april 2012, vol 3, no 2

© 2012 Green Hill Healthcare Communications, LLC

NAVIGATING PATIENTS ACROSS THE CONTINUUM OF CANCER CARETM

APRIL 2012 www.AONNonline.org VOL 3, NO 2

COMMUNITY OUTREACHPromoting Breast HealthAwareness on College Campuses

ORIGINAL RESEARCHBreast Health Education andCancer Awareness: A Community HospitalEmbracing a Novel Approach

ORIGINAL RESEARCHMujer a Mujer/Woman toWoman: Using a Unique Venue for Culturally Appropriate Outreach and Navigation in an Underserved Area to IncreaseScreening

WEB SITE REVIEWThe National ComprehensiveCancer Network® and NCCN®

Member Institutions

JONS_April 2012_v3_TON1110_FINAL 4/16/12 4:13 PM

7% 8%CR

43% 42%

ORRPrimary Endpoint

11% 12%

CR

53% 51%

ORR

SC (n=148)IV (n=74)

Subcutaneous VELCADE Demonstrated Efficacy Consistent With IV for the Primary Endpoint

N

RESPONSE RATES† IN RELAPSED MULTIPLE MYELOMA (MM): SUBCUTANEOUS AND IV

P

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▼ The study met its primary non-inferiority objective that single-agent subcutaneous VELCADE retained at least 60% of the overall response rate after 4 cycles relative to single-agent IV VELCADE

SUBCUTANEOUS VS IV TRIAL: a non-inferiority, phase 3, randomized (2:1), open-label trial compared the efficacy and safety of VELCADE administered subcutaneously (n=148) with VELCADE administered intravenously (n=74) in patients with relapsed MM. The primary endpoint was overall response rate at 4 cycles. Secondary endpoints included response rate at 8 cycles, median TTP and PFS (months), 1-year overall survival (OS), and safety.

* INDICATIONS: VELCADE is indicated for the treatment of patients with multiple myeloma. VELCADE is indicated for the treatment of patients with mantle cell lymphoma who have received at least 1 prior therapy.

†Responses were based on criteria established by the European Group for Blood and Marrow Transplantation.1

VELCADE IMPORTANT SAFETY INFORMATIONCONTRAINDICATIONSVELCADE is contraindicated in patients with hypersensitivity to bortezomib, boron, or mannitol. VELCADE is contraindicated for intrathecal administration.

WARNINGS, PRECAUTIONS AND DRUG INTERACTIONS ▼ Peripheral neuropathy, including severe cases, may occur – manage with dose modification or discontinuation. Patients

with preexisting severe neuropathy should be treated with VELCADE only after careful risk-benefit assessment ▼ Hypotension can occur. Use caution when treating patients receiving antihypertensives, those with a history of syncope,

and those who are dehydrated▼ Closely monitor patients with risk factors for, or existing heart disease ▼ Acute diffuse infiltrative pulmonary disease has been reported▼ Nausea, diarrhea, constipation, and vomiting have occurred and may require use of antiemetic and antidiarrheal

medications or fluid replacement▼ Thrombocytopenia or neutropenia can occur; complete blood counts should be regularly monitored throughout treatment▼ Tumor Lysis Syndrome, Reversible Posterior Leukoencephalopathy Syndrome, and Acute Hepatic Failure have been reported

a c

T m

a less-dose-intense schedule, or discontinuation. Please see full Prescribing Information for dose modification g

AT 24 WEEKS (AFTER 8 CYCLES) VELCADE±dexamethasone

AT 12 WEEKS (AFTER 4 CYCLES)Single-agent VELCADE® (bortezomib)

NOW APPROVED FOR SUBCUTANEOUS ADMINISTRATION IN ALL INDICATIONS*

JONS_April 2012_v2_TON1110_FINAL 4/16/12 9:13 AM

6%16%

GRADE ≥3

38%53%

SC (n=147)

IV (n=74)

ALL GRADES

Difference in Incidence of Peripheral Neuropathy With Subcutaneous VELCADE

PERIPHERAL NEUROPATHY (PN) IN RELAPSED MM: SUBCUTANEOUS AND IVR

Please see Brief Summary for VELCADE on next page.

For Patient Assistance Information or Reimbursement Assistance, call 1-866-VELCADE (835-2233), Option 2, or visit VELCADEHCP.comReference: 1. Moreau P, Pylypenko H, Grosicki S, et al. Subcutaneous versus intravenous administration of bortezomib in patients with relapsed multiple myeloma: a randomised, phase 3, non-inferiority study. Lancet Oncol. 2011;12(5):431-440.

w

a

m

▼ Starting VELCADE® (bortezomib) subcutaneously may be considered for patients with preexisting PN or patients at high risk for PN. Patients with preexisting severe neuropathy should be treated with VELCADE only after careful risk-benefit assessment

▼ Treatment with VELCADE may cause PN that is predominantly sensory. However, cases of severe sensory and motor PN have been reported. Patients should be monitored for symptoms of neuropathy, such as a burning sensation, hyperesthesia, hypoesthesia, paresthesia, discomfort, neuropathic pain, or weakness

▼ Patients experiencing new or worsening PN during therapy with VELCADE may require a decrease in the dose, a less-dose-intense schedule, or discontinuation. Please see full Prescribing Information for dose modification guidelines for PN

WARNINGS, PRECAUTIONS AND DRUG INTERACTIONS CONTINUED▼ Women should avoid becoming pregnant while being treated with VELCADE. Pregnant women should be apprised of the

potential harm to the fetus

▼ Closely monitor patients receiving VELCADE in combination with strong CYP3A4 inhibitors. Concomitant use of strong CYP3A4 inducers is not recommended

ADVERSE REACTIONS Most commonly reported adverse reactions (incidence ≥30%) in clinical studies include asthenic conditions, diarrhea, nausea, constipation, peripheral neuropathy, vomiting, pyrexia, thrombocytopenia, psychiatric disorders, anorexia and decreased appetite, neutropenia, neuralgia, leukopenia, and anemia. Other adverse reactions, including serious adverse reactions, have been reported

IN ALL INDICATIONS*

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Brief Summary

INDICATIONS:VELCADE® (bortezomib) for Injection is indicated for the treatment of patients with multiple myeloma. VELCADE® (bortezomib) for Injection is indicated for the treatment of patients with mantle cell lymphoma who have received at least 1 prior therapy.

CONTRAINDICATIONS:VELCADE is contraindicated in patients with hypersensitivity to bortezomib, boron, or mannitol. VELCADE is contraindicated for intrathecal administration.

WARNINGS AND PRECAUTIONS:VELCADE should be administered under the supervision of a physician experienced in the use of antineoplastic therapy. Complete blood counts (CBC) should be monitored frequently during treatment with VELCADE.

Peripheral Neuropathy: VELCADE treatment causes a peripheral neuropathy that is predominantly sensory. However, cases of severe sensory and motor peripheral neuropathy have been reported. Patients with pre-existing symptoms (numbness, pain or a burning feeling in the feet or hands) and/or signs of peripheral neuropathy may experience worsening peripheral neuropathy (including ≥ Grade 3) during treatment with VELCADE. Patients should be monitored for symptoms of neuropathy, such as a burning sensation, hyperesthesia, hypoesthesia, paresthesia, discomfort, neuropathic pain or weakness. In the Phase 3 relapsed multiple myeloma trial comparing VELCADE subcutaneous vs. intravenous the incidence of Grade ≥ 2 peripheral neuropathy events was 24% for subcutaneous and 41% for intravenous. Grade ≥ 3 peripheral neuropathy occurred in 6% of patients in the subcutaneous treatment group, compared with 16% in the intravenous treatment group. Starting VELCADE subcutaneously may be considered for patients with pre-existing or at high risk of peripheral neuropathy.

Patients experiencing new or worsening peripheral neuropathy during VELCADE therapy may benefit from a decrease in the dose and/or a less dose-intense schedule. In the single agent phase 3 relapsed multiple myeloma study of VELCADE vs. Dexamethasone following dose adjustments, improvement in or resolution of peripheral neuropathy was reported in 51% of patients with ≥ Grade 2 peripheral neuropathy in the relapsed multiple myeloma study. Improvement in or resolution of peripheral neuropathy was reported in 73% of patients who discontinued due to Grade 2 neuropathy or who had ≥ Grade 3 peripheral neuropathy in the phase 2 multiple myeloma studies. The long-term outcome of peripheral neuropathy has not been studied in mantle cell lymphoma.

Hypotension: The incidence of hypotension (postural, orthostatic, and hypotension NOS) was 13%. These events are observed throughout therapy. Caution should be used when treating patients with a history of syncope, patients receiving medications known to be associated with hypotension, and patients who are dehydrated. Management of orthostatic/postural hypotension may include adjustment of antihypertensive medications, hydration, and administration of mineralocorticoids and/or sympathomimetics.

Cardiac Disorders: Acute development or exacerbation of congestive heart failure and new onset of decreased left ventricular ejection fraction have been reported, including reports in patients with no risk factors for decreased left ventricular ejection fraction. Patients with risk factors for, or existing heart disease should be closely monitored. In the relapsed multiple myeloma study of VELCADE vs. dexamethasone, the incidence of any treatment-emergent cardiac disorder was 15% and 13% in the VELCADE and dexamethasone groups, respectively. The incidence of heart failure events (acute pulmonary edema, cardiac failure, congestive cardiac failure, cardiogenic shock, pulmonary edema) was similar in the VELCADE and dexamethasone groups, 5% and 4%, respectively. There have been

isolated cases of QT-interval prolongation in clinical studies; causality has not been established.

Pulmonary Disorders: There have been reports of acute diffuse infiltrative pulmonary disease of unknown etiology such as pneumonitis, interstitial pneumonia, lung infiltration and Acute Respiratory Distress Syndrome (ARDS) in patients receiving VELCADE. Some of these events have been fatal. In a clinical trial, the first two patients given high-dose cytarabine (2 g/m2 per day) by continuous infusion with daunorubicin and VELCADE for relapsed acute myelogenous leukemia died of ARDS early in the course of therapy. There have been reports of pulmonary hypertension associated with VELCADE administration in the absence of left heart failure or significant pulmonary disease. In the event of new or worsening cardiopulmonary symptoms, a prompt comprehensive diagnostic evaluation should be conducted.

Reversible Posterior Leukoencephalopathy Syndrome (RPLS): There have been reports of RPLS in patients receiving VELCADE. RPLS is a rare, reversible, neurological disorder which can present with seizure, hypertension, headache, lethargy, confusion, blindness, and other visual and neurological disturbances. Brain imaging, preferably MRI (Magnetic Resonance Imaging), is used to confirm the diagnosis. In patients developing RPLS, discontinue VELCADE. The safety of reinitiating VELCADE therapy in patients previously experiencing RPLS is not known.

Gastrointestinal Adverse Events: VELCADE treatment can cause nausea, diarrhea, constipation, and vomiting sometimes requiring use of antiemetic and antidiarrheal medications. Ileus can occur. Fluid and electrolyte replacement should be administered to prevent dehydration.

