Provider Manual - Show Me Healthy Women (SMHW)

Section 13 - Appendices

Providers

Client Referral

A complete list of providers is on the DHSS website. The list is updated regularly. Refer clients with Internet access to the website or they may call the SMHW toll-free number 866-726-9926.

RPC Contact Information

Names	Phone Numbers	Fax Numbers
Mary Young, RN; Kansas City/Northwest Area	816-859-4887	816-404-6986
Lisa Graessle, RN; Central/Northeast Area	573-522-2855	573-522-3023
Margaret Laycock, RN; St. Louis Area	314-657-1509	314-612-5005
Missy Rice, RN; Southwest Area	417-693-3409	573-522-3023
Mary Costephens, RN; Southeast Area	573-536-1809	573-522-3023

SMHW Regional Program Coordinator County List

View coordinator list

Request for Literature

Request literature using the “ Request For Literature” form available on Free Resources.

Available Literature in English

View literature

Available Literature in Spanish

View literature

Most Commonly Asked Questions

Several patients had an abnormal clinical breast exam reported as discrete palpable mass, suspicious for cancer, followed by a mammogram w/ negative result. Providers deemed this adequate follow-up/no further evaluation. Is this acceptable practice?

Question:

We have several patients who have had an abnormal clinical breast exam reported as “discrete palpable mass, suspicious for cancer”, followed by a mammogram with a result of “negative”. The providers deemed this adequate follow-up and no further evaluation was scheduled or completed. Is this acceptable practice even though the NBCCEDP guidelines recommend further testing?

Answer:

A negative mammogram does not rule out cancer for a patient with suspicious breast mass found on physical exam. To determine if the mass is malignant or not, complete additional evaluations such as an ultrasound or a needle biopsy. When providers identify a suspicious mass, they are obligated to follow-up with a complete evaluation and obtain a definitive diagnosis.

Since breast ultrasound CPT codes 76641 and 76642 are both unilateral, should we expect to see two CPT codes billed if a bilateral ultrasound exam is needed?

Yes. If complete examination is performed on both breasts, you should receive two ultrasound codes of 76641. If a limited exam is performed bilaterally, you should receive two 76642 codes.

Does CDC ever allow payment for services that exceed Medicare reimbursement rates?

No. As stated in the Breast and Cervical Cancer Mortality Prevention Act of 1990 that authorized the NBCCEDP, the program cannot provide reimbursements that are higher than Medicare reimbursement rates.

Is it appropriate to reimburse for an ultrasound prior to 6 months for BI-RADS 3 due to fat necrosis?

Yes, they should reimburse based on the findings; an earlier ultrasound is appropriate.

Would SMHW pay for HPV testing if the client has paid for the Pap and the results were ASCUS?

SMHW can cover the diagnostic work-up.

Is it appropriate to screen women with “Dense Breast” with an ultrasound alone w/o clinical risk assessment? Is it appropriate to use an ultrasound screening for women w/ dense breast tissue deemed high risk by clinical risk assessment tool?

Question: Is it appropriate to screen women with “Dense Breast” with an ultrasound alone without clinical risk assessment? Is it appropriate to use an ultrasound screening for women with dense breast tissue deemed high risk by a recognized clinical risk assessment tool?

Answer: Currently, there are no screening guidelines recommended for breast ultrasound. Use of ultrasound as a tool for breast cancer screening is still in an investigational phase. Inefficient use of any tool may provide the patient with false degree of relief or concern. The provider is accountable for any inappropriate use of BI-RADS results or testing.

How does the CDC address transgender-identified individuals in the health care setting?

Following the Breast and Cervical Cancer Mortality Prevention Act that authorized the NBCCEDP and specifically states “women”. The focus of the NBCCEDP is women who are at risk for breast and cervical cancer. Use the federal funds only to cover screening for female-to-male transgender individuals who have not yet undergone complete hysterectomy or bilateral mastectomy because these individuals are genetically female. We do not use federal funds for male-to-female individuals who are genetically males.

What if a physician, who does not participate in the SMHW program, refers a woman with a BI-RADS IV or V ultrasound to a SMHW provider; can that woman be enrolled into SMHW and be eligible for Breast and Cervical Cancer Treatment (BCCT) services?

If a client has a BI-RADS IV or V ultrasound prior to enrolling into SMHW, the nonparticipating provider should refer the client to a SMHW participating provider. The client must meet SMHW eligibility requirements and complete enrollment forms. Then the SMHW provider should submit the woman’s screening and diagnostic test results completed by the nonparticipating provider to SMHW by completing the MOHSAIC forms and submitting them as “reporting only”. The SMHW provider may then proceed with performing additional diagnostic services such as a biopsy and submit results to SMHW for reimbursement. If the biopsy is positive for cancer, the client can be qualified for BCCT services. (SMHW must have reimbursed at least one screening or diagnostic service in order for a client to be eligible to receive BCCT services. Please note that if the only SMHW reimbursement is for a SMHW administrative referral fee for reporting only screening and diagnostic services, the client will not qualify for BCCT services).

What happens when Show Me Healthy Women (SMHW) has covered the screening and/or diagnostic services, but the client needs treatment?

Most women who receive SMHW-paid screening and/or diagnostic services and are in need of treatment for breast and/or cervical cancer will be eligible for a special MO HealthNet (Medicaid) BCCT program.

How much of the reimbursement for services from SMHW must be paid to the subcontractor?

SMHW does not require service providers to pay any specific rate to the subcontractors. The service providers can negotiate a reimbursement rate with the subcontractor, as they feel appropriate. SMHW will only pay the established reimbursement rate to the service provider.

Can our facility funding amount be increased?

Yes. SMHW can increase the funding amount based on the availability of funds and if 80% of the facilities existing funds have been expended. Request an increase by calling SMHW at 573-522-2845, or sending an e-mail to the program manager with the amount of increase needed. The SMHW program must be in receipt of the letter or e-mail 14 business days prior to the end of the contract period for consideration for a funding increase.

If a woman under 35 contacts us reporting that she feels a lump in her breast, can we enroll her in SMHW program?

Yes. On October 1, 2024, SMHW lowered the age eligibility to women 21 years or older for services. If a provider needs assistance locating services for women under 21 years of age, please contact the Regional Program Coordinator assigned to your area.

What do I do when the client does not keep her mammogram appointment and her breast screening is now over 60 days?

