Increasing Access to Colorectal Cancer (CRC) Screening in Rural East Texas where there is a High rate of Adenomatous Polyps Detected Carlton Allen, MS, CHW, CHES Texas Public Health Association: 93rd Annual Education Conference

Objective Identify effective screening methods for Colorectal Cancer in a rural area.

Goals Education Screening Educate individuals regarding benefits of and guidelines for CRC screening. Screening Screen individuals through Fecal Immunochemical Test (FIT) and/or colonoscopy. Increase the rate of CRC screening services in East Texas 10% by 2019. Educated 12,000 (4k a year) individuals, and screen 5,600 individuals. Also looked at # of individuals that are interested in CRC screenings. # patients that use the grant to help assist in their CRC screening.

Outline Current status of CRC in East Texas Interventions Future Plans

Overview Compared to Texas as a whole, East Texas has higher incidence and mortality rates from CRC. ET 55.3 vs. Texas 47.2 per 100,000 individuals ET 20.6 vs. Texas 17.4 per 100,000 individuals CRC screening rates in Texas. 44.5% reported having a sigmoidoscopy or colonoscopy in the last five years 14.1% reported having an annual blood stool test Colorectal cancer (CRC) screening saves lives, yet screening rates among underserved populations, such as the uninsured and minorities, are low. Both in Texas and in the United States, CRC is the third most commonly diagnosed cancer in men and women and the second leading cause of cancer deaths overall. In Texas, colorectal cancer mortality and morbidity is highest in the eastern part of the state. Screening for CRC in asymptomatic patients can reduce the incidence and mortality of CRC.

Background UT Health Northeast originally used Hemoccult ® Cancer Prevention & Research Institute of Texas (CPRIT) Grant awarded in Fall of 2014 The University of Texas Health Science Center at Tyler (UTHSCT) has changed their stool screening test from Hemoccult ®, which has false positives and requires that the test be performed three times, to Fecal Immunochemical Testing (FIT), which is more sensitive and specific than Hemoccult ®. Fecal Immunochemical Testing (FIT) is less cumbersome than guaiac fecal occult blood testing (FOBT). It has also been shown effective in underserved populations. FIT is replacing guaiac FOBT as the preferred method to detect blood in the stool .

Benefits of FIT Access Cost Sensitive Can be done at home Lower costs to patient and health facility compared to colonoscopy Sensitive More specific for human blood and lower GI bleeding than Hemoccult ® Also less invasive.

Benefits of Colonoscopy Prevents CRC by polypectomy Identifies early-stage cancers, with a higher chance for cure. Identifies families at increased CRC risk

Outline Current status of CRC in East Texas Interventions Future Plans

Intervention Coordinated screening program to increase access to and delivery of CRC services (FIT and colonoscopy) to individuals in East Texas This study helped us reach participants who fear colonoscopies and allowed us to educate them on other screening options. These participants face unique challenges such as lack of transportation, financial resources, and/or insurance. There are no known organized CRC screening initiatives operating on a large scale in the targeted region which provide both CRC education and screening services to the underserved. Complementary, non-overlapping partnership with a federal and state program to optimize CRC screening Focuses on a mostly rural population with a high relative incidence of CRC, which poses unique challenges related to access, delivery of education and CRC services.

Intervention Multiple partnerships were established with existing community programs and clinical colleagues in primary care were engaged to assist with recruitment

Intervention Negative FIT or whose colonoscopy revealed no/benign polyps Positive FIT Colonoscopic biopsy demonstrating a precancerous/cancerous polyp

Results Educated 4,549 individuals for year 2, total of 6,524 since inception. Whites comprised 39.3% of the sample, African Americans 17.0%, and Hispanics 25.9% Seventy-four percent of the participants (n=3,344) lacked insurance this year. Uninsured individuals were significantly older than their insured counterparts. The greatest proportion came from Smith County (38.6%), followed by Gregg (8.4%), Cherokee (2.8%), Van Zandt (2.7%), and Henderson (2.4%) 49.0 vs 52.1. There were significantly greater than expected uninsured female participants than male participants

