New Lung Cancer Screening Guidelines and the Continued Benefits of Stopping Smoking

Yesterday, the US Preventive Services Task Force released a draft report recommending that older heavy smokers be screened annually for lung cancer using low-dose CT scans.  These guidelines - which closely reflect recommendations released by the American Cancer Society in January and which we wrote about here - mark a major shift in views on screening for lung cancer.

 Chest x-rays were used for many years as a screening test for lung cancer, but studies eventually found that they were ineffective.  Then, a 2006 study showed that low-dose CT screening in smokers significantly lowered the rate of death from lung cancer, but the study came under a cloud of suspicion when it was revealed that the study's primary funder and principal investigator had tobacco industry ties.  Yet, in 2008, a federally-funded randomized controlled trial largely confirmed the earlier results - showing that regular screening extended the lives of heavy smokers.

A Task Force recommendation in favor of screening typically means insurers and Medicare will begin reimbursing for the procedure.  As currently written, current and past heavy smokers age 55 - 79 are recommended for annual screening.

Being able to find lung cancer early when it is most treatable is a great advance for such a deadly cancer, which typically has a low rate of survival five years after diagnosis.  Quitting smoking, however, remains the best way to lower the risk of lung cancer and improve survival in smokers.  Compared to smokers who don't get screened, those who do have a 20 percent lower risk of dying from lung cancer over 6 years.  Compared to smokers who don't quit, those who do have a similar benefit over 5 years, and the longer someone has not smoked, the greater the benefit (see figure).  

The benefits of stopping smoking is an old story - not likely to grab many headlines any more - but it's one that should be trumpeted along with these new guidelines on lung cancer screening. 

Bloomberg Continues Fight Against Obesity One Step (or Stairway) at a Time

One thing is clear about New York City mayor Michael Bloomberg, he doesn't shy away from a good fight, especially if the health and well-being of citizens is at stake.  Whether it's getting food establishments to post calorie counts, cut back on trans fats, or limit the size of sugary sodas, he and his administration charge full steam ahead, all the while providing a great example of one of the main tenets of public health:  our surroundings  - the people, the choices, the places around us - make a real difference in our health behaviors.

In his latest push, the mayor signed an executive order focused on improving physical activity by promoting easier access to stairs in new buildings or those under significant renovation. Good evidence shows that stairways can be an effective and practical venue for increasing activity levels - improving fitness and hopefully combatting weight gain and obesity.  We've previously posted about an unscientific - but very entertaining - project showing how stairs can me made more engaging, likely increasing their use (see video).

Though building design has begun to slowly change as green design and smart design have started to take hold, most existing buildings built since the 70s seemingly hide stairways from regular use, and even when you can find them, they are often dark and uninviting and accessed by doors that may or may not let you return through. Not a recipe for daily use, to be sure.

Under Bloomberg's initiative - and in two proposed bills - stairways will be brought back into the fore - with the hope that being able to see and easily access stairs will increase their use.

There will be hiccups along the way as these initiatives are put into practice.  Change is always difficult.  This movement, though, may meet less resistance than some of the mayor's others, building as it does on the current design ethos to create healthy and energy-efficient structures.Time will tell.  One thing is sure, however, Bloomberg will keep moving ahead one step at a time.

References

Meyer P, Kayser B, Kossovsky MP, et al. Stairs instead of elevators at workplace: cardioprotective effects of a pragmatic intervention. Eur J Cardiovasc Prev Rehabil. 2010;17:569-75.

Nicoll G, Zimring C. Effect of innovative building design on physical activity. J Public Health Policy. 2009;30 Suppl 1:S111-23.

Soler RE, Leeks KD, Buchanan LR, Brownson RC, Heath GW, Hopkins DH. Point-of-decision prompts to increase stair use. A systematic review update. Am J Prev Med. 2010;38:S292-300.

Photo: PracticalHacks

Obesity Cuts Life Short

More than 15 yeas ago we showed conclusive evidence that obesity causes many chronic conditions in the US population1-3 -, that weight gain increases risk of diabetes 4-6, heart disease 7, breast cancer 8, and that this burden adds up quickly, even before we get to overweight, let alone obesity. In the New England Journal of Medicine (report) we summarized some of this evidence 9.

