Cervical Ovarian Cancer

good afternoon i'm john iskander. welcome to the july 2013 sessionof cdc public grand rounds. continuing education credits forpublic health grand rounds are available for physicians,nurses, pharmacists, health educators and others.for more information, please consult our website.grand rounds is available on facebook, twitter and youtube.we have a new featured video segment called beyond the data,which we post on our website and

on youtube shortly after thesession. scientific articles relevant tothis month's grand rounds are featured in this week's issue ofscience clips, which is produced and distributed in conjunctionwith the cdc library. please consult the website forsubscription information and articles where available.we wanted our audience to be aware of a special exhibit oncancer survivors currently at the cdc museum through thisseptember. denise's image and name are usedwith her permission.

on the day of baseball'sall-star game, we bring you our own all-star lineup for today.we now have some introductory remarks from the cdc director,dr. tom frieden. >> cancer kills more youngpeople in this country than any other disease.every year, more than 1 million americans are diagnosed withinvasive cancer. screening tests can help detectcertain cancers early, making them easier to treat or cure.that's particularly the case for cervical and colorectal cancerswhich often don't have any early

symptoms.but too few people get screened, and that causes avoidablesuffering and premature death. public health agencies canincrease cancer screening rates by working with state medicaidprograms and state insurance exchanges to help promote,coordinate and monitor cancer screening.they can also convene providers, patients, communityorganizations and others to develop communitywide programsto support patients. this approach can also reducedisparities in screening rates.

today, public health has atremendous opportunity. we can offer screening to everyperson in the united states who needs it.early screening is an essential life saving tool in our fightagainst certain cancers. let's work together to make surethat screening gets done and follow up gets done, as well. our first speaker isdr. otis brawley. >> thank you. it's a true pleasure to speakhere today.

i especially want to thank theorganizers of this event because this is a very well run grandround. i am a cancer doc.i'm an epidemiologist. i'm interested in outcomes.these are my disclosures. what i'm going to talk to youover the next 12 minutes about is screening.i'm going to tell you its purposes as well as talk aboutsome of the principals and give some real examples in screeningas we apply it to the real world.the aims of screening are

primarily reduction in cancerrelated mortality and secondarily reduction in cancerrelated morbidity. screenings can causeintervention. always important in assessing a screening test is the benefit toharm ratio in population to be screened.there are tests that have a significant net benefit and i'mgoing to talk about some tests in which the harms may very welloutweigh any benefit. the best way to tell if ascreening test saves lives is

through a prospective randomizedscreening trial, where people are randomized after entryeither to a screen group or to a control group that is unscreenedand their mortality is watched over time.this reduces bias. bias is most reduced throughgrant immunization. there are also going to be somehealthy volunteer effects because people that go into ourscreening trials tend to be healthier than the generalpopulation. one has to worry about drop inand drop out.

drop in is when people who arein the unscreened arm decide to get the screening test.drop out, of course, is when people who are supposed to bescreened regularly decide not to get screened.we also have to be careful of randomization by census rolls,which has become incredibly important or popular, i shouldsay, in europe where they take lists of men age 55 and aboveand randomize them to be screened or not screened inprostate cancer studies, for example.another important principal is

lead time bias.this is the reason why we do not look at survival as evidence ofscreening benefit. we look at decline in mortalityand not survival because lead time bias is simply someone getsscreened and they are diagnosed earlier.they still may die at the exact same time if they had not beenscreened as you see here and the difference between someone whois diagnosed due to symptoms and someone who is screened anddiagnosed is the lead time. now, screening tests areactually beneficial when they

have a lead time like this andyou also kick the time to death out further to the right.very, very important in the concept of screening is anunderstanding of cancer biology and that is less bias.if we actually take a large population and screen themannually for a specific disease, say, for example, breast cancer,or it can be lung or serve ix cancer or prostate cancer forthat matter, the people who are going to do the best are thepeople who are best at the initial screen, the downwardclick on the left there.