Results Table 1: Average number of days (n) between Education event and Scheduled screening date by Ethnicity, Gender, and Year of Program Interested 1,593 individuals for year 2, total of 2,090 since inception. Females comprised the majority of participants (70.8%)   Year One Year Two P-Value† African American total 57.3 ( 61) 51.2 ( 79) .362 Female 59.0 ( 44) 53.7 ( 57) .527 Male 52.9 ( 17) 44.5 ( 22) .452 Hispanic total 69.4 ( 89) 63.4 (134) .242 69.3 ( 65) 67.2 ( 98) .731 69.5 ( 24) 53.0 ( 36) .069* White total 62.4 (120) 50.0 (203) .005** 67.0 ( 83) 53.2 (140) .019** 52.1 ( 37) 42.9 ( 63) .110 Interested- Filled out our intake form to determine eligibility A majority came from the first three counties: Smith (27.6%), Gregg (21.1%), and Cherokee (5.6%) Counties. Whites comprised 48.4% of the sample, Hispanics 32.3%, and African Americans 17.6% In Year Two, over a third of all referrals were from two sources, both of which are Federally Qualified Health Centers (FQHCs). The largest source of referrals was an FQHC based in Gregg County (n=462 or 29.0%). The second largest referral source was an FQHC from Hunt County (n=179 or 11.2%). †Independent Samples T test; **<.05; .05<*<.10

Results Screened September 1, 2015 and August 31, 2016 (end of Year Two) there were 2,417 colorectal cancer screenings. In Year 2, 1,080 (44.7%) did not have insurance, or were underinsured. CPRIT funded these screenings. 1,337 screenings in Year 1. Increase of 81%. During Year Two, the majority of these individuals had insurance, but 1,080 (44.7%) did not have insurance, or were underinsured. CPRIT funded these screenings. Of those who screened through our program, whether insured or uninsured, 26.8% (n=648) were screened through FIT only. In Year One, only 8.2% (n=110) were screened through FIT.

Results Note: Age Hispanics Uninsured Table 2: Cases (%) showing Demographic differences by CPRIT Year   Year One Year Two P value Agea (average) 61.3 59.7 .000** Sexb Male Female 532 (39.8) 787 (58.9) 892 (36.9) 1,525 (63.1) .039** Ethnicityb African American Hispanic White 352 (26.3) 46 ( 3.4) 921 (68.9) 569 (23.5) 352 (14.6) 1,480 (61.2) Insurance statusb Insured Uninsured 1,161 (86.8) 176 (13.2) 1,337 (55.3) 1,080 (44.7) Note: Age Hispanics Uninsured **p<.05; a= T test, b=Chi Square

Results Note: Age Females Hispanics Table 3: Cases (%) showing Demographic differences by Insurance status, Year Two   Insured (n=1,337) Uninsured (n=1,080) P value Agea (average) 61.8 57.0 .000** Sexb Male Female 577 (64.8) 760 (49.8) 315 (35.3) 765 (50.2) Ethnicityb African American Hispanic White 374 (65.7) 41 (11.7) 912 (61.6) 195 (34.3) 311 (88.3) 568 (38.4) Note: Age Females Hispanics **p<.05; a= T test, b=Chi Square

Results Note: Males Colonoscopy vs. FIT Table 19: Uninsured number (%) by Screening method, Year Two Note: Males Colonoscopy vs. FIT   Colonoscopy only FIT only Total Age (average) 57.0 - Sex Male Female 165 (52.7) 345 (45.5) 148 (47.3) 413 (54.5) 313 758 Race White African-American Hispanic 268 (47.6) 95 (49.2) 145 (46.9) 295 (52.4) 98 (50.8) 164 (53.1) 563 193 309 It is uncanny how there were just as many uninsured individuals opting for the FIT test as the colonoscopy. In Year One, the proportions were more lopsided with a clear majority favoring colonoscopy. Of those uninsured in Year Two who chose colonoscopy as their screening method, 19.8% (101/510) had a previous screening. Of those who underwent colonoscopies, nearly half had some kind of abnormality (238/510 or 46.6%)

Outline Current status of CRC in East Texas Interventions Future Plans

Going Forward Confirm high abnormal rate in an additional cohort of patients Work with an Epidemiologist to determine if a high rate of precancerous polyps is present in our cohort, and if so why. We plan to continue to study to see if our belief is true that the removal of adenomatous polyps among our participants will decrease their risk of developing CRC, and that the detection of CRC in the screened individuals will improve their chance of survival. We believe that our approach to patient recruitment, which includes population outreach and clinician participation, combined with strategies to overcome barriers to participation such as provision of transportation to participate in CRC screening and/or treatment could be implemented by other health care systems in Texas and beyond which are located in areas of relatively low population density.

Thank you Paul McGaha, D.O., M.P.H. Bola Olusola, M.D. Ebube Nwaigwe, M.D. William Sorensen, Ph.D. My Team Sarah Malone Martha Ross Edward Caldwell Monica Barnett Miguel Gaona-Bustos Cancer Prevention & Research Institute of Texas (CPRIT)

Questions Carlton Allen UT Health Northeast Carlton.Allen@uthct.edu 11937 US HWY 271 Tyler, Texas 75708 (903) 877-8939