[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
ADDRESSING THE SCREENING GAP: THE NATIONAL BREAST AND CERVICAL CANCER
EARLY DETECTION PROGRAM
=======================================================================
HEARING
before the
COMMITTEE ON OVERSIGHT
AND GOVERNMENT REFORM
HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
__________
JANUARY 29, 2008
__________
Serial No. 110-52
__________
Printed for the use of the Committee on Oversight and Government Reform
Available via the World Wide Web: http://www.gpoaccess.gov/congress/
index.html
http://www.house.gov/reform
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COMMITTEE ON OVERSISGHT AND GOVERNMENT REFORM
HENRY A. WAXMAN, California, Chairman
TOM LANTOS, California TOM DAVIS, Virginia
EDOLPHUS TOWNS, New York DAN BURTON, Indiana
PAUL E. KANJORSKI, Pennsylvania CHRISTOPHER SHAYS, Connecticut
CAROLYN B. MALONEY, New York JOHN M. McHUGH, New York
ELIJAH E. CUMMINGS, Maryland JOHN L. MICA, Florida
DENNIS J. KUCINICH, Ohio MARK E. SOUDER, Indiana
DANNY K. DAVIS, Illinois TODD RUSSELL PLATTS, Pennsylvania
JOHN F. TIERNEY, Massachusetts CHRIS CANNON, Utah
WM. LACY CLAY, Missouri JOHN J. DUNCAN, Jr., Tennessee
DIANE E. WATSON, California MICHAEL R. TURNER, Ohio
STEPHEN F. LYNCH, Massachusetts DARRELL E. ISSA, California
BRIAN HIGGINS, New York KENNY MARCHANT, Texas
JOHN A. YARMUTH, Kentucky LYNN A. WESTMORELAND, Georgia
BRUCE L. BRALEY, Iowa PATRICK T. McHENRY, North Carolina
ELEANOR HOLMES NORTON, District of VIRGINIA FOXX, North Carolina
Columbia BRIAN P. BILBRAY, California
BETTY McCOLLUM, Minnesota BILL SALI, Idaho
JIM COOPER, Tennessee JIM JORDAN, Ohio
CHRIS VAN HOLLEN, Maryland
PAUL W. HODES, New Hampshire
CHRISTOPHER S. MURPHY, Connecticut
JOHN P. SARBANES, Maryland
PETER WELCH, Vermont
Phil Schiliro, Chief of Staff
Phil Barnett, Staff Director
Earley Green, Chief Clerk
David Marin, Minority Staff Director
C O N T E N T S
----------
Page
Hearing held on January 29, 2008................................. 1
Statement of:
Carey, Gail, recipient of breast and cervical cancer early
detection program benefits and volunteer, American Cancer
Society; Otis Brawley, medical director, American Cancer
Society; Shelley Fuld Nasso, director, public policy, Susan
G. Komen for the Cure Advocacy Alliance; Pama Joyner,
Ph.D., director, Breast and Cervical Health Program,
Washington State Department of Health; and Thomas Hoerger,
director, RTI-UNC Center for Excellence in Health Promotion
Economics and RTI Health Economics and Financing Program... 56
Brawley, Otis............................................ 63
Carey, Gail.............................................. 56
Fuld Nasso, Shelley...................................... 76
Hoerger, Thomas.......................................... 105
Joyner, Pama............................................. 92
Henson, Rosemarie, Deputy Director, National Center for
Chronic Disease Prevention and Health Promotion, U.S.
Centers for Disease Control and Prevention, accompanied by
Lisa Mariani, Assistant Branch Chief, Program Services
Branch, Division of Cancer Prevention and Control, National
Center for Chronic Disease Prevention and Health Promotion,
U.S. Centers for Disease Control and Prevention............ 23
Letters, statements, etc., submitted for the record by:
Brawley, Otis, medical director, American Cancer Society,
prepared statement of...................................... 65
Carey, Gail, recipient of breast and cervical cancer early
detection program benefits and volunteer, American Cancer
Society, prepared statement of............................. 60
Cummings, Hon. Elijah E., a Representative in Congress from
the State of Maryland, prepared statement of............... 14
Davis, Hon. Tom, a Representative in Congress from the State
of Virginia, prepared statement of......................... 11
Fuld Nasso, Shelley, director, public policy, Susan G. Komen
for the Cure Advocacy Alliance, prepared statement of...... 79
Henson, Rosemarie, Deputy Director, National Center for
Chronic Disease Prevention and Health Promotion, U.S.
Centers for Disease Control and Prevention, prepared
statement of............................................... 26
Hoerger, Thomas, director, RTI-UNC Center for Excellence in
Health Promotion Economics and RTI Health Economics and
Financing Program, prepared statement of................... 107
Issa, Hon. Darrell E., a Representative in Congress from the
State of California, prepared statement of................. 20
Joyner, Pama, Ph.D., director, Breast and Cervical Health
Program, Washington State Department of Health, prepared
statement of............................................... 94
Waxman, Chairman Henry A., a Representative in Congress from
the State of California, prepared statement of............. 4
ADDRESSING THE SCREENING GAP: THE NATIONAL BREAST AND CERVICAL CANCER
EARLY DETECTION PROGRAM
----------
TUESDAY, JANUARY 29, 2008
House of Representatives,
Committee on Oversight and Government Reform,
Washington, DC.
The committee met, pursuant to notice, at 9:50 a.m., in
room 2154, Rayburn House Office Building, Hon. Henry A. Waxman
(chairman of the committee) presiding.
Present: Representatives Waxman, Davis of Virginia,
Maloney, Cummings, Kucinich, Watson, Higgins, McCollum, Van
Hollen, Welch, Shays, Platts, Issa, and Sali.
Staff present: Karen Nelson, health policy director; Sarah
Despres, senior health counsel; Naomi Seiler, counsel; Teresa
Coufal, deputy clerk; Caren Auchman, press assistant; Kerry
Gutknecht, William Ragland, and Miriam Edelman, staff
assistants; Tim Westmoreland, consultant; David Marin, minority
staff director; Jennifer Safavian, minority chief counsel for
oversight and investigations; Benjamin Chance, minority clerk;
Jill Schmalz, minority professional staff member; and John
Ohly, minority staff assistant.
Chairman Waxman. The meeting of the committee will come to
order.
Almost everyone in this room has been touched by cancer
either directly or by a friend or family member. Great medical
advances have been made over the last few decades, but cancer
continues to be a cruel and difficult opponent. We still can't
prevent most cancers, and there are a number of cancers we
can't cure.
But in the case of breast and cervical cancers, we have a
very effective tool; early detection. For the many women and
some men who will be diagnosed with breast cancer, the earlier
the cancer is detected, the better the chance of survival. For
cervical cancer, tests let doctors find abnormal cells before
they even become cancerous. In other words, for cervical
cancer, early detection is prevention.
The basic tools to give women a fighting chance against
breast and cervical cancer, the mammogram and the pap smear,
have been around for many years, but what we have seen over the
last several decades is that many women were not getting
screened at the recommended intervals or at all.
Women who were poor, women who were uninsured and often
women of color were not getting tested at the same rates as
other women. These women were left to get cancer diagnoses at
later stages, often once it was too late to be treated
effectively. Many women in the United States who have died of
cervical cancer never had a pap test.
In 1990, Congress stepped in to give women access to early
cancer detection. With strong bipartisan support and after
hearing testimony of the Vice President's wife, Marilyn Quayle,
the Vice President at that time, Congress passed a law that
created a program to cover breast and cervical cancer
screenings to low income, uninsured and underinsured women. By
passing this law, we sent the message that no woman should have
to forego lifesaving tests because she couldn't afford them.
In 2000, we strengthened this program by passing another
law allowing States to cover these women if a cancer is
detected within their Medicaid programs. Since that time, all
States have elected this Medicaid option.
We are here today to talk about what the National Breast
and Cervical Cancer Early Detection Program has accomplished
and what is left to be done. Over the past 16 years, the
program has served over 3 million women. In 2006 alone, the
program detected over 4,000 cases of breast cancer and over
5,000 cervical cancers and precancerous lesions.
Every single one of those cases represents a woman who
might otherwise not have known she had cancer and might not
have had the opportunity to fight it. For these women, the
program has been successful.
But, overall, the women served only represent less than 15
percent of the eligible population. There are so many more
women whose lives this program could save if only the Federal
budget provided greater resources.
It is ironic that we spend money to create cancer awareness
and urge women to get mammograms and then have clinics with
long waiting lists for actually getting them. It is tragic that
this underfunding and these waiting lists undoubtedly mean that
women whose cancers could have been caught early and treated
instead find out when their disease has progressed and spread.
This program has worked hard to address a particularly
vexing problem, the issue of racial and ethnic disparities.
This is critical because disparities in screening contribute to
disparities in survival rates. For example: While screening
rates for African American women have recently equaled those of
White women, African American women face a higher mortality
rate, possibly because their cancer is detected at later
stages; a Hispanic woman diagnosed at the same age and at the
same stage of cancer as a non-Hispanic White woman is 20
percent more likely to die within 5 years; and, for both
cancers, women without insurance are screened at far lower
rates than women who are insured.
These disparities mirror countless disparities in
healthcare and health outcomes in the United States;
disparities that we as Congress and as a Nation have to
continue to investigate and address.
Today, we have the opportunity to focus on an area where an
existing Government program is working hard to address these
disparities, but which faces a serious challenge because of
limited funding. We have some outstanding witnesses who are
here to share their expertise about breast and cervical cancer
and about the national screening program.
I know that on both sides of the aisle we care deeply about
this issue, and I look forward to an interesting and
constructive discussion.
[The prepared statement of Chairman Henry A. Waxman
follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Chairman Waxman. Mr. Davis, I want to recognize you for an
opening statement.
Mr. Davis of Virginia. Thank you, Mr. Chairman, for calling
this hearing on the National Breast and Cervical Cancer Early
Detection Program administered by the Centers for Disease
Control and Prevention [CDC].
Today's discussion gives the committee an important
opportunity to emphasize the priceless value of screening and
early detection in the fight against breast and cervical
cancers. We need to know what works, what we can do to make it
work better to maximize the reach and effectiveness of Federal
funding for screening low income, underinsured and uninsured
women.
In the United States, one in eight women will be diagnosed
at some point in their life with breast cancer. Yet, due to
improvements in screening and treatments, breast cancer
survival rates have risen steadily.
Likewise, over the last three decades, the cervical cancer
incidents and mortality rate have declined by 50 percent.
Cervical cancer is actually preventable and curable if it is
detected early through proper screening.
These are important advances, but not all American women
are sharing equally in these critical health gains. According
to the CDC, essential screening tools--mammograms and pap
tests--are underused by women who have less than a high school
education, are older, live below the poverty level or are
members of certain racial or ethnic minority groups.
Failure to get appropriate screening has, in part, resulted
in these populations of women being diagnosed later and having
higher mortality rates than the national average. Timely
screening can prevent needless deaths.
Recognizing the value and importance of providing
preventive services to low income women, in 1990, the Congress
created the National Breast and Cervical Cancer Early Detection
Program. Since 1991, the program has served almost 3 million
women and diagnosed 26,000 breast cancers, 88,000 precursors to
cervical lesions and 1,700 cervical cancers. The 1990's saw the
program grow into maturity.
Every $3 in Federal funding must be matched from State or
local sources and at least 60 percent of Federal funds must be
spent on direct clinical services. Today, there are more than
65 State and tribal grantees who are given substantial
flexibility to manage individual programs.
If a woman is diagnosed with cancer through these screening
measures, a program case manager will assist her in getting the
appropriate treatment. But because the program serves uninsured
and underinsured women, finding affordable treatment can pose a
significant challenge.
To address the gap between diagnosis and treatment,
Congress, in 2000, allowed States to amend their Medicaid plans
to cover treatment needs identified by this early detection
program. All 50 States have amended their plans to allow these
women to have access through Medicaid.
Despite clear success in reaching a vulnerable population,
the percentage of eligible women reached through the program
remains low nationwide and varies significantly from State to
State. The CDC and the U.S. Census Bureau found in 2002-2003
that only 13 percent of eligible women across the United States
received a program-funded mammogram. Likewise, only 6 percent
of eligible women received a pap test through the program.
Within that number, the study found a staggering variation
in screening rates from just 2 percent to as high as 63 percent
among eligible women between the ages of 40 to 64, the highest
priority population.
This is an unmistakable indication some States have found
ways to be far more effective than others at using Federal
funds to reach eligible women. Is it just a question of money
or are there important lessons all States can learn about
increasing the efficiency and effectiveness of this vital
public health effort?
Despite the fact that prevention pays for itself many times
over in avoided costs and improved lives, resources for
programs like this will always be more limited than anyone
would like. Today, we need to talk about appropriate funding
levels and about the innovations in best practices that will
make sure those funds reach as many women as possible.