the population that is going todo the second best is the population diagnosed at thesecond, third or fourth screened and the population doing theworst is the population in between scheduled screens.this is the concept that there is varying biological behaviors.more aggressive tumors are less amenable to screening whereasless aggressive tumors, sometimes tumors that grow veryslowly can be easily picked up in screening.there is a slow-growing tumor called an over diagnosis tumor.think of cancer developing in an

individual and they arediagnosed due to screening, treat it and cured and they goon to die at a certain time later in life.but think of an identical twin, both genetically andenvironmentally who develops cancer, is never diagnosed ortreated for that cancer, but still grows old and dies ofsomething totally unrelated to the cancer, never knowing thatthey actually had the disease. now, these cancers that wouldnot go on to cause death or o r overdiagnosis cancers are tumorsthat people frequently don't

think about, but they do existand they exist in large numbers. some studies estimate that 60%of locally diagnosed prostate cancers are overly diagnosedtumors. others show that perhaps 50% ofradiologic diagnosed tumors. it's important that we actuallytalk about our definition of cancer because that's somethingthat needs to evolve. and that's one of the reasons wehave this difficulty with over diagnosis.here, this was a pathologist shown in the mid 19th century.he and a number of german

pathologists did a number ofbiopsies with a light microscope.they defined the profiles we use today for cancer.these profile res still used today despite saul of ouradvances in diagnosis. look at all of the things thatwe've developed over the last 160 years.to the point that today in a hospital near here, a biopsy isbeing done on a five or 6 millimeter tumor in a woman'sbreast, the same staining that veerkau used is going to beused.

a microscope is going to be usedto look at that biopsy and the pathologist is going to say thislooks just like what veerkau said killed that woman 150 yearsago. this fits the profile of cancer.what we desperately need today is a 21st century of cancermoving away from the morphlogic definition of cancer.we do not know if that five millimeter tumor which lookslike cancer is gee nomicily programmed to grow, metastasize,spread and cause harm. that being said, there areclearly screening tests that

have been put to study and havebeen shown to be beneficial at the to happen population level,meaning if they save lives and this is the focus of much ofthis grand rounds. there's some screening teststhat have been found to be beneficial for certain highrisks growths. we'll have an example of that.and then there's screening tests where the evidence shows thatthe harms are clearly outweighing the benefits.the u.s. preventive services task force is an independentpanel of nonfederal experts in

prevention and scientific reviewof evidence and they are preliminarily responsible forhealth recommendations based on health screeningrecommendations. that being said, consistentlydemonstrated mortality demonstrations, a number ofstudies for colon cancer, a number of studies for papnote with the stars the studies that have not been shown to bebeneficial with prospective randomized trials, but we stillhold them to be beneficial. recommended based on risk factorassessment is logo spiral ct

screening.let's talk now about colorectal cancer screening.it is incredibly important because as dr. frieden saidearlier, a large number of lives can be saved if we simply didcolorectal cancer screening in an aggressive, organized way.we estimate that 15,000 to 20,000 additional lives could besaved in the united states every year if the 40% to 45% of theamerican population over the age of 50 and under the age of 75who do not undergo colorectal cancer screening by anyrecommendation right now were to

actually start gettingcolorectal cancer screening and aggressive follow-up intreatment. subsequent grand rounds speakerswill address ways to address barriers to increasing screeningrates. in the case of prostate cancerscreening, 11 out of 11 randomized trials have shown theharms of prostate cancer screening with, meaningconsiderable diagnosis and treatment with numerous harms toinclude fever, sepsis, metal anguianguish, poor quality of life.

two of those studies show asmall reduced mortality due to prostate screening.but all 11 trial ves methlogical laws.today many organizations recommend that men understandthis and make an informed decision about whether they wantto be screened. chest x-ray screening for lungcancer in the 1960s actually increased survival and wasthought to be a good thing. when prospective randomizedstudies were done, it was shown that it did not decreasemortality.

indeed, there was a trend towardan increase in mortality in the screened arm versus the controlgroup. the national lung screeningtrial, which was done by the centers for -- done by thenational cancer institute in the early part of this century,randomized 54,000 people had high risk because of smoking andage, high risk of lung cancer to a spiral ct or a sham crestx-ray. this is done at 30 sites withexpertise in lung cancer training and treatment.and after ten years, it was

demonstrated a 20% decline inmortality in the screened group versus the control group.of the 27,000 or so people would were screened, this translatedinto 87 fewer deaths, but there were still about 350 lung cancerdeaths. and very importantly, there were16 deaths that had been attributed to interventionscaused by the screening. in this high risk group for lungcancer, the benefit risk ratio was 5.4 lives saved for everyone life lost, 87 over 16 is 5.4.the benefit risk ratio in terms

of putting people into intensivecare units and having major complications was even lower,2.7 to 1. again, the ames of screening areprimarily reduction and mortality.secondarily reduction and morbidity.screening can cause harm. therefore, the benefit harmratio screening is always important as is the risk of thepopulation to be screened. and we desperately need a 21stcentury definition of cancer, a way that we can say to apatient, you have something that