Continue to schedule the mammogram appointment and repeat the clinical breast examination (CBE), if recommended by the examiner. Client may have her screening mammogram any time before the ten (10) months have elapsed for her next annual screening. If the CBE was negative, she does not have to have a repeat CBE within the ten (10)-month period.

Is a client with no Social Security number and no proof of income and residency eligible for SMHW?

Yes. The client must sign the client eligibility agreement form found in Section 10. The English version is on page 10.6 and the Spanish version is on page 10.7.

How do I report when a SMHW client has surgery after I have sent in the reporting of her diagnostic services?

Contact your assigned RPC first. If the RPC is not available, call the SMHW central office tollfree at 866-726-9926, call 573-522-2845, or fax inquires to the SMHW office at 573-522-3023.

Whom do I call if I have questions?

Contact your assigned RPC first. If the RPC is not available, call the SMHW central office toll-free at 866-726-9926, call 573-522-2845, or fax inquires to the SMHW office at 573-522-3023.

I am waiting for lab results to complete paperwork. What should I do?

Hold paperwork until results are available. If it is close to the 60-day cutoff, contact the lab and express your need to have the results in order to be paid. Contact your RPC and document the lab contacts in the comments section.

What should I submit for reimbursement?

The clients’ reporting form(s).

Who establishes subcontracts?

The service providers may establish subcontracts with different facilities. SMHW does not play any role in establishing or assisting to establish subcontracts.

What happens if we submit our forms after 60 days?

Payment may be denied. If there are unusual circumstances, contact the billing coordinator at SMHW. Providers must file all forms in a timely manner.

What is the MO HealthNet Breast and Cervical Treatment (BCCT) program?

Beginning on October 2000, federal legislation allowed funded programs in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) to participate in the new BCCT program. In July 2001, Governor Bob Holden signed legislation authorizing matching funds for Missouri to participate in the Medicaid Program, effective August 28, 2001.

Who is eligible for BCCT?

Women screened and/or diagnosed with breast and/or cervical cancer, or certain precancerous conditions, through SMHW who are under 65 years of age and have a Social Security number or state identification number. SMHW works closely with Department of Social Services (DSS) FSD staff to enroll a client into the BCCT program.

How do SMHW clients enroll in BCCT?

SMHW providers establish presumptive eligibility, which entitles a client to temporary full MO HealthNet benefits through BCCT by completing the BCCT Temporary MO HealthNet Authorization letter. Give the client a copy of the letter. The SMHW provider submits the BCCT Temporary Authorization letter to the DSS FSD office following the directions found in the Provider Manual on page 7.4. The client and provider must also complete the BCCT Medical Assistance Application. The SMHW provider submits the completed application to the Green Co DSS FSD office after a cancer diagnosis from a tissue biopsy. Refer to Section 7: MO HealthNet for guidance and pages 10.16 and 10.17 for the appropriate forms.

A client received an annual SMHW screening that was normal. She contacts her SMHW provider because she has found a lump in her breast. What will SMHW cover?

SMHW will not cover the cost of the office visit but will pay for diagnostic testing if the CBE is abnormal. If the clinician does not find a lump and chooses to complete diagnostic testing as a direct result of the breast self-examination, SMHW will cover the cost of diagnostics.

Acronyms/Abbreviations

5 A’s – assess, advise, agree, assist, and arrange

A1C test – glycosylated hemoglobin test

ACS – American Cancer Society

ADA – American Diabetes Association

AGC – atypical glandular cells

AGUS – atypical glandular cells of undetermined significance

AHA – American Heart Association

AIS – adenocarcinoma in situ

ASCCP – American Society for Colposcopy and Cervical Pathology

ASC-H – atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion

ASCUS – atypical squamous cells of undetermined significance

BCCCP – Breast and Cervical Cancer Control Project is the former name of SMHW

BCCT – Breast and Cervical Cancer Treatment (through MO HealthNet)

BMI – body mass index

BSE – breast self-examination

CBE – clinical breast examination

CDC – Centers for Disease Control and Prevention

CHD – coronary heart disease

CIN – cervical intraepithelial neoplasia

CIS – Cancer Information Service; carcinoma in situ

CLIA – Clinical Laboratory Improvement Amendments of 1988

CPT – current procedural technology (code)

CVD – cardiovascular disease

CVH – cardiovascular health

DBP – diastolic blood pressure

DCN – departmental client number

DHSS – Missouri Department of Health and Senior Services

DNA – deoxyribonucleic acid

DOB – date of birth

DSS – Missouri Department of Social Services

ECC – endocervical curettage

EOB – explanation of benefits

EFT – electronic funds transfer

FDA – Food and Drug Administration

FLP – fasting lipid panel

FNA – fine needle aspiration

FPL – federal poverty level

FSD – Family Support Division

HBP – high blood pressure

HDL – high density lipoproteins

HDL-C – high-density lipoprotein cholesterol

HIPAA – Health Insurance Portability and Accountability Act

HPV – human papillomavirus

HSIL – high-grade squamous intraepithelial lesion

HTN – hypertension

IFG – impaired fasting glucose

ITSD – Information Technology Services Division

JNC 7 – Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7, 2004)

Kg – kilograms

LDL-C – low-density lipoprotein cholesterol

LEEP – loop electrosurgical excision procedure

LSP – lifestyle program

LSIL – low-grade squamous intraepithelial lesion

MDEs – minimum data elements

MI – motivational interviewing

MOAP – Missouri Arthritis & Osteoporosis Program

MOHSAIC – Missouri Health Strategic Architectures and Information Cooperative

MQSA – Mammography Quality Standards Act of 1992

NBCCEDP – National Breast and Cervical Cancer Early Detection Program

NCCDPHP – National Center for Chronic Disease Prevention and Health Promotion

NCEP – National Cholesterol Education Program

NCI – National Cancer Institute

NHLBI – National Heart, Lung, and Blood Institute

NIH – National Institutes of Health

NMR – nuclear magnetic resonance

OATS – Older Adults Transportation Service

Pap Stain – Papanicolaou stain

Pap Test – Papanicolaou smear

PHNPAT – Public Health Nurses Physical Assessment Training

RN – Registered Nurse

RPC – Regional Program Coordinator

SBP – systolic blood pressure

SMHW – Show Me Healthy Women – The current name of Missouri Breast and Cervical Cancer Control Project (BCCCP).