With a cut off of BMI at 25 defining overweight, we see that risk of diabetes, gall stones, and high blood pressure and heart disease are all elevated, and the risk continues to rise with higher levels of adiposity or BMI. This is true in the first figure – showing the relative risks for women, and in the second for men.

Relative Risk of Diabetes, and other chronic conditions by level of Body mass Index (BMI)

Women




Men




We recently completed and analysis of national data to predict life years lost associated with obesity-related diseases for U.S. non-smoking adults, and to examine the relationship between those obesity related diseases and mortality.10 We used data from the National Health Interview Survey, 1997-2000 (see report).

We analyzed these data to estimate the association between those obesity related diseases and mortality and used simulations to project life years lost associated with the diseases.

What did we find?

We found that obesity-attributable comorbidities are associated with early mortality that leads to large decreases in life years and increases in mortality rates. The life years lost associated with obesity related diseases is more marked for younger adults than older adults, for blacks than whites, for males than females. Furthermore, the magnitude of life years lost increases with increasing level of obesity.

Using U.S. non-smoking adults aged 40 to 49 years as an example to illustrate percentage of the life years lost associated with disease caused by obesity, we found that the mean life years lost for U.S. non-smoking black males aged 40 to 49 years with a body mass index above 40 kg/m2 was 5.43 years. This translates to a 7.5% reduction in total life years lived. White males of the same age range and same degree of obesity lost 5.23 life years on average - a 6.8% reduction in total life years. For black females the numbers are: 5.04 years, a 6.5% reduction in life years, and white females they are: 4.7 years, a 5.8% reduction in life years.

Overall, diseases caused by obesity increase the chances of dying and lessened life years by anywhere from 0.2 to 11.7 years depending on gender, race, BMI classification, and age. The effect of obesity related diseases on mortality is shown for each age group in the figure below.



The epidemic of obesity in the US continues to carry a heavy burden for society 11,12, on our health care system 13,14, our businesses 15, and on our families.

References

1.         Willett W, Dietz W, Colditz G. Guidelines for healthy weight. N Engl J Med. 1999;341:427-434.

2.         Colditz GA, Coakley E. Weight, weight gain, activity, and major illnesses: the Nurses' Health Study. Int J Sports Med. Jul 1997;18 Suppl 3:S162-170.

3.         Must A, Spadano J, Coakley EH, Field AE, Colditz G, Dietz WH. The disease burden associated with overweight and obesity. JAMA. Oct 27 1999;282(16):1523-1529.

4.         Colditz GA, Willett WC, Rotnitzky A, Manson JE. Weight gain as a risk factor for clinical diabetes in women. Ann Intern Med. 1995;122:481-486.

5.         Chan JM, Rimm EB, Colditz GA, Stampfer MJ, Willett WC. Obesity, fat distribution, and weight gain as risk factors for clinical diabetes in men. Diabetes Care. 1994;17:961-969.

6.         Colditz GA, Willett WC, Stampfer MJ, et al. Relative weight and increased risk of diabetes in a cohort of US women (abstract). Am J Epidemiol. 1987;126:750-751.

7.         Willett WC, Manson JE, Stampfer MJ, et al. Weight, weight change, and coronary heart disease in women: risk within the 'normal' weight range. J Am Med Assoc. 1995;273:461-465.

8.         Huang Z, Hankinson SE, Colditz GA, et al. Dual effects of weight and weight gain on breast cancer risk. JAMA. 1997;278(17):1407-1411.

9.         Willett WC, Dietz WH, Colditz GA. Guidelines for healthy weight. N Engl J Med. 1999;341:427-434.

10.      Chang SH, Pollack LM, Colditz GA. Life Years Lost Associated with Obesity-Related Diseases for U.S. Non-Smoking Adults. PLoS One. 2013;8(6):e66550.

11.      Oster G, Thompson D, Edelsberg J, Bird AP, Colditz GA. Lifetime health and economic benefits of weight loss among obese persons. Am J Public Health. Oct 1999;89(10):1536-1542.

12.      Colditz G. Economic costs of obesity and inactivity. Med Sci Sports Exerc. 1999;31:S663-667.

13.      Thompson D, Edelsberg J, Colditz G, Bird A, Oster G. Lifetime health and economic consequences of obesity. Arch Intern  Med. 1999;159:2177-2183.

14.      Thompson D, Brown JB, Nichols GA, Elmer PJ, Oster G. Body mass index and future healthcare costs: a retrospective cohort study. Obes Res. Mar 2001;9(3):210-218.