looks like cancer, but gee nomicily webb it is not going to grow, spread and metastasize oryou have something that looks like cancer and we knowgenomically this is something we need to treat because if it isnot treated, it is ultimately going to cause you harm.our next speaker will be dr. rachel ballard-barbash.>> good afternoon. it's a appreciate mr. your to behere today and to see so many faces and to follow on.one of my accomplishments in college was i was a secondbaseman for a woman's softball

league and we won our league.so just to give you a sense that the way we, in fact, arefollowing that illusion. so i was asked, what can wereally learn from cancer screening in internationalsettings? fist, i think it's reallyimportant, otis just finished an excellent overview and adiscussion of some specific tests that have been evaluatedby a randomized control trials. but we know that screen sg aprocess. it's not just one test.and it involves the areas of

assessing risk in individualsand figuring out who really needs to be screened, doingspecific tests to detect cancer and them doing more extensivefollow-up and diagnostic evaluation to understand if theabnormalities detected, in fact, are cancer and failurecommittees occur throughout that entire process.so what might we learn from some international models ofinnovation? and specific, the question i wasasked to think about was how a public health approaches venuesin other countries.

so it's important, of course, tounderstand that other countries have very different health caresystems. and for many of these countries,most of the organized screening programs have been organized aspublic health programs outside the context of routine clinicalcare. and it's because of that theyhave very active and comprehensive data collectionand evaluation systems. and they look at that entirescreening process and a goal and objective of qualityimprovement, quality assessment.

they also focus very much ontrying to identify and invite the relevant population forscreening to look at all the processes, as well as the oaks.both the near term and the long-term.and one of the innovations that's happening now in manycountries, particularly with electronics systems is they arebuilding timely and active feedback systems to personnelsand facilities to help and improve quality.i wouldn't say on an immediately realtime basis, but on a veryroutine basis that allows people

to change as they're providingcare. i thought it would be helpfulfor the group to have an understanding about an effortnci has been directing since about the late 1990s.the international cancer screening network and this wasinitiated to help us understand if the promise of breast cancerscreening that had been identified for randomizedcontrol trials was actually realized when it went intopractice. it started with 11 countries andwe expanded this about seven or

eight years ago to look atscreening for multiple other cancers.it includes now 35 countries around the world.and the purpose of this effort is to use and compare data fromorganized screening programs or in the case of countries likethe u.s. national data on screening where that screeningmay be opportunistic in many cases rather than organized andto really develop the method through evaluating the impact ofthese programs. while randomized control trialswere a major progress in the

last half of the last century, ithink our progress for the next half of this century is toreally understand how do we use data from clinical practice?so you can see from this map that many of the countries thatparticipate are predominantly from europe and the u.s.some from southeast asia. there's very few in southamerica or africa in part because they don't haveorganized programs and screening for cancer other than somecircumstances such as cervical cancer has not been a major areaof focus for those countries.

i'm going to talk about twoareas, cervical cancer and colon screening cancer program toesgive you a sense of what we're learning from this internationallandscape of research. so in the case of cervicalcancer screening, a comparison between the u.s. and thenetherlands, it's important to look at the parameters thatdetermine how these screening programs move forward.in the united states, the organization is through medicalscreening, seeing a physician. they're opportunistic or, infact, the phrase that is used in

most of the rest of the world iswild screening. and in comparison to thenetherlands, it's organized under a public health model.you can see similarly the differents in age groups in theu.s. much broader. they don't have upper agelimits, a more narrow constraints in the netherlands,much more often recommended intervals until very recently inthe united states compared to the netherlands and differencesin reimbursement. one of the issues that they moveforward in many countries now

that have organize onnedprograms is that they provide reimbursement for their cancerscreenings. we see how that shifts whetheror not screening is resisted according to guidance.this slide about the number of lifetime pap smears that a womanwould receive if one followed different guidelines recommendedare very important. the first line is for thenetherlands. over her lifetime, a woman mightreceive over seven pap smears in contrast, the range in theunited states is huge across

different guidelines, anywherefrom about 16 to -- or close to 50 depending on the groups thatyou look at. so we have three to four foldmore pap smears done in the united states that are decreasesin cervical cancer mortality between these two countries hasbeen nearly identical. this same story has held inother areas of cancer, somewhat similar, also, for example, inbreast cancer. moving on now to talk brieflyabout the organization structure in the united kingdom aboutcancer screening programs, they

