Implementation of an evidence-based cancer screening program for an urban

disabled population

Ryan Goetz BSCh Lewis Cancer & Research Pavilion at St. Joseph’s/ Candler

Sarah Dobra JD, MPHLewis Cancer & Research Pavilion at St. Joseph’s/ Candler

Janice Edenfield RNGeorgia Infirmary/ SOURCE at St. Joseph’s/ Candler

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Georgia Infirmary • Located in Savannah, Georgia

• Services for disabled, primarily elderly population

• First African American Hospital in the United States

• Staffed by two physicians, who each provide one half day a week

• All patients have Medicaid insurance and are on Supplemental Security Income (SSI), those 65 and above are dually covered by Medicare and Medicaid

• Intensive case management assists with addressing patient social conditions

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Nancy N. and J.C. Lewis Cancer and Research Pavilion at St. Joseph’s/Candler

(LCRP)• Regional Destination for Community

Cancer Care

• LCRP works to reduce cancer disparities through supporting several primacy care clinics serving underserved populations to implement evidence-based cancer screenings

• Began cancer screening programmatic

support of Georgia Infirmary in January 2014

• Provides nurse navigation and facilitates access to cancer care for any underserved patients diagnosed with cancer through screening programs

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The Importance of Cancer Screening• Cancer screening saves lives by detecting cancers early, while

they are still easily treatable

• This allows for more effective treatment with fewer side effects

• Prior to Lewis Cancer & Research Pavilion programmatic support clinic did not routinely offer evidence-based cancer screenings – High needs, medically complicated patients with multiple co-morbidities– Care primarily focused on acute and chronic conditions– Due to limited staffing resources and limited clinic hours, prevention and

health promotion activities, including cancer screenings, low priority

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Screening Considerations Among Disabled Populations

• Will cancer detection lengthen and/or improve the quality of life of this individual?

• Is individual willing and able to undergo treatment if cancer detected?

• Current functionality• Patients with intellectual and developmental

disabilities are screened for cancer less often than the general population

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Kuntz, H. Uptake of Colorectal Cancer Screening among Ontarians with Intellectual and Developmental Disabilities. 2015

Karnofsky Scale

• Used to assess patient’s physical capabilities• Used to help evaluate appropriateness of cancer screening • Physician made clinical decision whether or not to screen

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Timmerman, C. Just give me the best quality of life questionnaire’: the Karnofsky scale and the history of quality of life measurements in cancer trials. 2013

Cancer Assessment

Tool(CAT):

completed annually with all patients and appropriate referrals

made.

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TRIAGE STAFF – PLEASE COMPLETE FORM AS YOU ARE ASSESSING THE PATIENT BEFORE APPOINTMENT Circle age group; ask patient last date of each appropriate exam; circle if completed and write date; circle if NA; or circle & write “needed.”

Recommended Cancer Screening for Males Date________

Name: ___________________________________________________ Age: ______________________

Ethnicity (Circle one): Non-Hispanic Hispanic Race (Circle one): Black/African America White Asian

Age Prostate Colorectal Lung 21-29 Not Applicable

or Immediate Family History

Not Applicable or

Immediate Family History

Not Applicable

30-39 Not Applicable or

Immediate Family History

Not Applicable or

Immediate Family History

Not Applicable

40-49 African American or Family History

PSA Annually at 45+

Not Applicable or

Immediate Family History

Not Applicable

50+ For men with at least 10 year life expectancy, should have opportunity

to make informed decision about prostate cancer screening:

Digital Rectal Examination & PSA annually

Ages 50 – 79

Normal colonoscopy in past 10 years

or

Ages 50 – 79: FIT Kit annually

Not Applicable (Non Smoker)

Ages 55 -74: Current

smokers (or have quit in past 15 years) in good

health with at least a 30 pack-year history,

consider low-dose, non-contrast CT

IMMEDIATE FAMILY = FATHER, MOTHER, SISTER, BROTHER PSA = prostate-specific antigen test FIT = fecal immunochemical test REFERRAL:

PSA – DATE ___________

FIT Kit –Date Distributed: __________ Result ______

No tests needed at this time

Physician’s Only Please Circle

Colonoscopy Recommended Low Dose CT Recommended

Breast Cancer Screening Guidelines

• High quality, digital mammography (mammograms) is the preferred screening modality for breast cancer

