Health Care Delivery / Access
UAMS Winthrop P. Rockefeller Cancer Institute
Cancer Control Program THE ARKANSAS CANCER COMMUNITY NETWORK (AR-CCN)
The Arkansas Cancer Community Network (AR-CCN) at the University of Arkansas for Medical Sciences Winthrop P. Rockefeller Cancer Institute is engaging partners, researchers, students and Community Cancer Councils in community-based- participatory research (CBPR), education and training. Arkansas is predominantly rural with severe cancer disparities, especially in the Lower Mississippi Delta region. Due to statewide disparities, our geographical reach spans all 75 counties that include African-Americans and rural Caucasians. To enhance capacity building to support CBPR (AIM #1), AR-CCN’s oversight committees continue to provide direction on research activities, policy initiatives, and clinical practice issues. To conduct CBPR (AIM #2), AR-CCN has leveraged almost $4.4 million in non-CRCHD funding to date to support Research Development Teams, community action training, secondary prevention, capacity assessments and a health policy program. We have developed a Community Development Program (CDP) with our community partners, seven local Cancer Councils, to engage in cancer disparities research. The CDP resulted in an R24 for a CBPR proposal awarded in 2007 by the NIH National Center of Minority Health and Health Disparities (NCMHD). We will be working with two of the Cancer Councils to provide research for a colorectal cancer education and screening program. To support evidenced-based policy development evaluation (Aim #3), AR-CCN has held four bi-annual Legislative Cancer Briefings. We hosted the Arkansas Legislative House Committee on Public Health, Welfare and Labor on the UAMS campus. The agenda consisted of a report back of the Colorectal Cancer (CRC) Demonstration Program. The CRC Demonstration Program was funded by AR Legislators and implemented in 2006-2008. The program resulted in 553 patients being screened and five cancers being discovered and treated. It also measured the capacity of the current medical system to screen patients, and the impact of removing barriers to colorectal cancer screening on patients in need of screening. The data that was collected and reported also laid the groundwork for legislation that was passed this year to support a statewide program. The AR-CCN continues to actively meet preset goals of collaborating with researchers and communities toward addressing cancer health disparities.
Funding source: NCI Center to Reduce Cancer Health Disparities
Community Perspectives on Health Behavior and Chronic Illness
Breast cancer is second only to lung cancer as a leading cause of cancer death among US women.1 Racial differences in stage at diagnosis and survival are well established.2, 3 Associations of racial and other sociodemographic variables with nutrition,4-7 obesity,8-10 metabolic syndrome,11 and cancer morbidity and mortality12 suggest that differences in dietary habits and/or carbohydrate metabolism associated with metabolic syndrome may contribute to observed disparities. Attempts to better understand interactions between behavioral and biological processes that have been associated with metabolic syndrome and cancer risk must carefully consider the socio-cultural context in which these interactions occur. Salient issues requiring additional research include the influence of cultural factors on dietary habits,8-10 utilization of preventive health services13, and participation in cancer research. The proposed research uses focus group methodology to engage community partners in the design of research relevant to cancer disparities. The proposed study will inform the development of community-relevant and culturally appropriate research questions and methods to address current gaps in our understanding of associations between dietary habits, biological markers of carbohydrate metabolism, and cancer risk.
Working to Eliminate Barriers: Cancer Communities Online
In Arkansas, 61 out of 75 counties are considered rural which makes it difficult to collaborate effectively due to distance. Geographic barriers and a lack of local support resources in many rural communities present serious problems for creating and sustaining health coalitions. The goal of this project is to develop and evaluate a set of digital tools to support community-based participatory research in rural coalitions as a part of the Arkansas Cancer Community Network (AR-CCN) research effort. The eCommunities of Practice Tools (eCOPT) will be designed to help communities develop and support a framework for collaboration and decision-making and provide a mechanism for diverse stakeholders to participate in the process of a regular basis. Components of the eCOPT are customized and incorporated into knowledge management systems through a systematic planning process to meet the needs of the AR-CCN Community Advisory Board and the Community Cancer Councils via the internet. The eCOPT tools will also enable the Community Advisory Board and Community Cancer Councils to enhance effectiveness through greater access to training and educational programs to promote health, prevent disease, and eliminate communication barriers. The eCOPT provides easy to use web tools for conducting threaded discussions, archiving and retrieving messages, managing online work groups, conducting surveys and voting, distributing documents, and conducting training amongst a stakeholder community. We hypothesize that the implementation of the eCOPT software by the Winthrop P. Rockefeller Cancer Institute’s (Cancer Institute) AR-CCN will enable us to expand the scope of the Community Advisory Board and Community Cancer Councils by enhancing performance through better communication and organizational efficiency. More efficient and effective means of communicating within and among the Community Advisory Board and Community Cancer Councils would address many problems that we encounter. We will test this hypothesis through the following Specific Aims:
Specific Aim 1: Systematically develop the eCommunities of Practice Tools (eCOPT) to support and expand communication among the Arkansas Cancer Community Networks and the Community Advisory Board (CAB).
