Improving access to colorectal cancer screening for the underserved. Eliminating cancer disparities.

As we have noted previously, colorectal cancer is a leading preventable cause of cancer mortality. See related posts. Screening can be effective reducing deaths by half. Yet it is underutilized. Multi-level interventions addressing system changes and individual factors can effectively increasing screening. To date, most interventions have been implemented and evaluated in higher-resource settings such as health maintenance organizations.  Given the disparities evident for colorectal cancer and the potential for screening to improve outcomes, we describe our ongoing NCI funded research that is expanding the population included in such studies. We recently published the protocol for our ongoing study that includes economically disadvantaged patients. (see report online). We describe the study protocol for a trial designed to increase colorectal cancer screening in those ‘safety-net’ health centers that serve underinsured and uninsured patients in Missouri. This trial was designed and is being implemented using a community-based participatory approach.

What was our approach?

We developed a practical clinical cluster-randomized controlled trial. We are currently recruiting 16 community health centers to participate and collaborate in this trial. This systems-level intervention consists of a menu of evidence-based implementation strategies for increasing colorectal cancer screening. Health centers in the intervention arm then collaborate with our Siteman and Washington University based  study team to tailor strategies to their own setting to maximize fit and acceptability. Data are collected at the organizational level through interviews, and at the provider and patient levels through surveys. Patients complete a survey about their healthcare and screening utilization at baseline, six months, and twelve months.

How will we assess success in brining screening to our underserved communities?

The primary outcome for our study is colorectal cancer screening that we record through patient self-report. We will supplement these self –reports with a chart-audit in a subsample of patients. This is similar to the approach we used in a primacy care based intervention in New England that showed success in creasing screening rates more than a decade ago (see report).  Implementation outcomes informed by the Reach, Efficacy/Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) conceptual framework will be measured at the patient, provider, and practice levels. This approach has been used previously to evaluate interventions in low-income settings and assess the overall public health benefit.

Why is this study important?

Our study is one of the first to integrate community participatory strategies to a randomized controlled trial in a low-income healthcare setting. The multi-level approach will support the ability of the intervention to affect screening through multiple avenues. The participatory approach will strengthen the chance that implementation strategies will be maintained after study completion and, supports external validity by increasing health center interest and willingness to participate.
Ronald Rancher, a participant in the Photovoice project, 
stands next to the photo he submitted for the project. 
Washington University School of Medicine.

For more details on this and other innovative studies on colorectal cancer screening in low income populations see Associate Professor Dr. Aimee James‘ studies at Siteman Cancer Center:
Or watch the Photovoice video at… Watch the Photovoice project video

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