What Is the Right Cancer Screening Rate?

• Quality of health care
• Mammography
• Vaginal smears
• Obesity
• Communication

Recent commentaries have described growing concern about quality of care in the United States (1, 2). The problem of “medical mistakes” is getting increased media attention. However, the issue of quality is not new to physicians, who are trained to always do the best for their patients. What is new is the way that we are now asked to think and act about quality. Cancer screening—specifically Papanicolaou (Pap) smears and mammography—provides an interesting case study of the old and new ways of thought.

For more than a decade, research has consistently shown that screening for cervical and breast cancer is underused. Whether documented in medical claims data (3, 4), by medical record review (5), or by self-report (6), the percentage of eligible patients who have had Pap smears or mammography at the recommended intervals has been lower than any of us would accept as optimal. In national surveys, some of this deficit can be attributed to lack of access to medical care, but surveys of patients who have recently been seen in medical practice also show substantial degrees of underuse.

Furthermore, we have learned that the persons who are seen in medical practice but do not receive appropriate screening are not a random sample of the total patient population. Some patient characteristics are associated with lower screening rates: lower socioeconomic status (7), certain ethnic backgrounds (8), lack of health insurance (9), fee-for-service health plans (10), lack of a recent “check-up” visit (11), more comorbid conditions (12), and increased age (13). Some physician characteristics also predict lower rates of Pap smears and mammography, including male sex (4) and nongynecologic specialty (14).

In this issue, Wee and colleagues (15) present another patient …