Results from the National Breast and Cervical Cancer Early Detection Program, October 31, 1991-September 30, 1993

To reduce the burden of morbidity and mortality from breast and cervical cancers among U.S. women, Congress enacted the Breast and Cervical Cancer Mortality Prevention Act * in August 1990. This legislation authorized CDC to establish the National Breast and Cervical Cancer Early Detection Program (NBCCEDP), which provides state health agencies with grants to increase breast and cervical cancer screening among women (1). Most funds pay for screening and follow-up services for underserved women, particularly women who are elderly, have low incomes, are underinsured or uninsured, or are members of racial/ethnic minority groups (2). This report presents age- and race-specific cancer screening (i.e., mammography and Papanicolaou {Pap} smear) results for women who received these services through the NBCCEDP from October 1, 1991, to September 30, 1993.

During this period, eleven states ** with NBCCEDP-funded cancer screening programs reported data to CDC. For each woman who received a cancer screening examination, data were obtained about demographics, screening location and results, diagnostic procedures and outcomes, and treatment information. The forms used for data collection varied among local sites and states; state program officials standardized data formats before transmitting files electronically to CDC. CDC requests that radiologists report mammography results using categories specified in the Breast Imaging Reporting and Data System (BIRADS) of the American College of Radiology (3) and that laboratories report Pap smear results using categories from the Bethesda System (4). This analysis presents results from initial mammography screening examinations and excludes results from women who may have undergone subsequent screening examinations. Results were adjusted for state and age using all women undergoing screening through the NBCCEDP as the standard population.

From October 1, 1991, through September 30, 1993, approximately 67,000 women aged greater than or equal to 40 years had a mammogram through the NBCCEDP; of these women, 7.2% had abnormal results (i.e., suspicious abnormality, highly suggestive of malignancy, or assessment incomplete ***) (Table_1). Overall, the proportion of women who had abnormal results declined with increasing age, from 7.8% for women aged 40-49 years to 5.3% for women aged greater than or equal to 70 years. However, for results highly suggestive of malignancy (the most serious result) the opposite trend was observed. The proportion of abnormal mammography results was highest for non-Hispanic whites (7.9%) and non-Hispanic blacks (7.8%) and lowest for Asians/Pacific Islanders (4.1%).

During the same period, approximately 100,500 women had Pap smears; of these, 5.1% had abnormal results (i.e., low-grade squamous intraepithelial lesion {SIL}, high-grade SIL, or squamous cell carcinoma) (Table_2). The proportion of women with abnormal results declined sharply with increasing age, from 11.5% for women aged less than 30 years to 1.9% for women aged greater than or equal to 70 years. The proportion of abnormal Pap smear results varied slightly among racial/ethnic groups (except Asians/Pacific Islanders) ranging from 4.2% for Hispanics to 4.7% for American Indians/Alaskan Natives; the proportion was lowest for Asians/Pacific Islanders (2.0%).

Reported by: Epidemiology and Statistics Br and Office of the Director, Div of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: Despite the proven effectiveness of mammography and Pap smears in detecting breast and cervical cancers in early, more treatable stages, not all women have access to necessary screening and follow-up services. The NBCCEDP is mandated to detect cancer and precancerous lesions in women who are at high risk for not being screened and therefore at higher risk for having cancer diagnosed at a later stage. This report represents one of the largest case studies on screening services targeting underserved women.

The overall proportion of abnormal mammograms reported by NBCCEDP during 1991-1993 is consistent with findings in a previous study (5), although these two studies used different result categories. The overall decline with increasing age in the proportion of abnormal mammography results is attributable primarily to results categorized as assessment incomplete -- an outcome more common among younger women, whose dense breast tissue make radiologic assessment more difficult. The percentage of findings categorized as highly suggestive of malignancy increases with age, reflecting the increasing incidence of breast cancer with increasing age (6). The higher proportion of abnormal results among white and black women reflects the higher reported incidence of breast cancer in these groups than in other racial/ethnic groups. Reasons for these differences in incidence are unclear.

Most of the Pap smear results reported by NBCCEDP during 1991- 1993 are similar to findings in previous studies (7,8). The steady decline with increasing age in the proportion of abnormal Pap smear results is attributable primarily to the increase in results categorized as low-grade SIL.

The findings in this report are subject to at least two limitations. First, NBCCEDP results are derived from screening tests and therefore do not represent the final diagnoses. Some abnormal results classified as cancer may not be confirmed as such on biopsy, and some results classified as noncancerous may be found to be cancer. Because states have had difficulty tracking the diagnostic results of women with abnormal screening examinations, complete information is not yet available to analyze diagnostic outcomes. Second, because use of the BIRADS reporting categories was initiated in NBCCEDP in 1991 (before BIRADS was officially disseminated to U.S. radiologists by the American College of Radiologists), the categories for reporting results of mammography screening probably have not been used uniformly among the participating states, particularly during the first year of the program. However, as radiologists become more familiar with BIRADS, its use in different program sites probably will become more uniform.