To help us with that important discussion, I want to thank
our panelists today and I want to welcome Dr. Thomas Hoerger
with RTI International. He is leading a study of the long term
cost effectiveness of the CDC's early detection program. The
first phase of the study will be published next month, and
those findings should help us understand some of the factors
causing the wide variability between State program costs for
screening and diagnostic services.
He is here at the request of the minority members. We
appreciate his willingness and that of all of our witnesses
today to take time to testify today.
Thank you very much.
[The prepared statement of Hon. Tom Davis follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Chairman Waxman. Thank you very much, Mr. Davis.
I want to give any Member who wishes an opportunity to make
an opening statement that chance.
Mr. Cummings.
Mr. Cummings. Thank you very much, Mr. Chairman, and I
thank you for holding this vitally important hearing to examine
the National Breast and Cervical Cancer Program which is
administered by the Centers for Disease Control and Prevention.
As you know, breast and cervical cancers pose a real danger
to women's health. Nationwide, breast cancer is the leading
cause of death for women between the ages of 20 and 59. In my
home State of Maryland, the American Cancer Society estimated
in 2004 that 4,090 new cases of breast cancer will be diagnosed
and 760 women will die of breast cancer.
The statistics for cervical cancer are equally troubling.
An estimated 11,150 women were diagnosed with cervical cancer
in the United States last year. Notably, these diseases can be
treated if caught early, but far too many women never get that
chance.
Minority women are more likely to suffer from both diseases
primarily because of poor access to healthcare. African
American women develop cervical cancer at rates approximately
50 percent higher than White, non-Hispanic women. African
Americans are also less likely than White women to be diagnosed
at an early stage when the cancer is easier to treat.
Even more troubling, African American women are less likely
than Caucasian women to have breast cancer but they are 36
percent more likely to die from the disease. This higher
mortality rate has been attributed to late diagnosis, lower
access to early treatment and biological differences.
I have had the pleasure of working with Dr. Vanessa
Sheppard of the Lombardi Cancer Center at Georgetown
University, an African American woman and cancer survivor
herself who is conducting research into how to deliver
lifesaving care to minority women. With grant support from the
Susan G. Komen Foundation and the National Cancer Institute,
Dr. Sheppard has developed two programs to help African
American women and Latino breast cancer patients make informed
decisions about their treatment. Both programs match patients
with patient navigators who are often breast cancer survivors
themselves.
Individuals like Dr. Sheppard are making a real difference
for minority women and, as a result, we have begun to close the
screening and treatment gap that is at the core of the
unacceptable disparities that exist.
Further, programs like the CDC's National Breast and
Cervical Cancer Initiative are vitally important to closing the
screening gap. We know that we must lower barriers to care for
lower income, uninsured and underinsured women, and this
program aims to do just that. I am deeply concerned with recent
cuts the program suffered and am interested to hear how it has
affected the CDC's ability to achieve its mission.
I look forward to the testimony of today's witnesses, and I
yield back the remainder of my time.
[The prepared statement of Hon. Elijah E. Cummings
follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Chairman Waxman. Thank you very much, Mr. Cummings.
I am willing to recognize any Member who wishes to make an
opening statement on this side of the aisle. We will give you
another minute if you want.
OK, Mr. Issa, please.
Mr. Issa. I will be brief and ask that my entire statement
be put in the record.
Mr. Chairman, I just want to thank you for holding this
bipartisan hearing.
I believe that it is very clear through the last Congress
and into this Congress that we have a great opportunity to deal
with particularly these two most detectable and preventable
cancers, breast and cervical cancers, and it is that awareness
and funding that is so critical.
I am proud that this previous Congress, in 2006, passed the
Gynecological Cancer Education and Awareness Act known as
Johanna's Law and has authorized funding for gynecological
cancer education and awareness programs. It is clear we can do
more.
It is clear that in America the difference between life and
death is not necessarily access to healthcare but an awareness
that you need care. So it is, in fact, those preventions, the
early detection that would prevent the loss of at least 82,000
women who are diagnosed every year with gynecological cancer
and the 27,000 who die, mostly needlessly, for lack of early
detection.
As I said, I will put the rest of my statement in the
record, and I thank the chairman for holding this hearing.
[The prepared statement of Hon. Darrell E. Issa follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Chairman Waxman. Thank you, Mr. Issa.
Ms. Watson.
Ms. Watson. Thank you so much, Mr. Chairman. I join my
colleagues in thanking you for having this hearing.
Breast cancer has a disproportionate impact on the
different racial and ethnic groups. African American women are
less likely than Caucasian women to have breast cancer.
However, African American women are 36 percent more likely to
die from breast cancer disparity.
That began in the 1980's and continues over time. The
higher mortality rate is due to late diagnosis and lower access
to early treatment.
Breast cancer is the most common cause of cancer death in
Hispanic women. Hispanic women remain less likely than
Caucasian women to have had a mammogram in the past 2 years.
Screening access varies significantly by insurance status.
The diagnosis of 90 percent of women with breast cancer
will survive their disease at least 5 years. Breast-conserving
surgery or lumpectomy followed by local radiation therapy has
replaced mastectomy as a preferred surgical approach for
treating women with early breast cancer. Routine mammographic
screening is an accepted standard for the early detection of
breast cancer.
Cervical cancer is considered a preventable disease. It
usually takes a very long time for precancerous lesions to
progress to invasive cancers, and we have effective methods
that can detect precancerous that can generally be cured
without serious side effects.
Screening programs that are most effective in the United
States have led to the drastic decline in the numbers of
cervical cancer deaths in the last 50 years. Almost all cases
of cervical cancer can be prevented through screening. For
women who end up with cervical cancer in developed nations, 60
percent of them either have never been screened or haven't been
screened in the last 5 years.
The importance of regular cervical cancer screening cannot
be overstated. The importance of early screening and for low
income women who would otherwise lack access to services are
most needed.
So I thank you for bringing an experts panel and look
forward to hearing from you. Thank you very much, Mr. Chairman.
Chairman Waxman. Thank you very much, Ms. Watson.
Ms. McCollum, do you wish to make an opening statement?
Ms. McCollum. Thank you, Mr. Chair.
I agree with all the comments that my colleagues have made
before in generalities, if I may take a second and just talk
about some specifics.
Minnesota has better health indicators and better rates of
insurance than many States, and traditionally we are considered
a homogeneous, high income, high insurance rate State.
However, the diversity of Minnesota is growing and is
changing. We have populations of Hmong, Somali, Oromo, Tibetan,
Latino, resulting in high translation and high outreach costs,
and many of these people are the folks that are underinsured or
sometimes not insured at all.
Many States are facing economic problems. Minnesota is one
of them and, as our State moves forward with its budget
process, it is my fear that once again the State will look to
this program in cutting back.
There has been much focus on minority women, but I would
like to speak for the Native American women just to say that
they are often looked at as having access to wonderful
healthcare through the Bureau of Indian Affairs. That is not
the case. So I hope our testimony illuminates what Native
American women could expect in outreach.
Mr. Chair, it is also understanding, because Minnesota has
made some important investments in the health of our population
and we have done fairly well, as I said earlier, in providing
some access to insurance, this in fact may harm Minnesota in
the long run. Minnesota has been very efficient in delivering
its healthcare.
All too often then when the Federal Government looks at
programs, we don't look at the ways Minnesota could continue to
improve, to do better, to reach out to more women. Instead,
they say, Minnesota, you have done a good job. We are not going
to be involved in aggressively helping you do that next phase.
So, Mr. Chair, I thank you for this important hearing.
There is much work to do, and I look forward for us all working
together on this very important issue facing families.
Chairman Waxman. Thank you very much.
Mr. Welch, do you have an opening statement?
Mr. Welch. I don't.
Chairman Waxman. Mrs. Maloney.
Mrs. Maloney. Well, first of all, I truly and deeply want
to thank the chairman for focusing on health, and this builds
on his long commitment. His hearings and focus on the dangers
of cigarettes really revolutionized and saved lives in our
country.
Democrats are very committed to screening and prevention in
healthcare. As he mentioned, we passed legislation to have
Medicaid cover screenings. One of my first bills that passed
Congress actually had Medicare cover the screening for breast
cancer, and I have a bill in now that would have private
insurance companies, require them to include screenings for
cervical, breast and prostrate.
So this legislation and this hearing before us today will
help save lives. We can screen. We need every tool we can get
to get out there and screen better so that we are helping to
save lives in our country.
I thank the chairman for his leadership on this issue.
Chairman Waxman. Thank you very much.
Mr. Shays.
Mr. Shays. Thank you, Mr. Chairman. I just want to thank
our witnesses and thank you and the ranking member for holding
this hearing. It is a very important hearing, and it is nice to
have some hearings that we both can focus on together.
Thank you.
Chairman Waxman. Thank you.
For our first witnesses, we have Rosemary Henson who is the
Deputy Director for the National Center for Chronic Disease
Prevention and Health Promotion for the Centers for Disease
Control. Ms. Henson is responsible for providing leadership and
guidance on activities addressing the leading cause of
premature death and disability including cancer as well as
heart disease, stroke, diabetes, arthritis and obesity.
She is accompanied by Lisa Mariani, the Assistant Branch
Chief of the National Breast and Cervical Cancer Early
Detection Program.
Ms. Henson will testify about the program's history,
operations and challenges. Both she and Ms. Mariani are here to
answer questions, and accordingly both witnesses are going to
be sworn in which is the practice of our committee. So, if you
would, please rise and raise your right hands.
[Witnesses sworn.]
Chairman Waxman. The record will indicate the witnesses
answered in the affirmative.
We are pleased to have you here. Your prepared statements
will be made part of the record in full.
We would like to ask you, if you would, to try to keep
within a 5-minute timeframe for the oral presentation. We will
have a clock. That little part there will be green when it is
running, yellow when you have a minute to sum up, and then when
it is red the time is expired.
Ms. Henson.
STATEMENT OF ROSEMARIE HENSON, DEPUTY DIRECTOR, NATIONAL CENTER
FOR CHRONIC DISEASE PREVENTION AND HEALTH PROMOTION, U.S.
CENTERS FOR DISEASE CONTROL AND PREVENTION, ACCOMPANIED BY LISA
MARIANI, ASSISTANT BRANCH CHIEF, PROGRAM SERVICES BRANCH,
DIVISION OF CANCER PREVENTION AND CONTROL, NATIONAL CENTER FOR
CHRONIC DISEASE PREVENTION AND HEALTH PROMOTION, U.S. CENTERS
FOR DISEASE CONTROL AND PREVENTION
Ms. Henson. Thank you. Good morning. I am Rosemarie Henson.
I am the Deputy Director of the National Center for Chronic
Disease Prevention and Health Promotion at the Centers for
Disease Control and Prevention and allow me to express my
gratitude to Chairman Waxman and the distinguished members of
the committee for giving CDC this unique opportunity to discuss
the National Breast and Cervical Cancer Early Detection
Program.
In my brief remarks today, I will refer to the program as
the B&C Program.
I would like to begin with a survivor story. Nancy is a 60
plus Hispanic artist who lives in San Diego, CA. While
listening to the radio in her studio on an October day, she
heard a commercial promoting mammograms as part of Breast
Cancer Awareness Month.
Guess what? She hadn't had a mammogram for over 10 years
mainly because she didn't have health insurance. But she called
the number that the radio displayed in its ad, and she was
referred to the B&C Program at the Scripps Mercy Hospital.
The mammogram revealed a lump in her left breast which,
after a sonogram and biopsy, was found to be an early stage
breast cancer. Because the cancer had not spread, she received
surgery through the referral to the California Cancer
Collaborative followed by chemotherapy and radiation, and today
she is cancer-free.
Nancy's story can be retold by hundreds of women across the
country who have been in touch with the B&C Program in their
successful battles against breast cancer, the second most
common cause of cancer death in women. Many other women have
been spared of early deaths from cervical cancer due to the
detection through pap tests provided by the B&C Program.
The history of all of these success stories goes back to
1990. That year, to help improve access to mammograms and pap
tests among low income, uninsured and underinsured women,
Congress passed the Breast and Cervical Cancer Mortality
Prevention Act.
It authorized CDC to create the B&C Program which Congress
began by funding five States at a total $30 million in fiscal
year 1991. It has grown to be a nationwide program with a
funding level of $182 million in fiscal year 2008.
The B&C Program provides a full range of screening services
from screening tests to diagnostic tests to referrals to
treatment in all 50 States, the District of Columbia, five U.S.
territories and 12 tribes or tribal organizations. Today, the
B&C Program has in place a vast national network of more 17,000
screening sites.
Critical to the success of the B&C Program, its
comprehensive and its coordinated approach is key. First,
medically underserved women now have access to systematic
screening services through the existing healthcare delivery
system.
Second, the public awareness and outreach efforts inform
women of the need for screening and help them get to services.
Third, public education addresses the risks for breast
cancer and cervical cancer, recommended screening intervals and
the fears that women may have about the screening process.
