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, MPH Lewis Cancer & Research Pavilion at St. Joseph’s/ Candler Janice Edenfield RN Georgia Infirmary/ SOURCE at St. Joseph’s/ Candler 1

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 2

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 3

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 4

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 5 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 6 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. 7

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 8 American Cancer Society. Breast Cancer Prevention and Early Detection cdn.com/sites/default/files/imagecache/superphoto/editorial/images/savannah/mdControlled/cm s/2009/10/27/ jpghttp://sav- cdn.com/sites/default/files/imagecache/superphoto/editorial/images/savannah/mdControlled/cm s/2009/10/27/ 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 9

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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 11 American Cancer Society. Cervical Cancer Prevention and Early Detection

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 cdn.com/sites/default/files/imagecache/superphoto/ jpghttp://sav- cdn.com/sites/default/files/imagecache/superphoto/ 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 cancer.html American Cancer Society. Colorectal Cancer Prevention and Early Detection

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 14 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 /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 17

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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 with at least a 30 pack year history 19 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 20

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 21