implemented a public healthmodel. it was based on evaluatining daand they selected fobt for a narrow range of people than wedo in the united states for 60 to 69-year-olds and if there wasan abnormal fobt, those people would be evaluated bycolonoscopy. so they picked this regularmanin part because they only move forward if they have sufficientresources to screen all the widely developed groups.more to how does one cover the population?and their organization reflects

the public health model.they set up hubs that cover a very large population, 10million people in this instance. and those hubs manage thatentire process of screening. once they have an abnormal test,the people are referred to screening centers that areactually run by nurses and the nurses do the screening,evaluation and the screening endoscopy.so they spend a lot of time training nurse end opt endoscop.this is just one example of one of the efforts that they did.they were trying to track uptake

in their screening program.and this round refers to the fact that people are invited, across-section of the population. in this case because it's annualfobt, people are invited every year.so somewhat differently than some early work in the unitedstates, it appears that women are screened at slightly higherrates than men with colon cancer screening.it's very similar to results in the united states.people who have a high social deprivation score that relatesto a whole range of neighborhood

environmental ku yaal context ihave much lower rates of screening, only about 40%compared to 60% or 70% with people who are at the high --who have much moore resources. similarly, if they look atspecific racial ethnic groups, they look at the percentage ofpopulation coming from an indian subcontinent where people camefrom areas where there were a high proportion of people fromthe indian subcontinent, also these individuals had highersocial deprivation scores. they had much lower rates ofscreening.

and we know that people who donot respond to screening, and in this instance when they lookedat people who different respond to the first round, only about10% of them ever came in to a future round, this is the -- wehave the highest rates of late stage disease among people whohave never been screened. so we really need to perhapsshift our attention to just getting people to screen morewho are already being screened and focus on those people whonever come in for screening. so i want to close with brieflytalking about the provider

participant systems andorganizational factors that can improve uptake and our futurespeakers address this in more detail.we know that from many countries that people with higher scs ineducation, people who are white, older, men in terms ofcolorectal cancer and married people have an increase inuptake. but we also know that there area number of factors that can help to increase this uptake.if you look at the system level having specialized screeningservices and staff that are

focused on increasing uptakeactually planning your resources and programs so that you willmeet the anticipated design. there are a number of whatpeople might call in-reach kind of efforts to mobilize and trainhealth care providers and in terms of having them understandcues to action for targeting noncompliance.and as all things giving providers report cards, trainingand feedback really make a difference.it has been well established that in terms of patients ourhealth care users that remind,

stanls, personal outreach andeducation make a difference. that closes my remarks and we'removing now to ned calonge who will address the next topic.>> thanks, rachel. i'm thrilled to be here today totalk about the affordable care act and how it's going toprovide opportunities to improve population based cancerscreening. i think this is an unprecedentedtime for public health. i don't know if you've actuallyread the bill. it's only 973 pages, which isonly 140 pages longer than

"harry potter and the deathlyhollows." but it really is generated a lotof interest in public health, including this landmark reportfrom the institute of medicine. primary care and public health,exploring integration to improve population health.and it's interesting that within this report they actuallyrecommend making population based colorectal cancerscreening better by integrating public health and primary care.the report identifies specific provisions of the aca that cansupport this integration.

and i wanted to just talk abouta few of those. first, for those of you inpublic health, you know about the community transformationgrants. so these are opportunities thatlocal health departments have to apply and some of you have andsome of you have been awarded and some of you are stillwaiting. but to look at a populationapproach to your communities, the community health needsassessments, i always like to include that nonprofit hospitalsnow have to assess the health

needs of their community as partof their community benefit. and they realized, guess what?local public health has been doing this for years and many ofyou have completed a recent organization.the medicaid preventive services is an optional grant programthat states and local health departments can apply for andlocal health departments can actually either alone or inpartnership with safe net clinics become medicaidproviders and reach out to those hard to reach populations thatwe need to reach in order to

improve population health.the next two accountable care organizations and patients thatare in medical homes are looking for ways to better integratecare and take care of an entire population.and i would tell thaw i can't see that you can really improvethe entire population and be truly accountable withoutreaching out and including public health opinion finally,the last two, primary care extension programs and thecommunity health care centers are strengthening our primarycare safety nets.

and i think looking forpartnerships, again, with local public health that has theexperience and the knowledge about how to reach out to hardto reach populations is a real opportunity.there are specific provisions in the affordable care act that ithink can really push and improve population basedscreening. for example, there's now a firstdollar coverage, which is no additional out of pocket costsfop evidence based cancer screening, specifically breast,cervical and colorectal based on

the u.s. preventive servicestask for recommendation ps these are the a & b recommendationsthat like dr. brawley referred to, cleared outweighed theharms. the aca formally authorized thecommunity preventive task force which is a cdc program anddirect both task forces to look for, quote, how each task forcerecommendations interact at the neck clinic and community.the guide to preventive services, which is hosted by thecenters for disease control publishes recommendations madeby the task force.

