Transcript Colorectal Cancer Screening: A Patient Navigator Approach

COLON CANCER SCREENING:
A PATIENT NAVIGATOR APPROACH TO ELIMINATING
DISPARITIES WITHIN MILWAUKEE COUNTY
Sukit Ringwala
MD/MPH Candidate
9 May 2008
OVERVIEW
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Background
Purpose
Project Methods
Findings
Discussion
Conclusion
BACKGROUND
MILWAUKEE REGIONAL CANCER CARE NETWORK
(MRCCN)
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Coalition of health systems’ administrators,
nurses, physicians, public health workers,
epidemiologists
Stems from the Wisconsin Comprehensive
Control Plan
Goal: Promote access to quality cancer care
Specifically taken on the task of improving
colorectal cancer (CRC) care in Milwaukee and
Waukesha Counties
BURDEN OF DISEASE
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Colorectal cancer (CRC) is the 2nd leading
cause of death from cancer in the US
150,000 new cases per year in the US
50,000 deaths per year in the US
Ranks 3rd in cancer incidence and mortality
within Milwaukee County
SCREENING
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Modalities that reduce CRC mortality
Fecal Occult Blood Tests (FOBTs)
 Colonoscopy
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Lower Screening rates in:
The poor
 Recent immigrants
 People with lower educational levels
 Minorities
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Milwaukee County area
Breast, cervical, and prostate cancer screening at little
or no cost
 Few programs in place to address access to CRC
screening for populations in need
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PURPOSE
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Create a colon cancer screening program
 Address
disparities to access, specifically for the
uninsured
 Increase screening rates
 Decrease the time between screening and
diagnosis
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Goal: To improve mortality in disparate
populations by providing treatment earlier
PROJECT METHODS
SCREENING PROGRAMS
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Literature review conducted using PubMed
Query: colon cancer, screening programs,
navigator…etc.
Other criteria:
 Focus
on urban programs
 Address screening for uninsured
 Targeted to minorities
 Target to patients of lower socioeconomic status
SCREENING MODALITIES
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Literature review conducted using PubMed for
appropriate screening modality
Query: fecal occult blood test, colonoscopy,
IFOBT, FIT…etc.
Criteria:
 Study
year >2000
 AGA or USPSTF supported
FINDINGS
SCREENING PROGRAMS
CRC Screening Programs' Evidence
Maryland
East Harlem,
NY
Chicago,
IL
Population
1. Patient education
2. Physician referral
3. Phone calls
Uninsured
90%
+ 39%
Low-income
>80%
+ 17%
+ 11%*
Low-income
95%
+ 16 %
1. Patient navigation
2. Physician referral
1. Physician referral
*Change in patient compliance to a follow-up colonoscopy
% minority
Change in overall
screening rate
Interventions
SCREENING MODALITIES
CRC Screening Tests
Time Interval Sensitivity(%) Specificity(%)
gFOBT†
Annual
65
86
FIT
Annual
82
97
† Serial tests performed using Hemoccult SENSA
Results are for average risk adults ≥ 50 years old
gFOBT, guaiac - based fecal occult blood test; FIT, fecal immunochemical test
DISCUSSION
PATIENT NAVIGATOR MODEL
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Strengths
Successfully enhanced screening for breast and
prostate cancer
 Studies show improvement in screening rates
 CDC’s CRC screening demonstration project has laid
framework
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Limitations
Small sample size in studies of review
 Studies used only one clinical site
 Other studies may have been missed in query
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SCREENING TOOL
FIT
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Strengths:
1) Better sensitivity and specificity than gFOBT
2) Fewer demands placed on patient
3) Medicare reimbursement
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Limitations:
1) Sensitivity and specificity may vary depending on
manufacturer
2) More costly than gFOBT
3) Not established in clinical practice
CONCLUSION
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A CRC patient navigator program could be
successful in Milwaukee County
Points to consider:
 Cost
 Health
systems support
 Scalability of model
 Timeline
FUTURE ENDEAVORS
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Construct a navigator model tailored for Milwaukee
County and its health systems
Obtain stakeholder support
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Milwaukee health care systems
WI Comprehensive Cancer Control Program
Colorectal Cancer Task Forces
American Cancer Society
Implementation plan
Obtain source of funding
Initiate pilot program on a smaller scale within
Milwaukee
ACKNOWLEDGMENTS
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Lora de Oliveira, MPH, MBA
Griselle Sanchez
Milwaukee Regional Cancer Control Network
REFERENCES
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Freeman et al. Determinants of Cancer Disparities: Barriers to Cancer Screening, Diagnosis, and
Treatment. Surgical Oncol Clin N Am. 14 (2005) 655-669.
Intercultural Cancer Council 2006 Survivorship Report: Cancer Survivorship and the Medically
Underserved: Reducing the Disparities in Cancer Care. Intercultural Cancer Council, 2006.
Steinberg et al. Lay Patient Navigator Program Implementation for Equal Access to Cancer Care and
Clinical Trials: Essential Steps and Initial Challenges. Cancer. Dec 2006. Vol 107: No 11.
Seeff et al. Development of A Federally Funded Demonstration Colorectal Cancer Screening Program.
Preventing Chronic Disease: Public Health Research, Practice, and Policy. April 2008. Vol 5: No 2.
Tangka et al. Cost of Starting Colorectal Cancer Screening Programs: Results from Five Federally
Funded Demonstration Programs. Preventing Chronic Disease: Public Health Research, Practice, and
Policy. April 2008. Vol 5: No 2.
DeGroff, Amy. CDC’s Colorectal Cancer Screening Demonstration Project. Wisconsin Comprehensive
Cancer Control Summit April 10, 2008. Centers for Disease Control and Prevention. (Presentation)
Safarty et al. Choice of Screening Modality in Colorectal Cancer Education and Screening Program for
the Uninsured. Journal of Cancer Education. Vol 21: No 1. 2006.
Lawson et al. Colorectal Cancer Screening among Low-Income African Americans in East Harlem: A
Theoretical Approach to Understanding Barriers and Promoters to Screening. Journal of Urban Health:
Bulletin of the New York Academy of Medicine, Vol. 84, No. 1. 2006.
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REFERENCES CONT.
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Khankari et al. Improving Colorectal Cancer Screening Among the Medically Underserved: A Pilot
Study within a Federally Qualified Health Center. J Gen Intern Med 22(10):1410–4.
Jandorf et. al. Use of a Patient Navigator to Increase Colorectal Cancer Screening in an Urban
Neighborhood Health Clinic. Journal of Urban Health: Bulletin of the New York Academy of Medicine,
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Dower C, Knox M, Lindler V, O’Neil E. Advancing Community Health Worker Practice and Utilization:
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Levin et al. Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous
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Performance Characteristics. J Natl Cancer Inst 2007;99: 1462 – 70.
Levi et al. A Quantitative Immunochemical Fecal Occult Blood Test for Colorectal Neoplasia. Ann
Intern Med. 2007; 146: 244-255.
Guittet et. al. Comparison of a guaiac based and an immunochemical faecal occult blood test in
screening for colorectal cancer in a general average risk population. Gut 2007;56:210–214.
CDC WONDER
Wisconsin Cancer Registry