Abstract

Association of Rurality and Availability of Gastroenterologist with Early-Onset Colorectal Cancer Incidence in the U.S.

Young-Rock Hong¹, Sandhya Yadav, PhD, MHA¹, Lee Revere, PhD¹, Arch Mainous III, PhD¹, Simon Mathews, MD² (1)University of Florida, (2)Johns Hopkins University

APHA 2022 Annual Meeting and Expo

Background: The burden of early-onset (diagnosed at <50 years old) colorectal cancer (CRC) has been increasing among young adult populations in the U.S. Current evidence on risks for early-onset CRC is limited to individual behavioral factors (e.g., lifestyle, diet). Despite geographical access to care disparities such as rurality and availability of healthcare providers—which often shape cancer screening opportunities, little is known about the roles of community-level (county) health care resource access in the early-onset CRC burden. This study explored and examined the associations between county-level healthcare access factors and early-onset CRC risk among US counties.

Methods: This was an ecological study of early-onset CRC incidences among US counties that occurred between 2014 and 2018. Data was obtained from US Cancer Statistics—including CDC’s National Program of Cancer Registries and NCI’s Surveillance, Epidemiology, and End Results. County-level data, including sociodemographic (e.g., percentage of female, non-White residents, poverty rate, rurality) and healthcare resources (e.g., primary care physician and gastroenterologist supply) was obtained from AHRQ’s Social Determinants of Health Database and HRSA’s Area Health Resources Files. Incidence rate ratios (IRRs) of 5-year average (2014-2018) age-adjusted early-onset CRC with 95% confidence interval (CIs) were estimated from generalized estimating equation (GEE) modeling with robust standard error estimates clustered on within-state correlation. Models were adjusted for aggregate county-level socioeconomic characteristics. Multicollinearity was tested through variation inflation.

Results: The analyses included 850 US counties with complete information. Overall the average age-adjusted early-onset CRC incidence rate was 8.4 per 100,000 during 2014-2018 (with an annual percent change rate of 2.2%). In the multivariable GEE model, the age-adjusted CRC risk varied significantly by rurality and gastroenterology specialist supply. Rural counties had a 14% increased incidence rate (adjusted IRR, 1.14, 95% CI, 1.09-1.20) compared with urban counties. Counties with the highest gastroenterology specialist supply (6.1 per 100,000) had 10% decreased incidence rate (adjusted IRR, 0.90, 95% CI, 3.6-16.4), compared with counties with no gastroenterologists. Other county-level factors associated with increasing early-onset CRC risk included obesity prevalence, and the percentage of female or White residents. Poverty rate and primary care physician supply were not associated with early-onset CRC risk.

Conclusions: Populations living in rural counties or those without gastroenterologists had an increased risk for early-onset CRC. Our findings highlight geographic-related disparities in early-onset CRC, suggesting the need for early CRC screening efforts and the potential for expanding gastroenterological services and referrals in rural counties.

Abstract

The impact of in-house pathology services on down-staging cervical cancer in Tanzania over an 18-year period

Caroline Fuss¹, Khadija Msami, MD, MPH², Crispin Kahesa, MD, PhD², Julius Mwaiselage, MD, PhD², Amanda Gordon³, Lindsey Mattick, MPH⁴, Amr Soliman, MD, PhD⁵ (1)George Washington University, (2)Department of Cancer Prevention, Ocean Road Cancer Institute, Dar es Salaam, Tanzania, (3)Department of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA, (4)Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, The State University of New York, Buffalo, NY, USA, (5)Department of Community Health and Social Medicine, City University of New York School of Medicine, New York, NY, USA