15.      Thompson D, Edelsberg J, Kinsey K, Oster G. Estimated economic costs of obesity to U.S. business. Am J Health Promot. 1998;13:120-127.

New Study Shows HPV Vaccine Also Likely Protects Against Throat Cancers

Adding to the growing benefits linked to the human papillomavirus (HPV) vaccine that protects against cervical cancer, is a new study providing solid evidence that the vaccine will also likely help protect youth and young adults from developing throat cancers later in life. The study appeared in the journal PLoS One and was also written up in today's New York Times.

The study followed approximately 7,500 women ages 18 - 25 years old - half of whom received the HPV vaccine and half of whom did not - getting the hepatitis A vaccine instead. After four years, both groups were tested for oral HPV infection, and the group that had received the HPV vaccine experienced a single case of HPV while the unvaccinated group experienced 15 cases, making the vaccine 93 percent effective.

Just as cervical infection with HPV is strongly linked with cervical cancer, oral infection with HPV - which occurs largely through oral sex - is linked with oropharyngeal cancer (related post, here).  Cutting down or eliminating oral infection with HPV can significantly lower the risk of developing certain types of throat cancer later in life. 

With a little over half of all sexually active heterosexual youth and young adults ages 15 - 24 in the United States reporting oral sex as their first major sexual experience, these findings can have major implication for future rates of throat cancer - if vaccination programs continue to take hold.  

Yet, the use of the HPV vaccine in girls - which requires three shots over a number of months - hovers around 14 percent, leaving much room for improvement.  And in boys - who are also recommended to have the vaccine - rates are much lower, around one percent in targeted ages.   

For a vaccine that is demonstrated to be safe and effective, and that is a major highlight in the fight against important cancers in the United States - and the world - it is meeting slow uptake, and at times, outright resistance by some parents and politicians.  That it is a newer vaccine - and one that targets a sexually transmitted infection - makes it understandable that some parents have some questions about it.  Yet, as new data and better information come out, the reasons parents may have for not getting the vaccine strip away quickly.

As we do a better job breaking down barriers to getting the vaccine - whether it's through improving health care access or knowledge of the vaccine's safety and benefits - it's hard to imagine that high rates of parents will continue to avoid a vaccine that will lower their children's risk not only of cervical and oropharyngeal cancer but also vaginal, penile, and anal cancers.  

Photo: Melissa P

Reducing cancer disparities through participating in clinical research

Participation in therapeutic clinical trials rarely reflects the race and ethnic composition of the patient population. To meet National Institutes of Health-mandated goals, strategies to increase participation are required. We recently reported our work from Siteman Cancer Center and the Program for the Elimination of CancerDisparities to increase trial participation.

Clinical trials are crucial to advancing science across the cancer continuum. Comprehensive inclusion of diverse participants in clinical trials is essential to assuring generalizability of prevention, diagnostic and treatment recommendations and ultimately the identification of effective treatments for all sectors of society. Although federal mandates require investigators to demonstrate sufficient representation of minorities in study samples 1-4, there continues to be disparity in the representation of racial and ethnic minorities in clinical trials 5-10.

Data available from 2000 show that accrual to National Cancer Institute-sponsored clinical trials for African Americans, Hispanics or Latinos, Asian/Pacific Islanders and American Indians was 8.2%, 4.5%, 1.8% and 0.3%, respectively 5. An update for the period 2003 to 2005 indicates that NCI and publically funded phase 1, 2, and 3 trials showed a national average of 8% African American participants among the total enrollment. Addition of Asian Pacific Islander (2.8%) and Native American Alaska Native (0.5%) and multiple (.1%) brought the total minority participation by race to 11.4% 11.

For all aforementioned groups except American Indians, clinical trial accrual percentages are considerably lower than each group’s respective make-up of the United States population (12.3%, 12.5%, 3.7% and 0.9%, respectively) 12. Additionally, other groups have been under-represented in clinical trials, including uninsured and underinsured adults, adults with lower socioeconomic status, and those living in underserved or rural areas 8,13-15.

Factors that contribute to this disproportional representation are well-documented and are influenced by multiple levels of interaction in the clinical trial recruitment process. In a recent paper, our team at Siteman published a report of our initiative through the Program for the Elimination of Cancer Disparities (see report). We present a framework for institutional enhancement of minority clinical trial accrual.