CDC's NBCCEDP increases cancer screening among women by increasing access to screening and follow-up services, increasing education programs for women and health-care providers, and improving measures to assure quality of mammography and Pap smear testing. These activities are implemented through partnerships with state health agencies; 45 states are participating in NBCCEDP at different levels. These efforts should increase detection and treatment of precancerous cervical lesions and early-stage breast cancer and ultimately reduce the incidence of cervical cancer and morbidity and mortality from breast cancer among underserved women.

References

1. CDC. Implementation of the Breast and Cervical Cancer Mortality Prevention Act: 1992 progress report to Congress. Atlanta: US Department of Health and Human Services, Public Health Service, 1993 (in press).

2. CDC. Update: National Breast and Cervical Cancer Early Detection Program, July 1991-July 1992. MMWR 1992;41:739-43.

3. Kopans DB, D'Orsi CJ, Adler DD, et al. Breast Imaging Reporting and Data System. Reston, Virginia: American College of Radiology, 1993.

4. Broder S. Rapid communication: the Bethesda System for reporting cervical/vaginal cytologic diagnoses -- report of the 1991 Bethesda Workshop. JAMA 1992;267:1892.

5. Sickles EA, Ominsky SH, Sollitto RA, Galvin HB, Monticciolo DL. Medical audit of a rapid-throughput mammography screening practice: methodology and results of 27,114 examinations. Radiology 1990;175:323-7.

6. Hankey BF, Brinton LA, Kessler LG, Abrams J. Section IV: breast. In: Miller BA, Reis LAG, Hankey BF, et al, eds. SEER cancer statistics review, 1973-1990. Bethesda, Maryland: US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute, 1993:IV.1-IV.24; DHHS publication no. (NIH)93-2789.

7. Bottles K, Reiter RC, Steiner AL, Zaleski S, Bedrossian CW, Johnson SR. Problems encountered with the Bethesda System: the University of Iowa experience. Obstet Gynecol 1991;78:410-4.

8. Sadeghi SB, Hsieh EW, Gunn SW. Prevalence of cervical intraepithelial neoplasia in sexually active teenagers and adults. Am J Obstet Gynecol 1984;148:726-9.

* Public Law 101-354.

** California, Colorado, Maryland, Michigan, Minnesota, Missouri, Nebraska, New Mexico, North Carolina, South Carolina, and Texas. 

*** A mammography finding that requires additional radiologic evaluation (3).

TABLE 1. Percentage distribution of mammography screening results * among women aged >=40 years, by age group and
race/ethnicity -- National Breast and Cervical Cancer Early Detection Program (NBCCEDP), October 1, 1991-September 30, 1993+
======================================================================================================================================
                                                                                Abnormal results
                                                              -----------------------------------------------------
                            No.        Negative    Probably    Suspicious   Highly suggestive   Assessment           Unsatisfactory
Characteristic           examined      or benign    benign    abnormality     of malignancy     incomplete &  Total    examination
-----------------------------------------------------------------------------------------------------------------------------------
Age group (yrs)
  40-49                    29,316        83.5%       8.6%         1.7%             0.2%            5.9%      7.8%          0.1%
  50-59                    20,449        84.1%       8.5%         1.9%             0.3%            5.1%      7.3%          0.1%
  60-69                    12,536        86.0%       7.6%         1.5%             0.3%            4.6%      6.4%         <0.1%
   >=70                     4,529        87.8%       6.8%         1.9%             0.4%            3.0%      5.3%          0.1%

Race/Ethnicity
  White, non-Hispanic      23,712        83.9%       8.1%         2.0%             0.4%            5.5%      7.9%          0.1%
  Black, non-Hispanic      10,827        83.8%       8.4%         1.8%             0.3%            5.7%      7.8%          0.1%
  Hispanic @               18,385        84.0%       9.0%         1.3%             0.2%            5.4%      6.9%          0.1%
  Asian/Pacific Islander    1,666        88.8%       7.1%         1.7%            <0.1%            2.4%      4.1%         <0.1%
  American Indian/
    Alaskan Native          8,179        87.2%       6.2%         1.4%             0.4%            4.8%      6.6%         <0.1%
  Other/Unknown **          4,061        85.9%       7.4%         1.7%             0.3%            4.7%      6.7%         <0.1%

