Healthy People (HP), a program first initiated in 1979 as a Surgeon General’s report (1), tracks 10-year national objectives for improving the health of all Americans. It provides a framework around which public health agencies, private organizations, and the general public can take action. This framework is couched as a series of objectives focused on improvements in a wide variety of indicators for health status, risk reduction and prevention, health service delivery, and surveillance and evaluation. The objectives include specific metrics, or “targets,” that allow progress to be assessed (2).

HP calls for a reduction in cancer deaths overall and in the prevalence of specific cancers (cervical, breast, colorectal, and prostate) that may be reduced by the use of screening tests and the timely and appropriate treatment of early-stage cancers. The National Cancer Institute (NCI) and Centers for Disease Control and Prevention (CDC) jointly lead the development of the cancer screening objectives and targets. The HP 2020 objectives for cancer, launched in December 2010 (3), were developed by federal experts with input from a diverse group of individuals and organizations, and were refined through a process of public comment and interagency review. Data from the 2008 National Health Interview Survey (NHIS) were used in setting targets for cancer screening, counseling about screening for cervical and breast cancer, and access to health care. Several targets were established to be a 10% improvement over the 2008 levels reported in the NHIS.

Reducing cancer illness and death is a key public health goal for the United States, and evaluating attainment of HP 2020 cancer-related objectives is an important gauge of our success in meeting this goal. We examine NHIS data from 2008 and 2010 to provide a benchmark for achieving HP 2020 objectives for 4 categories of cancer-related preventive health services: receipt of cancer screening tests, provider counseling about cancer screening, genetic counseling for women at high risk for breast or ovarian cancer, and access to health care. We include HP objectives and NHIS measures for health insurance status and having a source of ongoing medical care because receipt of cancer-related preventive services is strongly associated with these indicators of health care access (4–6). We also examine use of cancer-related preventive services by sociodemographic subgroups. Our overarching goal was to examine the most current NHIS data to derive insights into population-level challenges in meeting HP 2020 objectives for cancer-related preventive services.

The NHIS is an in-person survey of a nationally representative sample of the US civilian noninstitutionalized population aged 18 years or older (7). Conducted annually by CDC’s National Center for Health Statistics (NCHS), the NHIS is one of the principal sources of information on the health status of Americans and their use of health services. To monitor national progress toward HP cancer goals, the Division of Cancer Control and Population Sciences, NCI, and the Division of Cancer Prevention and Control, CDC, have sponsored a Cancer Control Supplement to the NHIS, fielded every 5 years since 2000. Shorter supplements were fielded in 2003 and 2008. Table 1 provides the 2008 and 2010 NHIS sample sizes and corresponding US population denominators for each HP cancer control objective as well as the NHIS measure used to assess the objective. For the genetic counseling items, we used 2005 NHIS data instead of 2008 because questions about genetic counseling were not included in the 2008 NHIS. Complete NHIS survey instruments are available from NCHS (8). Response rates for the 2008 and 2010 NHIS were 63% and 61%, respectively, for the final samples, taking into account household nonresponse (9,10).

We observed marked disparities in cancer screening and provider counseling rates for certain population subgroups, especially the uninsured and those with low income or no usual source of health care. Population subgroups whose access to care was the most compromised as measured by not having health insurance and not having a usual source of care included Hispanics and those below 200% FPL.

Given the well-established link between economic recession and decreased health insurance coverage (14), and the strong relationship between health insurance and cancer screening use, the gaps we observed for some HP measures may reflect the adverse state of the US economy during 2008 through 2010. However, neither Pap test nor mammography use increased during the past decade (15), suggesting that factors influencing cancer screening trends predate the most recent economic downturn and that meeting HP 2020 targets for cervical and breast cancer screening may be challenging. Further, our results show consistent and persistent disparities in receipt of cancer screening and provider counseling and in health care access for certain subgroups, suggesting that attaining HP cancer-related targets by 2020 may be challenging in the absence of new approaches to expand health insurance coverage, improve access to cancer screening and treatment services, better integrate clinical and community preventive services, and improve health literacy.

One landmark development is the 2010 Patient Protection and Affordable Care Act; components of this national legislation are intended to reduce considerably the proportion of people who lack health insurance coverage or access to primary care providers or both. The importance of preventive health services for cancer control is recognized in the legislation, which makes certain services — including cervical, breast, and colorectal cancer screening — available with no cost-sharing in Medicare and in all new health insurance plans effective September 23, 2010 (16). Although newly eligible Medicaid beneficiaries also should experience improved access to these and other preventive services under health reform, some states may not provide equivalent coverage for existing Medicaid beneficiaries (17). It will be especially important to monitor attainment of HP objectives among health reform’s expanded Medicaid population. The legislation also calls for development of the National Prevention Strategy, which recommends improving integration of evidence-based clinical and community preventive services that may lead to an expanded role for public health in cancer screening (18–20). Finally, meeting HP objectives for counseling about cancer screening and genetic testing may require greater attention to provider-focused initiatives and interventions (21).

As the designated data source for evaluating many HP objectives, the NHIS has several strengths, including its large, nationally representative sample and high response rates. Limitations include the self-reported nature of the data; respondents may overestimate or underestimate cancer screening prevalence (22,23). The NHIS, though, is periodically revised to improve the description of screening tests and frame questions in a way intended to increase the accuracy of respondent reports. The NHIS also is limited in its ability to assess HP objectives for provider counseling about genetic testing and cancer screening. As previously mentioned, NHIS sample sizes of women at high risk for breast and ovarian cancer were too small for stable estimates of receipt of provider counseling for genetic testing. Regarding HP 2020 objectives for increasing the proportion of adults “counseled about cancer screening consistent with current guidelines,” the NHIS question about discussing with a health care provider whether to have PSA testing is descriptive of “counseling,” but the corresponding questions for cervical, breast, and colorectal cancer screening may be less so because they ask merely about doctor or health care provider “recommendation.” If broader issues of provider counseling for cancer screening tests, such as starting and stopping ages, differing screening intervals, or choice of screening tests, are incorporated into HP, the NHIS would need to be augmented. National surveys of health care providers — which NCI and CDC have supported for more than a decade, with several focusing on cancer screening (24–29) — might be an important, complementary data source to the NHIS.

Because cancer is a leading cause of premature death and a leading source of health care expenditures in the United States, HP goals for reducing cancer incidence and mortality are important for the public’s health and economic well-being. The NHIS is a key data resource for setting and evaluating HP objectives. Our assessment of the most currently available NHIS data suggests that meeting some cancer-related HP 2020 objectives may be feasible, but others — particularly those involving cancer screening and health care access — may depend on successful implementation of health reform provisions, better integration of clinical and community-based efforts to provide high-quality screening and treatment services, and elimination of health disparities in the United States.