September 14, 2009

Dr. Cathy Melvin

Dr. Cathy Melvin

Study seeks to boost cancer screening rates through community health partnership

One test that screens for colon cancer is pretty simple, but it requires taking three stool samples. That can be a daunting prospect, even for people who have the privacy of their own home and bathroom. When the patient is homeless and living out of his car, the challenges ratchet up quickly.

Yet health care professionals in High Point, N.C., were able to help a man in this situation – and even provide some follow-up care based on his test results — through a UNC-led study that centers on a strong community health care partnership. The study’s goal is to reduce colon cancer deaths by increasing the number of people who are screened early for the disease.

“Being able to talk with (the homeless man) and really educate him about the importance of screening, and also following up by helping him see a gastroenterologist, made a huge difference,” says Carin Hiott, director of chronic care for High Point Regional Health System. The system is one of the project’s partners, which also include the UNC Lineberger Comprehensive Cancer Center, the High Point Adult Health Center, Community Clinic of High Point, Piedmont Health Services and Sickle Cell Agency, High Point Gastroenterology, and physicians and other agencies in the High Point community.

Education and follow-up can make a huge difference throughout a community. Colon cancer is the second leading cause of cancer death in North Carolina, yet it’s highly treatable if caught early. African Americans tend to die from the disease at a higher rate than any other group, according to the Centers for Disease Control and Prevention (CDC). Screening rates have risen over the years but mostly among people with health insurance; those who are uninsured or underinsured tend to skip the screenings. The CDC reports that “as many as 60 percent of deaths from colorectal cancer could be prevented if everyone age 50 and older were screened regularly.”

UNC researchers, led by Cathy Melvin, PhD, research associate professor of maternal and child health at the UNC Gillings School of Global Public Health, and with Katya Roytburd, MPH, a research assistant in the Lineberger Comprehensive Cancer Center serving as project manager, set out to see if they could intervene.

They started the outreach screening study, which is a pilot project of the Carolina Community Network, funded by the National Cancer Institute’s Center to Reduce Cancer Health Disparities. The Comprehensive Cancer Control Collaborative of North Carolina (4CNC) at UNC’s Center for Health Promotion and Disease Prevention conducted formative research. 4CNC is funded by the CDC and the National Cancer Institute.

Alexis Moore, MPH, project director for 4CNC, says the early results are very encouraging, with home testing return rates as high as 70 percent at one participating clinic. The keys, she says, are solid education about the disease, clear instructions about screening and ensuring follow-up for positive tests regardless of a patient’s ability to pay. The screening method used is the fecal immunochemical test, or FIT, often called a stool test.

“In our focus groups, we discovered that people were willing (to try the test),” she says. “They had some reservations, but were reassured once they found out the kits were science-based, that they didn’t have to change their diet and knew they could get diagnostic follow-up.”

The focus groups of 28 African-American men and women, conducted in March 2007, recommended making available more pamphlets, videos and other educational materials. Because people over 50 may not read small print well, they helped researchers design a more user-friendly kit for the pilot project, with larger type and photos.

In all, 301 eligible adults have been enrolled in the study, with an overall FIT return rate of 67 percent. Of the 201 FIT that were returned, four were positive. All four patients have been referred for free diagnostic colonoscopy.

“We are excited about the high return rate,” Moore says. “We have learned that the stool test is affordable and can be distributed in clinics, and it’s terrific to know firsthand how many positives from this first sample will need follow-up.”

Lessons learned in the study have laid a good foundation, but questions remain as to whether the clinics can continue the outreach on their own and whether follow-up care will be available. Providing screening kits for people who need them is only the first step. It is also crucial that a “safety net” of gastroenterologists and other specialty care providers are available to provide prompt follow-up care to people who need it.

High Point Regional’s Hiott notes that the next steps would be tougher for all agencies, given limited resources and tight budgets. During the study, having a research assistant dedicated solely to promoting the FIT tests and talking with patients about colorectal cancer made a tremendous difference, she says.

Moore agrees that the challenges become greater without the study resources. Many clinics treating people who are uninsured or underinsured are acute care clinics, which must focus on more immediate problems, including hypertension and diabetes, rather than encourage preventive screenings for cancer.

Moore says that researchers are looking for additional partners to share expenses and successes. They hope to expand the project to additional communities.

The Comprehensive Cancer Control Collaborative of North Carolina (4CNC) at UNC’s Center for Health Promotion and Disease Prevention is funded by the Centers for Disease Control and Prevention and the National Cancer Institute.

— Kim Gazella

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