Cancer screening for women are you missing opportunities to prevent disease?

by Monica Zangwill, MD, MPH

Your health insurance company touts its preventive focus. And you think your doctors know what they're doing. So, can you rest assured that you will get all the cancer screening tests, such as mammograms and Pap smears, that you need? That may depend, some experts say.

"We know there are still a lot of missed opportunities out there," says Haya Rubin, MD, PhD, director of quality care research at Johns Hopkins Hospital. "There are a lot of women who should be getting mammograms who aren't," she says, pointing out that, on average, only 56% of Medicare-eligible women had a mammogram to screen for breast cancer in the past two years.

The number of women who receive regular Pap smears to screen for cervical cancer may be even smaller. A research study of patients from Kaiser Permanente, one of California's largest health maintenance organizations (HMO), revealed that among 240 women diagnosed with cervical cancer, 75% of them were seen at a primary care office sometime in the previous 2.5 years but did not receive a Pap smear. A Pap smear during one of those previous visits may have caught their cancer earlier or helped prevent it altogether.

Dr. Rubin says there are many reasons why screening tests, even ones recommended by the American Cancer Society, don't get done. The doctor may be too distracted by a patient's other health issues to remember to order or do the test. Or there might be a problem getting the right paperwork or staffing to do the test. Or the patient may not understand the reason for the test. But usually it is a combination of all these factors.

"It's kind of like a chain and if one of the links is missing, [screening] doesn't happen," Dr. Rubin says.

Elizabeth Gulitz, PhD, RN, associate dean of public health at the University of South Florida agrees. "[Getting screening tests done] is multi-faceted?it can break down in any place." She studies doctors' offices and says that a lot of doctors are very busy and often feel that they don't have enough time, so the preventive tests get lost in the shuffle.

Fortunately, many people are looking at ways to increase the number of women who receive regular screenings. Kaiser Permanente initiated a program to increase breast and cervical cancer screening. Any time a woman is seen at a Kaiser-Permanente doctor's office, a computer tells her doctor whether she is due for a Pap smear or a mammogram.

"If the patient has an overdue Pap smear, the doctor can tell her," says Hai-Yen Sung, PhD, of Kaiser Permanente's Department of Quality and Utilization. "That increases the probability of [her] getting a Pap smear. ?We have found this system to be very successful."

Dr. Rubin agrees that the best way to increase the number of women who receive regular Pap smears and mammograms is to make it easy for the doctor to remember to do these important tests. Computer reminders like Kaiser Permanente's are one option. Other offices use questionnaires that patients fill out before each visit to tell the doctor which tests they want to discuss.

Medicare, too, is working to increase the number of mammograms that are being done. It recently started to pay for a mammogram every year for women over 65, instead of for one mammogram every two years. The new policy is in line with the American College of Obstetrics and Gynecology's recommendations for breast cancer screening. Medicare also works in each state to help set up procedures to remind doctors to order mammograms.

To make sure you and your doctor are not missing opportunities to prevent disease, follow these tips from the experts:

• Choose a doctor whose office has a computerized or paper reminder system for its staff.
• Make sure your insurance covers annual mammograms for women over 50 years old and has a standard policy for routine Pap smears.
• Ask your doctor at your next visit about when to schedule your next Pap smear or mammogram. You don't have to wait for your annual check-up to discuss these important tests with your doctor.