, by John P. Williams, M.D.
The President’s Cancer Panel identifies high-priority issues that are impeding progress against cancer and develops recommendations for addressing those issues in a report submitted to the President. The panel’s new report, Closing Gaps in Cancer Screening: Connecting People, Communities, and Systems to Improve Equity and Access, was released on February 2. In this article, the chair of the President’s Cancer Panel, John P. Williams, M.D., F.A.C.S., describes key points of the report.
Much progress has been made in the past 50 years since the signing of the National Cancer Act of 1971, which included the establishment of the President’s Cancer Panel. Nevertheless, there remain significant opportunities to make improvements across the cancer spectrum, perhaps none more pressing than in the realm of prevention and early detection.
The COVID-19 pandemic has had broad and widespread impacts on our health care system. Among the most concerning have been disruptions in cancer screening. According to studies from NCI and others, postponed and canceled cancer screenings and delayed treatments will result in thousands of excess cancer-related deaths in the years to come.
This figure highlights the ability of cancer screening to save lives and the need to correct the misperception that it is “elective.” Furthermore, the pandemic may very well exacerbate long-standing disparities in screening and cancer outcomes overall by race/ethnicity, geography, income, and insurance status.
Underutilization and inequities in screening before, during, and beyond the pandemic is a problem that must be addressed.
For our 2020‒2021 report, the President’s Cancer Panel chose to shine a spotlight on cancer screening. To develop our report, we spent the last year meeting with stakeholders—including patients, patient advocates, health care providers, researchers, public and private insurers, and others. These meetings reaffirmed the need for more effective and equitable implementation of cancer screening.
The report we presented to President Biden identifies key gaps and barriers to cancer screening in the United States and provides evidenced-based and actionable recommendations to help increase equitable access to appropriate cancer screening and follow-up care for all Americans.
Identifying barriers to cancer screening and follow-up care
Timely cancer screening and early detection of cancer can help save lives.
Not only can early cancer detection prevent cancer deaths, it may reduce the need for aggressive cancer therapies. Avoiding aggressive cancer treatment not only spares patients potential side effects that lower their quality of life, it also spares patients and their families from what can be a significant financial burden.
There are evidence-based guidelines for how, who, and when to screen for several common cancers. Although there are differences between some guidelines, many people who are eligible for cancer screening are not screened when they should be—if they are screened at all.
As we learned during our stakeholder meetings, the barriers to screening and follow-up care after screening include
- lack of knowledge of guidelines
- lack of provider recommendation
- fears or concerns about medical procedures
- difficulty navigating the health care system
- logistical challenges, including lack of transportation, and
- lack of access to medical services.
But perhaps the most important thing we learned from these meetings is: There is an opportunity for stakeholders across the National Cancer Program to act NOW to ensure that everyone in the United States has access to and receives appropriate cancer screening.
In our report to the President, we describe those opportunities and suggest ways to address them.
Many factors influence whether individuals choose to get screened for cancer. But understanding why and when they should get screened, what their options are for screening, and how they can access screening is critical to ensuring that people get the preventive care they need.
Our latest report recommends that communications campaigns be developed to help all Americans better understand when and how they should be screened for various cancers.
These campaigns should make it easy for people to find information relevant to them from sources they trust. Information about cancer screening should be communicated clearly, in language that is easy to understand and that addresses common concerns and misconceptions.
Most importantly, communications campaigns should empower people to take action by clearly defining the steps they should take to get screened. To achieve this goal, we are recommending the expansion of national roundtables—groups comprised of stakeholders from multiple sectors working together—with a focus on cancer screening.
Improving access: Connecting people with care
Too many people in the United States face barriers to medical care, including cancer screening and appropriate medical follow-up. These access challenges can include language barriers, lack of transportation or time to visit a doctor, fears about medical procedures, mistrust of the health care system, lack of health insurance, or lack of nearby medical facilities.
To address these barriers, it is important for health care systems to meet people where they are to ensure they receive the support and care they need. In our report, we highlight two key areas that will help improve access to cancer screening: community-oriented outreach and expansion of self-sampling to screen for cervical and colorectal cancers.
