Abstract
A statewide cancer treatment and screening program in Delaware, with a side effort to eliminate racial disparities in colorectal cancer, improved screening rates and reduced incidence and mortality rates for colorectal cancer in all populations. In the process, it nearly eliminated wide disparities in mortality between African Americans and whites.
In Delaware between 2002 and 2009, a statewide cancer treatment and screening program, with a side effort to eliminate racial disparities in colorectal cancer, improved screening rates and reduced incidence and mortality rates for colorectal cancer among all populations. In the process, it nearly eliminated wide disparities in mortality between African Americans and whites.
Screening rates increased from 57% to 74% overall in Delaware from 2002 to 2009, and from 48% to 74% among African Americans, according to a report in the Journal of Clinical Oncology. Three-year incidence rates per 100,000 adults declined from 58 for whites and 67 for African Americans to 43 and 44 respectively. Three-year mortality rates per 100,000 adults fell by 42% (from 31 to 18) for African Americans, and they dropped slightly (from 19 to 17) for whites.
Nationally, analyses of Surveillance, Epidemiology, and End Results data have estimated the African American-white colorectal cancer mortality disparity at 44% or greater.
“We all know disparities exist,” says Sandra Wong, MD, chair-elect of the American Society of Clinical Oncology's Health Disparities Committee and an associate professor of surgery at the University of Michigan in Ann Arbor. “This demonstrates there is a way to move beyond describing them and toward pushing forward with interventions.”
The state already had effective breast and cervical cancer screening programs, so the Delaware cancer treatment program aimed to boost colon cancer screening. They selected colonoscopy as the standard because “it's one and done,” says co-author Stephen Grubbs, MD, a practicing oncologist with Christiana Care Health System's Helen F. Graham Cancer Center in Newark and a member of the program's planning committee. “There's no waiting and no extra steps.”
To address racial disparities, the program placed a nurse navigator into each of the state's 5 acute care hospitals to recruit people for screening and direct them to treatment. The nurses tailored their approaches on a local level and focused outreach on minorities by, for example, holding seminars in churches and community centers.
When necessary, navigators helped people find physicians for treatment. For those without medical insurance, the state program reimbursed two years of cancer treatment for patients earning up to 650% of the federal poverty level, which for a single person is just over $11,000 per year. Colonoscopies were reimbursed for uninsured patients earning up to 250% of the poverty level. These costs to the state were more than offset by savings from reduced incidence of colorectal cancer and detection of colorectal cancer at earlier stages, Grubbs says.
Despite some criticism, says Grubbs, the Delaware program lacked a control arm, because the literature has already amply shown the effectiveness of increased screening and early treatment. “It was logical,” he says. “We don't always have to have a randomized trial.”
“We need to do more things like this,” says Wong. “The next step would be to add more science to test implementation strategies and make sure the approach is generalizable and could be rolled out across the country.” For instance, a study might control for external influences, such as existing community screening programs, or a larger state might roll out a program only in certain counties to allow for comparisons.