Overall                    66,830        84.4%       8.3%         1.7%             0.3%            5.2%      7.2%          0.1%
-----------------------------------------------------------------------------------------------------------------------------------
 * Results are from initial screening examinations and exclude results for women who may have undergone subsequent screening
   examinations. Result categories are from the Breast Imaging Reporting and Data System (3). Data were adjusted for state and age
   using all women undergoing screening through the NBCCEDP as the standard population.
 + Data were reported to CDC from 11 states with NBCCEDP-funded cancer screening programs (California, Colorado, Maryland, Michigan,
   Minnesota, Missouri, Nebraska, New Mexico, North Carolina, South Carolina, and Texas).
 & A mammography finding that requires additional radiologic evaluation (3).
 @ May be of any race.
** Includes 2,079 white women and 437 black women of unknown ethnicity.
======================================================================================================================================

TABLE 2. Percentage distribution of Papanicolaou smear screening results *, by age group and race/ethnicity -- National
Breast and Cervical Cancer Early Detection Program (NBCCEDP), October 1, 1991-September 30, 1993 +
======================================================================================================================================
                                                                      Abnormal results
                                                          --------------------------------------------
                            No.       Negative            Low-grade   High-grade    Squamous                      Unsatisfactory
Characteristic            examined   or benign & ASCUS @    SIL **        SIL      cell cancer   Total     Other    examination
--------------------------------------------------------------------------------------------------------------------------------
Age (yrs)
    <30                    31,569      78.3%      8.0%       9.4%        2.1%         <0.1%      11.5%      0.6%       1.5%
  30-39                    18,359      86.9%      5.4%       4.2%        1.4%          0.1%       5.7%      0.5%       1.6%
  40-49                    23,455      89.5%      5.2%       2.4%        0.7%         <0.1%       3.1%      0.5%       1.8%
  50-59                    14,897      91.5%      4.3%       1.6%        0.7%          0.1%       2.4%      0.4%       1.4%
  60-69                     8,889      93.0%      3.3%       1.2%        0.3%          0.1%       1.6%      0.5%       1.6%
   >=70                     3,245      92.5%      4.0%       1.3%        0.6%         <0.1%       1.9%      0.5%       1.1%

Race/Ethnicity
  White, non-Hispanic      38,754      88.9%      4.4%       3.6%        1.0%         <0.1%       4.6%      0.4%       1.7%
  Black, Hispanic          21,971      89.5%      4.2%       3.8%        0.7%          0.1%       4.6%      0.3%       1.3%
  Hispanic ++              26,886      88.1%      5.7%       3.4%        0.8%         <0.1%       4.2%      0.4%       1.4%
  Asian/Pacific Islander    2,008      92.6%      4.2%       1.3%        0.7%         <0.1%       2.0%      0.2%       0.9%
  American Indian/
    Alaskan Native         13,544      85.6%      7.6%       3.9%        0.8%         <0.1%       4.7%      0.4%       1.8%
  Other/Unknown &&          6,251      84.4%      7.7%       4.7%        0.9%         <0.1%       5.6%      0.3%       1.9%

  Overall                 100,414      87.3%      5.4%       4.0%        1.1%         <0.1%       5.1%      0.5%       1.7%
--------------------------------------------------------------------------------------------------------------------------------
 * Result categories are from the Bethesda System (4). Data were adjusted for state and age using all women undergoing screening
   through the NBCCEDP as the standard population.
 + Data were reported to CDC from 11 states with NBCCEDP-funded cancer screening programs (California, Colorado, Maryland, Michigan,
   Minnesota, Missouri, Nebraska, New Mexico, North Carolina, South Carolina, and Texas).
 & Includes infection and reactive changes.
 @ Atypical squamous cells of uncertain significance.
** Squamous intraepithelial lesions.
++ May be of any race.
&& Includes 3,083 white women and 389 black women of unknown ethnicity.
======================================================================================================================================

Disclaimer   All MMWR HTML versions of articles are electronic conversions from ASCII text into HTML. This conversion may have resulted in character translation or format errors in the HTML version. Users should not rely on this HTML document, but are referred to the electronic PDF version and/or the original MMWR paper copy for the official text, figures, and tables. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. Government Printing Office (GPO), Washington, DC 20402-9371; telephone: (202) 512-1800. Contact GPO for current prices.

Page converted: 09/19/98

HOME  |  ABOUT MMWR  |  MMWR SEARCH  |  DOWNLOADS  |  RSS |  CONTACT POLICY  |  DISCLAIMER  |  ACCESSIBILITY

Morbidity and Mortality Weekly Report Centers for Disease Control and Prevention 1600 Clifton Rd, MailStop E-90, Atlanta, GA 30333, U.S.A Department of Health and Human Services

This page last reviewed 5/2/01