Four interrelated levels interact to influence enrollment of minorities to clinical trials. They range from individual level influences on patient trial participation (e.g. mistrust of research, faith beliefs, or fear of side effects) to interpersonal level factors (e.g. physician-patient relationships/communication or communication about trials between patients and friends or other patients) to institutional and clinical practice level influences (e.g. organizational infrastructure to reinforce minority recruitment, lack of physician awareness of available clinical trials, systemic lack of time for recruiting, or small minority patient pools), and finally, community and public policy level influences (e.g. federal mandates or inhibitive inclusion criteria that restrict participation due to a range of factors including co-morbidities) 16-31.

These discrete, but interrelated obstacles clearly indicate opportunities for intervention including careful consideration of required inclusion and exclusion criteria 19,32-35; structured evaluation of cancer trial results on strata such as age (or ethnicity) to understand tumor biology, treatment tolerability and the effects of comorbid conditions to help refine mandatory eligibility criteria for future studies 36,37; targeted patient communication via patient trusted communication vectors 38; use of peer coaches 39; and increased trust building between patient/provider and with communities 40,41.

Such interventions are essential in the path to achieve federal mandates for minorities in clinical trials. Emphasis is usually placed on individual and interpersonal levels of influence respective to both patients and providers. While this approach has merit and is part of the solution 42, closer linkage across levels of influence from individual to policy will speed attainment of minority clinical trial recruitment benchmarks over time. Sorensen et al. 43 illustrate this approach for cancer health behavior interventions across social contexts, and for achieving population-wide health advances in the United States 44. Without this linkage, interventions focused on individual and interpersonal levels of influence to increase minority participation are disconnected from parallel interventions at the community and public policy level of influence.

Consequently, an implementation gap results, which diffuses both progress toward and accountability for reaching national recruitment benchmarks, and makes way for slower progression of science discovery reinforcing poorer health status and quality of life for the population.

Fundamental to making the link across the continuum from individual to policy levels of influence is a focus on institutional level influences. Usually, there is an absence of any formal structure for ongoing monitoring of organizational/institutional progress in minority recruitment, beyond cancer center wide reporting at competitive peer review. To bridge this disconnect and underscore centralized accountability, tracking and monitoring across an organization, systematic adjustments to improve organizational infrastructure for minority clinical trial enrollment are required. Here, we describe a framework for centralized organizational accountability through systematic benchmark development, continuous progress monitoring and responsive adjustments at provider and organizational levels to enhance organizational infrastructure to induce and sustain increased minority participation in clinical trials.

Just how did we do this?

We implemented structural changes on four levels to induce and sustain minority accrual to clinical trials: (1) leadership support; (2) center-wide policy change; (3) infrastructural process control, data analysis, and reporting; and (4) follow-up with clinical investigators. A Protocol Review and Monitoring Committee reviews studies with 15 or more patients accruals as the target, and monitors accrual, and the Program for the Elimination Cancer Disparities leads efforts for proportional accrual, supporting the system through data tracking, web tools that allow investigators to see the average distribution of cancer by stage and race over the preceding 3 years, and provides feedback to investigators.

What did we find?

Following implementation in 2005, minority accrual to therapeutic trials increased from 12.0 % in 2005 to 14.0 % in 2010. The "rolling average" minority cancer incidence at the institution during this timeframe was 17.5 %. In addition to therapeutic trial accrual rates, we note significant increase in the number of minorities participating in all trials (therapeutic and nontherapeutic) from 2005 to 2010 (346-552, 60 % increase, p < 0.05) compared to a 52 % increase for Caucasians.

What dies this mean?

Implementing a system to aid investigators in planning and establishing targets for accrual, while requiring this component as a part of annual protocol review and monitoring of accrual, offers a successful strategy. We believe this approach can be replicated in other cancer centers, and may also extend to other clinical and translational research centers.