SMTS – Southeast Missouri Transportation Service SSN – social security number

TC – total cholesterol

TLC – therapeutic lifestyle changes

WIC – Woman, Infants and Children Program

WISEWOMAN – Well-Integrated Screening and Evaluation for Women Across the Nation - A heart health risk assessment and education program for women receiving a Show Me Healthy Women cervical and breast cancer screening service.

WNL – within normal limits

Glossary of Terms

A - C

adenocarcinoma - A cancer that develops from the glandular epithelium.

adenoma - A benign growth starting in the glandular tissue. (Also, refer to fibroadenoma.)

advanced cancer - A stage of cancer in which the disease has spread from the primary site to other parts of the body, directly or by traveling through the network of lymph glands (lymphatic) or in the bloodstream. Locally advanced means the cancer has spread only to the surrounding areas.

alert value - A screening result that is abnormal and requires tracking by the provider and/or Show Me Healthy Women Regional Program Coordinators to assure appropriate follow-up care is documented.

American College of Radiology Accreditation - A voluntary mammography accreditation program that is one of the standards for quality assurance and assesses the following major areas:

Personnel qualifications and experience
Equipment specification and technical procedures
Quality assurance practices
Evaluations of mammograms from the applicant’s practice and through the use of phantom images

anesthesia - A state characterized by loss of sensation, caused by a drug or gas. General anesthesia causes loss of consciousness. Local anesthesia is numbness in only a specified area.

antibiotics - Chemical substances, produced by living organisms or synthesized (created) in laboratories, for the purpose of killing other organisms that cause disease. Some cancer therapies interfere with the body’s ability to fight off infection, so antibiotics may be needed along with the cancer treatment to protect against or kill infectious diseases. The word means “destructive of life.”

areola - The dark area of flesh that encircles the nipple of the breast.

aspirate - Removal of fluid or cells from a breast lump.

aspiration biopsy - A procedure in which the specimen for biopsy is removed by aspirating it through an appropriate needle that pierces the skin and penetrates into the underlying tissue to be examined. (Also, refer to fine needle aspiration.)

asymptomatic - Without noticeable signs or symptoms of disease. Many cancers can develop and grow without producing symptoms, especially in the early stages. Detection tests, such as mammography, try to discover developing cancers at the asymptomatic stage, when the chances for cure are usually high.

atypia (also atypical) - The condition of being irregular or not conforming to type not usual, abnormal. Cancer is the result of atypical cell division.

axilla - Also known as the armpit.

Breast and Cervical Cancer Control Project (BCCCP) – See Show Me Healthy Women.

benign - Not malignant, not recurrent, favorable for recovery, not cancer. The main types of benign breast problems are fibroadenoma, fibrocystic changes, and cysts.

Bethesda System - A comprehensive system for the reporting and classification of Pap smear specimens, developed in December 1988. The Clinical Laboratory Improvement Act (CLIA) regulations mandate the use of the Bethesda System for laboratory reporting and proficiency testing.

bilateral - Affecting both sides of the body, for example bilateral breast cancer is cancer occurring in both breasts at the same time (synchronous) or at different times (metachronous).

biopsy - The removal and examination (by a pathologist) of tissue samples, cells or fluids from a living body. An examination of the appearance of the tissue under a microscope determines if cancer or other abnormal cells are present. Complete the biopsy with a needle or by surgery.

breast augmentation - Surgery to increase the size of the breast (also known as breast implants).

breast cancer - Cancer that begins in the breast. The main types of breast cancer are ductal carcinoma in situ, infiltrating ductal carcinoma, lobular carcinoma in situ, medullary carcinoma, and Paget’s disease of the nipple.

Breast Imaging Reporting and Data System (BIRADS) - A uniform reporting system for reporting mammography results.

breast self-examination (BSE) - A technique of checking your own breasts for lumps or suspicious changes.

breast specialist - A term describing health professionals who have dedicated interest in breast health.

calcifications – Also called microcalcifications. Tiny calcium deposits within the breast, singularly or in clusters, often found by mammography, which indicate a change within the breast.

cancer - A general term for more than 100 diseases in which abnormal or malignant cells develop. Some exist quietly within the body for years without causing a problem. Others are aggressive, rapidly forming tumors that may invade and destroy surrounding tissue. If cancer spreads, it usually travels through the lymph system or bloodstream to distant areas of the body.

cancer cell - A cell that divides and reproduces abnormally and can spread throughout the body.

capsule formation - Scar tissue that may form around a breast implant as the body tries to “wall off” or encapsulate the foreign object; a contracture.

carcinoma - A malignant tumor that begins in the lining (epithelial) cells of organs. Epithelial cells are those that cover the surfaces of tissue. It can occur in any part of the body. Eighty percent or more of cancers, and all breast cancers, receive carcinoma classification.

carcinoma in situ (CIS) - An early stage of cancer in which the cancer is still only in the structures of the organ where it developed and the disease has not invaded other parts of the organ or spread; cancer in situ or pre-invasive. This classification of most cancers is curable.

case manager - The member of the medical care team who acts as a liaison. This person coordinates all of the services needed by the client throughout diagnosis, treatment and recovery.

clinical breast examination (CBE) - A physical examination of the breasts performed by a physician, registered or advanced practice nurse or physician’s assistant.

cell - The basic unit of which all living things are made. Cells carry out basic life processes. Organs are clusters of cells that have developed specialized tasks. Cells replace themselves by splitting and forming new cells; cancer disrupts this process.

cervical intraepithelial neoplasia (CIN) - A cellular change to the mouth of the cervix that may include severe dysplasia and CIS. CIN 3 is the most severe of the three-category classification system.

cervical precancerous lesions - Cervical tissue biopsy results of CIN (CIN 1, 2, or 3) and AIS lesions are considered precancerous lesions. Treatment of many CIN 1 and 2 lesions is through simple excisional procedures. However, CIN 3 or AIS may require a hysterectomy.

cervix - The narrow outer end of the uterus that opens into the vagina.

chemotherapy - A drug treatment program that destroys cancer cells. This method often accompanies surgery or radiation, or to treat recurring cancer.

clinical - Description of information that pertains to or is founded on actual observation and treatment of patients, as distinguished from theoretical or basic sciences.

clinical trials - Research studies to test new drugs or procedures, or to compare to current standard treatments with others that may be better or equal.

coalition building - The process of organizing individuals, groups or organizations for the purpose of furthering a common goal or ideal.

colposcope - A magnifying, lighted optical instrument, which allows for the direct observation and study of vaginal and cervical cells.

colposcopy - Diagnostic procedure performed with a colposcope. Cervical biopsies are usually conducted by colposcopic examination.