another ncht nonfederalvolunteer body of experts of public health and prevent yopresearch practice and policy. the recommendations for thecommunity guide are also based on strength of scientificevidence and i don't think it's any mistake that there are nofewer than 11 community level intervention s designed toincrease participation in effective cancer screening.so, for example, rachel talked about reminder is systems,inreach andout reach, remind the provider, remind the patient,prompt them to get services.

those are strongly recommendedthrough the community guide. so you might ask why should wetake a public health approach to clinical preventive services?and i guess there's an answer we're trying to solve.it's clear that the u.s. health system is fragmented.we have tried to address that through what we have.for example, quality measurements such as the ncqadata has been shown to increase screening rates, but only instable subscribers are very little population impactmanifested by the fact that our

breast cancer screening rateshave not changed appreciably since 2000.so why cancer screening in public health?as dr. brawley talked about, cancer screening is differentfrom other screenings in that it identifies preclinical disease.when we look at our recommendation screenings, likescreening for cardiovascular disease risk factors, it'scritical the time that you give the screening tests becauseearly detection is time critical.we have to catch the cancer at

the time where earlyintervention makes a difference. i guess the other point i wouldbring up in cancer screening is that there really are remarkablehealth disparities, especially in colorectal cancer.this is from the 2010 national health interview survey andpoints out the disparities in the different forms of cancerscreening. and you can see the realdifference there inco low rec tall cancer.those of you from other states know that these disparities varyby state, so in colorado we have

more is significant disparitiesthan breast and cervical cancer than in manifested by thenational data. all right.so that is a good reason to do cancer screening.why public health supported population based screening?well, i think of the two speakers before me talked about,the benefits of screening are maximized when everyone in thecommunity partiticipates. as rachel talked about,preventable late stage disease is more prevalent in people whodon't get screened at all.

for example, late stage cervicalcancers are found in women who never get screened much lessfrequently in women getting every three years screening.the other point i would make is that we understand public healthservices can make wonderful uses.nearly 74% of our seniors 64 years and older are immunizedagainst influenza. and then i point out that 80% ofthose vaccines are given outside of the medical care system.either in public health clinics or other clinics using a publichealth approach.

we also know from colorado'sexperience that we can do cancer screening.we have ten local public health departments that provide directservices in breast and cervical cancer screening funded by boththe state and the national breast and cervical cancer earlydetection program aimed specifically at low-incomewomen. we also have the state fundedcolorectal cancer control program which supports crcscreening through a university coordinated xhund locatedpopulation based program.

and some of our local healthdepartments are looking for direct services for crcscreening in partnership with safety net clinics.so i want to finish with kind of providing you with a bold visionof the future for cancer screening.and just talk a little bit about the public utility model.so if you remember the public utility model works to providecore services to this geographical defined population.and why not take that approach to cancer screening?vermont health care reform

through their department ofvermont health access provides kind of an example of how onestate is doing that. so through health departmentoriginated program, they are providing chronic diseasemanagement, behavioral health and wellness and preventiveservices throughout the state in kind of this public utilitymodel. i believe that supported by theprovisions of the affordable care act, the future of cancerscreening may well see the development of screening as apublic utility that provides

population based services andare remarkable improvement in overall population and health.so i thank you for my time with you today and i'd like to turnthings over to tr levin. >> good afternoon.it's any pleasure to be here with so many faces in theaudience. i'm dr. t.r. levin.before talking about our screening program, it isworthwhile to review some of the evidence about the value of thefecal chemical test or f.i.t. i also review our our screeningprogram is structured and review

some of the patient outcomethat's we've seen since we've been increasing screening rates.in deciding between various screening tests, an importantconsideration is which test will patients do and the best test,really, is the ones the patient will do.the f.i.t. uses an antibody specific for hemoglobin.multiple studies indicate here patients are much more likely tocomply with f.i.t. test whg compared to goyak.while adherence in both arms of the study were low, theadherence with f.i.t. was

significantly higher than withcolonoscopy leading to more cancers being deat this timetexted in the f.i.t. arm. but these results reflect onlyone round of screening. the participants in the f.i.t.arm were due to have four more rounds of buy annual screeningin which their -- may have been detected.f.i.t., john endomie did a study in san francisco.providers were randomized in three-month-blocks offering thegee nom test, the colonoscopy or a choice of fobt.the california northern region