APHA 2022 Annual Meeting and Expo

Purpose: Reducing the time period between cancer diagnosis and initiation of treatment is best achieved when both services are available in the same hospital. Yet, comprehensive cancer centers are not typically available in low- and middle-income countries (LMICs), where resources are limited, and services are scattered. This study explored the impact of establishing an in-house pathology laboratory at the largest cancer hospital in Tanzania on down-staging cervical cancer.
Methods: We examined clinical datasets of 8,322 cervical cancer patients treated at the Ocean Road Cancer Institute (ORCI), Tanzania's largest public cancer center. The first period included patients treated from 2002 to 2016, before establishment of the pathology laboratory at ORCI, and the second period (post-pathology laboratory) included data from 2017-2020. Logistic regression analysis evaluated the impact of pathology laboratory on stage at cervical cancer diagnosis.
Results: Patients treated during the second period were more likely to be clinically diagnosed at earlier disease stages compared to patients in the pre-pathology establishment period (pre: 44.08%; post: 59.38%, p<.001). After adjustment for age, region of residence, and place of biopsy, regression results showed patients diagnosed during the post-pathology establishment period had higher odds of early stage cervical cancer diagnosis than patients in the pre-pathology establishment period (OR: 1.35, 95% CI: 1.16, 1.57, p<.001).
Conclusions: Integrated and comprehensive cancer centers can overcome challenges in delivering expedited cervical cancer diagnosis and treatment. In-house pathology laboratories play an important role in facilitating timely diagnosis and rapid treatment of cervical and possibly other cancers in LMICs.

Statements and Declarations
Funding Sources
This work was supported by the Cancer Epidemiology and Education in Special Populations (CEESP) grant, a research training program funded by the NIH/NCI grant (R25CA112383).

Ethical Approvals
Institutional Review Board approvals were obtained from George Washington University and by the Ocean Road Cancer Institute’s Academic, Research, Publications and Ethics Committee.

Data Availability
The data that support the findings of this study are available from the Ocean Road Cancer Institute, but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of the Ocean Road Cancer Institute.

Declaration of Interests
The authors declare no conflicts of interests.

Abstract

Implementing a virtual patient navigation program to increase follow-up colonoscopies after an abnormal FIT result: findings from a Federally Qualified Health Center in Southern California

Esmeralda Ruiz, MPH, Evelyn Torres-Ozadali, MPH, AltaMed Health Services

APHA 2022 Annual Meeting and Expo

Introduction:
Colorectal cancer (CRC) is the second-leading cause of cancer death in the US. Although screening has increased, it remains disproportionally low amongst Latinos. Fecal Immunochemical Tests (FIT) are an at-home screening tool that can help address this disparity. To be effective, abnormal FIT results must be followed by a timely colonoscopy to further evaluate colon health, potentially removing precancerous growths or diagnosing CRC. Many federally qualified health centers (FQHCs) face barriers in care coordination with gastroenterologists outside the primary care setting. This study assesses the impact of a virtual patient navigation program dedicated to increasing follow-up colonoscopies after an abnormal FIT result at an FQHC primarily serving Latinos in southern California.

Methods:
We developed and implemented a patient navigation intervention in April 2021 to: inform patients of abnormal FIT results, help schedule pre-colonoscopy and colonoscopy appointments, send appointment reminders, and offer virtual group bowel prep education sessions. We analyzed data from internal program tracking, EHR reports, and gastroenterology records to assess the program’s impact. A staggered implementation strategy allowed us to compare patients who were part of the patient navigation intervention (PN) versus those who were not.

Results:
In 2021, there was a total of 1,135 abnormal FIT results. 464 patients were excluded from the PN intervention and only 80 (17%) completed a follow-up colonoscopy within 6 months of their abnormal result. On the other hand, 671 patients were included in the PN intervention out of which 242 (36%) patients completed a follow-up colonoscopy. The program was also successful in decreasing poor bowel prep from 33% in 2020 to only 5% for patients who participated in virtual, group bowel prep education classes. Overall, out of the 434 colonoscopy records we have, 13 colorectal cancer diagnoses were made and 232 patients had polyp/s removed across the FQHC.

Conclusion:
Interventions to address care coordination between primary care providers and gastroenterologists are vital to address equity in colorectal cancer prevention and detection.

