Sukit RingwalaMD/MPH Candidate9 May 2008

Background Purpose Project Methods Findings Discussion Conclusion

Coalition of health systems’ administrators, nurses, physicians, public health workers, epidemiologists

Stems from the Wisconsin Comprehensive Control Plan

Goal: Promote access to quality cancer care

Specifically taken on the task of improving colorectal cancer (CRC) care in Milwaukee and Waukesha Counties

Colorectal cancer (CRC) is the 2nd leading cause of death from cancer in the US

150,000 new cases per year in the US 50,000 deaths per year in the US Ranks 3rd in cancer incidence and

mortality within Milwaukee County

Modalities that reduce CRC mortality Fecal Occult Blood Tests (FOBTs) Colonoscopy

Lower Screening rates in: The poor Recent immigrants People with lower educational levels Minorities

Milwaukee County area Breast, cervical, and prostate cancer

screening at little or no cost Few programs in place to address access to

CRC screening for populations in need

Create a colon cancer screening program Address disparities to access, specifically for

the uninsured Increase screening rates Decrease the time between screening and

diagnosis Goal: To improve mortality in disparate

populations by providing treatment earlier

Literature review conducted using PubMed Query: colon cancer, screening programs,

navigator…etc. Other criteria:

Focus on urban programs Address screening for uninsured Targeted to minorities Target to patients of lower socioeconomic

status

Literature review conducted using PubMed for appropriate screening modality

Query: fecal occult blood test, colonoscopy, IFOBT, FIT…etc.

Criteria: Study year >2000 AGA or USPSTF supported

Interventions Population % minorityChange in overall

screening rate

Maryland1. Patient education 2. Physician referral 3. Phone calls

Uninsured 90% + 39%

1. Patient navigation + 17%2. Physician referral + 11%*

Chicago, IL

1. Physician referral Low-income 95% + 16 %

*Change in patient compliance to a follow-up colonoscopy

CRC Screening Programs' Evidence

East Harlem, NY

Low-income >80%

Time Interval Sensitivity(%) Specificity(%)

gFOBT† Annual 65 86

FIT Annual 82 97

Results are for average risk adults ≥ 50 years old† Serial tests performed using Hemoccult SENSA

CRC Screening Tests

gFOBT, guaiac - based fecal occult blood test; FIT, fecal immunochemical test

Strengths Successfully enhanced screening for breast

and prostate cancer Studies show improvement in screening rates CDC’s CRC screening demonstration project

has laid framework Limitations

Small sample size in studies of review Studies used only one clinical site Other studies may have been missed in query

FIT Strengths:

1) Better sensitivity and specificity than gFOBT2) Fewer demands placed on patient3) Medicare reimbursement

Limitations:1) Sensitivity and specificity may vary depending

on manufacturer2) More costly than gFOBT3) Not established in clinical practice

A CRC patient navigator program could be successful in Milwaukee County

Points to consider: Cost Health systems support Scalability of model Timeline

Construct a navigator model tailored for Milwaukee County and its health systems

Obtain stakeholder support Milwaukee health care systems WI Comprehensive Cancer Control Program Colorectal Cancer Task Forces American Cancer Society

Implementation plan Obtain source of funding Initiate pilot program on a smaller scale within

Milwaukee

Lora de Oliveira, MPH, MBA Griselle Sanchez Milwaukee Regional Cancer Control

Network

Freeman et al. Determinants of Cancer Disparities: Barriers to Cancer Screening, Diagnosis, and Treatment. Surgical Oncol Clin N Am. 14 (2005) 655-669.

Intercultural Cancer Council 2006 Survivorship Report: Cancer Survivorship and the Medically Underserved: Reducing the Disparities in Cancer Care. Intercultural Cancer Council, 2006.

Steinberg et al. Lay Patient Navigator Program Implementation for Equal Access to Cancer Care and Clinical Trials: Essential Steps and Initial Challenges. Cancer. Dec 2006. Vol 107: No 11.

Seeff et al. Development of A Federally Funded Demonstration Colorectal Cancer Screening Program. Preventing Chronic Disease: Public Health Research, Practice, and Policy. April 2008. Vol 5: No 2.

Tangka et al. Cost of Starting Colorectal Cancer Screening Programs: Results from Five Federally Funded Demonstration Programs. Preventing Chronic Disease: Public Health Research, Practice, and Policy. April 2008. Vol 5: No 2.

DeGroff, Amy. CDC’s Colorectal Cancer Screening Demonstration Project. Wisconsin Comprehensive Cancer Control Summit April 10, 2008. Centers for Disease Control and Prevention. (Presentation)

Safarty et al. Choice of Screening Modality in Colorectal Cancer Education and Screening Program for the Uninsured. Journal of Cancer Education. Vol 21: No 1. 2006.

Lawson et al. Colorectal Cancer Screening among Low-Income African Americans in East Harlem: A Theoretical Approach to Understanding Barriers and Promoters to Screening. Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 84, No. 1. 2006.

Michael S Wolf; Melissa Satterlee; Elizabeth A Calhoun; Silvia Skripkauskas; .... Colorectal Cancer Screening among the Medically Underserved. Journal of Health Care for the Poor and Underserved; Feb 2006; 17, 1.

Khankari et al. Improving Colorectal Cancer Screening Among the Medically Underserved: A Pilot Study within a Federally Qualified Health Center. J Gen Intern Med 22(10):1410–4.

Jandorf et. al. Use of a Patient Navigator to Increase Colorectal Cancer Screening in an Urban Neighborhood Health Clinic. Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 82, No. 2

M. Sarfaty, S. Feng. Uptake of Colorectal Cancer Screening in an uninsured Population. Preventive Medicine 41 (2005) 703–706.

Dower C, Knox M, Lindler V, O’Neil E. Advancing Community Health Worker Practice and Utilization: The Focus on Financing. San Francisco, CA: National Fund for Medical Education. 2006.

Levin et al. Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008: A Joint Guideline From the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gasteroenterology. 2008

Allison et al. Screening for Colorectal Neoplasms With New Fecal Occult Blood Tests: Update on Performance Characteristics. J Natl Cancer Inst 2007;99: 1462 – 70.

Levi et al. A Quantitative Immunochemical Fecal Occult Blood Test for Colorectal Neoplasia. Ann Intern Med. 2007; 146: 244-255.

Guittet et. al. Comparison of a guaiac based and an immunochemical faecal occult blood test in screening for colorectal cancer in a general average risk population. Gut 2007;56:210–214.

CDC WONDER Wisconsin Cancer Registry