Thrombocytopenia/Neutropenia: VELCADE is associated with thrombocytopenia and neutropenia that follow a cyclical pattern with nadirs occurring following the last dose of each cycle and typically recovering prior to initiation of the subsequent cycle. The cyclical pattern of platelet and neutrophil decreases and recovery remained consistent over the 8 cycles of twice weekly dosing, and there was no evidence of cumulative thrombocytopenia or neutropenia. The mean platelet count nadir measured was approximately 40% of baseline. The severity of thrombocytopenia was related to pretreatment platelet count. In the relapsed multiple myeloma study of VELCADE vs. dexamethasone, the incidence of significant bleeding events (≥Grade 3) was similar on both the VELCADE (4%) and dexamethasone (5%) arms. Platelet counts should be monitored prior to each dose of VELCADE. Patients experiencing thrombocytopenia may require change in the dose and schedule of VELCADE. There have been reports of gastrointestinal and intracerebral hemorrhage in association with VELCADE. Transfusions may be considered. The incidence of febrile neutropenia was <1%.

Tumor Lysis Syndrome: Because VELCADE is a cytotoxic agent and can rapidly kill malignant cells, the complications of tumor lysis syndrome may occur. Patients at risk of tumor lysis syndrome are those with high tumor burden prior to treatment. These patients should be monitored closely and appropriate precautions taken.

Hepatic Events: Cases of acute liver failure have been reported in patients receiving multiple concomitant medications and with serious underlying medical conditions. Other reported hepatic events include increases in liver enzymes, hyperbilirubinemia, and hepatitis. Such changes may be reversible upon discontinuation of VELCADE. There is limited re-challenge information in these patients.

Hepatic Impairment: Bortezomib is metabolized by liver enzymes. Bortezomib exposure is increased in patients with moderate or severe hepatic impairment; these patients should be treated with VELCADE at reduced starting doses and closely monitored for toxicities.

(continued)

2:31 PM


Use in Pregnancy: Pregnancy Category D. Women of childbearing potential should avoid becoming pregnant while being treated with VELCADE (bortezomib). Bortezomib administered to rabbits during organogenesis at a dose approximately 0.5 times the clinical dose of 1.3 mg/m2 based on body surface area caused post-implantation loss and a decreased number of live fetuses.

ADVERSE EVENT DATA:Safety data from phase 2 and 3 studies of single-agent VELCADE 1.3 mg/m2/dose administered intravenously twice weekly for 2 weeks followed by a 10-day rest period in 1163 patients with previously treated multiple myeloma (N=1008, not including the phase 3, VELCADE plus DOXIL® [doxorubicin HCI liposome injection] study) and previously treated mantle cell lymphoma (N=155) were integrated and tabulated. In these studies, the safety profile of VELCADE was similar in patients with multiple myeloma and mantle cell lymphoma.

In the integrated analysis, the most commonly reported adverse events were asthenic conditions (including fatigue, malaise, and weakness); (64%), nausea (55%), diarrhea (52%), constipation (41%), peripheral neuropathy NEC (including peripheral sensory neuropathy and peripheral neuropathy aggravated); (39%), thrombocytopenia and appetite decreased (including anorexia); (each 36%), pyrexia (34%), vomiting (33%), anemia (29%), edema (23%), headache, paresthesia and dysesthesia (each 22%), dyspnea (21%), cough and insomnia (each 20%), rash (18%), arthralgia (17%), neutropenia and dizziness (excluding vertigo); (each 17%), pain in limb and abdominal pain (each 15%), bone pain (14%), back pain and hypotension (each 13%), herpes zoster, nasopharyngitis, upper respiratory tract infection, myalgia and pneumonia (each 12%), muscle cramps (11%), and dehydration and anxiety (each 10%). Twenty percent (20%) of patients experienced at least 1 episode of ≥Grade 4 toxicity, most commonly thrombocytopenia (5%) and neutropenia (3%). A total of 50% of patients experienced serious adverse events (SAEs) during the studies. The most commonly reported SAEs included pneumonia (7%), pyrexia (6%), diarrhea (5%), vomiting (4%), and nausea, dehydration, dyspnea and thrombocytopenia (each 3%).

In the phase 3 VELCADE + melphalan and prednisone study in previously untreated multiple myeloma, the safety profile of VELCADE administered intravenously in combination with melphalan/prednisone is consistent with the known safety profiles of both VELCADE and melphalan/prednisone. The most commonly reported adverse events in this study (VELCADE+melphalan/prednisone vs melphalan/prednisone) were thrombocytopenia (52% vs 47%), neutropenia (49% vs 46%), nausea (48% vs 28%), peripheral neuropathy (47% vs 5%), diarrhea (46% vs 17%), anemia (43% vs 55%), constipation (37% vs 16%), neuralgia (36% vs 1%), leukopenia (33% vs 30%), vomiting (33% vs 16%), pyrexia (29% vs 19%), fatigue (29% vs 26%), lymphopenia (24% vs 17%), anorexia (23% vs 10%), asthenia (21% vs 18%), cough (21% vs 13%), insomnia (20% vs 13%), edema peripheral (20% vs 10%), rash (19% vs 7%), back pain (17% vs 18%), pneumonia (16% vs 11%), dizziness (16% vs 11%), dyspnea (15% vs 13%), headache (14% vs 10%), pain in extremity (14% vs 9%), abdominal pain (14% vs 7%), paresthesia (13% vs 4%), herpes zoster (13% vs 4%), bronchitis (13% vs 8%), hypokalemia (13% vs 7%), hypertension (13% vs 7%), abdominal pain upper (12% vs 9%), hypotension (12% vs 3%), dyspepsia (11% vs 7%), nasopharyngitis (11% vs 8%), bone pain (11% vs 10%), arthralgia (11% vs 15%) and pruritus (10% vs 5%).

In the phase 3 VELCADE subcutaneous vs. intravenous study in relapsed multiple myeloma, safety data were similar between the two treatment groups. The most commonly reported adverse events in this study were peripheral neuropathy NEC (38% vs 53%), anemia (36% vs 35%), thrombocytopenia (35% vs 36%), neutropenia (29% vs 27%), diarrhea (24% vs 36%), neuralgia (24% vs 23%), leukopenia (20% vs 22%), pyrexia (19% vs 16%), nausea (18% vs 19%), asthenia (16% vs 19%), weight decreased (15% vs 3%), constipation (14% vs 15%), back pain (14% vs 11%), fatigue (12% vs 20%), vomiting (12% vs 16%), insomnia (12% vs 11%), herpes zoster (11% vs 9%), decreased appetite (10% vs 9%), hypertension (10% vs 4%), dyspnea (7% vs 12%), pain in extremities (5% vs 11%), abdominal pain and headache (each 3% vs 11%), abdominal pain upper (2% vs 11%). The incidence of serious adverse events was similar for the subcutaneous treatment group (36%) and the intravenous treatment group (35%). The most commonly reported SAEs

were pneumonia (6%) and pyrexia (3%) in the subcutaneous treatment group and pneumonia (7%), diarrhea (4%), peripheral sensory neuropathy (3%) and renal failure (3%) in the intravenous treatment group.

DRUG INTERACTIONS:Bortezomib is a substrate of cytochrome P450 enzyme 3A4, 2C19 and 1A2. Co-administration of ketoconazole, a strong CYP3A4 inhibitor, increased the exposure of bortezomib by 35% in 12 patients. Therefore, patients should be closely monitored when given bortezomib in combination with strong CYP3A4 inhibitors (e.g. ketoconazole, ritonavir). Co-administration of omeprazole, a strong inhibitor of CYP2C19, had no effect on the exposure of bortezomib in 17 patients. Co-administration of rifampin, a strong CYP3A4 inducer, is expected to decrease the exposure of bortezomib by at least 45%. Because the drug interaction study (n=6) was not designed to exert the maximum effect of rifampin on bortezomib PK, decreases greater than 45% may occur. Efficacy may be reduced when VELCADE (bortezomib) is used in combination with strong CYP3A4 inducers; therefore, concomitant use of strong CYP3A4 inducers is not recommended in patients receiving VELCADE. St. John’s Wort (Hypericum perforatum) may decrease bortezomib exposure unpredictably and should be avoided. Co-administration of dexamethasone, a weak CYP3A4 inducer, had no effect on the exposure of bortezomib in 7 patients. Co-administration of melphalan-prednisone increased the exposure of bortezomib by 17% in 21 patients. However, this increase is unlikely to be clinically relevant.

USE IN SPECIFIC POPULATIONS:Nursing Mothers: It is not known whether bortezomib is excreted in human milk. Because many drugs are excreted in human milk and because of the potential for serious adverse reactions in nursing infants from VELCADE, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother.

Pediatric Use: The safety and effectiveness of VELCADE in children has not been established.

Geriatric Use: No overall differences in safety or effectiveness were observed between patients ≥age 65 and younger patients receiving VELCADE; but greater sensitivity of some older individuals cannot be ruled out.

Patients with Renal Impairment: The pharmacokinetics of VELCADE are not influenced by the degree of renal impairment. Therefore, dosing adjustments of VELCADE are not necessary for patients with renal insufficiency. Since dialysis may reduce VELCADE concentrations, VELCADE should be administered after the dialysis procedure. For information concerning dosing of melphalan in patients with renal impairment, see manufacturer’s prescribing information.

Patients with Hepatic Impairment: The exposure of bortezomib is increased in patients with moderate and severe hepatic impairment. Starting dose should be reduced in those patients.

Patients with Diabetes: During clinical trials, hypoglycemia and hyperglycemia were reported in diabetic patients receiving oral hypoglycemics. Patients on oral antidiabetic agents receiving VELCADE treatment may require close monitoring of their blood glucose levels and adjustment of the dose of their antidiabetic medication.

Please see full Prescribing Information for VELCADE at VELCADEHCP.com.

VELCADE, MILLENNIUM and are registered trademarks of Millennium Pharmaceuticals, Inc. Other trademarks are property of their respective owners.

Millennium Pharmaceuticals, Inc., Cambridge, MA 02139 Copyright © 2012, Millennium Pharmaceuticals, Inc.All rights reserved. Printed in USA V-12-0017 3/12

2:31 PM


6 APRIL 2012 • VOLUME 3, ISSUE 2 AONNONLINE.ORG

PUBLISHING STAFFSENIOR VICE PRESIDENT, SALES & MARKETING

Philip [email protected]

PUBLISHERJohn W. Hennessy

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DIRECTOR CLIENT SERVICESJack Iannaccone

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MANAGING EDITORJim Scelfo

[email protected]

EDITORIAL ASSISTANTJennifer Brandt

SENIOR COPY EDITORRosemary Hansen

PRODUCTION MANAGERStephanie Laudien

QUALITY CONTROL DIRECTORBarbara Marino

BUSINESS MANAGERBlanche Marchitto

CIRCULATION [email protected]

Journal of Oncology Navigation & Survivorship, ISSN 2166-0999 (print); ISSN 2166-0980 (online), is published 6 timesa year by Green Hill Healthcare Communications, LLC,241 Forsgate Drive, Suite 205C, Monroe Twp, NJ 08831.Telephone: 732.656.7935. Fax: 732.656.7938. Copy right©2012 by Green Hill Health care Com muni cations, LLC.All rights reserved. Journal of Oncology Navigation &Survivorship logo is a registered trademark of Green HillHealthcare Communications, LLC. No part of this publica-tion may be reproduced or transmitted in any form or by anymeans now or hereafter known, electronic or mechanical,including photocopy, recording, or any informational stor-age and retrieval system, without written permission fromthe publisher. Printed in the United States of America.

