By: Dr. Geoffrey Modest
MMWR just published the 2013 National Health Interview Survey (NHIS) on cancer screening rates, with targets established by Healthy People 2020 using the US Preventive Services Task Force guidelines (see here).
Overall, there was not much improvement from 2010 to 2013 in breast, cervical or colorectal cancer (CRC) screening, and cervical cancer screening rates even declined. NHIS is an annual survey of a nationally representative sample of the civilian US population, with surveys of randomly selected adults. In 2013 had a 61.2% response rate.
Results:
–Mammography in women aged 50-74: 72.6%, below the target of 81.1%. no significant change from 2010. On more detailed review:
–lower in women aged 50-64 than 65-74
–lower among Hispanics
–lower among those with less education or income
—lowest in those without primary care (29.7%) or insurance (38.5%)
–Pap tests: 80.7% of women aged 21-65 had an appropriately recent pap test, below the target of 93.0%, below the 2008 baseline of 84.5%, and declined 5.5% from 2000 to 2013. On more detailed review:
–lower for Asians, Hispanics, foreign-born, and women aged 51-65
–lower in those with less education or income
—lowest in those without primary care (62.1%) or insurance (62.0%)
–CRC screening: 58.2% of those aged 50-75 had CRC screening, below the target of 70.5%, but above the 2008 baseline of 52.1%. Use increased dramatically from 2000 to 2013 by 24.6 percentage points, though did not increase from 2010 to 2013. On more detailed review:
–lower among Asians and all Hispanic subgroups except Puerto Ricans
–lower among those aged 50-64 (52.8%) than 65-75 (69.4%)
–lower in those with less education or income
—lowest in those without primary care (17.8%) or insurance (23.5%)
So, a few points.
–No real progress since 2010 (not much change in mammography or CRC testing, decline in paps)
–There were dramatically decreased rates of screening (35-40 percentage points less) in uninsured and those without primary care. This underscores perhaps the most glaring deficiency/disparity of our current health care system: we do not have an inclusive coherent system of care (as exists in the rest of industrialized and many less-industrialized countries) which not only is socially reprehensible, but ironically is a lot more expensive (it turns out, for example, that treating the undetected cancers later is quite expensive…)
–One concern I have brought up before is that the recommendation for decreased pap smear screening in 2012, with screening every 5 years in those >30yo and normal results, may reinforce both a more casual attitude to screening and less provider experience/comfort with doing pelvic exams even when important diagnostically (and in my role as an educator, that is my observation — even women with lower abdominal pain are not routinely getting pelvics). For more blogs on screening, see here.
–One should bear in mind that the above data are as reported by the patient. in fact, the actual screening rates may be quite different. for example, I have seen several women who state that they had a pap smear when in fact they have had only a pelvic exam in the emergency room
–Another real concern is that we are apparently not doing any better overall despite the increasing use of electronic medical records (EMRs) and reminder systems, since one of the obvious changes to improve screening would be increased reminders to patients and providers. Perhaps those of us using EMRs are a bit inured of these reminders, as nurses and others in ICUs are of alarms. This observation may undercut one of the strongest arguments for EMRs — that they would improve routine screening through incorporated reminder systems…