And, fourth, professional education and quality assurance
ensure top quality screening and followup.
And, finally, tracking systems and case management ensure
that women receive timely and complete followup for diagnostic
care and referrals to treatment when needed.
Also critical to the B&C Program's continued success are
active partnerships with national and private sector
organizations like the American Cancer Society, Susan G. Komen
for the Cure and the Avon Foundation. These partnerships are
critical because they expand the reach, the capacity and
resources of the B&C Program.
CDC places a very high priority on tightly managing the
program. We continuously monitor the performance of funded
programs to assess the completeness of followup for women
screened for breast and cervical cancers, the timeliness of
followup and the timeliness of the start of treatment.
In recent years, Congress has strengthened the B&C Program
by amending Title XIX of the Social Security Act to give States
and tribes the option to offer women screened through the B&C
Program, treatment through Medicaid.
Of course, the most important measure of success of the B&C
Program is its effectiveness in reaching medically underserved
women. Let me now review those data with you and the key
outcomes. Through 2006, the program served more than 3 million
women and provided 7 million screening exams. These are women
who, without the B&C Program, would have not had the means to
access screening services.
Another important issue that I would like to highlight is
that, in fact, we are focused on reaching those women who are
rarely or never screened and women from racial and ethnic
minority communities. CDC data show that 60 percent of all
women screened in the B&C Program are racial and ethnic
minorities, higher than the estimated 56 percent of all women
who are eligible for the program and members of minority
groups.
I will stop there and be pleased to answer any questions
that the chairman or other members of the committee would like
to ask. Thank you very much.
[The prepared statement of Ms. Henson follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Chairman Waxman. Thank you very much. I appreciate your
testimony.
I want to ask you about the program's ability to reach its
target population. What percentage of women eligible for breast
and cervical cancer screenings does the program serve?
Ms. Henson. Well, the States have done a wonderful job in
terms of reaching women, but the reality is that we are able to
reach about 15 percent of the need at this point in time.
Chairman Waxman. How many women in total did the programs
serve in 2006?
Ms. Henson. That is about 600,000 women.
Chairman Waxman. How many were served in 2007? Do you have
an estimate of that?
Ms. Henson. We have an estimate of that. We are actually
forecasting about the same at this point, about 600,000 women.
Obviously, the current funding level certainly can impact
the number of women screened, but there are other factors that
we have to take into account in terms of emerging new
technology such as digital mammography, outreach challenges
particularly in rural areas, that type of thing. But we are
confident that we are able to keep the numbers fairly high in
terms of screening women because of the extensive network of
providers and infrastructure that we have in place.
Chairman Waxman. Well, I don't think it is very high if you
are only reaching 14 percent of the eligible women that would
come in for these screenings.
You did get a little bit more money, but even I would guess
it is predictable if you don't have increasing funds to do the
job, while there may be other factors, you are just not going
to be able to reach more women.
What are the other factors you say that are keeping you
from increasing the number of women to be screened for breast
and cervical cancers?
Ms. Henson. Of course, we have spoken about the funding
level, but I think the other factors are clearly we are seeing
many changes in technology, for example, digital mammography
which is going to cost more, the cost around diagnostic tests.
Chairman Waxman. So, if it is increased costs, that really
goes back to the amount of money that you are getting. If you
are not getting increased money and the costs are increasing,
you are not going to be able to serve a greater number of
people.
The program was authorized, I think, until 2012. Is the
program receiving the full authorized amount for fiscal year
2008?
Ms. Henson. No, the program isn't. The authorization amount
for fiscal year 2008 was $225 million. We are receiving $182
million for the B&C Program at this point.
Chairman Waxman. How many women do you estimate you would
have been able to screen in 2008 if you had the full funding
that your authorization provides?
Ms. Henson. I think we would be able to probably reach
740,000 women if we had the 225 available to us.
Chairman Waxman. So, for $40 million or thereabouts, we
could have reached 740,000 more women, maybe saved their lives.
How many do you think you will screen, given the actual
funding amount?
Ms. Henson. I think at this point we are doing those
estimates, but I think, given the funding amount, it is going
to be in the area of about 600,000 women.
Chairman Waxman. Well, I am pleased that CDC has been able
to serve as many women as it does, but I am concerned that you
won't be able to keep making much progress without more
resources and if the expenses keep increasing, you may well go
downhill rather than uphill in reaching what, on a bipartisan
basis, Congress wanted you to be able to do. That is to provide
the screening and for those that have this early detection to
be able to get the medical care they need, if nowhere else,
through the Medicaid program.
Thank you for your testimony. We very much appreciate it.
Ms. Henson. Thank you very much.
Chairman Waxman. Mr. Davis.
Mr. Davis of Virginia. Thank you.
Let me ask, what does it cost for a test?
Ms. Henson. What does it cost for a test? That is a very
good question.
For clinical services per women served, the number is about
$248. Now, when we look at the entire program, that is to
include the public health components of the program, the median
cost per woman served is $550--$555, excuse me.
Mr. Davis of Virginia. Per patient.
Ms. Henson. Yes, per woman.
Mr. Davis of Virginia. If you were to get a cervical cancer
which has a very high incidence of mortality if it metastasizes
or breast cancer, what are the costs of treatment for that once
a cancer like that has metastasized?
Ms. Henson. Let me make it very clear that this doesn't
include data around treatment costs, and we are going to have
to get back to you.
Mr. Davis of Virginia. I am just asking you, the treatment
costs are very high, are they not?
Ms. Henson. They certainly are.
Mr. Davis of Virginia. Can it run into the hundreds of
thousands of dollars?
Ms. Henson. It could, depending on the stage of the cancer
and the kinds of needs that a woman would need.
Mr. Davis of Virginia. Correct. So, obviously, if you can
catch it early, you save the whole system. You save hundreds of
thousands, in some cases, tens of thousands, whatever.
Ms. Henson. Absolutely.
Mr. Davis of Virginia. As well as the lives.
Ms. Henson. Clearly, the program, and I didn't have an
opportunity to say but we have been very good. The performance
of the program is outstanding in terms of identifying early
stage cancers both on the breast side and the cervical cancer
side.
Mr. Davis of Virginia. Really, the old saying, a stitch in
time saves nine, this is just living proof of that.
Ms. Henson. Absolutely, yes.
Mr. Davis of Virginia. Now your written testimony notes
that cervical cancer incidents and mortality rates are
considerably higher among Hispanic and African American women
than the general population. Is that correct?
Ms. Henson. That is correct.
Mr. Davis of Virginia. Now, are these differences
attributable to screening levels or could it be attributable to
diet or some other cultural factors that maybe we haven't
factored in?
Ms. Henson. I think there are a number of factors there and
certainly awareness in terms of the need to get screened for
cervical cancer. Cervical cancer is really a disease of older
women. Clearly, women that haven't been in this country very
long are unaware that they need to get screened. It is really,
again, access to the medical care system.
Mr. Davis of Virginia. So screening is really the major
problem. If everybody got screened, then you could detect it
much earlier and save them.
Ms. Henson. That would certainly be our goal.
Mr. Davis of Virginia. With those two populations, your
penetration in terms of getting the word out and getting them
screened is much lower than with other populations.
Ms. Henson. Clearly, what we do need to have in place and
what we have in place is very strong and effective outreach
strategies. And so, for those populations that normally don't
come in for routine medical care, you know we have to do a fair
amount of outreach to reach them and get them into service, and
so that is critical.
Mr. Davis of Virginia. Now, if someone were in the country
and were not here legally, for example.
Ms. Henson. Excuse me?
Mr. Davis of Virginia. If someone were here illegally, if
they were undocumented and were afraid to come forward and they
developed a cancer, then the costs are still very high. Are
there any prohibitions on them getting treatment in a case like
that or does that go State by State in terms of eligibility?
Ms. Henson. Certainly, the eligibility around people in the
country that are not here legally, those decisions are made by
the States. OK. In terms of offering screening services,
Medicaid does not allow us.
Mr. Davis of Virginia. But let's just take this a step
further. Let's say you worked here, that you weren't
documented, that you entered illegally or maybe you came as a
young kid and your parents entered illegally. You didn't have
any say in it, but you came in.
You developed this. You developed cancer because you
couldn't come forward and get treatment or you weren't aware of
it or were afraid to come forward or whatever, but then you
developed it. Our hospitals would still have to take you when
you present yourself at the emergency room stage. Isn't that
correct?
So the costs still get borne across it.
There are no prohibitions on language component or anything
else in terms of getting the word out, are there, in terms of
advertising?
Ms. Henson. No.
Mr. Davis of Virginia. Are different States using different
tactics to try to reach a minority?
Ms. Henson. States use a whole variety of outreach
strategies and tactics.
Mr. Davis of Virginia. What has been the best model as you
look at States?
Ms. Henson. Well, I think particularly with racial and
ethnic minority women and women that are hard to reach, the
actual community health workers, particularly in Virginia, that
has been a very, very nice model in terms of lay health
workers.
Clearly, getting into senior centers and getting into the
community to have an opportunity to recruit women directly is
very effective.
Mr. Davis of Virginia. But is there any State that can be a
model for this that you can see, that you look for to say we
think they have done this right versus States that maybe
haven't done it right?
Ms. Henson. I think that certainly we do have models out
there, and we certainly would be willing to provide that for
the committee.
Mr. Davis of Virginia. I think it would be helpful. I mean
the whole idea of federalism is that these State and local
governments are laboratories of democracy. They all try
different things, and the ones that work can be replicated. The
ones that don't, then you learn from their mistakes and you
don't have to make them yourself.
Thank you.
Ms. Henson. Thank you very much.
Mr. Cummings [presiding]. Thank you very much.
Ms. Henson, does the CDC develop specific strategies at the
national level in order to reach out to underserved groups?
Ms. Henson. Certainly, the CDC is knowledgeable and works
very closely with States in terms of developing education and
outreach strategies to reach out to women that are hard to
reach and racial and ethnic minorities. So that is a piece of
work that we have done very closely in collaboration with
States.
Mr. Cummings. In my opening statement, I mentioned Dr.
Sheppard at the Lombardi Center. Are you familiar with her
work?
Ms. Henson. No, sir, I am not.
Mr. Cummings. All right. Well, apparently, they use a
navigator type system where they get people, women who are
survivors to work with other women.
It seems to me. I mean I have seen that work and that kind
of system work in various areas such as Healthy Start. When you
have mothers who have gone through the pregnancy process to be
able to talk to first-time women who are pregnant. There s a
relationship that is established, and a lot of those people are
from the very neighborhoods.
I was just wondering had you all done any? Do you have any
information on that?
Ms. Henson. Sir, we certainly do have information on
navigator programs, and we certainly can provide that to the
committee. It is a very effective strategy in terms of helping
women manage through our complicated healthcare delivery
system.
Mr. Cummings. A little earlier, the chairman, Mr. Waxman,
asked you about if you had additional money, how many people we
might be able to help.
I take it that here in the United States there are women
who are suffering and possibly dying because we don't put the
resources to the problem in a sufficient amount. Is that right?
Ms. Henson. That is correct.
Mr. Cummings. If you had to estimate how many women come
under the category of could be diagnosed and get treatment but
because they don't will likely perish in a year, what would you
estimate that figure to be, if you can?
Ms. Henson. That is a figure that we need to get back to
you. I think that one point I want to make here is that we have
estimated that there are 4 million women that would be eligible
for this program.
Mr. Cummings. Can you say that again?
Ms. Henson. We have estimated that there are 4 million
women in this country that are potentially eligible for this
program.
Mr. Cummings. And how many are reaching?
Ms. Henson. We are actually, as was said earlier, we are
actually reaching about 15 percent of that need.
Mr. Cummings. That is sad.
Ms. Henson. Yes, it is.
Mr. Cummings. One of the things that is very interesting in
my district in Baltimore, when I visit senior centers and I
have an opportunity to bring medical people to the town hall
meetings, one of the complaints that I get from my seniors is
that mammograms hurt. I am just telling you what they say. I
don't know.
But I mean is that something you all hear from women?
Ms. Henson. Yes, certainly, we do hear that.
Mr. Cummings. I can't hear you. I am sorry.
Ms. Henson. I am sorry. Certainly, we have heard that from
women. I mean they, women do have a variety of fears related to
the screening process.
Mr. Cummings. Have we looked at those fears and tried to
address them?
It seems like let's say the services are available, the
screening is available and if they are not taking advantage of
it, it seems like we would want to try to get to the bottom
line to try to alleviate their fears or concerns.
Ms. Henson. Certainly, we do that through our public
education and our direct outreach efforts to address those
fears so that women certainly are more likely to take advantage
of breast and cervical cancer screenings. We try to deal with
that barrier in an effective way.
Mr. Cummings. Now, last but not least, let me ask you this.
Existing law has a requirement that out of the
nonadministrative funds, 60 percent has to go to direct
clinical services. Is that right?