EDITORIAL CORRESPONDENCE should be ad dressed to MANAGING EDITOR, Journal of OncologyNavigation & Survivorship (JONS), 241 Forsgate Drive, Suite205C, Monroe Twp, NJ 08831. E-mail: [email protected] SUBSCRIPTION RATES: United States and pos-sessions: individuals, $50.00; institutions, $90.00; single issues,$5.00. Orders will be billed at individual rate until proof of sta-tus is confirmed. Prices are subject to change without notice.Correspondence regarding permission to reprint all or part ofany article published in this journal should be addressed toREPRINT PERMISSIONS DEPART MENT, Green HillHealthcare Communications, LLC, 241 Forsgate Drive, Suite205C, Monroe Twp, NJ 08831. The ideas and opinionsexpressed in JONS do not necessarily reflect those of the edito-rial board, the editorial director, or the publisher. Publication ofan advertisement or other product mention in JONS should notbe construed as an endorsement of the product or the manufac-turer’s claims. Readers are encouraged to contact the manufac-turer with questions about the features or limitations of theproducts mentioned. Neither the editorial board nor the pub-lisher assumes any responsibility for any injury and/or damageto persons or property arising out of or related to any use of thematerial contained in this periodical. The reader is advised tocheck the appropriate medical literature and the product infor-mation currently provided by the manufacturer of each drug tobe administered to verify the dosage, the method and durationof administration, or contraindications. It is the responsibility ofthe treating physician or other healthcare professional, relyingon independent experience and knowledge of the patient, todetermine drug dosages and the best treatment for the patient.Every effort has been made to check generic and trade names,and to verify dosages. The ultimate responsibility, however, lieswith the prescribing physician. Please convey any errors to theeditorial director.

ABOUT THE COVERThe Unveiling Acrylic by a Healthcare ProfessionalCalifornia

Artwork from the Lilly Oncology On Canvas: Expressions of a Cancer JourneyArt Competition (www.LillyOncologyOnCanvas.com).

APRIL 2012 • VOL 3, NO 2TABLE OF CONTENTS

COMMUNITY OUTREACH

9 Promoting Breast Health Awareness on CollegeCampusesBy Lillie D. Shockney, RN, BS, MAS

ORIGINAL RESEARCH

10 Breast Health Education and Cancer Awareness: A Community Hospital Embracing a Novel ApproachBy Danelle Johnston, RN, BSN, OCN, CBCN

20 Mujer a Mujer/Woman to Woman: Using a UniqueVenue for Culturally Appropriate Outreach andNavigation in an Underserved Area to IncreaseScreeningBy Sally Cascella, MAHSN, BSN, RN, CNORJacqueline Keren, MFA, BA

WEB SITE REVIEW

26 The National Comprehensive Cancer Network®

and NCCN® Member Institutions By Lillie D. Shockney, RN, BS, MAS


Journal of Oncology

The Official Journal of the Academy of Oncology Nurse NavigatorsNAVIGATION & SURVIVORSHIP

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LETTERS FROM LILLIE


Editor-in-ChiefLillie D. Shockney, RN, BS, MASUniversity Distinguished Service AssociateProfessor of Breast CancerDepts of Surgery and OncologyAdministrative Director, Johns HopkinsBreast Clinical ProgramsAdministrative Director, Johns HopkinsCancer Survivorship ProgramsAssociate Professor, JHU School ofMedicine, Depts of Surgery &Gynecology and ObstetricsAssociate Professor, JHU School of [email protected]

Section EditorsBreast CancerSharon Gentry, RN, MSN, AOCN, CBCNBreast Health NavigatorDerrick L. Davis Forsyth Regional Cancer Center

Prostate CancerFrank delaRama, RN, MS, AOCNSClinical Nurse SpecialistOncology/GenomicsCancer Care ClinicPalo Alto Medical Foundation

Healthcare Disparities Linda Fleisher, PhD, MPHAssistant Vice PresidentOffice of Health Communications & Health DisparitiesAssistant ProfessorCancer Prevention & ControlFox Chase Cancer Center

Health Promotion and OutreachIyaad Majed Hasan, MSN, FNPDirector and Nurse PractitionerSurvivorship Clinic and ProgramCleveland ClinicTaussig Cancer Center

AONN Research CommitteeMarcy Poletti, RN, MSN Program Administrator, Oncology ServicesWake Forest University Baptist Medical Center

Elaine Sein, RN, BSN, OCN, CBCNSenior Project ManagerFox Chase Cancer Center Partners

Penny Widmaier, RN, MSNNurse NavigatorBotsford Cancer Center

MISSION STATEMENTThe Journal of Oncology Navi gation &Survivorship (JONS) promotes reliance on evi-dence-based practices in navigating patients withcancer and their caregivers through diagnosis,treatment, and survivorship. JONS also seeks tostrengthen the role of nurse and patient navigatorsin cancer care by serving as a platform for theseprofessionals to disseminate original research find-ings, exchange best practices, and find support fortheir growing community.

Dear Colleague,

As we begin to welcome spring, we arealso welcoming the opportunity toconduct more health fairs and other

community outreach events to raise cancerawareness. This issue contains an articlethat is specifically focused on breast cancerawareness and educating women (andmen) about the facts regarding breast health and breast cancer. What makes thisarticle different is that it provides a bird’s-eye view of how to engage consumers ina fun way to learn, retain, and use information to help ensure their own breastsremain healthy. This is merely one way to creatively engage people in your localcommunities.So I want this example to serve as a challenge to all to get your creative juices

flowing and invent interactive ways for you, other healthcare staff, and cancer sur-vivor volunteers to develop and implement similar programs; join together todesign methods to promote cancer awareness and healthy lifestyle behaviors toreduce the risk of getting cancer; and explore ways to instill the facts and undo themyths associated with various forms of cancer. Perhaps once your program is devel-oped and implemented, you, too, can write an article for our editorial board to con-sider for a future issue of the journal. We are here to foster knowledge among all ofyou, and one of the best ways to do that is by sharing programs that have proven tobe successful in carrying out our mission!If in your navigation role you are not personally involved in community outreach

programs, please consider participating in a few. It helps consumers to know that ifthey do end up diagnosed with a particular type of cancer, there is someone like youwho will be ready, willing, and able to guide them through. g

With best regards,

Lillie D. Shockney, RN, BS, MASEditor-in-Chief

COMMUNITY OUT-REACH CHALLENGE

“Join together to designmethods to promotecancer awareness...”


AONNONLINE.ORG JOURNAL OF ONCOLOGY NAVIGATION & SURVIVORSHIP 9

COMMUNITYOUTREACH

Many young women, ages 18 to 22, areaway from their parents, living on col-lege campuses and exposed to lifestyle

behaviors that can increase their risk of gettingbreast cancer. Now that they have come of age,this is also a group that begins to fear this disease,joining the millions of women worldwide who areafraid that one day they will be diagnosed withbreast cancer. Many attempts have been made inthe past to educate college-age women aboutbreast health issues and most particularly breastcancer. The goal of these educational programshas historically fallen short due to low attendanceand lack of measurable knowledge learned.Given that this is a challenging consumer groupto reach and teach, in 2001, alpha Kappa DeltaPhi, a small sorority at the Johns HopkinsUniversity (JHU) Homewood campus, partneredwith the Johns Hopkins Avon Foundation BreastCenter to create a unique method of educationand called it a Breastival™. Eighty flash cards were created (true/false and

multiple choice), and 8 breast cancer organiza-tions were recruited to have booths where theflash cards would be shown. When a studentanswered a question correctly, she advanced tothe next booth. Students who answered a ques-tion at all 8 booths were rewarded with “boobyprizes.” Not only was this first event successful,its success was measurable. We knew the num-ber of students who came to the event (morethan half of the students living on campus),which questions they answered correctly andincorrectly, how many visited every booth, andwhether they wanted to receive e-mailreminders to mark their calendar each month toperform their breast self-exams. A list of themyths that students assumed were true (such asantiperspirants being the cause of breast cancer)were recorded and incorporated into teaching

activities provided later. Just a few days after this first Breastival was

held, students from other college campusesacross the United States (who were actually siblings of JHU students) began calling theDirector of the Breast Center inquiring howthey could hold a Breastival on their campus.This resulted in the Breastival program beingtrademarked under Johns Hopkins Medicine. ABreastival Resource and Planning Kit was creat-ed and distributed for a nominal fee to sororities,other breast centers, nursing schools, and othercancer organizations that wanted to replicatethis “learn and earn” model of educating peopleabout breast health and breast cancer.

Over the past decade, more than 250 collegesororities, breast centers, and breast cancerorganizations have purchased the kit and held aBreastival in their geographic area. Many havecontinued to hold the event annually. Theseevents have also been held in other countries,including Canada, New Zealand, and theUnited Arab Emirates. Recently, St Jude Medical Center (SJMC)

in Orange County, California, conducted 2Brestival events. On the following pages, wepresent a report by Danelle Johnston, RN, BSN,OCN, CBCN, detailing the SJMC Breastivalexperience.g

PROMOTING BREASTHEALTH AWARENESS ONCOLLEGE CAMPUSESBy Lillie D. Shockney, RN, BS, MAS

Just a few days after this first Breastival was held, students fromother college campuses...began... inquiring how they could hold a Breastival on their campus.


ORIGINAL RESEARCH


E xcluding skin cancer, breast cancer is themost common cancer among women and isthe second-leading cause of cancer death in

women.1-3 In 2011, the American Cancer Societyestimated there would be 230,480 new cases ofinvasive breast cancer.1 Orange County (OC)California is the third most populous county inCalifornia and has a slightly higher incidence ofbreast cancer than the state average.2 It is project-ed that by 2020, the adult female population inOC will increase by 25% from 974,643 to over1.2 million, and this increase is reported to bemostly in women aged 55 years and older.4Women have a 98% 5-year survival rate when

cancer is localized to the breast.5,6 Evidence showsthat early-stage diagnosis and intervention aredirectly related to decreased mortality rates forbreast cancer.5,6 Nevertheless, studies have indi-cated that many women are not establishing rou-tine screening schedules, are initiating screeningat a later age than recommended, or are delayingfollow-up after positive screening findings.6 Thesepractices result in women being diagnosed at amore advanced stage. Further decline in mortali-ty rates, however, can be made with improvementin routine use of mammography screening andthe provision of timely access to quality care.6

Table 1 summarizes the percentages of womenage 40 and over in the United States, inCalifornia, and in OC who have had a mammo-gram within the past 2 years. The national report-ed rates demonstrate a decline in mammographysince 2000.3 Yet, for California and OC, datashow an increase in compliance.7 However, OCreports a decline in compliance in the subset ofwomen in the 40- to 49-year-old age group. Also,the California Health Interview Survey for OCreported in 2009 that only 71.6% of physiciansexamined breasts for breast lumps within the past12 months and only 83% of physicians recom-mended a mammogram.7 According to a study bythe Robert Wood Johnson Foundation (2007),nearly 4000 lives could be saved yearly if mam-mography and clinical breast exam biannualscreening rates could be increased to 90%.8