Comprehensive Cancer Control Program (CCCP) - A statewide strategic plan, which includes the interaction of a cancer surveillance system, public and professional education, and a screening and follow-up system.

cone biopsy - The removal of a cone-shaped piece of tissue from the cervix. This is a more definitive procedure than a cervical biopsy. It is used when abnormal cells extend up into the cervical opening (Os) or through the tissue. This process also used to treat and cure carcinoma in situ and dysplasia.

conization - The process of removing a cone of tissue, as in partial excision of the cervix uteri. To better preserve the histologic elements cold conization is performed with a cold knife.

consensus statements - Recommendations for the management of a problem, in this case a disease or health problem, formulated by a group of experts based on scientific and clinical information.

cryosurgery - The destruction of tissue by exposure to extreme cold in order to produce well- demarcated areas of cell injury and destruction. Used to treat malignant tumors, control pain, reduce lesions in the brain and control bleeding.

cyst - A fluid-filled mass that is usually benign. The fluid can be removed for analysis.

cytology - Comes from “cyte” which means cell, the study or examination of cells, their origin, structure, function and pathology. The study determines whether cells are cancerous or benign.

D - F

detection - The finding of a case of a disease. Early detection means that the disease is found at an early stage, before it has grown large or spread to other sites. Mammography and Pap tests are the principal ways to detect breast and cervical cancer early.

diagnosis - Identifying a disease by its signs, symptoms and laboratory findings. The earlier a cancer is diagnosed, the better chance for cure.

diagnostic breast services - Refers to specialist consultation; additional mammography views; ultrasound; fine needle aspiration; needle, incisional and excisional biopsies relating to breast cancer.

diagnostic cervical services - Refers to specialist consultation, colposcopy with/without biopsy and diagnostic LEEP relating to cervical cancer.

diagnostic mammogram - Defined by the American College of Radiology as “mammography performed on women who, by virtue of symptoms or physical findings, are considered to have a substantial likelihood of having breast disease.”

dimpling - A pucker or indentation of the skin on the breast. It may be a sign of cancer.

dissemination - In health education, the dispersal of information, products or services to a population.

duct - A pathway. In the breast, a duct is a passage through which milk passes from the lobule (which makes the milk) to the nipple.

ductal carcinoma in situ - Cancer cells that started in the milk ducts and has not penetrated the duct walls into the surrounding tissue. Surgery is the treatment option for this highly curable form of breast cancer.

ductal papilloma - Small, finger-like, noncancerous growth in the breast ducts that causes bloody discharge and often found in women 45-50 years of age. When they exist, breast cancer risk is slightly higher.

dysplasia - An abnormality in size, appearance and organization of adult cells that requires a biopsy for diagnosis.

ectocervix - The outside, visible portion of the cervix.

endocervical curettage (ECC) - The surgical scraping of the lining of the uterine cervix.

endocervix - The mucous membrane lining the canal of the cervix, sometimes referred to as the endocervical canal.

endocrine glands - Glands that release hormones into the bloodstream. The ovaries are examples of endocrine glands.

endocrine therapy - Manipulation of hormones for therapeutic purposes.

endometrium - The membrane lining of the uterus.

epidemiology - The collection and statistical analysis of data relating to the factors that have an impact on health and how they relate to one another. In the study of people who get cancer, the analysis of specific types of cancer and the factors that play a part in the development of that cancer.

estrogen - A female sex hormone produced primarily in the ovaries, possibly in the adrenal cortex. In men it is produced in the testes (in much smaller amounts than in women). In women, levels of estrogen fluctuate on nature’s schedule, influencing the development of secondary sex characteristics, including breast size, regulation of the monthly cycle of menstruation and preparing the body for fertilization and reproduction. In breast cancer, estrogen may feed the growth of cancer cells.

etiology - The study of the cause of disease. In cancer, there are many etiologies, although research shows that genetics is a major factor in many cancers.

false negative - Negative results of a screening test, when in reality the result should be positive.

false positive - Positive results of a screening test that mistakenly identifies a disease when one is not present.

federal poverty level (FPL) - A measure of income determined annually by the U.S. Census Bureau based on the last calendar year’s increase in prices as measured by the Consumer Price Index. For some programs, it helps determine a person’s eligibility. A woman is eligible for SMHW if her income is at or below 250 percent of the FPL.

fibroadenoma - A type of benign breast tumor composed of fibrous tissue and glandular tissue. On clinical examination or breast self-examination, it usually feels like a firm, round, smooth lump. These usually occur in young women.

fibrocystic changes - A term that describes certain benign changes in the breast. Symptoms are breast swelling or pain. Signs are nodules, lumpiness and nipple discharge. Not cancerous.

fibrocystic condition - The presence of single or multiple benign cysts in the breasts.

fibrosis - Formation of fibrous (scar) tissue, which can occur anywhere in the body.

five-year survival - Survival of cancer for five years after treatment of the disease. This is a milestone for most cancer patients, indicating treatment was successful.

G - I

genes - Segments or units of DNA that contain information on hereditary characteristics such as hair or eye color and height. Women who have the BRCA1 gene have inherited a tendency to develop breast cancer.

genetic - Something related to the genes.

glands - Organs that produce and release chemicals used locally or elsewhere in the body. Often, this term refers, incorrectly, to mean lymph nodes. grade - The classification of the severity of a disease.

grade - The classification of the severity of a disease.

gynecological consultation - A referral to a gynecologist for an abnormal screening examination follow- up.

health education - Any combination of learning experiences designed to facilitate voluntary adaptations of behavior conducive to health.

health promotion - Activities directed toward developing the resources of clients that maintain or enhance well-being.

hereditary cancer syndrome - One or several types of conditions associated with cancers that occur within multiple family members, because they have an inherited, mutated gene.

high-grade squamous intraepithelial lesion (HSIL) - The Bethesda System classification for a Pap smear result that includes cellular changes of moderate to severe dysplasia (CIN 2 and 3/CIS).

high risk - A higher risk of developing cancer compared with the general population. Some factors that place a person at a higher risk are a family medical history, lifestyle choices and the exposure to environmental influences.

hormone - Chemical substance released into the body by the endocrine glands, such as thyroid or ovaries. The substance travels through the bloodstream and sets in motion various body functions. For example, prolactin, produced by the pituitary gland, begins and sustains the production of milk in the breast after childbirth.