Ms. Henson. That is correct.
Mr. Cummings. I understand that the new reauthorization
creates a limited waiver that will give some States flexibility
on this ratio. What is the purpose of that waiver?
Ms. Henson. The purpose of that waiver, first of all, is to
help strengthen the other public health components of the
program: professional education, public education, quality
assurance, our tracking systems. But the other requirement is
that, in fact, as we are doing that, that we maintain an
expanded number of women to be screened.
So we can't forego screening women, but we also need to be
able to leverage other non-Federal dollars to ensure that women
are getting the services.
Mr. Cummings. Has the CDC informed the States of the
option?
Ms. Henson. Yes. Yes, sir.
Mr. Cummings. How many States have shown an interest in
applying for it?
Ms. Henson. We have about four States that have shown an
interest at this point in time.
Mr. Cummings. When will these waivers come into effect?
Ms. Henson. June 30th of this year.
Mr. Cummings. All right. Thank you very much.
Mr. Shays.
Mr. Shays. Thank you, Mr. Chairman, and thank you to our
witnesses. To the second panel, I am the ranking member of a
subcommittee that will be meeting, and I will probably miss a
good part of that presentation.
We are dealing with an issue of flat funded over a number
of years, and some States do a better job than other States is
what I am hearing from the testimony.
Is there any documentation that shows that the States that
don't do as good a job, that there are more cases of cancer
that isn't detected soon enough and therefore dealt with and
that you have the resulting higher deaths or are we doing it
basically intuitive but not documented by statistics?
Ms. Henson. Sir, we would definitely have to get back to
you on that particular issue.
But I would like to add that CDC has a very, very nice
performance-based funding system in place, and we do a lot of
monitoring in terms of the ability of States to spend their
dollars, the ability of the State to make realistic screening
projections and to really monitor the quality of services.
Mr. Shays. Right. I am looking at this room and what I like
about this hearing is there is nothing that comes between a
Republican and Democrat on this issue, and it is a healthy
thing to see. I mean I look at my colleagues on the other side,
and they are champions on this issue, and I know that
Republicans as well feel this is a very important effort.
But it is important, I think, for the things that we
support most, to continue to continue to document. For
instance, wouldn't it be stunning if you found out that in the
States that didn't do as good a job, that the rates were even
much higher and that you would have real life, not just
anecdotal, but story after story of if only this person had
known sooner and they would have been more likely to know
sooner in another State that provided more?
I think that would be tremendously helpful.
Let me ask you about the cost, film versus digital.
Ms. Henson. Cost.
Mr. Shays. First, what is the cost of the program per test?
I have no sense of the cost per test.
Ms. Henson. Let me give you the cost in terms of providing
direct clinical services per woman.
Mr. Shays. No. Just a test, what does the test cost?
Ms. Henson. OK, $79.
Mr. Shays. $79.
Ms. Henson. $79 and $120 for digital.
Mr. Shays. OK, but the digital, I make an assumption, is
far more accurate because it is a more clarified picture. Is
that true?
I mean it has to be. Otherwise, why would we want to go to
digital? What would be the advantage of digital over film?
Ms. Henson. I think that clearly there are data to suggest
that there are benefits to digital mammography, that it
certainly would be more accurate in terms of women that have
dense breasts.
Mr. Shays. Then let me ask you, is there any other type of
test that is coming in that, rather than being more expensive,
will be less expensive?
I mean if your testimony touched on it, I am sorry. I
didn't catch it.
Ms. Henson. No, sir, not another test that I am aware of.
Mr. Shays. OK, thank you.
Thank you very much, Madam Chairwoman.
Mrs. Maloney [presiding]. Well, I want to thank my
colleague for really supporting this initiative on women's
health as you have so many others, and it is good to have
something we both agree on, although we agree on a lot of
things together, on 9/11 and so forth.
I would like to thank the witnesses and ask you, as you
have noted, you are reaching fewer than 15 percent of the
eligible women. When a clinic runs out of money, what happens
to a woman seeking a mammogram?
Ms. Henson. Well, certainly, that is a challenge for the
program, and you are going to hear from the other witness
around that. But I think that States really do try to get the
women connected to a service, so they can receive mammography
services or cervical cancer screening services, but it is a
challenge that the program faces.
Mrs. Maloney. I would agree with my colleague that getting
and keeping good data will help build your case for the needed
funds to go forward.
Since I have been in Congress, really, we have doubled,
more than doubled the amount of money going into mammograms and
cervical cancers and other cancers for women.
I recall when I came, one in seven women died of breast
cancer. What is the number now? How many women die of breast
cancer a year now?
That was the number that was always used, one in seven. It
could be your sister, your mother.
Ms. Henson. OK. It is one in seven women are diagnosed, and
we have at this point, that we have about 40,000 women per year
that die of breast cancer.
Mrs. Maloney. Excuse me. He was talking to me. You say one
in seven is diagnosed and how many?
Ms. Henson. We have had about 40,000 women that actually
die from breast cancer.
Mrs. Maloney. 40,000 a year, that is still astronomical.
One in seven is diagnosed and 40,000 die. Oh, my goodness.
What about the cervical cancer? What is the number on that?
Ms. Henson. In this country, we have, unfortunately, about
4,000 women in this country that are dying of invasive cervical
cancer.
Mrs. Maloney. 4,000?
Ms. Henson. Yes.
Mrs. Maloney. But you said 40,000 died of breast cancer.
Ms. Henson. Yes.
Mrs. Maloney. So many, many more die of breast cancer than
cervical cancer.
Ms. Henson. Yes, and we have done a very nice job in this
country in terms of getting cervical cancer services out to
women. We have really made some very nice progress, but it is
very hard.
Mrs. Maloney. Is that because the pap smear as a screening
device is more effective than the mammograms?
We have tremendous outreach on mammograms too now through
the Medicaid program, Medicare and just advertisements. I know
that in my home State there are literally billboards up,
telling people to go get their mammograms. Why do you think
that so many more die from breast cancer than cervical cancer?
Do you think it is the screening?
What do you think is the reason?
Ms. Henson. I don't think it is the screening tool. I think
it is that women, clearly for many years, during their
adolescent years, their younger years, certainly got accustomed
to going for pap testing and screening, and I think that
mammography is still a screening tool that women are aware of
but at times fear.
I don't think there is a difference in terms of the
screening tools, but I think that there is an issue in terms of
attitude and----
Mrs. Maloney. Use.
Ms. Henson. Use, yes.
Mrs. Maloney. Well, the chairman is very committed to
helping this program. So could I ask you to supply for the
record, if you don't have it with you today, your professional
judgment of how much funding would be required to meet the
needs of all eligible women?
Ms. Henson. We certainly will provide that to you.
Mrs. Maloney. I would like to talk a little bit about the
tools and technology.
Both the mammogram and the pap test have been around for
literally decades, and they are literally the primary screening
tools used because they are both effective in detecting signs
of cancer. But the law creating the program, which we are
discussing today, stated that if newer technologies are
developed and recommended, they can be covered as well.
Can you please explain how such coverage decisions are made
and can you tell me about the two tests that we are reading
about a lot, the digital mammograms and the HPV test, and does
the screening program now cover these new technologies?
Ms. Henson. Certainly. When the program is faced with this
type of decision, what we do is we usually bring together
experts to make those decisions, and basically they do look at
the effectiveness of the screening tool as well as looking at
the priorities of the program.
Currently, the program is providing a limited amount of
resources for HPV as well as for digital mammography. We
currently reimburse at the Medicare rate for these types of
procedures, and that has become an issue for the States because
the rates are low.
Mrs. Maloney. Thank you.
Congresswoman McCollum.
Ms. McCollum. Thank you.
I would like to go back. When you were asked the cost of
the screening, you came up with $500. Is that what you said for
the cost of screening?
Ms. Henson. $555 is the median cost per woman screened.
Ms. McCollum. I would like you to break that down because I
served on the Health and Human Services Committee in Minnesota
and screening per woman, when we talked about it on the House
floor and recently, it has been screening at $88 per woman,
then maybe $85 to recruit women.
Are you just putting that all together for you $500?
Ms. Henson. Basically, what that number represents is
clinical services as well as the public health components of
the program. So that is why there is a difference in that
particular number.
Ms. McCollum. Do you break that out by State?
Ms. Henson. That is something that we are looking at right
now. We have looked at nine States to get a handle of the cost,
and we have a phase two initiative to look at more States.
Ms. McCollum. Well, I think best practices should really be
moving forward because there are discussions in my State of the
State actually cutting back on some of its costs.
Just listen to the State of the Union. If I advocated for a
program now in Minnesota maybe to reach Somali women, it would
be considered something terrible. It would be called an earmark
to develop a best practice or something that States could use
as a laboratory to move forward, to help other women around
this country live healthy, productive lives.
Could you maybe speak a little bit about what you are doing
with your efforts for Native American women?
I say this in particular because although States are
laboratories, the funding goes toward States. Native American
women are part of nations where the Federal Government has
relationships with. So can you speak to what your plans are to
increase this issue of Native American women not being screened
because after all that then becomes a nation to nation issue?
Can you also address if the CDC monitors and starts
becoming concerned or alarmed when States start cutting back on
their participation in these programs? Because if the State
cuts back, then the Federal match is less. So then that is good
maybe for another State or maybe that is good for someone who
is looking to cut the budget in these areas, which I don't
think is a prudent thing to do.
Could you maybe speak to that, please?
Ms. Henson. Sure. Well, let me begin with your question
about the American Indian-Native American population. This
program is one of the first programs at CDC that actually
funded tribes directly along with a clear direction to States
that they need to reach out to American Indian-Alaska Native
populations. And so, we have been doing this work for many,
many years.
Another part of this strategy is that----
Ms. McCollum. Excuse me. What is your success rate then if
you have been doing it for so many years?
When you started out, you were at zero. Where are you now?
Ms. Henson. Is there in terms of screening?
Ms. McCollum. Well, the first year, you had a baseline of
how many women you screened. The second year, you had how many?
I mean what is our success rate if you have been doing this for
so many years?
Ms. Henson. We certainly can get that data back to you.
Actually, what I will do is get the actual numbers back to you,
but we are reaching, at this point, about 3 percent of the
women that are Alaska Native-American Indian.
Ms. McCollum. Three percent.
Ms. Henson. I actually can give you actual screening
numbers if you'd like to have them.
Chairman Waxman [presiding]. Could you speak into the mic?
Ms. McCollum. I had asked another question about States
that cut back. I was waiting for the answer.
Ms. Henson. OK. In terms of--can you please repeat your
second question? That would be helpful.
Ms. McCollum. There are Federal dollars that go into the
screening program. The States often match those Federal
dollars, yielding more opportunities for women to be screened.
Does the CDC become concerned?
Do they express through letters or questions why a State
might be looking at cutting back in doing some of the outreach
for women because when some of the dollars are pooled together,
the dollars much more effective and much more powerful if
someone is using best practices?
If a State pulls back, fewer women are going to be reached.
That means those Federal dollars going into the program aren't
going to be as effective as they could be.
Ms. Henson. Certainly, the CDC expresses their concern. We
clearly don't have control over the State dollars, but we work
with the program to see what we can do to reach the women that,
in fact, won't be screened because of the cutback in terms of
State dollars or other sources of resources that are coming in
for screening. So we do work with them.
We do provide a lot of technical assistance. We have a real
clear sense in terms of how many women would not be screened if
the State dollars or other sources went away from the screening
program. We hold the States very accountable for the match
requirement in the law.
Chairman Waxman. Thank you, Ms. McCollum.
Mr. Welch.
Mr. Welch. Thank you and thank you for your good work.
In addition to funding, always a challenge, what are the
other elements of making the screening test available to women?
Ms. Henson. Well, I think that, clearly, the other parts of
the program that are critical are certainly the public health
components elements.
We would want to ensure that we have very good tracking
systems, we have very good case management, that we have strong
public education and outreach programs on the ground, and
clearly very strong professional education for the providers
that are seeing these women. So those are all.
Mr. Welch. I don't actually know what that means.
Let's say you are a low income woman living in the inner
city, how do you find out about it? What are the impediments to
access?
What are the impediments for the providers to making the
service available when money is not the issue but some of these
other practical obstacles are?
Ms. Henson. Certainly. Well, clearly, there is the public
education through a radio spot, through a television spot,
recruitment in senior centers or other community-based
organizations where we can talk to the women about the
availability of services through this program.
If a woman says to us she doesn't have transportation, we
assist with that. If she clearly needs some help in terms of
getting to the screening site, she needs someone with her, we
help her do that as well. And, clearly, if she is diagnosed
with a cancer, we provide case management services.
Mr. Welch. I think in response to Congresswoman McCollum's
question or one of them, you said the cost of each screening
was $555. Does that cost figure include these other support
elements that go from advising the availability of the service
to, in some cases, you mentioned providing transportation to
the actual test itself?