Anticipating that OC will have an increase inthe aging population, it is evident that the mes-sage of breast health awareness and screeningneeds to be conveyed to the community.Barriers to women having mammography

screening and clinical breast exams have beenidentified. These barriers include lack of knowl-edge about cancer and cancer screening, deficien-cy in physician referral, low motivation, fear,transportation problems, lack of health insurance,and forgetfulness.9 Identifying interventions toaddress the barriers is imperative in order toincrease compliance in breast cancer screening. Dr Harold Freeman established the first patient

navigation program in 1990 to assist the medical-ly underserved and uninsured by providing timelyaccess to screening and treatment.10 Programs likeDr Freeman’s that emphasize screening and out-reach have demonstrated significant and measur-able successes.10 The Oncology Nursing Society’sposition statement for oncology navigation iden-tifies that navigators must have education on anddemonstrate knowledge about community assess-ment, resolution of system barriers, and cancerhealth disparities.11 The oncology nurse navigatorhas a unique opportunity to take the lead to ensurethat communities have access to cancer screeningand receive timely access to care. The navigator isan advocate within the healthcare system to facil-itate community outreach and education. The American College of Surgeons Com -

mission on Cancer has established standards thatfocus on community outreach (Standard 1.8) andpatient navigation (Standard 3.1).12 These stan-dards require a hospital seeking accreditation todemonstrate that community needs have beenassessed and health disparities identified.Community outreach programs need to bedesigned to address the needs and barriers.Patient navigators participate in identifying barri-ers and facilitating timely access to care across thecare continuum. St Jude Medical Center (SJMC) in OC began

an innovative nurse navigator program in thespring of 2007. The oncology nurse navigator

Breast Health Education and Cancer Awareness: A Community Hospital Embracing a Novel ApproachBy Danelle Johnston, RN, BSN, OCN, CBCNSt Jude Medical Center, Fullerton, California



ORIGINAL RESEARCH

leads the multidisciplinary team in programdevelopment and process improvement initia-tives to assure sustainable and measurable pro-gram growth using current evidence-based prac-tices. As part of this process, the oncologynavigator acts as a resource to promote cancerawareness through community events and educa-tional activities.The American Cancer Society states, “Further

reductions in breast cancer death rates are possi-ble by improving regular use of mammographyscreening and providing timely access to high-quality follow-up and treatment.”6 Therefore,SJMC clearly has an opportunity to make a posi-tive impact in the north OC communities byimplementing an intervention to directly influ-ence patient outcomes and decrease barriers tocare. This can be accomplished by improvingcommunity breast health practices, increasingscreening mammography, and increasing breastawareness practices, thereby diagnosing breastcancer earlier.

PLANNING AND IMPLEMENTATIONLillie Shockney, RN, BS, MAS, discussed theBreastivalTM community outreach program at theFirst Annual Navigation & SurvivorshipConference held in Baltimore, Maryland,September 17-19, 2010.13 The BreastivalTM eventis an opportunity to creatively facilitate commu-nity outreach and education on breast health andawareness developed by Ms Shockney and theJohns Hopkins Breast Center and supported bythe Johns Hopkins University sorority of alphaKappa Delta Phi. The university hosted its firstBreastivalTM event in 2001 and reported out-comes that included the number of attendees, thenumber of participants for group activities, andthe number of attendees who reported learningthe correct technique for breast self-exam on abreast model.13 A BreastivalTM Resource andPlanning Kit is available to groups interested inreplicating the trademarked event.14 The goal of the Breastival is to provide an

enjoyable and nonthreatening atmosphere where

the community can learn about breast health/awareness and breast cancer. The event allows forlocal breast cancer organizations to partner andshare the resources and support available in thecommunity. Additionally, the event offers severaldifferent opportunities and activities for interact-ing with healthcare professionals and communityorganizations. The activities include opportuni-ties to address breast health questions, interactwith breast cancer community organizations, playgames, and attend educational mini-seminars.Measurable program outcomes can be obtained toassess the impact of the event in the community.

The Breastival outreach program aligns withthe goals of the California Dialogue on Cancer(CDOC), the American Cancer Society (ACS),the Orange County Affiliate of Susan G. Komenfor the Cure, and SJMC. All these organizationsplace importance on and invest their resources inbuilding relationships with community-basedbreast programs and hospitals in order to wage thewar against breast cancer. One of the CDOC’sgoals is to increase the number of women havingboth a clinical breast exam and mammogram by7.5% by 2015.15 The researchers at ACS statedthat it will take a coordinated effort to increasecancer awareness and move forward in preventingcancer.16 Komen literature states that efforts needto be placed on partnerships within the commu-nity to develop a comprehensive plan for out-reach and education.2The mission at SJMC is “to extend the healing

ministry of Jesus in the tradition of the Sisters ofSt. Joseph of Orange by continually improving

Table 1 Mammography Screening Within the Past 2 Years

United States (2010)3 California (2009)7 Orange County, CA (2009)7

Age 40-49 62.3% 72.5% 64.3%

Age 50-64 72.7% 86.1% 80.1%

Age 65 and older 64.3% 89.7% 85.4%

Further reductions in breast cancerdeath rates are possible by improvingregular use of mammography screeningand providing timely access to high-quality follow-up and treatment.


ORIGINAL RESEARCH


the health and quality of life of people in thecommunities we serve.”17 The hospital’s strategicgoals include developing and implementing dis-ease-specific programs to enhance presencethrough “perfect care,” having the “healthiestcommunities,” and creating “sacred encounters.”Offering community health education and aware-ness complements the mission of our institutionby striving to achieve healthy communities.

The outreach program was presented to theBreast Workgroup at SJMC in January 2011 inorder to gain their support to move forward withthe implementation of this innovative program.The Breast Workgroup is an interdisciplinarybreast care team that develops and sets programgoals, reviews and discusses clinical practice withcurrent evidence, and reviews quality indicatorsand outcomes under the supervision of theCancer Committee. The team consists of themedical director of oncology services, the co-medical directors for the St Jude Kathryn T.McCarty Breast Center, director of the SJMCBreast Center, director of oncology services, nursenavigators, clinical nurse specialist, physicians,and other interdisciplinary team members. Therole of the navigator was to champion this eventand build excitement and momentum to achieveapproval. The committee gave its full support toimplementing the community outreach program.Strategies were designed to establish an organ-

ized process for successful execution. TheBreastivalCommittee was formed to plan the out-reach event. The committee members includedthe director of imaging, director of oncology serv-ices, manager of the breast center, breast nursenavigator, lead technologist, manager of theinpatient oncology unit, marketing representa-tive, radiologist, SJMC executive chef, and thecorporate sponsor. The radiologist was the physi-cian chair and the navigator was the committeechair. The committee reviewed the event tool kit.

It was decided to host 2 events: 1 for the SJMCstaff and 1 for an SJMC community. The committee decided to tie in the employee

health campaign called “Choose Well.” The focusof this campaign is to help employees improveindividual health outcomes and develop healthi-er lifestyles. Offering this event at the workplacegives employees easy access to cancer screeningand breast health education and serves to increaseawareness and support. It was decided to hold theSJMC employee event on the hospital campusOctober 13, 2011, because October is BreastCancer Awareness Month.The Oncology Services Department had

previously partnered with Harley-Davidson®

Anaheim-Fullerton in community outreach pro-grams. The general manager of Harley-Davidsonenthusiastically agreed to participate in Breastivalby donating space at their facility in Fullerton,which has a large outdoor venue, and providingvolunteers, entertainment, and additionalresources. Because Harley-Davidson already hadan annual event scheduled in October, theBreastival event was scheduled for November20, 2011. The project was divided into 6 sections and

assigned to subcommittees: (1) food and venue,led by the SJMC executive chef, (2) sponsors, ledby director of oncology services, (3) communityorganizations, led by breast nurse navigator, (4)games and educational seminars, led by managerof the SJMC Breast Center, (5) volunteers, led bylead technologist of SJMC Breast Center, and (6)marketing, with co-leaders the director of imag-ing and Breast Center nurse navigator. Breakingthe responsibilities and details into smaller com-mittees that reported back to the BreastivalCommittee made the work more manageable andtime efficient. The subcommittees met as needed,and the BreastivalCommittee met monthly. Thecommittee chair communicated frequently withthe group via e-mail to keep the team updated onthe subcommittees’ progress.The Breastival tool kit describes very detailed

processes on how to host the event. Also, MsShockney made herself available to answer anyquestions and give guidance. Once the venuesand dates were secured, we needed to establishpartnerships with community breast cancerorganizations to sponsor the events. The follow-ing organizations played a vital role in the event:Orange County Breast Cancer Coalition, ACS,

Breaking the responsibilities and detailsinto smaller committees that reportedback to the Breastival Committee made the work more manageable andtime efficient.



ORIGINAL RESEARCH

Susan G. Komen for the Cure, Healing Odyssey,St Jude Kathryn T. McCarty Breast Center,Virginia K. Crosson Cancer Center, St JudeExpressions Appearance Center, and Synergy StJude Fitness Center. Each of these organizationshad community resources, educational materials,and information to offer. Marketing strategy and development of a

design that would be recognizable for the 2events were components in the planningprocess. The committee established a collabora-tive relationship with the hospital marketingdepartment. Print media were developed thatincluded the event logo, flyers, both internaland external advertisements, as well as eventmaterials such as educational message boards,passports, and evaluations.During the 9 months prior to the events, the

subcommittees worked diligently to securesponsors for food and raffle prizes. The educa-tional content was identified, and games thatwere fun and interactive were created toemphasize key points. An “Ask the Doc” seg-ment was built into the event to offer an oppor-tunity for the attendees to ask the breast carephysician team questions about breast healthand breast cancer. Speakers were secured for theeducational mini-seminars and topics wereselected offering a cross section of breast healthand self-care topics. The educational mini-sem-inars were on yoga, “Taking Care of Mind, Body,and Spirit”; mammography, “To Squish or Notto Squish”; proper bra fitting, “Does Your CupRunneth Over?”; nutrition, “ABCs of a HealthyDiet”; self-care, “Keeping Humpty Dumpty onthe Wall—Hang in There Baby”; and breastself-exam, “The Breast Macarena.” There wasalso a booth with men’s health and cancer pre-vention information that was made available toattendees. Women had an opportunity to makea “pinky promise” stating they would have anannual clinical breast exam and mammogramand were given an opportunity to schedule amammogram. If a woman did schedule a mam-mogram, she was given a pink ring. At each ofthe events, food and entertainment were sup-plied by our sponsors.Booths allocated to the 8 participating commu-

nity organizations were arranged around theperimeter of the space. Each organization show-cased the services offered to the community.Educational posters featuring breast cancer statis-

tics and health facts were created and placedthroughout the space to capture participants’attention. The space was designed so it was easy tonavigate, allowing for participation in all eventactivities. Table 2 outlines the BreastivalTM eventactivities.The attendees were given a passport that out-

lined the event and gave instructions on how tofind their way through the experience; on thereverse side was the event evaluation. As theattendees visited each of the 8 booths, they wereasked a breast health question, and if theyanswered correctly, were given a stamp on thepassport. If the attendees visited all 8 booths andanswered the questions correctly (as evidenced bycompleting their passport), they had an opportu-nity to submit their passport for a “booby prize.”Prior to submitting the passport, the attendeewas asked to complete the evaluation on theback for feedback. Optionally, participantsattended an educational mini-seminar, partici-pated in games, and could schedule a mammo-gram. They then signed a banner that stated“BREASTIVALTM Celebrating Breast CancerAwareness 2011.” After the events, the bannerswere hung outside on buildings at each of thevenues, displaying the many signatures and spe-cial messages to the community.