Specific Aim 2: Field test and evaluate the eCommunities of Practice Tools (eCOPT) with a Cancer Council to support Community-Based Participatory Research.
The Impact of Mobile Mammography Units in Eliminating Barriers to Breast Cancer Screening
Cancer Disparities Determinants Addressed
Limited access to a FDA-approved mammography facility, personal inconveniences and physician compliance with screening mammography recommendations are barriers to obtaining yearly screening mammograms.
We hypothesized that the use of mobile mammography programs is an innovative approach to addressing the access barrier and has made an impact on breast cancer screening in the state of Arkansas.
Research Methods and Outcomes
The targeted population was women living in a county in which a permanent FDA-approved mammography facility did not exist. Using the Arkansas Department of Health Registry, we obtained data on the number of women over the age of forty per county. We reviewed prospective data registries of women who received screening mammography via the mobile and modular mammography units and compared them with the mammography centers. We identified 23/75 counties that have no FDA-approved mammography facility, five mobile units, and one modular unit. These 6 units screened an additional 8,198 women per year (mean 1366, range 877-2025), which was 0.5% to 15.7% of the total women that should be screened for that area. The modular unit provided more detailed data: From March 2004 to February 2005, they screened 877/159684 (0.5%) women, mean age 57 ± 12.3 years, during 69 trips into 23 rural counties. Of these 877 screening mammograms, 701(80%) were annual and 182(20%) were baseline. The women in these counties on average would have needed to travel 54 + 12 miles one-way to obtain a mammogram at a facility. CONCLUSIONS: A mobile mammography unit can provide high quality screening mammography to women in rural areas where access to a mammography facility is limited. This program offers the unique ability to attract first time users while aiding other women to maintain their annual mammogram schedule through their primary care physicians.
Colorectal Demonstration Program Household Survey
The University of Arkansas for Medical Sciences, the Arkansas Department of Health and the Arkansas State Legislature are collaborating to implement provisions of the Colorectal Cancer Act of 2005 addressing disparities in colorectal cancer. This study reports the results of a household survey conducted to assess factors associated with colorectal cancer disparities in Arkansas. A random digit dialed telephone survey (N=2021) adapted from the Health Information National Trends Survey was conducted to identify factors associated with colorectal cancer screening in Arkansas. Respondents 50 years of age and older were invited to complete the survey. Study procedures were approved by the UAMS IRB. The proportion of respondents who reported screening advice from a health care professional was lower in the south east public health region (53%; OR=0.51, p<0.0001) and in the south west region (55%; OR=0.54, p<0.0001) compared to the central region (69%). Similarly, the proportion of respondents currently screened in accordance with recommendations was lower in the south east public health region (43%; OR=0.56, p<0.0001) and in the south west region (46%; OR=0.63, p=0.0013) compared to the central region (57%). Lowest rates for screening advice and screening uptake were reported in public health regions where large proportions of the population are African American, have limited formal education, and earn a minimal income. These and related data will be presented to the state legislature in periodic briefings to promote the development of evidence-based policy and legislation supporting public health services to address cancer disparities.
CRC Physician and Facility Assessments
In order to determine the current capacity of Arkansas to provide endoscopic colorectal cancer screening and follow-up examinations to age appropriate persons residing in Arkansas, an assessment is being conducted to identify physicians, including family practitioners, gastroenterologists, and surgical endoscopists who perform colonoscopy and the regions in which they practice. The assessment has three aims: Aim 1: To assess current screening rates and the capacity of endoscopists across the state to screen for colorectal cancer, Aim 2: To assess current screening rates and the capacity of primary care physicians, (primary care physicians, general medicine, Obstetrician/gynecologists, gynecologists and internal medicine physicians), to refer/screen patients for colorectal cancer, Aim 3: To assess the capacity of endoscopy facilities to screen Arkansans for colorectal cancer.
