1. 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

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

3. 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 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.

4. Outline
Current status of CRC in East Texas
Interventions
Future Plans

5. 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.

6. 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 .

7. 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.

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

9. Outline
Current status of CRC in East Texas
Interventions
Future Plans

10. 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.

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

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

13. 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 There were significantly greater than expected uninsured female participants than male participants

14. 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

15. 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.

16. 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

17. 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

18. 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%)

19. Outline
Current status of CRC in East Texas
Interventions
Future Plans

20. 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.

21. 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)

22. Questions
Carlton Allen UT Health Northeast US HWY 271 Tyler, Texas (903)