Ms. Henson. Yes, sir. It clearly does.
Mr. Welch. Are many of the women who benefit from the
screening test also women without Medicaid or Medicare or other
form of health insurance?
Ms. Henson. Certainly, we are talking about a population of
women that are uninsured or underinsured. So they have no real
form of health insurance.
Mr. Welch. When you say uninsured, they are not even
Medicaid or Medicare covered?
Ms. Henson. Correct.
Mr. Welch. So what then happens to those folks who have a
need for further medical care because it is a positive test?
Ms. Henson. Certainly. Well, through the screening program,
if a woman has a positive test, then we will provide diagnostic
services.
Mr. Welch. Right.
Ms. Henson. And then if she is diagnosed with cancer, we
are able to refer her to Medicaid for treatment through the
Medicaid option that was approved by Congress.
Mr. Welch. Are there any impediments to that women then
being made immediately eligible for Medicaid and getting the
medical treatment for her cancer that is required?
Ms. Henson. Excuse me. I didn't hear.
Mr. Welch. Is there any impediments to that person being
made eligible for Medicaid and then immediately getting the
care or getting the care in a timely way for the cancer that
has been diagnosed?
Ms. Henson. Our finding is that, in fact, the whole process
is pretty simple in that we have found that many of our women
who have been diagnosed with a cancer and that initiate
treatment, that time period is actually very, very short. So
that has been very, very helpful to have that Medicaid option
for these women.
Mr. Welch. Thus, the better survival rates from the
treatment and the early diagnosis.
Ms. Henson. Exactly. Exactly.
Mr. Welch. Thank you very much.
I yield the balance of my time.
Ms. Henson. Thank you.
Chairman Waxman. Thank you, Mr. Welch.
Mr. Higgins.
Mr. Higgins. Thank you, Mr. Chairman, and thank you for
holding this important hearing.
Thank you, presenters here. Your message of prevention and
early detection is urgent and timely.
My understanding is that less than 10 percent of cancer
deaths are a result of the original tumor. It is when cancer
spreads. It is when cancer metastasizes that cancer becomes
deadly.
Over the years, the Nation has invested a lot of money in
cancer research through the National Cancer Institute. You know
30 years ago, if you were diagnosed with cancer, less than 50
percent of those lived beyond 5 years of their diagnosis.
Today, it is 65 percent for adults, 80 percent for kids. More
people are living with cancer than are dying from cancer.
Despite this, it seems as though the Federal Government is
pulling back on its investment into early detection, prevention
programs and funding promising new research in therapies which
become the basis for tomorrow's standard treatments.
I think the most important point here is that to a nation,
to our Nation, it is much more expensive to treat advanced
cancer than it is to treat early stage cancer. You, in your
testimony, point that out.
My first year here, there were a bunch of cancer advocates
from the entire Nation, who converged on Washington to promote
what is referred to as the 2015 Campaign. I didn't know
anything about it. I inquired about it. In the 2015 Campaign,
the goal was to eliminate all human suffering and death due to
cancer by the year 2015.
Upon further inquiry, I knew that there was also some
controversy within the cancer community about whether or not
that goal is attainable. Well, that is the wrong focus. So long
as you are making progress toward the goal, that is what is
most important.
But over the past 5 years, Congress cut cancer funding to
the National Cancer Institute by about $250 million.
The goal or progress toward the goal of eliminating all
human suffering and death due to cancer, eradication of cancer
in our lifetime, should not just be the National Cancer
Institute's goal or those that advocate along with them. It
should be the Nation's goal.
But Congress has to insist on a massive investment behind
cancer prevention, early detection and promoting new therapies
that give great promise to effectiveness moving forward. As I
mentioned, it is an investment. It is not only an economic
issue. It is an important healthcare issue as well.
Any thoughts on that?
Ms. Henson. Certainly, the concerns that you have raised
and the priorities that you have raised are, from our
perspective, very much on target.
I think that the National Breast and Cervical Cancer Early
Detection Program has done a fine job with the types of
resources that we have to reach underserved women. Clearly, to
reach all women, we are going to have to make a stronger
financial investment in this particular program.
But, clearly, what we have seen is we have strong
accomplishments in terms of reaching these very hard to reach
women, and we have really seen since the inception of the
program that we have been very successful in terms of detecting
early stage cancers.
Mr. Higgins. What happened to the 2015 Campaign?
You don't hear much about it anymore. Is it still the goal?
Is it still established? What happened?
Ms. Henson. Well, certainly, we can get back with you on
that, but clearly 2015 continues to be a very important goal
and very, very strong priorities. But we can get back to you in
terms of what is actually happening.
Mr. Higgins. One word of advice, and I haven't been here
all that long, but that first year all these cancer advocates
asked Members of Congress to sign their petition, their
resolution, a non-binding expression to promote increased
funding to achieve the 2015 goal. In my response, I signed it
respectfully, but the cancer community is letting Congress off
too easily.
Yes. A non-binding recommendation means nothing.
I would encourage because as what is stated here, that
everybody is touched by cancer, directly and indirectly and
likely both. I think it is one of these issues that, as others
have mentioned, doesn't have a partisan label to it, and I
think that there is a consensus that if our Nation does not
make that investment, we can't expect that anybody else will.
Ms. Henson. Well, thank you very much for your support.
Mr. Higgins. Yes. I yield back.
Ms. Henson. I much appreciate it.
Chairman Waxman. Thank you very much, Mr. Higgins.
Mr. Van Hollen.
Mr. Van Hollen. Thank you, Mr. Chairman. Thank you for
holding this hearing and thank you for your testimony.
As my colleagues have said, obviously, we need to commit, I
think, a lot more national resources to this effort to make
sure that we do get the screening programs and get as many
people as we possibly can to take advantage of those programs
and then be sure that we are providing the followup treatment
for those who are detected with breast cancer, cervical cancer
and other cancers.
I just want to followup on one of the questions by my
colleague, Congresswoman Maloney on the new technologies
because in both areas there are new technologies. I wanted to
ask you with respect to the HPV DNA test that has been approved
by the FDA, compared to the pap test, is the HPV DNA test
better able to detect cervical cancer?
Ms. Henson. In terms of cervical cancer, the recommendation
is that we continue to do pap tests in conjunction with the HPV
testing. Actually, what is happening now in the program is that
we don't offer it routinely, but we offer the HPV test for
women that show up with certain abnormal findings at this point
in time, but it is offered in conjunction with the pap test.
Mr. Van Hollen. I guess my question is do the findings
suggest that the HPV test in some instances is better able to
detect cervical cancer?
In other words, could a woman come and take a pap smear and
it show up as negative but the HPV DNA test show a positive
finding?
Ms. Henson. Sir, I would like to get back to you on that
particular question. I don't have the information readily
available to me.
Mr. Van Hollen. OK. I mean there are two major issues here,
obviously. One is we want to cover, obviously, more women in
screening and the other is we want to be using the most up to
date, the test that is best able to make that detection.
So I would be interested whether the findings suggest that
someone who may test negative on a pap smear, that same person,
if you use the DNA test, HPV DNA test would be found positive.
Then the question is if that is the case, shouldn't we consider
making that part of the original screening?
Could you talk a little bit about the state of the
recommendations from CDC and other U.S. Government health
agencies with respect to the vaccine for cervical cancer?
Ms. Henson. The vaccine, well, certainly. Currently, the
HPV vaccine is really targeted for girls and women, age 9 to 26
years old, and this is really not a population that is served
by the National Breast and Cervical Cancer Early Detection
Program.
We certainly would be pleased to provide you with the
actual guidelines that particular program is managed. The
science is managed in a different center at CDC, but clearly
the focus is on girls and women that are much younger than the
women that are actually through the B&C Program.
Mr. Van Hollen. Right. I guess what I am trying to
understand is what the current recommendations are from the CDC
or others, from the U.S. Surgeon General if you know, with
respect to recommending whether or not females between these
ages should get the vaccine or not? Do you know what the
current state is?
Ms. Henson. Basically, the recommendation is at this point
that women regularly receive cervical cancer screening through
the pap test; that HPV vaccine for girls and women, age 9 to
26, is supported; that HPV vaccine for women, age 27 or older,
is not supported. All women receiving the HPV vaccine should
continue to receive a pap test according to the established
screening recommendations.
We can get that to you in writing if that would be helpful.
Mr. Van Hollen. That would be helpful. Thank you.
Thank you, Mr. Chairman.
Ms. Henson. Thank you.
Chairman Waxman. Thank you very much, Mr. Van Hollen.
Ms. Henson and Ms. Mariani, thank you for being here and
answering our questions and making your presentation. It has
been very helpful to us. Thank you.
Ms. Henson. Thank you very much for this opportunity.
Chairman Waxman. We are going to now hear from our second
panel, but before I call on them I want to ask unanimous
consent that the record be open for additional testimony that
may be submitted to us for the record.
Our second panel will provide a broad range of information
and perspectives on the National Breast and Cervical Cancer
Early Detection Program.
Gail Carey is a breast cancer survivor from Long Island.
She experienced firsthand the benefits of the screening program
through the Healthy Women's Partnership in New York.
Dr. Otis Brawley is the medical director for the American
Cancer Society where he is charged with promoting the goals of
cancer prevention, early detection and quality treatment
through cancer research and education. As an acknowledged
global leader in the field of health disparities research, Dr.
Brawley is a key leader in the Society's work to eliminate
disparities in access to quality cancer care.
Shelley Fuld Nasso is the director of public policy for the
Susan G. Komen for the Cure Advocacy Alliance and facilitates
Komen for the Cure policy and legislative efforts. She also
oversees the Komen Community Challenge, a series of events
designed to make breast cancer a national priority and to help
close the gap in access to care.
Pama Joyner is the program director for the Washington
Breast and Cervical Health Program. She served as the 2006-2007
Chair of the National Association of Chronic Disease Directors
Breast and Cervical Cancer Council.
Finally, Dr. Thomas Hoerger is the senior fellow in health
economics for RTI International and the director of RTI's
Health Economics and Financing Program. He is also the director
of the RTI-UNC Center for Excellence in Health Promotion
Economics and has led numerous research projects for the CDC
and CMS.
We are pleased to welcome all of you to our hearing today.
It is the practice of this committee to ask that all
witnesses that testify do so under oath. So, if you would
please rise and raise your right hands.
[Witnesses sworn.]
Chairman Waxman. The record will indicate that each of the
witnesses answered in the affirmative.
Your prepared statements will be made part of the record in
full.
We would like to ask each of you to limit your oral
presentation to 5 minutes, and we do have a timer. Right now,
it is red, indicating there is time, but we will start off with
green. It will turn to yellow when there is 1 minute left and
then will turn red, indicating the time is expired.
Ms. Carey, why don't we start with you? There is a button
on the base of the mic that will actually turn it on and be
sure to pull it close enough so that it is picked up.
We are delighted you are here.
STATEMENTS OF GAIL CAREY, RECIPIENT OF BREAST AND CERVICAL
CANCER EARLY DETECTION PROGRAM BENEFITS AND VOLUNTEER, AMERICAN
CANCER SOCIETY; OTIS BRAWLEY, MEDICAL DIRECTOR, AMERICAN CANCER
SOCIETY; SHELLEY FULD NASSO, DIRECTOR, PUBLIC POLICY, SUSAN G.
KOMEN FOR THE CURE ADVOCACY ALLIANCE; PAMA JOYNER, PH.D.,
DIRECTOR, BREAST AND CERVICAL HEALTH PROGRAM, WASHINGTON STATE
DEPARTMENT OF HEALTH; AND THOMAS HOERGER, DIRECTOR, RTI-UNC
CENTER FOR EXCELLENCE IN HEALTH PROMOTION ECONOMICS AND RTI
HEALTH ECONOMICS AND FINANCING PROGRAM
STATEMENT OF GAIL CAREY
Ms. Carey. I am here to testify because I was fortunate to
be a recipient of this network. When I was diagnosed with
breast cancer, I also had no insurance. I know in this world,
it is inconceivable.
From the time when I was a little kid, my mom had emphysema
and she was forced go to on Medicaid, and we hated it. As
little kids, we hated it because right after my mom got sick,
my dad lost his job at Republic Aviation. Financially, they
split up, and we were stuck on Medicaid for many years.
When I was 18, I went out on my own, got my own job. With
my first job, I had insurance, and I never looked back. I
always had insurance every single year, no matter what job I
had.
When I got married, we had insurance. When I had my kids,
we had insurance. When my husband and I also split up, still
had a great job, still had insurance.
Ironically, at one point, I was working for a medical
facility. It was a panel of neurologists, and a young man came
in. He was an immigrant, and he had been having seizures, and
he had no insurance. The doctor was very reluctant to work with
this child and sent him to the hospital across the way which
was State-sponsored.
At that point, I said, you know what? I don't want to work
for this doctor anymore.
I entered into a different world, and I worked for a trade
show company. I worked for a trade show company doing air
traffic control and whatnot. Again, always had insurance. It
was always overlapping.