RESULTSThe outcomes of both Breastival events are out-lined in Table 3.Each of the events was seen by the committee

as a success. The SJMC staff members expressedthat the event was educational and fun. A meas-urement of success was the number of attendeesreporting new knowledge gained on the eventevaluation. In addition, 42 mammograms werescheduled. Several women had not had a mam-mogram for 6 to 10 years, and further outcomestudies must be done to assess whether thesewomen will follow up and actually have theimaging completed as scheduled. Periodicallythroughout the day there were “Ask the Doc” seg-

Speakers were secured for the educational mini-seminars and topicswere selected offering a cross sectionof breast health and self-care topics.


ORIGINAL RESEARCH


Table 2 Breastival Event Activities

Component Objective Description

Passport The attendee will demonstrate knowledge of breasthealth and breast cancer by completing the event passport.

The attendee is given a passport with instructions on howto navigate the Breastival activities. The attendee mustvisit each booth to learn of resources, answer questions,and have the passport stamped. Completed passports areentered to win a “booby prize.” An evaluation form is onthe back of the passport.

Game: Match the Rack The attendee will match the appropriate size bean bags to the appropriate size bra.

The game has 3 different size bras and 3 different size beanbags. The purpose of this game is to identify that women’sbreasts come in different shapes and sizes. There were a lotof laughs at this station.

Game: One Lump or Two The attendee will feel for and identify beans in a bucket of rice.

The attendee will be able to identify the anatomy ofthe breast and state the signs and symptoms to reportto her physician.

The attendee is blindfolded and places a hand in a bucketof rice representing breast tissue. The object is to locate the beans in the rice, which symbolize lumps in the breast.This is harder than it sounds. Attendees learn about theanatomy of the breast and the importance of becomingfamiliar with their breast in order that they might be ableto detect a change. Attendees learn about breast signs andsymptoms to report to their physicians.

Game: Booby Trapper The attendee will identify where the breast model ishidden.

The attendee will demonstrate how to do a breast self-exam.

The game has 3 drinking cups that are placed facing downon a table. A small breast model is placed underneath oneof the cups, then the cups are shuffled. The attendee identifies which cup the breast model is under. After thegame is completed, the attendee has an opportunity to palpate a breast model and learn how to do a breast self-exam.

Educational Seminars The attendee will state the importance of participatingin breast health and self-care activities such as annualmammography, breast self-exam, exercise, and main-taining proper nutrition.

The attendee has an opportunity to attend 1 or more of the following seminars:• To Squish or Not to Squish• ABCs of a Healthy Diet• Keeping Humpty Dumpty on the Wall—Hang inThere Baby

• Does Your Cup Runneth Over?• Taking Care of Mind, Body, and Spirit

The educational seminars were offered every hour duringthe event.

Breast Macarena The attendee will demonstrate the Breast Macarena.

The attendee will be able to demonstrate how to dovisual inspection of the breast.

Our Clinical Nurse Specialist, Kathy Pearson, RN, CNS,AOCN, created an innovative approach to teaching visualinspection of the breast by modifying the Macarena. Thiswas a great way to engage the whole room in a fun activity,while educating the attendees at the same time. Lots oflaughs and giggles.

DJ and Live Band The attendee listens to music while participating inthe event activities.

At the SJMC event, a DJ emceed and played music duringthe event. At the Harley-Davidson venue, a band named“Carisma” donated their services and played music duringthe event. The music added to the atmosphere and fur-ther engaged the attendees.

Food The event provides food for the attendees as a way toentice the attendees to participate.

Several sponsors donated food for the 2 events.

Banner Signing The banner signing demonstrates that attendeesacknowledge the importance of breast cancer awareness.

The banner signing was an activity for the attendees toparticipate in to acknowledge the importance of breast cancer awareness. Each banner was signed by attendees and hung at each prospective site.



ORIGINAL RESEARCH

ments during which the physicians/nurse practi-tioners would answer written questions addressingcommon concerns about breast health and breastcancer treatment. This was cumbersome and inter-fered with the event flow and activities. It wasdecided by the committee to continue to incorpo-rate the concept at the second event but to havean “Ask the Healthcare Professional” booth thatwould be manned for 15 minutes on the hourthroughout the event. Unfortunately, due to rainthis activity was canceled. The community event at Harley-Davidson inAnaheim-Fullerton was well attended in spite oftorrential rain. Over 300 attended, and half of theattendees completed the passport. Unfortunately,the rain and wind would not let up and the eventwas closed 2 hours prior to the scheduled time.Regardless of the weather, people commentedthat they enjoyed learning about breast health,eating barbeque, and listening to a live band. The20 members of the Positively Pink Club fromFullerton High School, which raises breast cancerawareness and education at the high school level,participated in the event. There was high trafficat the mammogram scheduling booth, but due tothe attendees having various medical homes,many needed to be referred to different facilities.St Jude Breast Center did schedule 2 mammo-grams. For future events, it will be imperative toidentify community members who have differentmedical homes and identify ways in which theirneeds can be addressed. The event message wasreceived, as evidenced by women inquiring aboutscheduling a mammogram and acknowledgingthe value of early detection. There were severalopportunities during which services to the under-

insured and underserved populations were offeredby community organizations. These women werenetworked into programs for cancer screeningand supportive care, which was one of the out-come goals for the event. Harley-Davidson askedSJMC to partner together for next year and hostanother Breastival event.

Additional outcome surveys from both eventsasked the attendees to rank their favorite parts ofthe event. The outcomes were as follows: (1)opportunity to ask experts and healthcare profes-sionals questions; (2) presentations on breasthealth and cancer prevention; (3) convenience—easy to visit all booths and presentations; (4) gamesand raffles; and (5) food and entertainment.Attendees suggested that the event could beimproved by extending hours, offering more men’shealth information, incorporating survivor stories,having more booths, providing Spanish-languagematerials, and having better weather. The atten-dees felt that the events were well organized, fun,interactive, and informative.

DISCUSSIONThe Task Force on Community PreventiveServices has made some evidence-based recom-mendations on interventions to increase breast,

(Table 2 Breastival Event Activities (Continued)

Component Objective DescriptionMammogram Scheduling The attendee will schedule her yearly mammogram.

The attendee will be able to state the importance ofyearly mammography screening.

The St Jude Kathryn T. McCarty Breast Center arrangedfor 2 computers to be set up that had access to the mam -mography schedule. Staff were available to schedulewomen for their mammogram at the breast center. This was 1 initiative put in place to reduce barriers to care.Women were given a pink ring if they scheduled a mammogram.

“Ask the Doc” The healthcare professional identifies questions thatcommunity members have regarding breast health and breast cancer.

The SJMC breast cancer team was asked to participate inthe “Ask the Doc” segments. The healthcare professionalanswered common questions about breast health and breastcancer. At the SJMC employee event, there was a scheduledesigned to have a healthcare professional address the attendees every hour for 5 minutes.

These women were networked intoprograms for cancer screening andsupportive care, which was one of theoutcome goals for the event.


ORIGINAL RESEARCH


cervical, and colorectal screening.18 These recom-mendations include the use of small media such asprinted materials, one-on-one education, increas-ing community access, and reducing barriers,which are the methods used in the Breastival.The structure of the event allowed for many dif-ferent opportunities to interact and learn, maderesources available, and facilitated access toscreening by reducing the barriers. The words “boob” and “booby” have been used

in design and implementation of the Breastivalevent. This may be offensive to some when refer-encing the breast. The terms were used to facili-

tate communicating the breast health awarenessmessage in a fun and nonthreatening manner.The terminology is also consistent with that usedin the Breastival tool kit. In hosting both a hospi-tal employee and a community event, our com-mittee did not receive any negative feedback orcomments about the words “boob” or “booby.” Infact, the terminology created a less frighteningatmosphere and broke down some barriers to talk-ing openly about breasts. Nurse navigators are in a key position to cham-

pion the message for breast cancer awareness andscreening. The steps to implementation of a com-

Table 3 St Jude Medical Center Breastival Event Outcomes

OutcomesSt Jude Medical Center

Employee EventCommunity Event at Harley-Davidson

in Anaheim-FullertonNote: The event had to close down 2 hours prior to scheduled time due to heavy rain.

Number of attendees N = 497**This represents 41% of the employees

working the day of the event.

88% women12% men

N = 31569% women31% men

Attendance at the educational mini-seminars

N = 14128% of attendees participated

N = 3511% of attendees participated

Note: Due to rain, the seminars were canceled after hosting 2 sessions.

Number of mammograms scheduled 42 2

Number of passports completed N = 40882% completed a passport

N = 17355% completed a passport

Number of attendees who completed an evaluation

N = 33868% completed an evaluation

N = 11035% completed an evaluation

Number of attendees who had never attended a breast health educationalevent

N = 28484%

N = 6963%

Was there something specific theattendee learned?

38% responded no61% responded yes1% did not respond

32% responded no68% responded yes

Top 5 responses about what attendeeslearned

1. Risk Factors for Breast Cancer2. Men and Breast Cancer3. Genetics4. Breast Cancer Statistics5. Breast Self-Exam

1. Community Resources and Programs2. Men and Breast Cancer3. Genetics4. Breast Cancer Statistics5. Breast Cancer Screening

Would the attendee attend anotherBreastival event?



Was the attendee previously performingbreast self-exams monthly?



If not performing breast self-exammonthly, will attendee begin doingthem now?





ORIGINAL RESEARCH

munity outreach program start with identifyingthe current compliance rates for screening mam-mography, physician practices for screening mam-mography referrals, and clinical breast exams.Next, the navigator must identify the needs of thecommunity and barriers related to breast cancerscreening and seeking early follow-up care andtreatment. Finally, the navigator develops a planfor education and outreach that aligns with plansat the national, state, and local levels as well aswith the hospital organization. To achieve suc-cess, it is imperative that the navigator receiveadministrative and physician support and buy-in.The vision for the Breastival event was to look fornew and innovative ways to get the message andresources out to staff and the surrounding commu-nity. The challenge of this event was to step out-side of what is comfortable and raise the bar inoffering ground-breaking opportunities to meetthe needs of the community for breast healthawareness and screening. We believe that we metthis challenge and look forward to repeating thissuccessful project in the future. g

For information on the Breastival or on how toorder a Breastival™ Resource and PlanningKit please contact Lillie Shockney at [email protected].