References

1. Freedman LS, Simon R, Foulkes MA, et al. Inclusion of women and minorities in clinical trials and the NIH Revitalization Act of 1993--the perspective of NIH clinical trials. Control Clin Trials. Oct 1995;16(5):277-285; discussion 286-279, 293-309.
2. Hohmann AA, Parron DL. How the new NIH Guidelines on Inclusion of Women and Minorities apply: efficacy trials, effectiveness trials, and validity. J Consult Clin Psychol. Oct 1996;64(5):851-855.
3. NIH Revitalization Act of 1993. Vol PL 103-43June 10, 1993.
4. Amendment: NIH Policy and Guidelines on the Inclusion of Women and Minorities as Subjects in Clinical Research - October 2001. Vol NOT-OD-02-001 October 9, 2001.
5. Christian MC, Trimble EL. Increasing participation of physicians and patients from underrepresented racial and ethnic groups in National Cancer Institute-sponsored clinical trials. Cancer Epidemiol Biomarkers Prev. Mar 2003;12(3):S277-S283.
6. Murthy VH, Krumholz HM, Gross CP. Participation in cancer clinical trials: race-, sex-, and age-based disparities. JAMA. Jun 9 2004;291(22):2720-2726.
7. Stewart JH, Bertoni AG, Staten JL, Levine EA, Gross CP. Participation in surgical oncology clinical trials: gender-, race/ethnicity-, and age-based disparities. Ann Surg Oncol. Dec 2007;14(12):3328-3334.
8. Baquet CR, Ellison GL, Mishra SI. Analysis of Maryland cancer patient participation in national cancer institute-supported cancer treatment clinical trials. J Clin Oncol. Jul 10 2008;26(20):3380-3386.
9. National Cancer Institute. NCI-Supported clinical trials: facts and figures. [Website]. 2000; NCI clinical trials: an overview. Available at: http://www.cancer.gov/clinicaltrials/facts-and-figures/page1. Accessed 12 December, 2008.
10. Movsas B, Moughan J, Owen J, et al. Who enrolls onto clinical oncology trials? A radiation Patterns Of Care Study analysis. Int J Radiat Oncol Biol Phys. Jul 15 2007;68(4):1145-1150.
11. Springfield S. Racial and Ethnic Minorites Accrual to NCI Clinical Trials. Bethesdda, MD: Center to Reduce Cancer Health Disparities, National Cancer Institute, NIH;2010.
12. U.S. Bureau of the Census. DP-1. Profile of General Demographic Characteristics: 2000. Census 2000 Summary File 1 (SF 1) 100-Percent Data: U.S. Census Bureau; 2000.
13. Sateren WB, Trimble EL, Abrams J, et al. How sociodemographics, presence of oncology specialists, and hospital cancer programs affect accrual to cancer treatment trials. J Clin Oncol. Apr 15 2002;20(8):2109-2117.
14. Elliott TE, Elliott BA, Renier CM, Haller IV. Rural-urban differences in cancer care: results from the Lake Superior Rural Cancer Care Project. Minn Med. Sep 2004;87(9):44-50.
15. Klabunde CN, Springer BC, Butler B, White MS, Atkins J. Factors influencing enrollment in clinical trials for cancer treatment. South Med J. Dec 1999;92(12):1189-1193.
16. Ford JG, Howerton MW, Bolen S, et al. Knowledge and access to information on recruitment of underrepresented populations to cancer clinical trials. Evid Rep Technol Assess (Summ). Jun 2005(122):1-11.
17. Tournoux C, Katsahian S, Chevret S, Levy V. Factors influencing inclusion of patients with malignancies in clinical trials. Cancer. Jan 15 2006;106(2):258-270.
18. Ford JG, Howerton MW, Lai GY, et al. Barriers to recruiting underrepresented populations to cancer clinical trials: a systematic review. Cancer. Jan 15 2008;112(2):228-242.
19. Adams-Campbell LL, Ahaghotu C, Gaskins M, et al. Enrollment of African Americans onto clinical treatment trials: study design barriers. J Clin Oncol. Feb 15 2004;22(4):730-734.
20. Holcombe RF, Jacobson J, Li A, Moinpour CM. Inclusion of black Americans in oncology clinical trials: the Louisiana State University Medical Center experience. Am J Clin Oncol. Feb 1999;22(1):18-21.
21. Baquet CR, Commiskey P, Daniel Mullins C, Mishra SI. Recruitment and participation in clinical trials: socio-demographic, rural/urban, and health care access predictors. Cancer Detect Prev. 2006;30(1):24-33.
22. Robinson SB, Ashley M, Haynes MA. Attitude of African-Americans regarding prostate cancer clinical trials. J Community Health. Apr 1996;21(2):77-87.
