recommendations and practices. Prev Med 2003 March;36(3):352‐62. (14) Zoorob J. Cancer Screening for Primary Care Physicians: Part I. Primary Care Reports 2002;8:85‐92. (15) Zoorob J. Cancer Screening for Primary Care Physicians: Part II. Primary Care Reports 2002;8:93‐100. (16) Flocke SA, Stange KC, Zyzanski SJ. The association of attributes of primary care with the delivery of clinical preventive services. Med Care 1998 August;36(8 Suppl):AS21‐AS30. (17) Shappert SM. National Ambulatory Medical Care Survey, 1991 summary. Vital and Health Statistics 1994;13(116). (18) Katz ML, James AS, Pignone MP et al. Colorectal cancer screening among African American church members: a qualitative and quantitative study of patient‐provider communication. BMC Public Health 2004 December 15;4:62. (19) Breen N, Kessler L. Changes in the use of screening mammography: evidence from the 1987 and 1990 National Health Interview Surveys. Am J Public Health 1994 January;84(1):62‐7. (20) Fox SA, Siu AL, Stein JA. The importance of physician communication on breast cancer screening of older women. Arch Intern Med 1994 September 26;154(18):2058‐68. (21) Screening mammography: a missed clinical opportunity? Results of the NCI Breast Cancer Screening Consortium and National Health Interview Survey Studies. JAMA 1990 July 4;264(1):54‐8. (22) Bessler P, Aung M, Jolly P. Factors affecting uptake of cervical cancer screening among clinic attendees in Trelawny, Jamaica. Cancer Control 2007 October;14(4):396‐404. (23) Coughlin SS, Costanza ME, Fernandez ME et al. CDC‐funded intervention research aimed at promoting colorectal cancer screening in communities. Cancer 2006 September 1;107(5 Suppl):1196‐204. (24) Facione NC. Breast cancer screening in relation to access to health services. Oncol Nurs Forum 1999 May;26(4):689‐96. (25) Hewitt M, Devesa SS, Breen N. Cervical cancer screening among U.S. women: analyses of the 2000 National Health Interview Survey. Prev Med 2004 August;39(2):270‐8. 10 (26) Cardarelli R, Kurian AK, Pandya V. Having a personal healthcare provider and receipt of adequate cervical and breast cancer screening. J Am Board Fam Med 2010 January;23(1):75‐81. (27) Ferrante JM, Gonzalez EC, Pal N, Roetzheim RG. Effects of physician supply on early detection of breast cancer. J Am Board Fam Pract 2000 November;13(6):408‐14. (28) Ferrante JM, Gonzalez EC, Roetzheim RG, Pal N, Woodard L. Clinical and demographic predictors of late‐stage cervical cancer. Arch Fam Med 2000 May;9(5):439‐45. (29) Roetzheim RG, Pal N, Gonzalez EC et al. The effects of physician supply on the early detection of colorectal cancer. J Fam Pract 1999 November;48(11):850‐8. (30) Cardarelli R, Thomas JE. Having a personal health care provider and receipt of colorectal cancer testing. Ann Fam Med 2009 January;7(1):5‐10. (31) Schueler KM, Chu PW, Smith‐Bindman R. Factors associated with mammography utilization: a systematic quantitative review of the literature. J Womens Health (Larchmt ) 2008 November;17(9):1477‐98. (32) Haque R, Quinn VP, Habel LA et al. Correlates of screening sigmoidoscopy use among men in a large nonprofit health plan. Cancer 2007 July 15;110(2):275‐81. (33) Dulai GS, Farmer MM, Ganz PA et al. Primary care provider perceptions of barriers to and facilitators of colorectal cancer screening in a managed care setting. Cancer 2004 May 1;100(9):1843‐52. (34) De A, I, Sweningson JM. English proficiency and physicians' recommendation of Pap smears among Hispanics. Cancer Detect Prev 2006;30(3):292‐6. (35) Norman SA, Talbott EO, Kuller LH et al. The relationship of Papanicolaou testing and contacts with the medical care system to stage at diagnosis of cervical cancer. Arch Intern Med 1991 January;151(1):58‐64. (36) Wei EK, Ryan CT, Dietrich AJ, Colditz GA. Improving colorectal cancer screening by targeting office systems in primary care practices: disseminating research results into clinical practice. Arch Intern Med 2005 March 28;165(6):661‐6. 11 The University of North PR MARY CARE Texas Health Science Center, Fort Worth’s medi- Research Institute cal school and more, is one of the nation’s distin- guished graduate Vision academic health science Healthy Texans through innovative centers, dedicated to edu- cation, research, clinical care and community primary care and public health research engagement. It comprises the Texas College of Osteopathic Medicine (TCOM), the Department The Primary Care Research Institute strives to of Physician Assistant Studies, the Graduate improve the lives of Texas citizens through School of Biomedical Sciences, the School of interdisciplinary primary care and public health Public Health, and the School of Health Profes- service, research, and education. The Institute is sions. UNT Health, the TCOM faculty practice a consortium of stakeholders in the North Texas program, provides direct patient care in 33 clin- region who collaborate and build upon one ics across Tarrant County. another’s strengths and resources to improve health and increase equity. We are dedicated to In 2007, TCOM was named a top 50 medical working with interdisciplinary partners and school in primary care by U.S. News and World translating research into primary care and Report for the sixth consecutive year. The insti- public health practice. The Primary Care tution contributes almost $500 million to Tarrant Research Institute is housed at the University of County and Texas economies annually. North Texas Health Science Center. www.hsc.unt.edu Primary Care Research Institute Roberto Cardarelli, DO, MPH, Director Place 855 Montgomery, 2nd ﬂoor stamp Fort Worth, TX 76107 here email@example.com www.hsc.unt.edu/PCRI To:
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