human papillomavirus (HPV) - A sexually transmitted virus implicated in the pathogenesis of cervical cancer and its precursor lesions. HPV infections of the genital tract are often thought to be the most common sexually transmitted viral disease. The manifestations of HPV are variable, ranging from occult infection to overt disease in which there is clinical and pathological evidence of HPV infection. Of the approximately 70 types of HPV, 20 types are detectable in the female genital tract and 15 types are evident in the majority of invasive carcinomas.

hyperplasia - An abnormal increase in the number of cells in a specific area, such as the lining of the breast ducts. This overgrowth may be due to hormonal stimulation, injury or continuous irritation. It is not cancerous by itself, but when the proliferating cells are atypical, the risk of cancer developing is greater.

hysterectomy - The surgical removal of the uterus. Types include a total hysterectomy, removal of the uterus and cervix, and radical hysterectomy, the removal of ovaries, oviducts, lymph nodes, lymph channels, uterus and cervix.

imaging - Any method used to produce an image of internal body structures. Some methods used to detect cancer are x-rays, magnetic resonance imaging (MRI), bone scans, scintigraphy, computerized axial tomography (CAT scans), and ultrasonography.

immune system - The complex system by which the body resists invasion by a foreign substance such as a bacterial infection or a transplanted organ.

incidence - The number of new cases of a disease or condition diagnosed during a specified time.

incisional biopsy - The surgical removal of a portion of an abnormal area of tissue for microscopic examination.

indicated but not performed (refused) - An examination result that applies to the field used to record examination results. This entry is marked when a client does not want the recommended examination or when a client has periodically missed appointments.

infiltrating ductal carcinoma - A cancer that starts in the milk passages of the breasts (ducts) and then breaks through the duct wall, where it invades the fatty tissue of the breast. When it reaches this point, it has the potential to spread or metastasize elsewhere in the breast, as well as to other parts of the body through the bloodstream and lymphatic system. Infiltrating ductal carcinoma is the most common type of breast cancer, accounting for about 80 percent of breast malignancies.

inflammation - A local response to cellular injury to the immune system that is marked by capillary dilatation, redness, heat, pain, swelling, or infiltration by cells.

inflammatory breast cancer - A rare cancer, where the breast looks as if it is inflamed because of its red appearance and warmth. The skin shows signs of ridges and wheals or may have a pitted appearance, and the cancer tends to spread quickly.

infraclavicular nodes - Lymph nodes located beneath the clavicle (collarbone). They are part of the network of axillary (armpit) nodes.

internal mammary nodes - Lymph nodes beneath the breast bone on each side. The lymph glands of the breast drain into the internal mammary nodes.

intervention - A strategy incorporating methods and techniques that interact with a patient or population.

intraductal papilloma - A benign tumor that starts in the ductal system of the breast. It can cause discharge from the nipple. A woman with papillomatosis (multiple intraductal papillomas) is at increased risk of developing breast cancer.

invasive cancer - A cancer that has invaded surrounding tissue and spread to distant parts of the body.

invasive cervical carcinoma - Infiltration of cancer cells into the tissue beyond the epithelium of the cervix. This term indicates that a malignant growth extends deeper than 3 mm into the stroma.

L - O

lobes, lobules, acini - Milk-producing tissues of the breast. Each of the breast’s 15 to 20 lobes branches into smaller lobules, and each lobule ends in scores of tiny acini. Milk originates in the acini and is carried by ducts to the nipple.

lobular carcinoma (infiltrating or invasive) - A type of breast cancer that starts within the lobules. It may be multicentric (occurring in multiple lobules). Compared with other types of breast cancer, this type has a higher chance of occurring in the opposite breast as well. It can often be difficult to diagnose, even with careful physical examination or mammography.

lobular carcinoma in situ - A very early type of breast cancer developing within the milk-producing glands (lobules) of the breast. It does not penetrate through the wall of the lobules. Researchers think that lobular carcinoma in situ does not eventually become an invasive lobular cancer. They believe, instead, that it places women at an increased risk of developing an invasive breast cancer later in life. This condition makes it important for women with lobular carcinoma in situ to have a physical examination three to four times per year and an annual mammogram.

local excision - The removal of a lesion or tumor confined to the breast.

localized breast cancer - A cancer that arose in the breast and is confined to the breast.

loop electrosurgical excision procedure (LEEP) - A surgical procedure used on the cervix by which an electrical current generating a radio frequency is passed through a wire loop, which is then drawn around the cervical opening (Os) to excise the tissue. The procedure, usually performed in an outpatient setting, uses local anesthesia. Either the transformation zone or a cone-like specimen can be obtained and depends on the size of the loop and lesion. Terms used for this procedure are LEEP and LLETZ (large loop excision of transformation zone).

low-grade squamous intraepithelial neoplasia (LSIL) - The Bethesda System classification for a Pap smear result, which includes cellular changes of HPV, mild dysplasia (CIN 1) or koilocytotic atypia.

lump - Any kind of mass that can be felt in the breast or elsewhere in the body.

lumpectomy - Removal of the breast lump plus a margin of normal tissue around it. If malignant tissue is found, radiation therapy or mastectomy often follows. Also known as limited breast surgery.

lymph - Clear fluid that passes within the lymphatic system and contains cells known as lymphocytes. These cells fight infections. They have a lesser role in fighting cancer.

lymph nodes (lymph glands) - Small masses of bean-shaped tissue located along the lymphatic vessels that remove waste fluids from lymph and acts as filters of impurities in the body.

malignant tumor - A mass of cancer cells that may invade surrounding tissues or spread to distant areas of the body.

mammogram - An x-ray of the breast.

mammography facility - An entity that has met SMHW requirements to become an approved provider or provides mammography services for other SMHW-approved providers.