23. Coyne CA, Demian-Popescu C, Brown P. Rural cancer patients' perspectives on clinical trials: a qualitative study. J Cancer Educ. Fall 2004;19(3):165-169.
24. Brown DR, Fouad MN, Basen-Engquist K, Tortolero-Luna G. Recruitment and retention of minority women in cancer screening, prevention, and treatment trials. Annals of Epidemiology. 2000;10(8, Supplement 1):S13-S21.
25. Pinto HA, McCaskill-Stevens W, Wolfe P, Marcus AC. Physician perspectives on increasing minorities in cancer clinical trials: an Eastern Cooperative Oncology Group (ECOG) Initiative. Ann Epidemiol. Nov 2000;10(8 Suppl):S78-S84.
26. Advani AS, Atkeson B, Brown CL, et al. Barriers to the participation of African-American patients with cancer in clinical trials: a pilot study. Cancer. Mar 15 2003;97(6):1499-1506.
27. Outlaw FH, Bourjolly JN, Barg FK. A study on recruitment of black Americans into clinical trials through a cultural competence lens. Cancer Nurs. Dec 2000;23(6):444-451; quiz 451-442.
28. Hudson SV, Momperousse D, Leventhal H. Physician perspectives on cancer clinical trials and barriers to minority recruitment. Cancer Control. Nov 2005;12:S93-S96.
29. Giuliano AR, Mokuau N, Hughes C, et al. Participation of minorities in cancer research: The influence of structural, cultural, and linguistic factors. Annals of Epidemiology. 2000;10(8, Supplement 1):S22-S34.
30. Linden HM, Reisch LM, Hart A, Jr., et al. Attitudes toward participation in breast cancer randomized clinical trials in the African American community: a focus group study. Cancer Nurs. Jul-Aug 2007;30(4):261-269.
31. Shavers VL, Lynch CF, Burmeister LF. Racial differences in factors that influence the willingness to participate in medical research studies. Ann Epidemiol. May 2002;12(4):248-256.
32. George SL. Reducing patient eligibility criteria in cancer clinical trials. J Clin Oncol. Apr 1996;14(4):1364-1370.
33. Fuks A, Weijer C, Freedman B, Shapiro S, Skrutkowska M, Riaz A. A Study in contrasts: Eligibility criteria in a twenty-year sample of NSABP and POG clinical trials. Journal of Clinical Epidemiology. 1998;51(2):69-79.
34. McCabe MS, Varricchio CG, Padberg RM. Efforts to recruit the economically disadvantaged to national clinical trials. Semin Oncol Nurs. May 1994;10(2):123-129.
35. Elks ML. The right to participate in research studies. J Lab Clin Med. Aug 1993;122(2):130-136.
36. Townsley CA, Selby R, Siu LL. Systematic review of barriers to the recruitment of older patients with cancer onto clinical trials. J Clin Oncol. May 1 2005;23(13):3112-3124.
37. Swanson GM, Bailar JC, 3rd. Selection and description of cancer clinical trials participants--science or happenstance? Cancer. Sep 1 2002;95(5):950-959.
38. Wood CG, Wei SJ, Hampshire MK, Devine PA, Metz JM. The influence of race on the attitudes of radiation oncology patients towards clinical trial enrollment. Am J Clin Oncol. Dec 2006;29(6):593-599.
39. Fracasso PM, Walker MS, Mathews KJ, et al. Coaching intervention as a strategy for enhancing accrual to phase I/II clinical trials. Journal of Clinical Oncology. June 20 2007;2007 ASCO Annual Meeting Proceedings Part I. Vol 25:S6580.
40. Fouad MN, Partridge E, Green BL, et al. Minority recruitment in clinical trials: a conference at Tuskegee, researchers and the community. Ann Epidemiol. Nov 2000;10(8 Suppl):S35-S40.
41. Fouad MN, Partridge E, Wynn T, Green BL, Kohler C, Nagy S. Statewide Tuskegee Alliance for clinical trials. A community coalition to enhance minority participation in medical research. Cancer. Jan 1 2001;91(1 Suppl):237-241.
42. Lai GY, Gary TL, Tilburt J, et al. Effectiveness of strategies to recruit underrepresented populations into cancer clinical trials. Clin Trials. 2006;3(2):133-141.
43. Sorensen G, Emmons K, Hunt MK, et al. Model for incorporating social context in health behavior interventions: applications for cancer prevention for working-class, multiethnic populations. Prev Med. Oct 2003;37(3):188-197.
44. Emmons K. Behavioral and Social Science Contributions to the Health of Adults in the United States. In: Smedley BD, Syme SL, eds. Promoting Health: Intervention Strategies from Social and Behavioral Research. Washington DC: The National Academies Press; 2000:254-321.