Acknowledgements: I would like to thank theBreastival Committee for all the hard work anddedication that created 2 successful events. Thecommittee team members are: Will Gotay; GiannaLaiola, RN, BS, OCN; Tom Loveland; MaryAnnPerez; Lea Powell, RN, MSN, OCN; Paula Reese,RTM; Judy Ricci, RN, BSN; Cathy Shircliff, CTR;Phillip Unger, MD; and Bertha Vargas, ARRT,RTM, RDMS, BR. Also, a special acknowledge-ment to my mentor Kathy Pearson, RN, CNS,AOCN, who always challenges me to pursue clin-ical excellence and never stop learning.

REFERENCES1. Desantis C, Siegel R, Bandi P, et al. Breast cancer statistics,2011. CA Cancer J Clin. 2011;61:409-418.2. Orange County Affiliate of Susan G. Komen for the Cure.Community profile report 2011. http://www.komenoc.org/atf/cf/%7B7DAE5A7D-C3F4-4C8C-BA7A-FEBDCE255920%7D/2011%20CPReport%20Final_6.7.2011.pdf. AccessedMarch 15, 2012.

3. American Cancer Society. Breast cancer facts & figures2011-2012. American Cancer Society Web site. http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/docu-ments/document/acspc-030975.pdf. Accessed March 15, 2012.4.Orange County Affiliate of Susan G. Komen for the Cure® &UCI Data Project. Breast cancer incidence & prevalence inOrange County. IV. Planning for breast cancer in OrangeCounty. http://www.komenoc.org/atf/cf/%7B7dae5a7d-c3f4-4c8c-ba7a-febdce255920%7D/MONOGRAPH%204.PDF.Accessed March 30, 2012. 5. Henley SJ, King JB, German RR, et al. Surveillance ofscreening-detected cancers (colon and rectum, breast, andcervix) – United States, 2004-2006. MMWR Surveill Summ.2010;59:1-25.6. American Cancer Society. Cancer prevention & early detec-tion: facts & figures 2011. American Cancer Society Web site.http://www.cancer.org/acs/groups/content/@epidemiology-surveilance/documents/document/acspc-029459.pdf. AccessedMarch 12, 2012.7. Mammogram Screening History 2009. California HealthInterview Survey Web site. www.chis.ucla.edu. AccessedNovember 18, 2011.8. New study: boosting five preventive services would save 100,000lives each year. Robert Wood Johnson Foundation Web site.http://www.rwjf.org/pr/product.jsp?id=21904. Published 2007.Accessed November 26, 2010. 9. Breslow RA, Rimer BK, Baron RC, et al. Introducing thecommunity guide’s reviews of evidence on interventions toincrease screening for breast, cervical, and colorectal cancers.Am J Prev Med. 2008;35(suppl 1): S14-S20.10. Varner A, Murph P. Cancer patient navigation: where dowe go from here? Oncol Issues. 2010;May/June:50-53.http://accc-cancer.org/oncology_issues/articles/mayjune10/MJ10-VarnerMurph.pdf. Accessed March 18, 2012.11. Oncology Nursing Society, Association of Oncology SocialWork, National Association of Social Workers. OncologyNursing Society, the Association of Oncology Social Work, andthe National Association of Social Workers joint position onthe role of oncology nursing and oncology social work inpatient navigation. Oncol Nurs Forum. 2010;37:251-252.12. Cancer program standards 2012: ensuring patient-centeredcare. American College of Surgeons Web site. http://www.facs.org/cancer/coc/programstandards2012.html. Published 2011.Accessed December 3, 2011. 13. Shockney L. Reaching your community can be more thanstandard educational events. J Oncol Navigation & Survivorship.2010;1:22. http://issuu.com/aonn/docs/jons_november2010.Published November 19, 2010. Accessed March 18, 2012.14. Johns Hopkins Breast Center. The John HopkinsBreastivalTM Resource and Planning Kit. Lillie Shockney:[email protected]. California’s comprehensive cancer control plan, 2011-2015. California Dialogue on Cancer Web site. http://www.cdoc-online.org/cccp.html. Updated July 2011. AccessedMarch 18, 2012.16. ACS report: more collaboration needed to increase anti-cancer efforts. American Cancer Society Web site. http://www.cancer.org/Cancer/news/News/acs-report-more-collaboration-needed-to-increase-anti-cancer-efforts. Published May 19,2011. Accessed November 2, 2011. 17. St Jude Medical Center mission statement. St Jude MedicalCenter Web site. http://stjudemedicalcenter.org/content/about-us-0. Accessed November 2, 2011.18. Task Force on Community Preventive Services.Recommendations for client- and provider-directed interven-tions to increase breast, cervical, and colorectal cancer screen-ing. Am J Prev Med. 2008;35(suppl 1):S21-S25.


September 14-16, 2012 • Phoenix, Arizona • Third Annual Navigation and Survivorship Conference

www.regonline.com/aonn2012

GoalAONN’s Third Annual Navigation and Survivorship Conferencewill advance the role of navigation and survivorship in cancer careto ultimately improve the quality of patient care.

Objectives• Discuss the evolution of the role of navigation in healthcare• Assess strategies for navigating diverse patient populations by cancer type and environmental factors

• Define methods for providing patient support and guidance inthe age of personalized cancer care

• Evaluate best practices regarding survivorship and psychosocial care

CONTINUING EDUCATION INFORMATION

AONN’s Third Annual Conference will continue to advance the nav-igation profession by expanding the scope of educational sessions, net-working opportunities, and poster presentations. In addition, this year’sconference will address the evolving challenges of program improve-ment, the role of personalized medicine, and implementing best prac-tices in navigation, survivorship, and psychosocial care.

CONFERENCE OVERVIEW

This is an opportunity to share research, programs, and results withyour colleagues. Submit your abstract via e-mail to [email protected] Deadline: August 1, 2012

CALL FOR ABSTRACTS

AONN’s Third Annual Conference is the only meeting that gives youaccess to decision-makers and key practitioners involved in oncologynavigation and survivorship. If your company provides any of the follow-ing services/products for the oncology healthcare community, this is themeeting for you.

• Pharmaceutical/Biotech• Genetic Laboratory Services• Navigation Software• Patient Advocacy• Training

TARGET AUDIENCE

• Patient Access• Reimbursement• Publishers• Education• Certification

This educational initiative is directed toward oncology nurse naviga-tors, patient navigators, and social workers.

This activity is jointly sponsored by AONN Foundation for Learning, Inc.,and Medical Learning Institute, Inc.

SPONSORS

Friday, September 141:00 – 3:00 pm Pre-Conference Workshops

• Core Principles of Navigation• Grant Writing, Research, and Getting Published

• Providing Optimal Community Outreach• Implementing a Survivorship Program/Clinic

3:15 – 5:15 pm Pre-Conference Workshops• Core Principles of Navigation• Grant Writing, Research, and Getting Published

• Providing Optimal Community Outreach• Implementing a Survivorship Program/Clinic

5:15 – 7:00 pm FREE TIME7:00 – 9:00 pm Welcome Reception/Posters in the Exhibit Hall

Saturday, September 157:30 – 8:30 am Breakfast Symposium/Product Theater8:30 – 8:45 am Welcome & Introductions Conference Co-Chairs8:45 – 9:45 am General Session 1: Navigation Update: 201210:00 – 11:30 am Disease-Site–Specific Breakouts

A) Breast Cancer NavigationB) Lung Cancer NavigationC) GI Cancer NavigationD) Prostate Cancer NavigationE) Head & Neck Cancer NavigationF) Hematologic Malignancies NavigationG) Gynecologic Cancers NavigationH) Navigation Program Administration

11:45 am – 1:00 pm Lunch in the Exhibit Hall1:15 – 2:15 pm Advocacy Keynote 2:15 – 3:15 pm General Session 2: Best Practices in Survivorship

Care Planning3:15 – 4:15 pm General Session 3: Plenary Session

Moderator: Research Committee Member4:15 – 5:00pm Poster Reception in the Exhibit Hall5:00 – 7:00 pm FREE TIME7:00 – 10:00 pm Awards Dinner

Sunday, September 167:30 – 8:30 am Breakfast Symposium/Product Theater8:30 – 9:30 am General Session 4: Navigation in the Age of

Personalized Cancer Care9:30 – 10:30 am General Session 5: Best Practices in Psychosocial Care 10:45 am – 12:15 pm Practice-Setting–Specific Breakouts

• Urban• Suburban• Rural

12:15 – 1:15 pm Lunch in the Exhibit Hall1:30 – 2:30 pm Survivor Keynote2:30 – 2:45 pm Conclusion of the Conference*Preliminary agenda, subject to change.

PRELIMINARY AGENDA*

� �� JONS_April 2012_v2_TON1110_FINAL 4/16/12 2:25 PM

• Arizona Grand Survivorship Conference

www.regonline.com/aonn2012w

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Register online: www.regonline.com/aonn2012

CONFERENCE REGISTRATIONMedical Learning Institute, Inc.Provider approved by the California Board of Registered Nursing, Provider Number15106, for up to 12.25 contact hours.

REGISTERED NURSE DESIGNATION

This activity is pending approval from the National Association of Social Workers.Contact hours for this continuing social worker education activity have been submittedto the National Association of Social Workers.

SOCIAL WORK DESIGNATION

Current Members $295New Members $345Nonmembers $425*

*Register by July 15 and save $100 off full registration of $525.

T

Juli Aistars, RN, APNProstate Nurse NavigatorNorthwest Community HospitalArlington Heights, IL

Robin Atkinson, RN, BSN, OCNGYN Nurse NavigatorForsyth Medical CenterWinston-Salem, NC

Karyl Blaseg, RN, MSN, OCNManager of Cancer ProgramsBillings Clinic Cancer CenterBillings, MT

Linda Fleisher, PhD, MPH Assistant Vice President, Health Com-munications and Health DisparitiesFox Chase Cancer CenterCheltenham, PA

Kristin Holmberg, MN, RNLung Cancer Nurse NavigatorOverlake Hospital Medical CenterBellevue, WA

Kimberly F. Leake, RN, MSNNurse NavigatorHematologic Malignancies Program University of Virginia Health SystemHematologic Malignancies Program andCancer CenterCharlottesville, VA

Coralyn Martinez, MSN, RN,OCNGI Nurse NavigatorThe Lacks Cancer CenterSaint Mary’s Health CareGrand Rapids, MI

Pamela Matten, RN, BSN, OCNNurse NavigatorThoracic Oncology ProgramThe Center for Cancer Prevention andTreatmentSt. Joseph HospitalOrange, CA

Nicole Messier, BSN, RNUpper GI and GU Nurse Navigator/Clinical Program CoordinatorVermont Cancer CenterFletcher Allen Health CareBurlington, VT

Roxanne Parker, MSNClinical Nurse NavigatorArizona Oncology AssociatesPhoenix, AZ

Mandi Pratt Chapman, MAAssociate Director GW Cancer Institute Community ProgramsCo-Director, GWCI Center for theAdvancement of Cancer Survivorship, Navigation and PolicyProject Director, National Cancer Survivorship Resource CenterWashington, DC

Elaine Sein, RN, BSN, OCN,CBCNSenior Project Manager, Fox Chase Cancer Center Fox Chase Cancer Center PartnersRockledge, PA

Jean B. Sellers, RN, MSN, OCNAdministrative Clinical DirectorUNC Cancer OutreachChapel Hill, NC

Julie Silver, MDAssistant ProfessorDepartment of Physical Medicine andRehabilitation Harvard Medical School Boston, MA