Mammography Quality Standards Act of 1992 (MQSA) - The national accreditation of mammography units through the FDA.

mastectomy - Surgical removal of the breast(s): (1) Modified radical mastectomy: removal of the breast, skin, nipple, areola and most of the auxiliary lymph nodes on the same side, leaving the chest muscle intact. (2) Halstead radical mastectomy: removal of the breast, skin, both pectoral muscles, and all auxiliary lymph nodes on the same side. (3) Extended radical mastectomy: removal of the breast, skin, pectoral muscles (major and minor), and all auxiliary and internal mammary lymph nodes on the same side. (4) Partial mastectomy: removal of less than the whole breast, taking only part of the breast in which the cancer occurs and a margin of healthy breast tissue surrounding the tissue. (5) Prophylactic mastectomy: removal of the interior of one or both breasts. For cancer prevention, this procedure is done before any evidence can be found. It is a recommendation for a woman at a very high risk of breast cancer; its efficacy is unproven. (6) Quadrantectomy: a partial mastectomy that removes the quarter of the breast that contains the tumor. (7) Segmental mastectomy: partial mastectomy. (8) Total mastectomy: removal of only the breast.

medical professional/clinician - Physician, physician’s assistant, certified nurse practitioner, certified nurse midwife, or registered nurse.

medullary carcinoma - A specific histology of infiltrating breast cancer in which the tumor appears well defined, with obvious boundaries between tumor tissue and normal tissue. Medullary carcinoma accounts for five percent of breast cancer.

menarche - The first menstrual period. Early menarche (before age 12) is a risk factor for breast cancer, possibly because the earlier a woman's periods begin the longer the exposure to estrogen.

menopause - The time in a woman's life when monthly cycles of menstruation cease forever and the level of hormones produced by the ovaries decreases. Menopause usually occurs in the late 40s or early 50s, but surgical removal of the ovaries (oophorectomy) or the ovaries and uterus (total hysterectomy) can induce it, as can some chemotherapy that destroys ovarian function. Some breast cancer chemotherapies are among those that can cause menopause.

metaplasia - Abnormal replacement of cells of one type by cells of another type. It does not represent a malignant or premalignant condition.

metastasis - The spread of cancer cells to distant areas of the body by way of direct extension, lymph system, or bloodstream.

minimum data elements (MDE) - Clinical data items submitted to CDC two times a year.

needle aspiration - Removal of fluid from a cyst or cells from a tumor. In this procedure, a needle and syringe (like those used to give injections) are used to pierce the skin, reach the cyst or tumor, and with suction, draw up (aspirate) specimens for biopsy analysis. If the needle is thin, the procedure is called fine needle aspiration (FNA).

needle localization - A procedure used to do a breast needle biopsy, when the lump is difficult to locate or in areas that look suspicious in the x-ray but do not have a distinct lump. During the procedure, and after local anesthesia numbs the area, an X-ray guides a thin needle and wire to the area to be biopsied. A tiny hook on the end of the wire holds it in place. Then, using the wire path as a guide, the physician inserts a hypodermic needle (as the type used to give injections) and takes a sample of the tissue. The biopsy is complete. (Also see needle aspiration.)

neoplasia - The pathologic process that results in the formation and growth of a neoplasm.

neoplasm - Any abnormal growth; neoplasms may be benign or malignant. Cancer is a malignant neoplasm.

nipple - The tip of the breast; the pigmented projection in the middle of the areola. The nipple contains the opening of milk ducts from the breast.

nipple discharge - Any fluid coming from the nipple. It may be clear, milky, bloody, tan, gray or green.

nodal status - A count of the number of lymph nodes in the armpit (axillary nodes) to which cancer has spread (node-positive) or has not spread (node-negative). The number and site of positive axillary nodes help forecast the risk of breast cancer recurrence.

node - A lymph gland.

nodule - A small, solid lump that can be located by touch.

Nolvadex - Trade name for tamoxifen, an antiestrogen drug commonly used in breast cancer therapy. (Also see tamoxifen.)

noncancerous - Benign; not malignant; no cancer is present.

normal hormonal changes - Changes in breast and other tissues that are caused by fluctuations in levels of female hormones during the menstrual cycle.

not needed (omitted) - A category used to record examination results when it is not appropriate to perform a screening test on that particular woman. This choice might be marked under mammography results, if a woman had a mastectomy of one breast. Or, under the Pap smear results if she had a recent Pap smear at her provider's office, is pregnant, or has had a hysterectomy.

nucleus - The powerhouse at the center of a cell where the cell's important activities are carried out. DNA resides and replicates in the nucleus.

nurse practitioner - A nurse who is licensed as a registered nurse (RN) and has taken additional highly specialized training and is nationally certified and recognized by the Missouri State Board of Nursing as an Advanced Practice Registered Nurse. Nurse practitioners must have written collaborative agreements with a physician. They take on additional duties in diagnosis and treatment of patients, and in many states they may write prescriptions. (Also, refer to oncology nurse specialist.)

oncologist - A physician who is specially trained in the diagnosis and treatment of cancer. Medical oncologists specialize in the use of drugs and chemotherapy to treat cancer. Radiologic oncologists specialize in the use of x-rays (radiation) to kill tumors. Surgical oncologists specialize in the use of surgery to treat cancer. Medical and radiation oncologists often cooperate in giving complicated treatments.

oncology nurse specialist - A nurse who has taken highly specialized training in the field of cancer after being licensed as a RN (registered nurse). Oncology nurse specialists may mix and administer treatments, monitor patients, prescribe and provide aftercare (only if the Missouri State Board of Nursing as an Advanced Practice Registered Nurse recognizes them), and teach and counsel patients and their families. Many oncology nurse specialists are also certified nurse practitioners. (Also see case manager, nurse practitioner.)

oncology social worker - A person who has a master's degree in social work and has specialized in the field of cancer. This person provides counseling and assistance to people with cancer and their families, especially in dealing with the crises that can result from cancer but are not medical, such as financial problems, housing when treatments must be at a facility far away from home, and childcare or eldercare.

ovary - A reproductive organ in the female pelvic region. Normally a woman has two ovaries. They contain the eggs (ova) that joined with sperm, result in pregnancy. Ovaries are also the primary site of production of estrogen. (Also, refer to estrogen.)

P - R

Paget's disease of the nipple - A form of breast cancer that begins in the milk passages (ducts) and involves the skin of the nipple and areola. A sign of Paget's disease is a crusting, scaly, red inflamed tissue (dermatitis) lesion on the nipple. With true Paget's disease, cancer is usually also present within the breast. This rare breast cancer type occurs in only 1 percent of cases. If no lump felt, there is generally a good outcome or prognosis.

palliative treatment - Therapy that relieves symptoms, such as pain, but does not cure the disease. Its main purpose is to improve the quality of life.

palpation - A simple technique in which a health care provider presses on the surface of the body to feel organs or tissues underneath. One can feel a palpable mass in the breast.

Papanicolaou smear (Pap test) - A screening test of the cells of the cervix used to detect early signs of cervical cancer.