stentsdz from santa rosa in thenorth, fresno in the south, san francisco to the west andsacramento to the east. we currently have a 46% marketshare and our patients are generally representative of thesurrounding population. with the exception of theextreme highs and lows of socioeconomic status.ourco low rec taller screening consisted of both an outreachand an inreached. in reach refers to theelectronic systems that prompt support staff and physicians toremind members that are coming

due for screening and distributetest kits. we also use electronic systemtoes track patients who are fit positive to ensure that they gettheir follow-up colonoscopies. our outreach program begins withthe identification that are eligible for the hetus measure.the electronic databases are reviewed to identify who isoverdue or coming due for aco low rec tall cancer screeningthis year and at the noted screening intervals.a sample of 13,000 or more members are mailed test kiddkits each week from january to

september.we use a vendor to assemble the test kits on demand.after using demographic data that we upload using hippacompliance test sites. we use a single sample test witha cut off of 100 -- the outreach sale kit.local teams at least medical center are send securitymessages and make phone calls. the kits may be distributed asclinic visits or during the fall flu shot clinics.we have several reports and reminder system that's we workwith to help move the work

forward.we report to each medical center monthly information on theirscreening rates, the access to colonoscopy, colonoscopyproductivity and admoma detection rates.at the point of tear, the health care team can see a preventivehealth care prompt which will be involved into a populationreminding outreach monitor and patient tracking tool.we report the follow-up and why patients are.over time, we have seen significant improvement in ourscreening rates as measured by

the quality of care measure is.both for our medicare and our commercial members.the screening rates started increasing in 2007 as ouroutreach program ramped up. before starting outreach, ourprogram has now seen higher rates and we are above the 90%profile. the result of this is that as inevery screening, study or effort, when screening ratesincrease, there was an increase in diagnosis of prevalentcancers. as our screening started toincrease, we saw an apparent

riserise in colorectal incidence. we're tracking survival, aswell. we have successfully increasedscreening rates by taking the approach we use in our systemfor all population care initiatives.leaders throughout the organization are committed tothe goal of improvingco low rec tall screening rates.as a medical group, we set targets for our populationscreening rates prior to the start of every year.our incentives are aligaligned.

this represents a truecollaboration between primary care and specialist.there has been a concerted effort to monitor and expandcolonoscopy capacity and we use a mix of tests, allowing primarycare providers for screening of colonoscopy and activelyoutreach would fit. most patients are screenedbecause of f.i.t., but a growing proportion are screened bycolonoscopy. we use organized systems inbothout reach and ip reach to provide education andencouragement and results are

monitored.quality management staff are aware of how much additionalwork needs to be done. on a regional basis, it is ourjob to actively study locations that are doing whole and workfor them. pe skill have an ongoing game.at this point, i will turn it over to marcus plescia.>> well, thank you very much. i'd like to close by taking acouple of minutes to just describe a little bit of thecurrent programs we have that are focused on cancer screeninghere at centers for disease

control.and then i'd like to describe some of the approaches we hopeto take in the future to begin to move our programs more in thedirections of some of the ideas that you've heard during thecourse of these grand rounds. the national breast and cervicalcancer early detention program is cdc's core cancer screeningprogram. and this program since itsinception has been designed to reach and provide services towomen in the united states who don't have health insurance.as you can see from the slide,

the reach of this program hasbeen quite significant over the last two decades.but, you know, twal equally important, we're very proud ofthe fact that not only have we been able to reach a lot ofwomen with these programs, but these are women who weregenerally from underserved communities and we feel that thenational breakfast and cervical program is probably one of thecore reasons why over the last two decade, we've been able toclose some of the gaps in screening disparities across ourdifferent populations.

in addition to significantreach, our screening programs at cdc also, i think, perhaps evenmore importantly have substantial capacity.you see from this slide -- we have -- we fund every state inthe united states to provide screening services.we fund 11 tribes. and we fund five territories.and each of those health departments, then, has anextensive network of clinical providers they work with toprovide these services. and so you see that from thisslide.