Jay R. Swanson, RN, BSN, OCNOncology Nurse NavigatorSaint Elizabeth Cancer InstituteLincoln, NE

Pamela Vlahakis, RN, CEN, CRN,CBCNNurse CoordinatorHunterdon Regional Breast Care ProgramHunterdon Regional Cancer CenterFlemington, NJ

Cindy Waddington, RN, MSN,AOCNClinical Nurse SpecialistCancer Care Management Certified Health and Wellness CoachMind, Body and Spirit Wellness Pro-gramHelen F. Graham Cancer CenterChristiana Care Health SystemNewark, DE

*Subject to change

F

INVITED FACULTY*

Breast Health NavigatorDerrick L. Davis ForsythRegional Cancer CenterWinston-Salem, NC

University Distinguished Service Associate Professor of Breast Cancer Depts of Surgery and OncologyAdministrative Director, Johns Hopkins Breast Clinical ProgramsAdministrative Director, Johns Hopkins Cancer Survivorship ProgramsAssociate Professor, JHU School of Medicine, Depts of Surgery & Gynecology and ObstetricsAssociate Professor, JHU School of NursingBaltimore, MD

Sharon Gentry, RN, MSN, AOCN, CBCN

Lillie Shockney, RN, BS, MAS

CONFERENCE CO-CHAIRS

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� �� JONS_April 2012_v2_TON1110_FINAL 4/16/12 2:25 PM

ORIGINALRESEARCH


T he Norma F. Pfriem Breast Care Center(NPBCC) is a comprehensive breast carecenter, providing screening, diagnosis,

treatment, outreach, and supportive services.The center serves Connecticut’s southernFairfield County, including the low-incomecommunity of Bridgeport, a city of more than139,000 residents, with over 21% living inpoverty. Bridgeport is almost 70% minority,split nearly evenly between Hispanics (33.5%)and African Americans (34.8%).1 About 43%of residents speak a language other thanEnglish at home.1Connecticut has the second highest rate of

new breast cancer cases in the nation and thetwelfth highest death rate in the nation (withhigher death rates for African Americanwomen).2 Nearly one-third of breast cancers inConnecticut are detected at later stages, aftersome metastasis has occurred.2Within the NPBCC’s service areas, the statis-

tics are even more troubling. The city ofBridgeport is characterized by high stage IV breastcancer diagnoses, high breast cancer incidence,and above-average breast cancer mortality.3 Inaddition, Bridgeport has one of the highest risksfor death from breast cancer in the state (30.1 per100,000, well above the state average of 23.9).4For the last 10 years, the Breast Care Center’s

community-based outreach program has helpedlow-income and medically underserved womenunderstand the importance of screening to detectbreast cancer at an early stage. The program hasalso taught women how to access free mammo-grams and other screening and diagnostic proce-dures (at the NPBCC and elsewhere) and where to

find support and counseling services in their localcommunity. The NPBCC provides the largest outreach

program of its kind in the area, reaching over2500 women each year. Nurse educators partici-pate in programs at churches, places of employ-ment, community centers and agencies, clinics,health fairs and other neighborhood fairs, com-munity colleges, and senior housing.

A COMMUNITY AT RISKSeveral risk factors converge in Bridgeport to cre-ate a community at increased risk of breast can-cer. Lack of adequate health insurance is com-mon. In Connecticut, Hispanics are 5.4 timesmore likely—and blacks 2.7 times more likely—than whites not to have health insurance.5 Thisleaves 40% of Connecticut’s Hispanic communi-ty uninsured.6 The uninsured and Medicaidrecipients are more likely to be diagnosed withcancer at a later stage compared to those withhealth insurance.2 People from lower social class-es are also less likely to receive cancer screenings,and their survival rates are lower, even when theyhave healthcare coverage.2Health disparities also play a part. African

American women across all age groups are morelikely to die from breast cancer.7 This disparity,now at 37%, continues to grow, according to arecent report from the American Cancer Society.With the African American population at over30%, the impact in Bridgeport is enormous. Finally is the question of sheer numbers. The

Latino population is growing in Bridgeport as it isacross the nation, where it is expected to triple by2050. With that growth will come a rise in the

MUJER A MUJER/WOMANTO WOMAN: Using a unique venue for culturally appropriate outreach and navigation in an underserved area to increase screening By Sally Cascella, MAHSN, BSN, RN, CNORNorma F. Pfriem Breast Care Center, Bridgeport Hospital, Bridgeport, Connecticut

Jacqueline Keren, MFA, BANorma F. Pfriem Breast Care Center, Bridgeport Hospital, Bridgeport, Connecticut

Jacqueline Keren, MFA, BA



ORIGINALRESEARCH

number of Latinas with breast cancer, accordingto Lydia Buki, PhD, a professor of communityhealth at the University of Illinois, who has stud-ied incidence and mortality rates for breast andother cancers among Latinas.8 Breast cancer, shenotes, is the most common cancer afflictingLatinas in the United States, and the 5-year sur-vivorship rate for Latinas is lower than for non-Latina whites.8 Latinos are more likely than non-Latino whites to present with larger tumors or atmore advanced stages of disease.8 Further,researchers from the Arizona Cancer Center andMD Anderson Cancer Center have found thatbreast cancer appears to be occurring at an earli-er age among Hispanics, something we haveobserved at the NPBCC.9

Raising awareness is critical to serving thisgrowing community and detecting breast cancerearly, when it is more treatable. “[The issue] iswomen knowing the importance [of cancerscreening], and at the same time being able toaccess information and screening services,”according to Dr Buki.8

CHANGING TACTICS While the NPBCC has been successful in reach-ing many underserved women through its out-reach program, over the years it became clearthere were some women—the very poorest, with-out English, distrustful of the healthcare sys-tem—who wouldn’t come to a health fair orother outreach program or follow up on a referralform, even under the best of circumstances. Wesaw a need to reach more deeply and aggressivelyinto the community.

This paper will describe how we developed anew outreach program to connect with our mostisolated clients using evidence-based outreachmethods in a unique venue. Mujer a Mujer/Woman to Woman trains bilingual cancer sur-vivors as volunteer lay outreach workers to navi-gate women into screening. After the initial suc-cess of the bilingual outreach effort, the programbecame a regular fixture at a weekly food pantryto reach women in a medically underservedneighborhood. This paper will outline theprocess for setting up and executing the program(Figure 1) and establishing a presence at aunique venue to target the neediest. Initial resultsand program benefits will also be discussed, aswell as lessons learned and plans for enhancingand expanding the program.

MUJER A MUJER/WOMAN TO WOMANIn 2009, with a grant from the Avon Breast CareFoundation, the Breast Care Center began a newprogram, Mujer a Mujer/Woman to Woman. Aspart of the program, volunteer bilingual breastcancer survivors accompanied nurse educators atoutreach programs.

There was evidence to support making thischange. Studies indicate that peer role models areeffective in helping Latinas navigate the health-care system to obtain exams.8,10 They are trustedsources of information, speak the same language,and know the culture. By discussing cancer, atopic not normally broached in traditional Latinoculture, role models help to break down barriersto screening.

We scheduled community workshops at exist-ing venues while adding other more creative set-tings, such as job training programs, parent

Program Setup

Identify outreach sites; develop talkingpoints for lay outreach workers

Develop and distribute recruitment flyers to patients and volunteers via e-blasts, newsletters, and MD offices

Vet survivors; train in one-on-one sessions

Establish relationships with MDs formaking appointments available to outreach program; develop

tracking database

Develop and distribute promotionalmaterials to internal and external

media outlets

➤➤

➤➤

➤

Outreach and Follow-up

Nurse educator and survivors attend outreach programs and schedule

women for appointments

Patient outreach coordinator trackswomen referred through outreach

program, sends reminders, and notifiesnurse educator of no-shows

Nurse educator schedules survivors tomake follow-up calls: appointmentreminders, rescheduling no-shows

➤➤

➤

Figure 1: Flowchart: Setting up and executing a new outreach program, Mujer a Mujer/Woman to Woman.


ORIGINALRESEARCH


groups, and outreach programs for the homeless,to create a multisite program tailored to the com-munity, an approach that has been shown toincrease participation in screening amongLatinas.11 Initially, we identified breast cancersurvivors from our existing pool of patients andvolunteers and recruited some of them to join ournurse educators at our outreach programs. Later,we created a flyer, in English and Spanish, to dis-tribute to patients (in person and via e-mail) forrecruitment purposes. Volunteers were offered a$50/day stipend plus $15/day for transportation.While the response was good, many respondentswere not bilingual, lacked flexible schedules, orwere looking for regular employment. In the end,we built our pool slowly, contacting womenamong our volunteers and patients who appearedto have the skills and flexibility to succeed as layoutreach workers. The nurse educator wrote talking points,

trained survivors individually as outreach work-ers, and attended outreach programs with sur-

vivors. To the public, there was no apparent dif-ference between the professional and lay out-reach worker, but the nurse could observe andlisten and step in as necessary. Eventually sur-vivors were able to attend outreach programs ontheir own. The nurse secured a list of available appoint-

ment times from doctors at our clinic and used itto schedule women who expressed an interest.Later, the nurse negotiated the ability to call intothe office for more time slots. Teaching materialsincluded breast self-exam shower cards andpatient education sheets. We created a programdatabase to track clients and English/Spanishreferral forms to distribute at events. The formswere coded by venue, so we could track referralsfrom the program events. The foundation requiredus to track demographic information as well, usingan anonymous client intake form (CIF). We pro-moted the program through our newsletter, patiente-mail list, ads in local newspapers—includingSpanish-language papers—press releases, and

The Norma F. Pfriem Breast Care Center’s Senior Nurse Navigator-Educator Sally Cascella (center) worked with Deacon Donald Foust (left), the administrator of Holy Rosary Church, toimplement the outreach program.



ORIGINALRESEARCH

Web-based community calendars maintainedby local media outlets, which resulted in sever-al radio interviews during the morning newsshows about the outreach program and breasthealth in general. It quickly became clear that while the number

of women we referred for appointments wasincreasing, only a small percentage were follow-ing up on their own. To increase participation, webegan scheduling appointments while weengaged women in conversation at our outreachevents rather than giving them the option of call-ing us. Staff began taking appointments withthem, and this made a significant difference.Women were also offered a $15 cash card to alocal grocery store if they scheduled an appoint-ment, and we developed a contact sheet toaccompany the CIFs so we could follow up withthe women. Later, we gained the ability to call infor alternate appointment dates and times forwomen who couldn’t make available slots.Scheduled and completed appointmentsincreased each quarter—mammograms increasedby 36% and clinical breast exams by 37% fromthe second to the third quarter, and by 34% and59%, respectively, from the third to the fourthquarter (Figure 2). The no-show rate remained high and needed

to be addressed. It had become clear that manywomen were scheduling appointments simply toget the grocery store cash card but were not fol-lowing through. We changed our process; clientswould receive a grocery store card only if theycame in for their appointment. With manywomen below the poverty level, the cards provedto be a powerful incentive, much more so thanother items we had tried in the past such as freecosmetics and jewelry, and use of the cards result-ed in increased compliance. We also shifted fol-low-up to our volunteer breast cancer survivorsbecause of their language skills. Survivors calledwomen before their appointments and followedup if they didn’t show. Although transportationwithin our urban location, including the avail-ability of free rides through Medicaid, did notappear to be a factor preventing women fromkeeping their appointments, keeping in touchwas often challenging. Because of their financialsituations, our low-income clients move often.Many do not have phone service or lose phoneservice when their finances change. However,with the combination of our increased calling

and the grocery store cards as incentives, manymore women were completing their appoint-ments. By the fourth quarter, our no-show ratehad decreased by 23%. Despite challenges in the beginning, by the

end of the year we had developed an outreachprogram that navigated women into screening atthe annual rate we had set for ourselves of 150.