Papanicolaou stain (Pap stain) - A multichromatic staining process used primarily on gynecological specimens. It provides great transparency and delicacy of detail, which is important in cancer screening, especially of gynecologic screens.

pathologist - A physician who specializes in the identification of abnormalities and disease by examining body tissue under a microscope and organs. The pathologist determines whether a lump is benign or cancerous.

pathology - A study of disease through examination of body tissues and organs under a microscope for evidence of disease. Diagnosis of any tumor thought to be cancer by examination under a microscope.

Patient navigation (PN) - Individualized assistance provided to women to overcome barriers and facilitate timely access to quality screening and diagnostic services, as well as initiation of timely treatment for those diagnosed with cancer.

pectoral muscles - Muscles attached to the front of the chest wall and upper arms; the larger muscle group is known as pectoralis major, and the smaller muscle group is known as pectoralis minor. Because these muscles are in close proximity to the breast, they may become involved in breast cancer or surgery to treat it.

pelvic examination - An internal physical examination used to detect a variety of gynecological disorders. Performed by a physician, nurse or physician's assistant, the pelvic examination is, and includes, a visual inspection of the vagina and cervix, as well as palpation of the uterus and ovaries.

pigment - A class of substances that provide color, including in the human body. The areola and nipple of the breast are pigmented with melanin. Normally a brownish tint, melanin, in these areas of the breast can range from pale pink to deep brown.

predisposition - Susceptibility to a disease that can be triggered under certain conditions. For example, some women have a family history of breast cancer and are therefore predisposed (but not necessarily destined) to develop breast cancer.

premalignant - Abnormal changes in cells that may, but not always, become cancer; also known as precancerous. Most of these early lesions respond well to treatment and result in cure.

prevalence - A measure of the proportion of persons in the population with a particular disease at a specified time.

prevention - Avoiding the occurrence of an event, such as development of cancer, by avoiding things known to cause cancer and participating in activities that can or might prevent cancer. For example, avoiding smoking may prevent lung cancer, and taking tamoxifen may prevent breast cancer in women who are at high risk for the disease.

preventive services - Programs or products that are developed and provided for the purpose of health promotion and maintenance.

primary site - The site where cancer begins; usually named after the organ in which it begins; for example, breast cancer.

progesterone - A female sex hormone released by the ovaries to prepare the uterus for pregnancy and the breasts for milk production (lactation).

prognosis - A prediction of the course of disease, including the prospects for a cure. For example, women with early detected breast cancer and receive prompt treatment have a good prognosis.

prosthesis (breast) - An artificial form that can be worn under the clothing after a mastectomy to simulate the shape and form of a natural breast. (Plural: prostheses.)

protocol - A formalized outline or plan.

public health district - Missouri is divided into six public health districts. In the manual, the word regions is used.

quality assurance - The overall process of assessing and maintaining the highest possible quality in the acquisition and interpretation of results.

radiologic technologist - A health professional (not a physician) trained to properly position patients for x-rays, to load film and take the images, and to develop and check the images for quality. For mammograms (breast x-rays) machines, the technologist must have special training in mammography. A radiologist reads the films taken by the technologist.

radiologist - A physician who has taken additional years of training to produce and read x-rays and other types of images (for example, ultrasound or magnetic resonance imaging) to diagnose abnormalities.

radiology - A branch of medicine concerned with the use of radiant energy in the diagnosis and treatment of disease.

radiotherapy - Treatment with radiation to destroy cancer cells. Methods used include linear accelerators, x-rays, cobalt, and betatrons. Radiation treatment may reduce the size of a cancer before surgery, or destroy any remaining cancer cells after surgery; also known as irradiation and radiation therapy.

Reach to Recovery - A visitation program of the American Cancer Society for women who have a personal concern about breast cancer. Carefully selected and trained volunteers, who have successfully adjusted to breast cancer and its treatment, provide information and support to women newly diagnosed with the disease.

reactive changes - Normal changes in tissue as a result of the body's reaction to an irritation or infectious agent.

recurrence - Cancer that has re-occurred or reappeared after treatment. Local recurrence is at the same site as the original cancer. Metastasis means that the disease has recurred at a distant site. Regional recurrence is in the tissue or lymph nodes near the site.

regimen - A strict, regulated plan of diet, exercise, or other activity designed to reach certain goals. In cancer treatment, it is a plan to treat cancer.

regional involvement - The spread of cancer from its original site to nearby areas such as muscles or lymph nodes, but not distant sites such as other organs.

Regional Program Coordinator (RPC) - SMHW staff persons located in several regions of the state who assist with referrals for diagnosis and treatment and provide service coordination/case management services for women enrolled in SMHW.

rehabilitation - Activities to adjust, heal, and return to a full, productive life after injury or illness. This may involve physical restoration (such as the use of prostheses, exercises and physical therapy), counseling and emotional support.

risk factor - Anything that increases a person's chance of getting a disease such as cancer. The known risk factors for breast cancer include being a woman over the age of 50; family history of the disease, especially in one's mother or sister; beginning menstrual periods at a young age (before age 12); obesity; never having completed a pregnancy; first pregnancy after age 30.

S - Z

saline solution - A saltwater solution.

scan - A study using either x-rays or radioactive isotopes to produce images of internal body organs.

scant cellularity - An unsatisfactory Pap smear with inadequate cellularity.

scirrhous cancer - A breast cancer with a hard, firm, fibrous texture; usually an infiltrating ductal carcinoma.

screening - The search for disease, such as cancer, in people without symptoms. Screening may refer to coordinated programs in large populations. The principal screening measure for breast cancer is mammography.

screening guidelines - Recommendations for the application of screening procedures, which are formulated by professional and governmental agencies.

screening mammogram - American College of Radiology defines a screening mammogram as “an x-ray breast examination of asymptomatic women in an attempt to detect breast cancer, when it is small, nonpalpable and confined to the breast."

screening provider(s) - Health departments, primary care facilities, and/or any other entities under contract with Missouri’s SMHW program to provide breast and cervical cancer screening services.

screening services - Refers to clinical breast examination, Pap smear, pelvic examination, mammography, instruction in breast self-examination, and informational and educational services relating to breast and cervical cancer by providers of SMHW services.

secondary tumor - A tumor that forms as a result of spread (metastasis) of cancer from its site of origin.

shall/must/should - Reference to the words "shall" and "must" indicate mandatory program policy. "Should" indicates recommended program policy relating to program management and patient care that the provider is urged to follow.