The three surveys were compiled by modifying existing national surveys. The Facilities Survey of Endoscopic Capacity was modeled with permission on the SECAP survey developed by the Centers for Disease Control (CDC). The Primary Care Physician Survey of Endoscopic Capacity and the Endoscopist Survey of Endoscopic Capacity were based on surveys developed by the National Cancer Institute’s Cancer Control and Population Sciences Division. The AR-CCN collaborated with Dr. Croyle and his staff to ensure that modification was acceptable to the division. The return rate for the facility surveys was 49%. An incentive of $50 was offered to physicians and facilities that completed the survey. The GI survey return rates were 79/220, 36% and PCP return rates were 91/300, 30%. Data analysis of the surveys is ongoing. However, 72% of GIs reported that capacity is just right or more than enough to meet demand.
An assessment has been made of the number and location of primary care providers within the state who have been trained to screen for CRC surveillance activities to include the provision of CRC education and screening using Fecal Occult Blood (FOBT), Double Contrast Barium Enema (DCBE), and Sigmoidscopy. The Primary Care Survey was modified and a random sample of family physicians, internists, and obstetrician/gynecologists were selected. The PCP Survey return rates were 91/300, a return rate of 30%.
The Endoscopist Survey of Endoscopic Capacity was mailed to all gastroenterologists and general/colorectal surgeons in the state (n=220). This survey will gather information from physicians that may be trained in endoscopy to determine which procedures are used most often, training background, and CRC screening preferences.
The Facilities Survey of Endoscopic Capacity was mailed to all hospitals that may have endoscopy facilities plus the approximate 25 free standing ambulatory endoscopy centers in the state (n= approximately 94). This survey was mailed to facilities that may offer endoscopy services. It will assess the number of procedures completed, the type of procedures, and the number of physicians using the facility.
Preliminary Findings of GI and PCP Surveys
Physician Capacity Surveys- 2 surveys sent to a random sample of primary care physicians and all colon surgeons, general surgeons, and gastroenterologists.
- Effectiveness of screening procedures in reducing cancer mortality in average-risk patients aged 50 years and older
- Extent of factors that are influential in medical recommendations for colorectal cancer screening
- Over the past 2 years, has the volume of colorectal cancer screening procedures you order, perform or supervise
Arkansas Colorectal Cancer Control and Research Program- (Promoting Colorectal Cancer Screening in Primary Care Practices)
Colorectal Demonstration Program Results
CRC Screenings September 2006 to September 2008
- 700 patients referred
- 679 eligible
- 553 screened
- 507 received colonoscopy
- 176 had polyps (small growths in colon)
- 96 adenomatous polyps (a precursor to cancer)
- 6 cancers were diagnosed
The Arkansas Colorectal Cancer (CRC) Act of 2005 established a demonstration project to address racial disparities in CRC incidence and mortality. This study reports the effects of the demonstration project on CRC screening rates in un-insured and under-insured primary care patients. IRB approved strategies to promote screening were implemented in 2 primary care clinics in each of the 5 Arkansas public health regions (N=10). Clinics were randomly assigned to independent screening (usual care) or integrated screening (professional and patient education, patient navigation). Each clinic had an accrual goal of 40 patients for a total of 200 per study condition. Eligible patients were within 200% of the federal poverty level, asymptomatic and >50 years old or symptomatic. Patients with cancer and those currently adherent to screening recommendations were excluded. Screening was provided at no cost to patients. When examining accrual goals (n=40 per clinic) integrated clinics (education and navigation) referred a higher proportion of patients (94%) than the independent clinics (59%) which is significant at p<0.0001. OR=11.1, CI= 5.8-21.2). Actual referral rates were higher since some integrated clinics referred more than their goal. A total of 451 patients were referred from participating clinics (Integrated N= 308; Independent N=143). Integrated clinics were more likely to meet and exceed the accrual goal than were independent clinics. Strategies piloted in the demonstration project effectively reached patients previously not adherent to screening recommendations. The program ended in September 2008 resulted 553 patients screened (see Table 1). Results were presented to the state legislators on June 25, 2008 as evidence based data to promote the establishment of a state-wide CRC program.