Improving access to colorectal cancer screening for the underserved. Eliminating cancer disparities.

As we have noted previously, colorectal cancer is a leading preventable cause of cancer mortality. See related posts. Screening can be effective reducing deaths by half. Yet it is underutilized. Multi-level interventions addressing system changes and individual factors can effectively increasing screening. To date, most interventions have been implemented and evaluated in higher-resource settings such as health maintenance organizations.  Given the disparities evident for colorectal cancer and the potential for screening to improve outcomes, we describe our ongoing NCI funded research that is expanding the population included in such studies. We recently published the protocol for our ongoing study that includes economically disadvantaged patients. (see report online). We describe the study protocol for a trial designed to increase colorectal cancer screening in those 'safety-net' health centers that serve underinsured and uninsured patients in Missouri. This trial was designed and is being implemented using a community-based participatory approach.

What was our approach?

We developed a practical clinical cluster-randomized controlled trial. We are currently recruiting 16 community health centers to participate and collaborate in this trial. This systems-level intervention consists of a menu of evidence-based implementation strategies for increasing colorectal cancer screening. Health centers in the intervention arm then collaborate with our Siteman and Washington University based  study team to tailor strategies to their own setting to maximize fit and acceptability. Data are collected at the organizational level through interviews, and at the provider and patient levels through surveys. Patients complete a survey about their healthcare and screening utilization at baseline, six months, and twelve months.

How will we assess success in brining screening to our underserved communities?

The primary outcome for our study is colorectal cancer screening that we record through patient self-report. We will supplement these self –reports with a chart-audit in a subsample of patients. This is similar to the approach we used in a primacy care based intervention in New England that showed success in creasing screening rates more than a decade ago (see report).  Implementation outcomes informed by the Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) conceptual framework will be measured at the patient, provider, and practice levels. This approach has been used previously to evaluate interventions in low-income settings and assess the overall public health benefit.

Why is this study important?

Our study is one of the first to integrate community participatory strategies to a randomized controlled trial in a low-income healthcare setting. The multi-level approach will support the ability of the intervention to affect screening through multiple avenues. The participatory approach will strengthen the chance that implementation strategies will be maintained after study completion and, supports external validity by increasing health center interest and willingness to participate.

Ronald Rancher, a participant in the Photovoice project, 

stands next to the photo he submitted for the project. 

The photos were on display at 

Washington University School of Medicine.

More... 

For more details on this and other innovative studies on colorectal cancer screening in low income populations see Associate Professor Dr. Aimee James' studies at Siteman Cancer Center: http://www.siteman.wustl.edu/contentpage.aspx?id=6130

Or watch the Photovoice video at… Watch the Photovoice project video

Colon Screening saves lives: Massachusetts Success Story

A new report by our CNiC team summarizes the rapid changes in colorectal cancer screening in Massachusetts and more broadly through New England over 15 years from 1997 onwards. The move from scientific evidence to public health strategy hinged on a sustained strategy described by the collective impact approach where common goals, a shared measurement system, mutually reinforcing activities, and continuous communication with a backbone organization sustain changes that lead to improved population health outcomes.

The Massachusetts Colorectal Cancer Workgroup united academics and clinicians from medical and public health schools across the state, and together with the American Cancer Society, the Massachusetts Medical Society, and the Massachusetts Department of Public Health, coordinated and facilitated a broad range of outreach and education activities for providers and the general public. The goal of these activities was to increase awareness and use of colon cancer screening tests.

The results, summarized in a new short report show a marked increase in screening in Massachusetts, to the highest level in the nation, and a drop in mortality from colon cancer by 27%.

More will be done to sustain these changes. Of course, many states and regions of the country still have much lower levels of colorectal screening. Renewed effort to bring access to colorectal cancer screen are needed as this strategy clearly saves lives. Other prevention approaches to complement screening are also summarized in or 8ightWays to prevent colon cancer and other tools available from this CNiC site under the "extras" button.

See related posts

Cancer News in Context: 8IGHT WAYS to Prevent Colon Cancer

Preventing colon cancer: Screening works – mortality down 30