Unfortunately, I was working for the trade show company
when the jets hit the World Trade Center and we all know what
happened to the country, let alone trade shows. Everything just
shut down. Everything immediately shut down. That was in
September.
By March, our boss was paying us out of his own pocket. We
knew he was just holding us on.
When I lost my job, of course, it was devastating because I
also lost my insurance. Couldn't afford the Cobra because I
didn't have a job. I had two kids. I had no husband. I was
paying for my house. As a mom, most women know that your
priority is your children and your house and keeping a house
over their heads.
So I was going crazy for a couple of weeks, writing out my
resumes. You know resumes that I hadn't had to prepare for many
years, and at that time, in the interim, I found. I was taking
a shower, and I felt what I perceived to be a lump.
Now I also have to preface this by saying that I also
worked for a medical facility for some time in mammography. I
knew exactly what cancer was. I had seen it a thousand times
because I worked in the records.
I had seen dense breasts. I had seen young breasts. You
know. I knew exactly about calcifications and carcinomas. I
knew exactly what it was.
So when I saw it, of course, I panicked. But I thought,
well, we have a history of cysts. Maybe it is just a cyst.
I scrambled to get a job. I worked little jobs, and then I
finally found one job where he suggested after 3 months that I
would get insurance.
Now I got laid off in April, discovered the cyst or what
came to be my cancer a couple of weeks later. I started this
job in July. So here I am waiting like 2 months to get this job
that promised me medical benefits.
It is kind of like I took a pay cut just to get this job
because it promised medical benefits. He said I would get them
in 3 months.
Now I already knew I had a problem, but I thought to
myself, OK, so I will gamble here. You know. I always had
control over my life. This was the first time I didn't. So let
me do this.
So I went from July to October and come October, I went to
this boss and I said to him. I said, OK, I have put in my 3
months. You know I would like to get those medical benefits
going because I have a problem I think that needs to be
addressed.
I am sure he was aware of it because I had spoken to my
manager about it. His answer to that was to call me into his
office at about 10 minutes to 9, look at his watch and tell me
I had 10 minutes to clean out my desk because I was fired.
So, here I was, 3 months later, still no insurance, no job,
no prospects, still pushing my kids out of the hole that I dug
them out of, and I realized that I was going to die. There, I
had no choice.
I kind of walked out with dignity, and I just waved to him
and said bye-bye. I got to my car and broke down and cried.
So I went home and I pooled all my resources, and I figured
out everything I could do. There was no way I was going to go
to a doctor. I knew from the neurologists that they frown on
people that don't have money, let alone no insurance. So I was
certainly not going to go to a doctor for a screening for what
I already knew to be cancer. I already knew it.
So I pooled all my money, pooled it all together, my tax
money and what-not, and I went out and I bought a little, tiny
used car for my daughter. She was 18 at the time, and I said to
myself, well, I am going to die. She is not going to be saddled
with a car payment.
That was my mind set. I was just going to make sure. I was
going to set up my life. A couple of weeks later, my
girlfriend, Kim, who worked with me in the medical facility in
mammography came over and says to me, I haven't seen you for a
while. What is going on? What is happening?
That is when I broke down and cried and told her, Kim, I
think I have a problem. And she goes, what is wrong? And I
hadn't seen her in months, and she goes the very next day. It
was October 31st, Halloween, set me up for a mammography. She
is a certified mammotech.
We both looked at the films. We both nearly threw up
because we both knew it was. Not only was it a carcinoma, which
is a lump, but it was already traveling to my lymph nodes at a
very rapid rate. I was in big trouble. I was in big trouble. It
was like stage three cancer.
She set me up immediately for a sonogram. Again, because I
worked for this particular medical center, they were extending
a courtesy. Normally, that particularly mammography would have
cost me $200 which I did not have at the time. They told me
that I could pay it off eventually.
They set me up with a sonogram which probably was going to
cost about $1,000. Then I was like, Kim, I can't do this. It
started with tech, biopsy, sonography. She said, we will do
this. They did the biopsy. Of course, the lab tests came back
positive, and I was just sick to death.
I went home and I told the girls. I said, OK, girls,
listen. I think we are in trouble. Katie said, well, what is
the matter? She was my 18 year old. She comes in from Halloween
trick-or-treating, and I said, I think we are in trouble.
She goes, what is the matter? I said, I think I might be
sick. I might have cancer. She goes, how much is it going to
cost? Usually, we joke about if something is too expensive, we
say it is going to cost $100. I said, well, it is going to cost
more than $100.
The next day, Katie got on a bus after school and went to
the mall to get a job because she was going to help me pay for
this. Actually, it didn't have to happen that way because Kim
went to the hospital where she worked, and she says there is
this new program. She said, Gail, you are not going to believe
this because New York State only just instituted it this month,
this year. It is brand new.
It's the--we couldn't even. We didn't even get the name
right. It was Woman's Healthy Partnership. We didn't even know
what it was. They didn't even have forms. They have no cards.
That had a brochure that described. It was a letter of
introduction that described what this program was.
She goes, take this to the doctor. They set me up with a
surgeon. She gave me the name of this wonderful women in the
American Cancer Society in Hyde Park. Her name was Maureen
Massellaro. She was my patient navigator. The women had wings,
seriously. You look at her, and she was just an angel because
she set me up with the surgeon and I called up the surgeon.
I went into the office. They asked me, do you have
insurance? Do you have your insurance card? I wanted to run out
of there. And I said, no, all I have is this letter, and I
handed the letter. She goes, oh, OK, and she takes it. And I
was like that's it? This letter of introduction? That was it.
Chairman Waxman. You were being covered by the program.
Ms. Carey. It was covered by this program.
Chairman Waxman. By Medicaid.
Ms. Carey. It was unbelievable. They took the letter, no
problem. I spoke to the doctor. I spoke to the Secretary.
Chairman Waxman. But your Senator had a large part in
adopting in the Congress.
Ms. Carey. I was absolutely terrified with this disease. I
think I was more terrified because I couldn't pay for it. I was
absolutely humiliated that all I had was a letter. I thought
they were going to laugh me right out of that office.
I was accepted immediately. They were so dignified. They
were so encouraging. They were so sympathetic, and they
absolutely said, no question, we will take care of this.
Chairman Waxman. Well, thank you very much, Ms. Carey. You
have given us a good example of how this program has succeeded.
Ms. Carey. Extraordinary.
Chairman Waxman. We want more people to be able to have the
wings of angels come and fan them and help them as well.
Ms. Carey. Amazing.
Chairman Waxman. Thank you.
Ms. Carey. Thank you.
Chairman Waxman. Thank you very much for being here.
[The prepared statement of Ms. Carey follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Chairman Waxman. Dr. Brawley.
STATEMENT OF DR. OTIS BRAWLEY
Dr. Brawley. Mr. Chairman and distinguished members of the
committee, I am Otis Brawley. I am a medical doctor. I am a
medical oncologist and epidemiologist, and I serve as chief
medical officer of the American Cancer Society and, in that
capacity, represent the 3 million volunteers of the American
Cancer Society.
As a medical oncologist and epidemiologist, I treat and
study outcomes. I should also tell you that I have served on
the Advisory Committee to the CDC Breast and Cervical Cancer
Program. I have also directed a cancer center which did
participate and still does participate in the Breast and
Cervical Cancer Screening Program from the CDC.
In that program, we have leveraged money from the Komen
Foundation, the Avon Foundation, the American Cancer Society
and the State of Georgia for education and outreach, and it is
very important that we emphasize that education is a very big
part of this program, a very necessary part of this program in
addition to providing medical care.
I am very proud that over the 6-years that I was director
of the cancer center, with CDC funding and funding from our
partners, we were actually able to create a stage shift in a
large county hospital in Georgia where we halved the number of
advanced breast cancers diagnosed on an annual basis and
doubled the number of early stage breast cancers.
Chairman Waxman, I wrote at this point I was going to say
that I can't say it better than you said in your opening
statement. I will amend that to say I can't say it better than
you in your opening statement and Ms. Carey in her statement.
It is my belief that the CDC is to be congratulated but
that the CDC has been tremendously handcuffed by the lack of
funds. Fifteen percent of those who should be getting these
services are getting these services. These are people of all
races and, in many respects, race does not matter. Regardless
of race, all people, all women over the age 40 ought to be
getting these lifesaving interventions.
Indeed, for mammography and breast cancer screening with
clinical breast exam, it has been document that it can decrease
the death rate by 25 percent.
The fruits of research from the 1970's, 1980's and 1990's
are not being enjoyed by a substantial number of individuals.
These are women who are dying. They are White. They are Black.
They are Asian. They are Native American. They are Hispanic.
They are of all races and all ethnicities, and they actually
have in common the fact that they are poor or people who do not
have resources.
As an epidemiologist, I would conservatively estimate the
number of deaths per year that could be avoided at being
somewhere in the neighborhood of 2,000 to 3,000; 2,000 to 3,000
human lives that could be saved if we were to expand this
program.
Now, since I am an epidemiologist, I will answer a couple
of the questions, if you don't mind, that several of the
Congressmen asked earlier.
It is about one in seven or one in eight women who will be
diagnosed with breast cancer in their lifetime. Among women who
get the screenings that they should be getting, it is about 3
percent of all women who will ultimately die of breast cancer.
Among women who do not get the screenings, it is going to
be over 4 percent. That 25 percent decrease in death rate is a
4 percent lifetime rate going down to a 3 percent lifetime
rate.
There were questions about digital mammography versus
conventional mammography. Right now, we think of both of them
as being equal in terms of their diagnostic abilities.
However, digital mammography allows for easier storage and
increased computerization, ultimately in the next several
years, will allow for computerized abilities to read a digital
mammogram to assist the radiologist and perhaps create a
mammogram of higher quality and more likely to pick up the
mass. We are virtually on the verge of that right now.
Also, there were questions about HPV testing. Someone who
has a positive HPV test does not necessarily have cervical
dysplasia, a precancerous condition or cervical cancer. It
means that they actually have an infection with the virus that
causes the disease.
At this juncture, pap smears are the standard, and we
should use HPV testing judiciously to augment pap smear
testing, but all women should get a pap smear on a regular
basis. A few women ought to get a pap smear along with HPV
testing.
If I could just enter my written statement into the record,
sir, I will conclude with that.
Chairman Waxman. Thank you very much. Your statement in its
entirety is part of the record.
Dr. Brawley. Thank you, sir.
[The prepared statement of Dr. Brawley follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Chairman Waxman. Ms. Fuld Nasso.
STATEMENT OF SHELLEY FULD NASSO
Ms. Fuld Nasso. Thank you very much, Mr. Chairman, and
thank you to all the committee members for holding this very
important hearing today and for allowing me to testify.
My name is Shelley Fuld Nasso, and I am director of public
policy for Susan G. Komen for the Cure Advocacy Alliance.
Komen for the Cure was founded in 1982 and is the largest
grassroots network of survivors, breast cancer survivors and
activists and the world's largest non-profit source of funds
for fighting breast cancer.
As you heard, one in eight women will be diagnosed with
breast cancer in her lifetime, and every one of them deserves
the same chance to succeed, to survive. Unfortunately, in the
United States, whether you live or die from breast cancer
depends in large part on how much money you earn, whether you
have health insurance, the color of your skin and where you
live.
This is unconscionable especially since breast cancer has
become such a treatable disease. We know that when breast
cancer is detected early and is still confined to the breast,
the survival rate is 98 percent.
Over the past 10 months, we have been traveling around the
country with the Komen Community Challenge, our grassroots
campaign to restore the sense of urgency to breast cancer.
Everywhere we go, we meet women like Ms. Carey who are alive
today for one reason, because of the breast and cervical
screening program. I was going to share a couple of their
stories with you, but I think Ms. Carey said it all, and you
understand how important this program is.
Some of the women were uninsured during transitions in
their lives, like Ms. Carey, because they found themselves
without insurance. Others were uninsured for longer periods of
time. They maybe were poor and working, and some of them
working multiple jobs but still couldn't afford health
insurance. This screening program was a really important source
for them to be able to have that care.
One of the women that spoke at one of our events was
screened on a regular basis through the program which is very
important. It wasn't just that she found a lump. She considered
herself a health nut. She had no concerns, no lump that she
felt, but she was screened regularly which is very important to
helping treat, to detect the disease early.
The program saves lives every day, but as you know we are
only reaching a fraction of the women who are eligible and
serving less than one in five, and that means millions of women
are going without the screenings that they need.
I am not an epidemiologist, so I wouldn't have estimated
the number of women whose lives could be saved, but I
appreciate your, Dr. Brawley's estimates because it is a very
important question because we know that we don't have enough
money for this program to save lives that need to be saved.
We have talked a little bit about digital mammography which
we know is more expensive than standard mammography, but its
use is spreading rapidly. While it may be more effective for
some groups of women, Dr. Brawley has said it is considered
about equal.