COLORECTAL CANCER EDUCATION AND SCREENING PROGRAM (CCESP)
Cancer health disparities are a major problem that continues to plague our communities. In 2004, the Report of the Trans-HHS Cancer Health Disparities Progress review group “Making Cancer Health Disparities History” 1 was submitted to the Secretary of the Department of Health and Human Services with specific objectives outlined for addressing the unequal burden of disease in our society. These include: “Defining and identifying issues related to cancer health disparities; Identify areas of strength, gaps, opportunities and priorities to address these disparities through research and intervention development; Facilitate the adoption and implementation of cancer research, policy, community programs and clinical interventions with evaluation of their impact on such disparities and to ensure unbiased access to continuous quality preventive care, early detection, and treatment of cancer for every American.”1 In a report to the Arkansas Minority Health Commission on Health Disparities2 Colorectal cancer (CRC) was identified as a major concern in regards to disparities and high mortality rates in African Americans and the poor in rural Arkansas. In 2006, the Community Survey on Colorectal Cancer conducted by the UAMS/ACRC Arkansas Cancer Community Network (AR-CCN) surveyed 2,092 Arkansans. This survey demonstrated screening rates with Fecal Occult Blood Test (FOBT) in the past year in the Northeast and Southeast parts of the state to be well below the national average of 35%3, at 16% and 13% respectively. In addition, cost for care of this disease was also identified as a major concern. In 2002, there were fewer discharges with a diagnosis of colorectal cancer, but hospital costs continue to increase in regards to this diagnosis, with over 2,400 discharges costing more than $55 million.2 This most likely correlates with the more advanced presentation of colorectal cancer and lower screening rates within poor and rural counties.
Community Based Participatory Research (CBPR) is an essential component to the reduction of cancer health disparities. By using CBPR with community partners, we will increase colorectal cancer screening in underserved areas. In order to increase screening, we plan to provide education and screening for Arkansans in two underserved counties in the Arkansas Delta, specifically Northeast (Mississippi County) and Southeast (St. Francis County). Both education and provision of FOBT kits with reminders are proven means of increasing screening rates. A combination of the two within a community setting has not been investigated to determine if screening rates can be further improved. Based on this, we hypothesize that a CBPR intervention providing education, awareness and FOBT screening tests in two underserved communities will increase screening uptake rates above either treatment alone or control.
ARKANSAS CANCER COALITION
Mobile Mammography Program
A total of 1,790 new cases of breast cancer are expected to be diagnosed in 2008, and 410 women in Arkansas will die of this disease.1 According to the July 2006 United States Government Accountability Office (GAO), current nationwide capacity assessments report accessibility barriers continue to exist in many locations in the state of Arkansas. The loss of existing facilities leads to decreased access for women when receiving age-appropriate breast cancer screenings, especially for underserved and rural populations. Therefore, the access problem leads to lengthy travels and considerable wait times to receive appropriate breast cancer services, in addition presents as a concern for uninsured and poor women with already lower rates of screening. The GAO reports that rural Arkansas lost more than 25 percent of their mammography machines during October 1, 2001 to October 1, 2004.2 This accounts for a decrease in facilities by nine facilities, leaving Arkansas with only 102 FDA-approved mammography facilities. Barriers to women obtaining screening mammograms include lack of access, lack of knowledge, cost, and lack of physician recommendation. The MMP will provide access to services for breast cancer screening by increasing the availability of breast cancer screening to populations facing geographic, economic or cultural barriers. The MMP provides secondary prevention that addresses the lack of FDA-approved mammography screening facilities in 25 of Arkansas’ 75 counties, therefore, reducing community-level health disparities.
Colorectal Cancer Screening Program
The 2005 Colorectal Cancer Demonstration Program determined that Arkansas has the capacity to provide colorectal screenings to the state. The Colorectal Cancer Screening Program will provide screenings to at risk and underserved populations which will allow us to develop regional referral lists. Women participating in BreastCare or their spouses that meet screening guidelines will qualify to receive colorectal cancer screening services. Uninsured/Underinsured patients referred by previous CRC Demonstration physicians.
Physicians that previously participated in the program will be contacted by the Physician Educator to see if they are still interested in providing the service. They will be asked to perform a screening colonoscopy at the reduced rate of $600 if the patient has no insurance. If the patient has insurance, the procedure will be covered in that method.
Once a patient is enrolled in the Colorectal Cancer Screening Program they will be contacted by a Navigator to assist them with scheduling a screening procedure. It is estimated that approximately 20% of the patients screened will need follow-up screening. The Navigator will assist them with making those appointment and funds are provided for 60 follow-up screening procedures. The patient who receives the screening will be assisted and monitored throughout the screening continuum to ensure that they receive the best and most thorough care possible.