Abstract

Liver Cancer Prevention for Chinese Americans: Effectiveness of a Community Health Worker-Delivered Services

Zihan Zhang, MS¹, Zihan Zhang, MS¹, Haocen Wang, PhD¹, Yu-Lyu Yeh, PhD, CHW², Judy Huei-yu Wang, PhD³, Lei-Shih Chen, PhD, MCHES®, CHW¹ (1)Department of Health and Kinesiology, Texas A&M University, (2)Department of Healthcare Administration, Asia University, (3)Department of Oncology and Cancer Control Program, Georgetown University Medical Center

APHA 2022 Annual Meeting and Expo

Background: Chinese Americans have the highest incidence of liver cancer among all ethnic groups in the United States. Liver cancer is the fourth most common cancer among Chinese American men. Hepatitis B Virus (HBV) vaccination is a common approach to preventing liver cancer. Adopting community health workers (CHWs) for cancer prevention has proven to be an effective way to promote healthy behavior among racial/ethnic minorities and hard-to-reach communities. Thus, we trained 46 Chinese CHWs to provide liver cancer prevention services to Chinese Americans in Texas. This study provides an evaluation report.
Methods: A total of 1,129 Chinese Americans received liver cancer prevention services from Chinese CHWs. Participants completed the pre-, post-, and three-month follow-up surveys. Generalized linear or logistic mixed modeling was used for data analysis.
Results: Comparing to the baseline data, participating Chinese Americans’ knowledge of HBV and liver cancer was significantly improved at both immoderately post- and three-month follow-up (Ps<0.001). HBV vaccination rate was significantly improved (P<0.001): 77.6% of participants were vaccinated at the three-month follow-up whereas the HBV vaccination rate was 61.9% at baseline. For those who were unvaccinated at three-month, the reasons provided by participants were perception of no value of HBV vaccination since they were healthy, unfamiliar with the U.S. healthcare system, and lack of time.
Conclusions: The liver cancer prevention intervention delivered by Chinese CHWs successfully increased the Chinese American participants’ HBV and liver cancer knowledge and HBV vaccination rates. More education and navigation services from Chinese CHWs and an extended timeframe are needed to help unvaccinated HBV participants get vaccinated.

Abstract

Multicomponent, system-level intervention to increase colorectal cancer screening among Federally Qualified Health Center (FQHC) patients

Alison Herrmann, PhD¹, Beth Glenn, PhD¹, Debra Rosen², Narissa Nonzee, PhD³, Analissa Avila, MS¹, Jessica Tuan, MPH¹, Folasade P May, MD, PhD⁴, Catherine Crespi, PhD¹, Alicia Lwin, MD², Christine Park, MD², Roshan Bastani, PhD¹ (1)UCLA Kaiser Permanente Center for Health Equity, UCLA Fielding School of Public Health, (2)Northeast Valley Health Corporation, (3)City of Hope, (4)UCLA Fielding School of Public Health, the UCLA Kaiser Permanente Center for Health Equity, UCLA David Geffen School of Medicine

APHA 2022 Annual Meeting and Expo

CRC screening is universally recommended for adults aged 50-75, but less than 70% of US adults are up-to-date on screening, with lower uptake among Latinos, recent immigrants, and the uninsured. Federally Qualified Health Centers (FQHCs) provide substantial care to low-income, minority, and uninsured populations in the US, and interventions to increase CRC screening that are feasible to implement in this setting are critically needed. Therefore, UCLA collaborated with Northeast Valley Health Corporation (NEVHC), one of the nation’s largest FQHCs, to implement and evaluate a multicomponent, system-level intervention aimed at increasing CRC screening by reducing missed opportunities to provide the fecal immunochemical test (FIT) kit during patient encounters. The study was conducted in four clinics that serve approximately 6,000 low-income patients eligible for CRC screening (62% Latino, 20% uninsured). Two clinics were randomized to the intervention and two to usual care. The intervention, which included physician and staff trainings, workflow modifications, and patient text message prompts and reminders, was initiated in November 2019. The onset of the COVID-19 pandemic occurred only four months later, leading to substantial reductions in CRC screening rates between baseline and one-year follow-up in intervention (12 percentage points) and usual care (18 percentage points) clinics. Intervention strategies were modified to align with COVID-19 protocols, including mailing FIT kits for telehealth visits. Although CRC screening has not returned to pre-pandemic levels (<40% up-to-date in both groups), intervention clinic patients had 2.3 times the odds of being up-to-date with CRC screening at two-year follow-up, compared to usual care clinic patients (p<.001). Study findings suggest that our multicomponent intervention reduced pandemic-related declines in CRC screening and can inform similar efforts at FQHCs and other safety net clinics.