Show Me Healthy Women (SMHW) - The functional entity created within the Missouri Department of Health and Senior Services, Division of Community and Public Health, Section for Community Health Services & Initiatives, Bureau of Cancer and Chronic Disease Control, to implement and manage all components of the grant.

silicone gel - Synthetic gel compound used in breast implants because of its flexibility, strength, and texture, which is similar to the texture of the natural breast. Silicone gel breast implants are available for women who have had breast cancer surgery. (See breast augmentation.)

sonogram - An image produced by using high-frequency sound waves. This technique is used to examine and measure internal body structures and detect bodily abnormalities but does not utilize radiation or x-rays.

speculum - A metal or plastic instrument that permits visual inspection of the cervix and performance of a Pap smear.

staging - A method of determining and describing the extent of cancer, based on the size of the tumor, whether regional axillary lymph nodes are involved, and whether distant spread (metastasis) has occurred. Knowing the stage at diagnosis determines the best treatment and the prognosis.

stages of breast cancer:

Stage 0: The earliest stage of breast cancer; the disease is in situ.

Stage I: The tumor is 2 cm or less in size and contained within the breast tissue; not spread beyond the breast.

Stage II: The tumor is more than 2 cm and spreads to regional lymph nodes, such as the lymph nodes under the arm, or the tumor is more than 5 cm in diameter and no regional nodes are involved.

Stage III: The tumor, any size, has spread to several regional lymph nodes and/or other tissues near the breast.

Stage IV: The cancer has spread to other organs and/or tissues by way of direct extension, lymph system and/or bloodstream.

stages of cervical cancer:

Stage 0: The earliest stage of cervical cancer; the disease is in situ.

Stage I: Cancer has not spread beyond the cervix and uterus.

Stage II: Cancer has spread beyond the uterus, but not to the pelvic wall or to the lower third of the vagina.

Stage III: Cancer has spread to the pelvic wall and/or involves the lower third of the vagina and/or regional lymph nodes.

Stage IV: The cancer has spread to other organs and/or tissues by way of direct extension, lymph system and/or bloodstream.

stereotactic biopsy - A diagnostic procedure that combines the technology of radiological imaging with surgical biopsy. Images taken at different angles of the area surrounding a lesion and a computer precisely calculates the lesion’s location. An automatic biopsy needle obtains samples of the tissue at the exact spot calculated by the computer.

subcutaneous mastectomy - A surgery to remove internal breast tissue, yet the nipple and skin are left intact.

supraclavicular nodes - Lymph nodes that are above the collarbone (clavicle).

surgery - An operation, a procedure performed by a surgeon to repair or remove a part of the body or to find out if disease is present.

surgical or specialist consultation - A referral of a woman to a surgical specialist for additional diagnostic evaluation, following detection of a breast or cervical abnormality.

survival rate - A way of expressing how long, on average, people may live after diagnosis of disease or after treatment of the disease and expressed as the percentage of people who live a certain period, as opposed to the percentage of those who die. For example, the five-year survival rate for women with localized breast cancer (including all women living five years after diagnosis, whether the patient was in remission, disease-free, or under treatment) was 78 percent in the 1940’s, but in the 1990’s it was 93 percent.

suspicious abnormality - A finding on a test that indicates cancer might be present.

synchronous - At once or at the same time.

systemic disease - In breast cancer, a tumor that originated in the breast has spread to distant sites, such as the liver, chest, brain, bones, or lungs.

tamoxifen (brand name: Nolvadex) - A drug that blocks estrogen; an antiestrogen drug. Blocking estrogen is desirable in some cases of breast cancer because estrogen feeds the growth of certain types of tumors.

target population - The desired or intended audience, in this case for SMHW interventions.

therapy - Any of the measures taken to treat a disease. Alternative therapy is any unapproved therapy and sometimes called questionable methods or unproven methods. Sometimes alternative and standard therapies are used together. Some are harmless, some may be helpful, and others can be dangerous, especially if they divert a person with cancer from receiving standard therapy. Some people use alternative therapies along with standard therapy; in this approach, the healthcare team should be informed of the alternative method used. Experimental therapy is any new, as-yet- unproven method that is undergoing testing for specific purposes in a scientific clinical trial. Standard therapy is any method that has been scientifically tested and proven useful for specific purposes and is the standard treatment.

tissue - A collection of similar cells, united to perform a particular function. There are four basic types of tissue in the body: epithelial, connective, muscle, and nerve.

tomosynthesis - An optional method of performing high-resolution mammogram with three-dimensional images of the breast.

transformation - A multistep process by which normal cells change into neoplastic cells.

tumor - Tissue growth in which the cells multiply uncontrollably, also called neoplasm. It can be either benign or malignant. Benign tumor is a noncancerous tumor (i.e., does not invade and destroy adjacent normal tissue). Malignant tumor is a tumor that is cancerous and likely to cause death unless adequately treated.

ultrasonography (ultrasound) - An imaging method in which high-frequency sound waves, transmitted through the area of the body being studied, are used to outline a part of the body; the echoes are read, displayed and transmitted to a television screen. The painless procedure mainly determines if a structure is solid or liquid. It is useful in detecting breast cysts in young women with firm, fibrous breasts. No radiation exposure occurs.

underinsured - A patient is considered underinsured if she has medical insurance that does not cover SMHW screening services, or if she has an unmet deductible or required copayment for services covered by SMHW.

underserved - Groups of individuals who chronically lack access to health care for a variety of reasons.

unilateral - Affecting one side of the body. For example, unilateral breast cancer occurs in one breast only. (Also see bilateral.)

unproven methods of cancer management - Any therapy that has not been subjected to traditional scientific study and proved effective in clinical trials. Such methods range from harmless to life- threatening, especially if used in place of medically sound methods of treatment. The American Cancer Society maintains a reference file on proven methods of cancer management. Information is available by request from the society's toll-free cancer information hotline, 1-800-ACS-2345. (Also see therapy.)

x-rays - One form of radiation that can, at low levels, produce an image of cancer on film, and at high levels can destroy cancer cells.

Provider Manual - Show Me Healthy Women (SMHW)

Section 13 - Appendices

Provider Manual - Show Me Healthy Women (SMHW)

Section 13 - Appendices

Providers

Client Referral

RPC Contact Information

SMHW Regional Program Coordinator County List

Request for Literature

Available Literature in English

Available Literature in Spanish

Most Commonly Asked Questions

Acronyms/Abbreviations

Glossary of Terms

Table of Contents

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