M a y 2 0 10 PR MARY CARE
Research Brief Research Institute
The Role of
Roberto Cardarelli, DO, MPH
Erin Carlson, MPH
Graduate Research Assistant
Center for Community Health
Rachael Jackson, MPH
Center for Community Health
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.
The Role of Primary Care Providers in Cancer Screening. Primary Care Research Institute,
The Role of Primary Care Providers
in Cancer Screening
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.
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
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
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
Colon Average risk men and Colonoscopy Every 10 years, beginning
Cancer7 women 50 years of age or at age 50
Flexible sigmoidoscopy or Every 5 years, beginning at
double‐contrast barium age 50
Fecal occult blood test Every year, beginning at
* 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.
Table 2. Incidence, Mortality, and Survival Information on Breast, Cervical, and Colorectal
Cancer Site Estimated New Estimated Deaths 5‐Year Relative Survival Rate,
Cases in 2009 in 2009 1999‐2005
Localized Cancer Non‐Localized
Breast 192,370 new 40,610 deaths 98% 27% to 84%
Colorectal 106,100 colon 49,920 deaths 90% 11% to 68%
Cervical 11,270 cases of 4,070 deaths 92% Not available
*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
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
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
• Ability to pay for tests
• Acceptance of screening procedure
• Trust in health care provider
• Comfort with gender of health care provider
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.
Table 3. Barriers to Screening for Breast, Cervical, and Colorectal Cancer*
Level of Barrier Barrier to Screening in Primary Care
Mammography referral and adherence
Lower socioeconomic status2
Lack of personal PCP31
Failure to receive other screenings31
Provider Lack of time2
System Lack of health insurance coverage2, 31
PCP failed to recommend screening31
Patient Low acceptance2
Failure to receive other screenings32
Provider Lack of expertise2
Disagreement with recommendation2
System Inadequate space for equipment2
Health insurance coverage2, 33
Lack of time to perform test33
Absence of performing providers33
Patient Low acceptance2
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
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
• 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.
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.
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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-
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