our interests in the future,particularly as we begin to see implementation of the affordablecare act is to think about huk we use this substantial capacitywe've built, to move the bar and some of these other solutionsare more population based. i'd like to spend the lastcouple of minutes talking about a couple of examples of some ofthe work that we're doing. perhaps the best champ of thisnew direction that we're trying to move cdc's cancer screeningprograms is colorectal cancer screening program.it's program we funded about

three owe or four years ago tolook at the issue of colon cancer screening in the unitedstates where we feel that we are very much behind.and you see in the slide that the order of private isreversed. we still provide fund to gostates to pay for screenings, but the real emphasis of thisprogram is in population based screening promotion.we've used evidence based modalities amongst our differentgrantees and our grantees have been able to work with our wideselection.

we can begin to bring about someof these more organized types of approaches.another example that i'm particularly interested in iscollaborations between health departments and state medicinecare cade programs. i think everybody knows that inmost settings, the medicaid program is some of the placesthat the most underserved patients and communities residein. so a number of communities arelooking for ways to reach out to their sister medicaid agenciesand look at ways to systemically

reach this population.a good example of this is the state of minnesota.cdc has funded minnesota for what we think is a veryinnovative program with their state medicaid program whereminnesota is using medicaid claims dated to active ly.and then when we do very aggressive outreach and remindersystems and even incentives to try to reach those patientes andbring them in. and encourage them toparticipate in cancer screening. so i'd like to close by justsummarizing a little bit of some

of the ideas and the directionsi think we can go as we think about new, more population basedand more organized approaches to cancer screening in the unitedstates. and you see in this slide,really, i think the two different areas we can work in.on the right are patient centered or patient orientedapproaches. on the left are populationoriented approaches. i think patient orientedapproaches to improve screening in the health care system areextremely important at the point

that we have right now.these are certainly areas where wink public health departmentscan be engaged to bring some of these changes about.ultimately, i think the leadership will -- particularlyin public health practice, the leadership role and theopportunity to add value to the affordable care act is anadvancing some of these large scale population based organizedapproaches to screening. like you see on the left hand ofsh slide. and like some of the examplesyou've heard from of speakers.

i think if we really want tooverthe community health measures that we in publichealth are responsible for. ultimately, if we want to beginto turn the tide auto some of these pernicious healthdisparities we see in cancer control.thank you very much for your interest and attention and i'mnow going to open things up for questions for our panelists.>> i'll warm people up a little bit and ask any of the panelistswho want to respond. we talked about these new rolesfor public health.

one of the interesting issuesis, you know, what are the skill sets that our public healthworkforce needs to develop to really be able to perform wellin these kind of roles? would anybody like to speak toyour ideas about that? >> well, i'll start off.i personally believe that health education of the populous isgoing to be incredibly important.if the affordable care act is going to be successful, if we'regoing to skim the tide of the obesity epidemic.and when i look at health in the

united states, teaching peoplehow to eat, teaching people how to exercise and teaching peoplehow to consume health care is going to be incrediblyimportant. >> you know, mark, i think theadvice i would live to love health departments of any size,and maybe it's a willingness to engage the medical care system.integration with primary care can only half if the two sidesare standing by each other. local health directives, i theyneed to reach out and look for those natural alliances.i think that's the only way

we're going to see theintegration. so moving from the traditionalthings that you still have to do, disease control, publichealth immunizations and thinking outside the box tocancer screening and chronic disease management, looking forthose relationships with the existing care system areessential. reaching out to the kaiserpermanentes, thopts, is other sources of care, that's howintegration and the whole popular approvement.>> my learning over the last

five or seven years i've beendoing this is the value of making an emotional connectionto the work in addition to just tan lthe analytical information that we have been taught in school.if you want to change behavior, people have the analytical side,but you have to connect with them on an emotional level tomake them want to know somewhere, as well.>> questions from the audience. bob.>> thank you. so let me just say first of all,those were outstanding

presentations.and i respect appreciate the common themes runing acrossthem. the questions that you wereasking, mark, it really speaks to what is the opportunity toactually achieve the kind of quality in an incidentapproached for cleaning. we have follow up that doesn'ttake place after screening takes place.we have a persistent problem that we -- it's almost as if themarket has to solve it where there's low access to services,geographic access in some

instances and we're watching,for example, that we have not ideal access to g.i. services,some women have to travel further .further distance toesmammography. so i'm wondering, to a certaindegree, how might the affordable care act tighten up a lot ofthese loose ends? >> i think it's a greatquestion. you know wa is remarkable to meis that all of the elements are in the act, but they won'thappen by themselves. it's going to taking like thecraig jones, the reaching out

and take advantage and lookingfor the opportunities. looking for the opportunitiesthat cdc and cms could take working together between theinnovation center and the community transformation grant,trying to team up to address exactly those caps and cancerscreening that we could fill in with funding and opportunityfrom the affordable care act. so i guess i want to make surethat the that people know that the ability to do it is thereand the opportunity to do it is now.there needs to be leadership and