But the concern is that as it spreads in its use, that
women are not going to have access if a community in a rural
area or an urban area has only digital access available, and
providers are not necessarily willing to accept the lower
reimbursement rates for standard mammography. And so, we are
seeing anecdotally from our Komen affiliates around the country
that some women are not able to have access because all of the
facilities in their area have become digital.
We are asking Congress to support this program at a higher
level, but we are not asking you to do it alone. We really
believe that this is a true public-private partnership, and
Komen and its 125 affiliates are doing their part.
Last year, we provided $70 million in grants to community
health programs including $25 million around the country for
the State programs and some of their providers to augment the
screening services available. This funding provides State
programs with more flexibility to maintain or increase the
number of women screened per year, alleviating waiting lists
and helping to detect cancer earlier.
One question was asked as to what happens when the money
run out. Some programs really strategically use their money
throughout the year so that the money doesn't run out, but in
other States the funding does run out during the year.
Our mid-Kansas affiliate has helped to fill that gap when
the program in Kansas has run out every year for the last 3
years. In addition, the Kansas program serves women 50 and
older, and the Komen funds are used to serve the women in their
40's for the program.
In addition to funding, Komen affiliates have joined with
other advocates like the American Cancer Society in urging
State legislatures to do their part. Not all States do provide
money for this program. We think that only about a third of the
States are providing funding.
They do not have to provide their own dollars for that one
to three match that we were discussing earlier, and some of our
advocacy campaigns in conjunction with our colleagues have
helped raise significant amounts of money at State
legislatures. In North Carolina, the State assembly approved $2
million per year for the next 2 years which will allow an
additional 8,000 women to be served. In Ohio, the State
approved $5 million over 2 years which will triple the number
of women who can be served.
In our first 25 years, Komen invested $1 billion in the
fight against breast cancer, and we have pledged to invest
another $2 billion in the next 10 years. So we are not asking
the Federal Government to do it alone. But, at the same time,
we can't do it without the Federal Government.
This program is an important, cost effective and lifesaving
program. In order to close the gaps that make breast cancer
deadlier for some women than others, we need the Federal
Government to increase its commitment to funding the program
because every woman's life is valuable and every woman is
someone's mother, wife, sister or friend.
Thank you very much for listening.
[The prepared statement of Ms. Fuld Nasso follows:]
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Chairman Waxman. Thank you very much for you testimony.
Dr. Joyner.
STATEMENT OF PAMA JOYNER
Ms. Joyner. And I am not a doctor but today I am, I guess.
Thank you, Mr. Chairman and distinguished members of the
committee for the opportunity to testify before you today on
the experience of Washington State with our Breast and Cervical
Health Program and that of other members, States, tribes and
territories of the National Association of Chronic Disease
Directors Breast and Cervical Cancer Council.
My name is Pama Joyner, and I am the program director for
Washington's program. My responsibilities include providing
leadership for program implementation, overall program focus
and direction, and establishing and maintaining key stakeholder
relationships.
Early detection is the best way to reduce deaths from
breast and cervical cancer and all States, the District of
Columbia, 12 tribes and 5 territories support a variety of
strategies to reach underserved women.
In Washington, our program not only saves lives but also
enhances the overall health and well being of women who
participate. Since the program's inception, we have offered
vital services to thousands of Washington's most economically
burdened women.
It is a core value that each woman enrolled received state-
of-the-art screening, diagnostic and treatment services. The
women's health examination, provided at initial enrollment and
then repeated with each re-screening, is often the only primary
care visit these women receive.
An increasing number of women across the Nation meet the
eligibility requirements, yet system and resource capacity is
pressed to even maintain existing service levels with each
State only able to reach a fraction of the eligible population.
In Washington, we are reaching approximately 30 percent of
the eligible uninsured population. In Virginia, they are
screening 22 percent of their eligible uninsured population
where Tennessee and New York are reaching 11 percent.
Illinois, where they recently received a substantial
increase in State funding for their program, is still only able
to screen 17 percent of the eligible population. In California,
they are able to screen approximately 23 percent of the
eligible uninsured and underinsured population for breast
cancer and just 8 percent for cervical cancer.
States use a variety of strategies so that funding either
meets their screening goals or ensures services are available
throughout the year. Some States report they run out funding
before the end of the program year due to meeting their
screening goals early, and in other States the programs monitor
enrollment and expenditures to ensure services are available
all 12 months of the program year.
Waiting lists are a good indication of program need.
However, many are uncomfortable in creating waiting lists as
there is a sense that eligible women are being promised
services the program may not be able to deliver.
In Washington State, when screening resources were limited
to Federal and State funding only, waiting lists were
instituted. At one point, more than 1,000 women across the
State were waiting for screening services. We were able to stop
having waiting lists upon receiving grant awards from the Susan
G. Komen for the Cure to support breast health screening
services.
In Virginia, providers have begun to maintain waiting
lists. The program currently projects there are approximately
100 women waiting for services. Florida and Idaho also report
similar numbers at some of their screening sites by the end of
the program year. The reason, though, for Ohio's waiting list
is not due to a lack of funding but to staffing and appointment
limitations.
In Tennessee, there is no waiting list. The program
projects it will need to stop screening mid-May and plans to
ask women to call back after the start of the new program year,
July 1st.
New technologies and increasing health costs impact a
program's ability to increase their screening numbers. Level
funding year after year is recognized as a cut, resulting in
fewer women screened. Other operational costs continue to
increase while funding remains relatively flat, impacting a
program's ability to maintain or increase its screening
numbers.
Tennessee experienced a significant cost increase when they
decentralized their program. This created a greater demand for
services as more eligible women became aware of the program,
and it impacted their costs in other areas of the program. This
includes advertising the service, providing the services and
supporting access to treatment for those women diagnosed with
cancer. All of these activities are required to meet the
program performance measures.
Increasing financial resources to screen more women is
necessary but having provider capacity to screen more women is
critical. Many programs rely on the local public health
agencies and network of community health clinics and others.
While they use these systems, they also contract with
individual providers and large private clinic systems.
In fiscal year 2007, Washington State screened 2,000 more
women than they did in 2006 and, our goal this year is to
screen 2,000 more women than we did last year. With just 10
percent more funding each year, we could continue to increase
these numbers over the next 4 years and reach 41 percent.
Early detection is the best way to reduce deaths from
breast and cervical cancer. Access to screening, diagnostic
services and treatment is critical for all women, regardless of
income, education, race or ethnicity.
However, women with low incomes are less likely to receive
cancer screening and are more likely to be diagnosed with more
advanced diseases than higher income women. This national
program not only saves lives but also enhances the overall
health and well being of the Nation's most economically
burdened women.
Thank you.
[The prepared statement of Ms. Joyner follows:]
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Chairman Waxman. Thank you very much, Ms. Joyner.
Dr. Hoerger.
STATEMENT OF THOMAS HOERGER
Mr. Hoerger. Thank you. Mr. Chairman and members of the
committee, I am pleased to appear before you today to provide
you with information regarding a cost analysis conducted by
researchers at RTI International of the National Breast and
Cervical Cancer Early Detection Program.
I am Tom Hoerger, a senior fellow at RTI International and
also director of the RTI-University of North Carolina Center of
Excellence in Health Promotion Economics. RTI International is
an independent, non-profit research organization based in North
Carolina that conducts a wide range of research and technical
services for the U.S. Government and private sector clients.
The study in question was conducted by RTI researchers in
collaboration with researchers from the U.S. Centers for
Disease Control and Prevention. Although I am not an author of
this particular study, I am very familiar with its findings and
have significant experience in conducting similar studies. The
study will appear in the February 2008 issue of the journal,
Cancer.
The study analyzed the costs associated with the Breast and
Cervical Cancer Program established by Congress in 1990 to
deliver breast cancer and cervical cancer screening to
medically underserved, low income women.
The study looked at nine participating programs in nine
different States to answer three economic questions. No. 1,
what is the cost per women served in the program? No. 2, what
is the cost per woman served by program component? And, No. 3,
what is the cost per cancer detected through the program?
There was wide variation in the nine programs from State to
State in terms of organization, reliance on in-kind
contributions and the number of women served. These and other
factors contributed to a fairly wide variation in costs.
We found that the median cost in the nine State programs
was $555 per woman served. This figure includes the value of
in-kind contributions such as donated goods and services.
Without in-kind contributions, the cost was $519 per woman
served.
The term, women served, includes the number of women
screened in the program plus the number of women who were
screened outside the program and were referred to the program
at the diagnostic stage for followup of abnormal results.
When looking at the screening alone, screening for breast
cancer costs $94 per patient while the cost for cervical cancer
screening was $56 per patient. These estimates are within the
range of estimates for the costs of breast and cervical cancer
screening in other settings and programs.
The median number of breast and cervical cancers detected
per program was 75 and 26, respectively. Based on these
figures, the study found that the cost per breast cancer
detected was $10,566. The cost per detection of cervical cancer
was $13,340.
Based on the research, there is also some evidence of
possible economies of scale in that average costs may go down
with the number of women screened. However, the evidence is not
conclusive because only a small number of programs were
surveyed. In addition, the sites were not randomly selected.
The study also assessed the program's allocation of funds.
Almost 60 percent of the program funds were used for direct
clinical services which include screening and diagnostic
followup, referral for treatment and case management.
The remaining 40 percent of program resources were
dedicated to activities including public education and
outreach, professional education, quality assurance and
improvement, surveillance and evaluation. These activities help
address issues other than financial barriers that prevent low
income women from receiving cancer screening services.
Studying only nine of the programs for just 1 year leaves
some limitations in the findings because the sample size is
small and we know that funding and other sources of resources
vary from year to year depending on activities planned.
However, we are currently conducting a second phase of this
study that will provide a more comprehensive examination of the
costs associated with screening in the program. Phase two of
the study is examining all 68 breast and cervical cancer
programs operating in the United States.
Collecting cost data from all of the programs will provide
a much richer understanding of program variation and will
support econometric analysis of cost determinants. We will test
for economies of scale and be able to control for differences
in cost of living between programs. The data may allow us to
identify best practices and learn more about the optimal mix of
spending across program activities.
This study is expected to be completed in 2009.
Thank you for your time.
[The prepared statement of Mr. Hoerger follows:]
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Chairman Waxman. Thank you very much for your testimony. I
want to thank all of you for your presentations.
I want to start the questioning. For Ms. Joyner, I want to
thank you for your work in Washington State and for the
National Council of State Programs. I would like to ask some
questions about the shortfalls you have described in various
States' breast and cervical cancer screening programs.
First of all, all States have to make some contribution to
their screening program. Isn't that correct?
Ms. Joyner. Yes, that is correct.
Chairman Waxman. Have all States been able to contribute
additional State funds?
Ms. Joyner. No, not all States contribute State funding.
So, in terms of their in-kind or match that they are needing to
come up with, they can either find providers are kicking or
another way would be looking at what the usual and customary
cost is of a particular test and when you subtract the Medicare
reimbursement rate, whatever that balance is can also be
counted as an in-kind cost.
Chairman Waxman. So they have a number of streams of
funding. Is there always a steady stream that State directors
can rely on for their annual planning?
Ms. Joyner. No.
For Washington State, we do have an annual or biennial
budget in State funds. We have our Federal grant which through
the 5-year cooperative agreement, and then we receive funding
from three Komen affiliates, a private local foundation and,
most recently, American Cancer Society. And those, of course,
are all annual grant awards that we apply for and are
contingent on the priorities of the affiliates' boards.
Chairman Waxman. I would imagine the States with high
numbers of eligible women might be among the States least
equipped to allocate State dollars to screening. Is that an
accurate statement?
Ms. Joyner. I think there is a variety of States that have
a high eligible population, and some of those States do have
State funding and some don't have any State funding.
Chairman Waxman. When a State program runs out of money for
the year, what happens to women who are seeking mammograms?
Ms. Joyner. Well, a number of things can happen. In some
States, they have the ability to make resources available,
especially if they have women who are calling, who are
reporting systems of some sort. So they would not turn them
away. So they have that assurance that women needing services
will continue to be screened.
In other States, they have to just stop and either start
taking names or asking women to call back after the start of
the new program cycle.
Chairman Waxman. So they either put them on a waiting list
or they refer them then to public clinics?
Ms. Joyner. They could refer them to the public clinic,
again, where they might be facing looking at a sliding fee
scale or taking on bills that they can't pay.
Chairman Waxman. Dr. Brawley, a vaccine to prevent
infection with several of the cancer-causing strains of HPV
have been licensed by the FDA and is recommended for young
women and adolescents from age 9 to 26. A second vaccine, HPV
vaccine, is in the pipeline.
This is a potentially lifesaving advancement, but the
vaccine is more expensive than many of the older vaccines.
Isn't that correct?
Dr. Brawley. Yes, sir. The vaccine is somewhere in the
neighborhood of $200 a dose, and it requires three doses.
