University of North Carolina researchers have launched an ambitious multi-pronged initiative to improve cancer screening rates in North Carolina, with the goal of reducing cancer-related deaths.
The Carolina Cancer Screening Initiative (CCSI) brings together researchers from the UNC Gillings School of Global Public Health, clinicians from the UNC Lineberger Comprehensive Cancer Center and community partners to implement evidence-based cancer screening programs to reduce cancer burden among North Carolinians. A key project of the initiative focuses on reducing the colorectal cancer mortality gap in the northeastern part of the state.
Colorectal cancer screening has proven effective in reducing cancer deaths. The American Cancer Society reported that screening contributed to a substantial decline in colorectal cancer deaths in the United States between 1976 and 2014. Although regular screening is recommended for people ages 50 to 75 years, gaps persist in screening rates by race and geographic region, and the highest rates of colorectal cancer mortality remain primarily concentrated in rural communities.
“Experts agree that the current colon cancer screening tests not only are really good at detecting cancer and preventing unnecessary deaths, but also are cost-effective and possibly even cost-saving in the long-term,” said Dr. Stephanie Wheeler, associate professor of health policy and management in the Gillings School, UNC Lineberger member and CCSI investigator. “There really is no controversy about it. Despite it being a best-case screening scenario, too few people are being screened.”
Dr. Wheeler worked with Dr. Daniel S. Reuland, director of CCSI, and Dr. Alison Brenner, associate program director of CCSI – both Lineberger members – to launch the initiative.
One of the major catalysts for their effort was an American Cancer Society-led study in 2015 that identified an 11-county area of northeastern North Carolina as one of three hotspots in the country with elevated colorectal cancer death rates. An initial focus of CCSI will be to address this geographic disparity, as well as racial and ethnic disparities that negatively impact colorectal cancer screening and mortality in the state. Researchers are working to identify and launch initiatives that focus on the specific screening needs of local areas, such as these hotspots.
In Hertford and surrounding counties in the northeastern part of the state, UNC researchers are working with health-care leaders to address screening barriers through stakeholder meetings. They plan to hire a population health manager to work in the hotspot, to improve access to endoscopy services in the region, and to seek additional funding for screening programs and implementation studies, Dr. Reuland said.
Drs. Wheeler and Brenner, in partnership with Community Care of North Carolina and the Mecklenburg County health department, also have launched an effort to boost screening rates for Medicaid recipients in Mecklenburg County in southwest North Carolina. Researchers mailed reminder letters, with or without stool-based colorectal cancer test kits, to Medicaid recipients who were age-eligible for, but not up-to-date with, screening. The investigators currently are measuring the reach and cost effectiveness of directly mailing test kits to patients.
The stool-based mailed test does not require the same type of intense preparation as colonoscopy, nor does it require anesthesia, and it can be done at home. Dr. Brenner said researchers believe the test could help overcome barriers to screening for people who are lower-income, cannot take time off work for a more invasive procedure, or may be barred from some medical practices because of their insurance type.
The team launched CCSI after a study led by Dr. Wheeler found that Mecklenburg, the state’s most populous county, was one of two counties in North Carolina that had the highest concentration of endoscopy facilities but relatively low predicted likelihood of colorectal cancer testing for people with Medicaid and other insurance types.
The researchers also are focused on testing an approach they used to boost screening rates at community health clinics in North Carolina and New Mexico, which largely served patients who were Latino, low-income, on Medicaid or lacking insurance. Drs. Reuland and Brenner and colleagues developed a strategy that used a bilingual video about screening options and one-on-one “patient navigation” support to help patients get scheduled for screening. This approach increased screening rates to 68 percent, which was 41 percentage points higher than the group who did not receive the intervention. Their findings were published online May 15 in JAMA Internal Medicine.
“We’ve shown that if we structure care such that we catch patients right when they are seeing their doctor, systematically provide them with clear and compelling information about screening and what their choices are, and then give them the support they need to get the screening test they prefer, we can substantially improve screening rates,” Dr. Reuland said.
Dr. Wheeler underlined that successful interventions will be specifically tailored to local needs.
“We see huge variation in screening rates not just by where people live, but by income, insurance status, and race and ethnicity,” she said. “The kinds of interventions that are going to work to bring everybody up to the recommended screening levels are not going to be the same everywhere, because the barriers are different. To move the needle on colorectal cancer screening, we must be much more cognizant of the needs of each local population.”