• The American Cancer Society (ACS) recommends breast cancer screening, beginning at age 40 and continued as long as the patient is in good overall health

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American Cancer Society. Breast Cancer Prevention and Early Detection. 2014

http://sav-cdn.com/sites/default/files/imagecache/superphoto/editorial/images/savannah/mdControlled/cms/2009/10/27/509740979.jpg [Accessed Jan 29, 2015]

Clinic Programmatic Interventions to Support Breast Cancer Screening

• While completing the CAT, the intern marked if the patient was ambulatory

• Ambulatory patients were scheduled on a mobile mammography unit that made 2 trips to the clinic in 2014

• Non-ambulatory patients were scheduled for a mammogram at the Telfair Pavilion at Candler Hospital

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Cervical Cancer Screening Guidelines

• The Papanicolaou (Pap Test) is the preferred screening method for cervical cancer

• American Cancer Society recommendations:– Women 21-29: Pap every 3

years– Women 30-65: Human

Pappiloma Virus (HPV) testing and Pap every 5 years (preferred) or Pap alone every 3 years

11American Cancer Society. Cervical Cancer Prevention and Early Detection. 2014.

Clinic Programmatic Interventions to Support Cervical Cancer Screening

• Limited community resources for Cervical Cancer Screening for disabled and Medicaid eligible women

• We are currently collaborating with the Chatham County Health Department to facilitate Pap testing for our patients

• First patient completed cervical cancer screening in 2015

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•http://sav-cdn.com/sites/default/files/imagecache/superphoto/12347195.jpg

Colorectal Cancer Screening Guidelines

• American Cancer Society recommended modalities: – Colonoscopy (10 years), – Flexible sigmoidoscopy (5 years), – CT Colonography (5 years), – Fecal Immunochemical Test (FIT)

kits (annually), or – Fecal Occult Blood Test (FOBT)

kits (annually)

• Screening beginning at age 50

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http://www.mwrelayforlife.org/2011/03/support-funding-for-colon-cancer.html

American Cancer Society. Colorectal Cancer Prevention and Early Detection. 2014.

Clinic Programmatic Interventions to Support Colorectal Cancer Screening

• Clinic utilized FIT – Patient convenience and acceptability– Reduced structural barriers (transport) and

access– Low cost

• FIT referral prompted from CAT

• Used teach-it-back education method to ensure patients understood how to complete the kit

• Patient given stamped envelope to return kit; periodical motivational interviewing phone calls made to follow up with the patient until completion

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http://hemosure.com/wp-content/uploads/2013/10/T1-CK301.jpg

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Prostate Cancer Screening Guidelines

• The Prostate Specific Antigen (PSA) and Digital Rectal Exam (DRE) are the recommended screening modalities for prostate cancer screening

• The American Cancer Society recommends conversation to discuss prostate cancer screening at age 50– Additional screening

recommendations for African American men and

– Those with relatives diagnosed with prostate cancer

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https://d13yacurqjgara.cloudfront.net/users/345782/screenshots/1554503/prostate.jpg

American Cancer Society. Prostate Cancer Prevention and Early Detection. 2014

Clinic Programmatic Interventions to Support Prostate Cancer Screening

• Prostate Specific Antigen blood testing

• Special considerations for prostate cancer screening among this population:– Significant co-morbidities – “Shared Decision Making

Process”: Ability to understand relative benefits and risks

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http://psatests.org.uk/

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Lung Cancer Screening Guidelines

• Low-dose, non-contrast lung screening CT is the preferred modality for lung cancer screening

• American Cancer Society screening recommendations: screen patients ages 55-74 with at least a 30 pack year history

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•http://www.lungcanceralliance.org/images/features/cancer-screening.jpg

American Cancer Society. Lung Cancer Prevention and Early Detection. 2014

Clinic Programmatic Interventions to Support Lung Cancer Screening

• All age eligible patients assessed for smoking history

• For patients with >30 year pack history, provider evaluated patient for screening

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•http://bionews-tx.com/news/news-tags/lung-cancer/

Conclusion/ Next Steps

• Screening is possible among an urban disabled population and can help to improve quality of life

• Programmatic support by LCRP key to program’s success

• 2015: Transitioning program responsibility to clinic to ensure sustainability

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