a few zell yots out there totake advantage of it. >> one more question back here.>> the u.s. preventive services tough with respect to variouscancer screenings. the vast majority of therecommendations are for not screening.there is a lot of controversy about ovarian cancer screening.we have number of organs that, you know, that should not bescreened and the conversation that i have heard is promotingeffective screening. what i do not hear is effectiveways of promoting not screening

for cases that screen sginjurious and has negative outcome and a good part of it isthe issue of reimbursement. say a 70-year-old man undermedicare can go and get screened for prostate cancer r consider.giving a recommendation for screening.so there is some sort of a disconnect.and i would love to hear some thought on the part of thisparticular as to what are being done, like the kaiser permanentemodel. i wanted to ask the speaker,have you monitored the uptake of

psa testing?at the -- as a moniker, that should not be university use inthe population setting of your institution.>> i can tell you what we do at kaiser, certainly for theevidence based screenings that are part of the hetus measure.we are actively promoting, advertising, reaching out topeople. for prostate cancer, it's verymuch of a shared decision making model.there are some prablg tissue ners who are strong zell yot zdoing it.

we don't have reminders forpeople when they come into the office to make sure that theyhave it done. but we're still inmaker, sopeople are loud to -- >> but i get.the problem i have is if the recommendation is against, whyare we even promoting informed share decision making?i mean, the recommendation means that the physician should noteven discuss it, should not bring it up.>> otis, this is your favorite topic.>> well, i've been dealing with

this for about 20 years.i think that people are now starting to understand thatfinding the disease early and cutting it out is not always theappropriate answer. people are starting tounderstand that screening tests can be harmful.i was telling dr. colange i thought that the preventiveservices task force recommendation was -- is nowviewed by most people as being a very wise one now that justwithin the last two months the american neurologicalassociation has really

tightened.their recommendationson prostate screening. they no longer say all menshould be screened. they say men age 55 to 07 shouldbe told about the potential ricks and it is potentialbenefits and are encouraged to make a decision.so there is a change, a small exchange, but there's a changefor the best within the medical community as we start learningthe screening can be harmful. i'll be right or call you.>> also i am note a federal employee and kegging.in 2007, when the largest study

was done to save lives, congresspassed a law decomplaining that psa screening does save livesand that's why medicare has to pay for it.>> so i think the first thing i'd point out is that psa is anexample of premature acceptance. how many randomized controltrials did we have before we started recommending psa?zero. but we prematurely accepted itand offered promise. it was very well sociallymarketed. now trying to pull all thatback in was different.

>> the most common rating is the"i," insufficient evidence, which is not a recommendationfor or against, but a request, not for this room, but for ourfriends over at the national cancer institute or someone todo research to fill in those gaps.about whether or not the benefits outweigh the harms.and so it's a little different than don't do it.it's like we really don't know. >> we have a couple of questionsfor people outside the remote. i can move on.>> one point, that, in fact, you

may need the most discussionabout the test that you shouldn't be using.24r is so much push to the population that they should dothese things. it's really to convince peoplethat they shouldn't be doing those things.so that issue saying it needs to be discussed is a key one.>> it takes much longer for a clinician to suggest why youshouldn't do something than it does to just order it.>> some of our online and social media audiences, given thatthere's now data supporting low

dose ct scans for smokers whohave quit for less than 15 years, is lung cancer going tobe included and paid for for those people who meet all thecriteria. and what will persuade otherhealth insurance providers to cover it?>> if i can very quickly, so we can get to more questions, thepreventive services task force has not yet spoken about lungcancer screening. some organizations like the acs,the american cancer society that i work for recommend informeddecisions for those who would

have qualified for the trial.there are increasing study that's show that lung cancerscreening is more beneficial for people in that trial who werevery, very heavy smokers and not very qualified for the study.so this is going to be a -- you know, based test for people atvery high risk. and it's going to requireinformed decision making. >> that's going to have to beour last question. i did want to say one thing.i really do appreciate our speakers who came out for this.and i want to say because we had

folks who are sos steamed intheir field and were willing to travel such a long way, we weredetermined to fill this aud formus and we did.so thank you, those of who you came.>> thank you all very much. thanks to our speakers for ourin-person audience. there is an event at the cdcmuseum. for the rest of our audience, wehave an encore presentation next month.our next live public health grand rounds will be inseptember.

thank you.