Chairman Waxman. So $200 for each dose or $200 for the
three?
Dr. Brawley. Yes, sir, per dose, $600 total.
Chairman Waxman. $600.
The Vaccines for Children Program will provide vaccines for
eligible girls 18 and under, but there is no comprehensive
program to make the vaccine available to uninsured or
underinsured women from age 18 to 26.
Are you concerned that uninsured and underinsured women
will not be able to afford this vaccine and will therefore miss
out on its benefits?
Dr. Brawley. Yes, sir. I am tremendously concerned about
that, sir.
Chairman Waxman. Representative Roybal-Allard and I on the
House side and Senator Kennedy on the Senate side have
introduced legislation to create a Federal Vaccine for
Uninsured Adults Program. This program is modeled on the
Vaccines for Children and would give women who may not be able
to afford the HPV vaccine, access to this vaccine as well as
other important adult immunizations.
I hope that the American Cancer Society will take a look at
this legislation. We would love to have your support.
Dr. Brawley. Sir, I can promise you, we definitely take a
look at it, and I would be shocked if we don't support it.
Chairman Waxman. OK. Thank you.
One of the unfortunate disappointments to me in this so-
called stimulus package that we are going to be voting on, on
the House floor today is that we didn't provide more money for
the Medicaid program for the States. We did last time there was
a recession and we passed a stimulus program, a one-time
stimulus.
I think that is something that many of you might want to
speak up about because if the States, looking at more people
losing their jobs, more people losing their insurance, more
people going on Medicaid because they have no other
alternative, whether it is for this program or any other, they
are going to be hard put because the States are going to be
cutting back on Medicaid. They will be generating less revenues
as unemployment goes up. That is what we call counter-cyclical.
I am disappointed it is not in this package, but I think we
ought to be pushing to get some more help for Medicaid because
we are going to need those funds as more people find
themselves, even in surprising ways, unexpectedly uninsured,
like the situation Ms. Carey had to confront.
Thank you very much.
I want to recognize my colleague for questions for 5
minutes.
Mr. Higgins. Thank you, Mr. Chairman.
Dr. Brawley, I would just like to ask you about, again, the
status of the 2015 Campaign. Where are things at and is it
still a stated goal?
Dr. Brawley. Well, sir, there were two 2015 goals out
there. The first was the American Cancer Society's goal which
was to halve the incidents of cancer and significantly
decreased mortality from cancer from 2015, and it is still
there.
We are slightly off target. Part of the reason that we have
been pointing out the access to care is a huge problem in the
United States is because we need to fix the access to care
problem to get back on track for the ACS 2015 goals, which are
still reachable.
But this is a breast and cervical cancer hearing, but I
will tell you one is better off in this country with stage two
colon cancer and insurance than to have stage one colon cancer
and no insurance. Better to have the more advanced disease with
insurance than to have the less advanced disease without
insurance because the 5-year survival rate of a stage two
insured patient in the United States, regardless of race, is
superior to the 5-year survival of a stage one patient without
insurance.
But that is a long-winded way of saying we need to look at
access to care. We need to look at all kinds of programs like
this to get treatments that are proven.
You gave a wonderful talk about research. I was at the
National Cancer Institute for years, and I am a tremendous
believer in doing more research, but we are talking about today
is research that has already been completed that people do not
get to enjoy.
Mr. Higgins. The 14 or 15 percent of those who are getting
treated, who are eligible for the Breast and Cervical Cancer
Early Detection Program, what is the approximate breakdown?
Anybody from the panel, what is the approximate breakdown of
the sources of funding for those programs?
I am trying to get, I suppose, at the level to which the
Federal Government is responsible for that 14 percent of those
who are eligible.
Ms. Joyner. So all 68 programs receive Federal funding from
CDC, and then out of those 68 programs a variety have some
State funding, have Komen funding, have American Cancer Society
funding, but there still are a handful of States that have only
Federal funding and no other sources.
Mr. Higgins. How are those moneys distributed?
My understanding is a lot of the cancer research funding,
there are comprehensive cancer centers that do research, and
then they apply to the National Cancer Institute for funding
relative to promising research. How is the Federal piece
accessed, I suppose?
Ms. Joyner. For the screening program?
Mr. Higgins. Yes.
Ms. Joyner. OK. Well, the screening program doesn't have,
first of all, anything to do with research.
Mr. Higgins. Right.
Ms. Joyner. So, and each grantee has their way of going
about allocating funds.
So, in Washington State, we have a service delivery system
which we call our prime contractors. Those are seven
organizations. Four are local public health jurisdictions. Two
are hospitals, and one is a community-based organization. They,
in turn, subcontract with providers that are made up of
community health networks, private practices and some larger
clinical systems.
Mr. Higgins. Given limited funding, is that an efficient
way to distribute those moneys?
Ms. Joyner. It has been an extremely efficient way of
expending the funds. Prior to moving the decentralized model,
we operated as a centralized State where the State Health
Department put all the dollars out, collected all the data,
ensured that all the women were being screened, and there were
many challenges and the funding was not expended in the most
efficient manner.
Mr. Higgins. You would identify Washington State as a model
for efficient delivery of those?
Ms. Joyner. For what works for the geographic regions of
our States, how we are laid out, the system that we built, yes.
Mr. Higgins. I have no more questions, Mr. Chairman. Thank
you.
Chairman Waxman. Thank you very much, Mr. Higgins.
I want to ask a few more questions if I might.
Ms. Carey, one of the concerns that many of us have is
whether women know about this program for screening and then
for care if they need it. You found out about it through the
American Cancer Society. Is that right? Somebody from the
American Cancer Society told you about it?
Ms. Carey. Actually, I found out about it from this woman
who worked at the hospital because she worked at the
mammography division of the hospital as a certified mammotech,
and I mean she is my best friend. She was frantic to save my
life, and she found out because they had the literature at the
center itself.
And I think that would be part of the problem is that they
are not reaching enough people, but then also the problem is
that the people they are reaching, like they say, they are
over-booked.
I mean I was extremely fortunate. I say that I am extremely
lucky. I shouldn't be sitting here today. If not for Kim
letting me know, I wouldn't have known because I had gone to. I
went to the HIPP center for Medicaid. I was looking for a
Healthy New York type of program, like a policy for insurance
just to get me through until I could have my own insurance.
And the woman took all my identification, my pay slips and
my identification and my birth certificate, and then she very
flippantly says. Well, she goes.
I said, well how long do you think it will take to process
this?
She goes, well, this could sit on somebody's desk for 2
months.
And I was panicking. I said, well, I don't have 2 months,
and I just gathered up all my stuff. I said, you know what?
Just forget about it.
That is when Kim came to me. She said, Gail, you are not
going to believe this, and I didn't believe it.
Chairman Waxman. Well, the program just started in New
York.
Ms. Carey. It had only just started that month, that year.
Chairman Waxman. We hope that more women hear about it even
if they don't have a very close friend, personally, to tell
them about it.
Ms. Carey. Absolutely.
Chairman Waxman. So you think the outreach to women to let
them know, the education about such a program is essential, I
would assume.
Ms. Carey. Absolutely, and they have made huge strides in
the past 5 years alone, huge strides. It is unbelievable how
many people they have been able to reach and caught this so
much earlier.
And, again, you know what they have stressed here, because
I was so advanced in my cancer, the cost of my treatment was
absolutely cost-prohibitive. I am embarrassed to say. Again,
the reason that I am here is because I am absolutely paying
back for the rest of my life because I am that grateful because
if I hadn't been so frightened and so proud about, I would have
sought treatment a great deal earlier.
If this program, for women who seek treatment, the cost is
unbelievable. I would have gotten screening. I would have been
treated. I would have had no problem.
Chairman Waxman. You were trying to get into Medicaid, and
that was taking time.
Ms. Carey. I absolutely was trying. I was frantic.
Chairman Waxman. Getting right through the screening
program got you into the Medicaid program right away for the
care you needed.
Ms. Carey. Right through, immediately.
You know what? The other misconception, and I really want
to address this, is a lot of people say, oh, my gosh, you know
every year we are going to have to pay for these people in
Medicaid.
It is not that way. We are not looking for a handout. We
are people who have worked all of our lives. We have paid our
taxes. We have paid our insurance. We have always had
insurance. We are not deadbeats.
I was frantic to save my house. When I finally did get my
feet, when I was able to establish that I actually had.
I mean even my boss. I started working at this, for a
doctor actually. Two weeks later, I was diagnosed with this
cancer, and she held my job for me here, 5\1/2\ years later,
and I am still with the same doctor. He is extremely
sympathetic for the program, for anybody else who is on
Medicaid.
Chairman Waxman. Let me ask you one other question, and
then I want to ask some of the other members in the short time
I have left.
Ms. Carey. Yes.
Chairman Waxman. The program is not just to screen, as
important as that is. Originally, that is all we got was a
screening program for breast and cervical cancer.
Ms. Carey. Right, right.
Chairman Waxman. I remember when Mrs. Quayle came in, and I
was chairman of the subcommittee and authored the bill to
provide for the breast and cervical cancer program.
Ms. Carey. Wow. Thank you.
Chairman Waxman. But I said what if we find out that they
have cancer? What are we going to do then?
She said, well, at least we want to give them that
information. Of course, it is pretty harmful.
Ms. Carey. But they don't leave you hanging.
Chairman Waxman. Yes, it leaves you hanging.
Ms. Carey. They don't.
Chairman Waxman. Once you're covered for treatment, what I
have heard and from your own experience, is that it is really
essential to have a case manager to help you through the whole
process.
Ms. Carey. Yes, unbelievable. Yes.
Chairman Waxman. Did you think that was essential for you?
Ms. Carey. That was the most astounding thing. It was a
brand new program, and they had such a network. It was like I
was passed from person to person to person from oncologists,
surgeons, hospitals, and you never ever felt like you were
being dropped.
The support system through the American Cancer Society was
like nothing I have ever seen. You don't realize how important
the Society is until you have the opportunity to use them, and
I have been so blessed by this Society.
Chairman Waxman. You are a very strong and excellent
spokesperson for this effort from your own experience.
Ms. Carey. Thank you, and I have since gotten off the
program. I am on my own insurance now. So I am saying it is not
a handout. It is just hand up.
Chairman Waxman. Absolutely not.
Ms. Carey. We just need to get from one place to the other.
Chairman Waxman. Absolutely not. I agree with you
completely.
Ms. Carey. Now I am good to go. So, thank you. Thank you so
much.
Chairman Waxman. Even though my time is expired, since I am
the chairman, I am going to take advantage of the opportunity
to ask Ms. Fuld Nasso a question. [Laughter.]
Your organization helps a number of States to address the
gap in breast screening programs. How do you make the decisions
of where the Komen funds are going to go?
Ms. Fuld Nasso. We have a network of 125 affiliates around
the country.
Chairman Waxman. Is your mic on?
Ms. Fuld Nasso. Let me pull it closer.
We have a network of 125 affiliates around the country, and
they raise money through events like the Komen Race for the
Cure and other events in their community. They keep 75 percent
of that, of the money in their community and give 25 percent to
our research programs.
Each one of those affiliates has a grants committee that
reviews requests for grants, and so in some cases they give the
money directly to the State program in order to supplement.
Like the example that Ms. Joyner said, in Washington where she
receives money, her program receives money from three of the
affiliates in Washington.
In other cases, the affiliates work with the State program
to identify the right providers that need additional funding
and give that money directly to those providers. Sometimes it
is also to help with the outreach and the advertising.
Chairman Waxman. It first goes to the people. It first goes
to the area where the people who are raising the money direct
it.
Ms. Fuld Nasso. Right, it goes in the community where the
affiliate is. Right.
Chairman Waxman. Then 25 percent can go elsewhere to other
places where there is a huge gap in funding?
Ms. Fuld Nasso. The 25 percent actually to our national
research program, and we are planning to grant $100 million for
research this year, and that comes from money that we raise in
headquarters and also money that our affiliates around the
country raise.
Chairman Waxman. Well, I would assume that you probably
have a pretty good sense of where the holes in screening are
around the country.
I want to ask you for the record if you would send us this
information, recommendations you would make about how the
Federal and State governments can systematically narrow that
screening gap in the areas where we have seen it. If you would
send that information, we would welcome it.
Ms. Fuld Nasso. Yes, we can definitely get you that
information.
Chairman Waxman. I thank all of you very much for your
presentation. I hope this hearing will be able to give us the
ability to make the case, as you have eloquently done, why this
program is essential, why we need to fund it adequately, and
the absolute benefit of putting money into find cancer at an
early time when it can be dealt with.
I thank each and every one of you.
Ms. Fuld Nasso. Thank you very much.
Chairman Waxman. That concludes our hearing today, and the
committee stands adjourned. Thank you so much.
[Whereupon, at 11:55 a.m., the committee was adjourned.]
[Additional information submitted for the hearing record
follows:]
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