1. Sukit Ringwala MD/MPH Candidate 9 May 2008

2.  Background  Purpose  Project Methods  Findings  Discussion  Conclusion

4.  Coalition of health systems’ administrators, nurses, physicians, public health workers, epidemiologists  Stems from the Wisconsin Comprehensive Control Plan  Goal: Promote access to quality cancer care  Specifically taken on the task of improving colorectal cancer (CRC) care in Milwaukee and Waukesha Counties

5.  Colorectal cancer (CRC) is the 2 nd leading cause of death from cancer in the US  150,000 new cases per year in the US  50,000 deaths per year in the US  Ranks 3 rd in cancer incidence and mortality within Milwaukee County

6.  Modalities that reduce CRC mortality  Fecal Occult Blood Tests (FOBTs)  Colonoscopy  Lower Screening rates in:  The poor  Recent immigrants  People with lower educational levels  Minorities  Milwaukee County area  Breast, cervical, and prostate cancer screening at little or no cost  Few programs in place to address access to CRC screening for populations in need

7.  Create a colon cancer screening program  Address disparities to access, specifically for the uninsured  Increase screening rates  Decrease the time between screening and diagnosis  Goal: To improve mortality in disparate populations by providing treatment earlier

9.  Literature review conducted using PubMed  Query: colon cancer, screening programs, navigator…etc.  Other criteria:  Focus on urban programs  Address screening for uninsured  Targeted to minorities  Target to patients of lower socioeconomic status

10.  Literature review conducted using PubMed for appropriate screening modality  Query: fecal occult blood test, colonoscopy, IFOBT, FIT…etc.  Criteria:  Study year >2000  AGA or USPSTF supported

15.  Strengths  Successfully enhanced screening for breast and prostate cancer  Studies show improvement in screening rates  CDC’s CRC screening demonstration project has laid framework  Limitations  Small sample size in studies of review  Studies used only one clinical site  Other studies may have been missed in query

16. FIT  Strengths: 1) Better sensitivity and specificity than gFOBT 2) Fewer demands placed on patient 3) Medicare reimbursement  Limitations: 1) Sensitivity and specificity may vary depending on manufacturer 2) More costly than gFOBT 3) Not established in clinical practice

17.  A CRC patient navigator program could be successful in Milwaukee County  Points to consider:  Cost  Health systems support  Scalability of model  Timeline

18.  Construct a navigator model tailored for Milwaukee County and its health systems  Obtain stakeholder support  Milwaukee health care systems  WI Comprehensive Cancer Control Program  Colorectal Cancer Task Forces  American Cancer Society  Implementation plan  Obtain source of funding  Initiate pilot program on a smaller scale within Milwaukee

19.  Lora de Oliveira, MPH, MBA  Griselle Sanchez  Milwaukee Regional Cancer Control Network

20.  Freeman et al. Determinants of Cancer Disparities: Barriers to Cancer Screening, Diagnosis, and Treatment. Surgical Oncol Clin N Am. 14 (2005) 655-669.  Intercultural Cancer Council 2006 Survivorship Report: Cancer Survivorship and the Medically Underserved: Reducing the Disparities in Cancer Care. Intercultural Cancer Council, 2006.  Steinberg et al. Lay Patient Navigator Program Implementation for Equal Access to Cancer Care and Clinical Trials: Essential Steps and Initial Challenges. Cancer. Dec 2006. Vol 107: No 11.  Seeff et al. Development of A Federally Funded Demonstration Colorectal Cancer Screening Program. Preventing Chronic Disease: Public Health Research, Practice, and Policy. April 2008. Vol 5: No 2.  Tangka et al. Cost of Starting Colorectal Cancer Screening Programs: Results from Five Federally Funded Demonstration Programs. Preventing Chronic Disease: Public Health Research, Practice, and Policy. April 2008. Vol 5: No 2.  DeGroff, Amy. CDC’s Colorectal Cancer Screening Demonstration Project. Wisconsin Comprehensive Cancer Control Summit April 10, 2008. Centers for Disease Control and Prevention. (Presentation)  Safarty et al. Choice of Screening Modality in Colorectal Cancer Education and Screening Program for the Uninsured. Journal of Cancer Education. Vol 21: No 1. 2006.  Lawson et al. Colorectal Cancer Screening among Low-Income African Americans in East Harlem: A Theoretical Approach to Understanding Barriers and Promoters to Screening. Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 84, No. 1. 2006.  Michael S Wolf; Melissa Satterlee; Elizabeth A Calhoun; Silvia Skripkauskas;.... Colorectal Cancer Screening among the Medically Underserved. Journal of Health Care for the Poor and Underserved; Feb 2006; 17, 1.

21.  Khankari et al. Improving Colorectal Cancer Screening Among the Medically Underserved: A Pilot Study within a Federally Qualified Health Center. J Gen Intern Med 22(10):1410–4.  Jandorf et. al. Use of a Patient Navigator to Increase Colorectal Cancer Screening in an Urban Neighborhood Health Clinic. Journal of Urban Health: Bulletin of the New York Academy of Medicine, Vol. 82, No. 2  M. Sarfaty, S. Feng. Uptake of Colorectal Cancer Screening in an uninsured Population. Preventive Medicine 41 (2005) 703–706.  Dower C, Knox M, Lindler V, O’Neil E. Advancing Community Health Worker Practice and Utilization: The Focus on Financing. San Francisco, CA: National Fund for Medical Education. 2006.  Levin et al. Screening and Surveillance for the Early Detection of Colorectal Cancer and Adenomatous Polyps, 2008: A Joint Guideline From the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology. Gasteroenterology. 2008  Allison et al. Screening for Colorectal Neoplasms With New Fecal Occult Blood Tests: Update on Performance Characteristics. J Natl Cancer Inst 2007;99: 1462 – 70.  Levi et al. A Quantitative Immunochemical Fecal Occult Blood Test for Colorectal Neoplasia. Ann Intern Med. 2007; 146: 244-255.  Guittet et. al. Comparison of a guaiac based and an immunochemical faecal occult blood test in screening for colorectal cancer in a general average risk population. Gut 2007;56:210–214.  CDC WONDER  Wisconsin Cancer Registry