To improve community-oriented outreach, we believe that community health workers are well positioned to play an integral role in supporting cancer screening.
Community health workers serve as key connectors within communities to help people navigate health care systems, including providing culturally appropriate information to increase awareness and understanding of cancer risk and cancer screening options. Because they understand the communities they serve, they are well positioned to cultivate relationships of trust between health care systems and individuals in the community.
Community health workers can also help people overcome logistical barriers to medical care by connecting them with resources such as transportation and services providing dependent care. We recommend the expansion and sustainable funding of community health worker programs so that they can meet their full potential and connect more people with cancer screening and follow-up care.
A visit to the hospital or the doctor isn’t always necessary for people to receive screening for some cancers. During our stakeholder meetings, it became clear that self-sampling, including at-home testing, can increase access to cancer screening for people who live far from medical facilities, have competing demands on their time, or are uncomfortable in medical settings.
Currently, there are two cancers that can be screened for using self-collected samples: stool-based tests for colorectal cancer and HPV self-sampling tests to screen for cervical cancer. Stool-based tests for colorectal cancer are currently integrated into US colorectal cancer screening guidelines, but HPV self-sampling tests—although already adopted in other countries—have not yet been approved by the US Food and Drug Administration (FDA).
Our report recommends the expansion of stool-based testing for colorectal cancer screening and that FDA prioritize the review of HPV self-sampling tests for cervical cancer.
Expanding self-sampling for cancer screening can further enable health care providers to meet people where they are and has the potential to reach more people who are eligible for cancer screening in the United States.
Helping medical teams work more effectively
Providers play a critical role in patients’ decisions to get screened for cancer. However, many providers—particularly in primary care—are increasingly stretched thin with limited time available during appointments.
That’s why we recommend that health care systems and medical offices set up systems and processes that allow all members of the medical team to work together to support cancer screening programs. Providers should collaborate with nurses, medical assistants, office staff, and others to help ensure their patients get appropriate screenings. This includes establishing processes and systems for these staff to collect family and personal health histories, identify patients who are eligible for cancer screening or genetic risk assessment, initiate conversations about screening, and help coordinate recommended follow-up care.
Every person a patient encounters during their health care visit has the potential to support cancer screening. Through a team-based approach to medical care, patients will, we believe, have more opportunities to get access to the care they need.
We also considered issues for people who are at higher risk of cancer because of their family history or other factors. For example, some people have inherited mutations in specific genes that increase their risk of cancer, such as mutations in BRCA genes that increase the risk of breast and ovarian cancer. These people may benefit from earlier, more frequent, or enhanced cancer screening.
Currently, most people with mutations in such cancer-susceptibility genes never know they have them or don’t find out until after they are diagnosed with cancer. That’s why it’s so important that those with a family history of cancer be informed about genetic testing for risk assessment.
Our report recommends empowering providers to offer genetic testing with informed consent without the need for pretest counseling by a certified genetic counselor or medical geneticist. For patients, this could mean fewer trips to the doctor, further reducing the burden of time and logistics.
The final recommendation in our report is focused on improvements in health information technology (IT). This includes widespread integration of cancer screening guidelines and clinical decision-support tools into technologies commonly used in the clinic—including, but not limited to, electronic health records.
These improvements in health IT will streamline provider visits and improve access to appropriate recommended care. Providers would be better equipped to deliver recommendations about appropriate cancer screening and follow-up care after an abnormal screening test because computer systems can keep track of patient eligibility and provide clinical decision support when needed.
Meeting the challenge
We believe that improving equity and access to cancer screening is a significant opportunity for the National Cancer Program.
We consider this report a call to action for all stakeholders—health care providers, health systems, insurers, community and patient advocacy organizations, professional societies, government agencies, and individuals—to work together to close gaps in cancer screening for all populations in the United States.
Through this action, we can continue to build on the progress of the past 50 years and contribute to saving many more lives.