FINDING THE NEEDIESTTargeting the neediest for early detectionrequired us to be creative. One neighborhoodwith a high incidence of late-stage diagnosiscalled out for our attention. The central/eastarea of Bridgeport is a low-income, medicallyunderserved area designated as a primary carehealth professional shortage area.12 The popula-tion is primarily Hispanic. As in other areas ofBridgeport, women have difficulty navigatingthe healthcare system because of language andcultural barriers. As a result, many have notseen a doctor in years, nor are they likely to ven-ture outside the neighborhood for healthcare.Many are without insurance because of a lack ofawareness or misconceptions about public insur-ance. These were women with the greatest need,yet they were the least likely to come to an out-reach program. And no outreach workers hadgone to them.

A UNIQUE VENUE With the help of a local church, the Holy RosaryChurch in Bridgeport, we set up shop at theirfood pantry, believing we had a better chance ofreaching women where they lived and at institu-

Figure 2: Results of screening recruitment.

Appointments Mammograms

2nd quarter3rd quarter4th quarter100

80

60

40

20

0Clinical Breast

ExamsPe

rcen

t Inc

reas

e


ORIGINALRESEARCH


tions they were sure to frequent. About 70 womenfrom our target population came to the food pantryeach week, including some who were homeless. Deacon Donald Foust, the church administra-

tor, was an enthusiastic supporter. He explained,“By providing access to these important servic-es, I believe we have the potential to save livesin a population that is in dire need of pre-ven-tive care.”

RESULTSThe program took place monthly, and we spoketo 35 women at our first event. After that, out-reach workers spoke with 30 to 40 women eachmonth. Women were scheduled for and complet-ed appointments at a rate similar to our otheroutreach programs. About 30% were scheduledfor mammograms, for many their first, and about25% completed their appointments. Womenwith abnormal results received advanced diag-nostic services. Women were tracked and fol-lowed at the Breast Care Center. We also helped women without regular health-

care connect with a doctor. Patients met with afinancial advocate who helped them access theirbenefits, including the Connecticut Breast andCervical Cancer Early Detection Program andMedicaid. Spanish speakers were referred to abilingual social worker.The program has already saved lives. One 47-

year-old woman, homeless and mentally ill, who

had never had a mammogram, met with a nurseeducator and a bilingual breast cancer survivorand signed up for a free mammogram. She wasseen at the Breast Care Center’s clinic atBridgeport Hospital and later learned she hadbeen diagnosed with breast cancer. Now she isreceiving treatment through the Breast CareCenter without having to worry about medicalbills or insurance. For this woman, the grocerystore cards were a very meaningful incentive andkey to getting her to complete her first and subse-quent appointments. Although maintaining con-tact has been challenging, we continue to workwith her through her treatment.

BRIDGING BARRIERSWomen overall were receptive to the breastcancer survivors as outreach workers. They weremore likely to talk about breast health and shareexperiences with someone who had beenthrough the breast cancer experience and whospoke their language, an important factor formany women we encountered. Many of theiranxieties were lessened when they met thesesurvivors and understood that breast cancercould be overcome. Alicia, one of the bilingual breast cancer sur-

vivors who accompanied our outreach workers,reported that many of the women she encoun-tered were surprised to find someone who couldspeak with them in Spanish. She also reportedthat many women had no idea when or how toexamine themselves for breast cancer. Alicia wasvery open with women about her breast cancerjourney. When they learned that her cancer wasfound during a routine mammogram, they under-stood the importance of an annual mammogram.It gave them hope when they met a survivor whowas doing well and had returned to her life as itwas before breast cancer. Survivors and clients also bonded as women.

At the East Side Senior Center in Bridgeport,Alicia met a 50-year-old woman who had not hada mammogram in 2 years. Alicia shared her story,and the conversation shifted to how, as women,they put others before themselves. The womansaid she was inspired to make (and keep) herappointment and do something for herself. During these conversations, there is also the

opportunity for women to learn more aboutbreast cancer, such as identifying risk factors theyweren’t aware of. One woman with a family his-

Survivor-educator Alicia Berry (left) schedules a clinical breast examduring the breast health outreach program at the Holy Rosary Churchfood pantry.



ORIGINALRESEARCH

tory of breast cancer came to a community healthfair for a completely different issue, but when shesaw our breast cancer survivor handing out infor-mation, made an appointment for a breast examand mammogram. She said she had neverthought about the importance of getting a base-line mammogram and being monitored at her age(she was in her late 30s) despite her family histo-ry. The results of her exam were fine, and she isnow aware that she needs to be watched moreclosely and come in annually for exams. The program also provides survivors with a way

to channel their passion for helping other womenwith breast cancer. “I am thankful that I had thepeople who helped me through my [breast can-cer] journey during treatment,” said one survivor.“So now, as a survivor, I can make a difference byhelping women in the community.”

CHALLENGESOne of the main challenges of the program isrecruiting survivors who are excited to volunteerand can articulate the exam process. Despite the$50/day stipend plus $15/day for transportation,we had to move aggressively to recruit survivors.As noted above, we sent an e-mail blast to ourpatient list and placed English and Spanishannouncements in our newsletter and in theBridgeport Hospital employee newsletter. Somewomen who expressed an interest had difficultymeeting their obligations when they were sched-uled for programs, while others would haverequired a great deal of training, more than ourlean staff had time for. Others were looking for ajob with regular hours rather than irregular eventsthat took place at different times, and on differ -ent days of the week, including weekends.Occasionally, a bilingual social worker from ourpartner organization CancerCare attended some ofour programs. Ideally, a pool of volunteers with avariety of schedules would create more flexibilityand provide backup volunteers when someone’sschedule changed at work or at home. Because ournurse educators split their time with their duties asnurse navigators, the program would also benefitfrom a person dedicated solely to education whocould also train survivors as volunteers.

LOOKING FORWARDBecause we see many of the same women at thefood pantry each month, we are now trying toreach out to women whom we don’t see by pro-

viding men from the community with a packet ofinformation. Our hope is that it will reach theadult women in their family. The packet containsan informational pamphlet, a bracelet with ourname, and other items. These small tokens aremeaningful to individuals who have so little.Women can learn about the center and contactus through the church. In the future, we see repli-cating the program at other food banks on amonthly basis. We also continue to experimentwith new venues.Once the program was established, we were

able to attract additional grant funding forexpenses such as grocery store debit cards,stipends for survivors, and teaching materials. Wewill continue to explore new grant opportunitiesas the program grows. g

REFERENCES1. US Census Bureau. American Community Survey, 2005-09.http://www.census.gov/acs/www/data_documentation/2009_5yr_data/. Accessed April 8, 2012.2. Connecticut Cancer Partnership. Connecticut Comp rehensiveCancer Control Plan, 2005-08. Hartford, CT: ConnecticutCancer Partnership; 2005.3. Connecticut Affiliate of Susan G. Komen for the Cure.Community Report, 2009. Hartford, CT: Connecticut Affiliateof Susan G. Komen for the Cure; 2010. 4. Connecticut Department of Public Health. Cancer Incidencein Connecticut Towns, 2000-2003. Hartford, CT: ConnecticutDepartment of Public Health; 2006. 5. Connecticut Department of Public Health. ConnecticutHealth Disparities Project. The 2009 Connecticut HealthDisparities Report. Hartford, CT: Connecticut Department ofPublic Health; 2009.6. Latino Policy Institute. A Profile of Latino Health inConnecticut. Hartford, CT: Hispanic Health Council; 2006. 7. Centers for Disease Control and Prevention. CDC healthdisparities and inequalities report—United States 2011.MMWR Morb Mortal Wkly Rep. 2011;60(suppl):1-116.8. Buki LP, Selem M. Cancer screening and survivorship inLatino populations: a primer for psychologists. In: VillarruelFA, Carlo G, Grau JM, et al, eds. Handbook of U.S. LatinoPsychology. Thousand Oaks, CA: Sage Publications Inc;2009:363-368.9. Avon Foundation for Women. Breast cancer rates ques-tioned in Latina population. http://www.avonfoundation.org/press-room/breast-cancer-rates-questioned-in-latina-popula-tion.html. Accessed July 25, 2011.10. Saad-Harfouche FG, Jandorf L, Gage E, et al. Esperanza yVida: training lay health advisors and cancer survivors to pro-mote breast and cervical cancer screening in Latinas. J Community Health. 2011;36:219-227.11. Sudarsan NR, Jandorf L, Erwin DO. Multi-site implemen-tation of health education programs for Latinas. J CommunityHealth. 2011;36:193-203.12. Connecticut Department of Public Health. Federal short-age designation information, CT towns. http://www.ct.gov/dph/lib/dph/practitioner_licensing_and_investigations/plis/jvisa/designatedareas.pdf. Accessed July 25, 2011.


WEB SITEREVIEW


T he National Comprehensive CancerNetwork® (NCCN®) is a nonprofit allianceof 21 of the world’s leading cancer centers.

With the contributions of clinical professionals atNCCN Member Institutions, NCCN developsresources that present valuable information tomembers of the healthcare system. As an arbiter

of high-quality cancer care, the NCCN pro-motes continuous quality improvement and rec-ognizes the significance of creating clinical prac-tice guidelines appropriate for use by patients,clinicians, and other healthcare decision-mak-ers. The primary goal of all NCCN initiatives isto improve the quality, effectiveness, and effi-

ciency of oncology practice so patients can livebetter lives.

Each year at NCCN Member Institutions,more than 160,000 new patients receive cancercare from world-renowned experts who are recog-nized for dealing with complex, aggressive, or rarecancers. NCCN Member Institutions pioneeredthe concept of the multidisciplinary teamapproach to patient care and continue to inte-grate programs in patient care, research, and edu-cation. Forty-one Nobel Prize winners haveserved on the faculties of NCCN MemberInstitutions.

There is a wealth of information on NCCN’sWeb site for healthcare professionals (www.nccn.org), including screening criteria, surveil-lance guidelines, and treatment guidelines thathave now been expanded to include survivor-ship care guidelines. There is also a specific Website for patients (www.nccn.com) that providesa listing of the Member Institutions and infor-mation in layman’s terms that helps patientsunderstand the phases of treatment and whatthey might expect as they embark on their owncancer care. g

THE NATIONAL COMPREHENSIVE CANCER NETWORK® AND NCCN®

MEMBER INSTITUTIONSBy Lillie D. Shockney, RN, BS, MAS

There is a wealth of information onNCCN’s Web site for healthcare professionals...including screening criteria, surveillance guidelines, andtreatment guidelines....


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