Screen to Save: Results from NCI's Colorectal Cancer Outreach and Screening Initiative to Promote Awareness and Knowledge of Colorectal Cancer in Racial/Ethnic and Rural Populations

Screening to detect cancer and excise premalignant lesions has been proven to reduce overall colorectal cancer (CRC) incidence and mortality rates. Since the screening recommendations three decades ago, trends in overall cancer incidence and mortality have declined for men and women and most racial/ethnic populations (1). Similarly, a decline in disease and death has been noted for CRC, although decreases in morbidity and mortality are not equal across all populations (1, 2).

CRC is the third most commonly diagnosed cancer in the U.S. (3). Prior research in the general population indicates racial/ethnic minorities and medically underserved populations (defined as subgroups of people living in a defined geographic area with a deficiency of health care resources and services; ref. 4) are more likely to face increased colorectal cancer-related morbidity and mortality (5). For example, age-standardized incidence and mortality rates for cancers of the colon and rectum are highest among African Americans (AA)/Blacks when compared with non-Hispanic Whites (NHW; ref. 6). It has also been documented that screening is underutilized, as is timely follow-up on abnormal results in these populations (7–10). Such disparities are likely attributable to sociocultural barriers including economic disadvantage, lack of insurance and provider continuity, and longer travel distances to care (3, 11–13). Given these factors and a commitment to address the critical need for improved knowledge of CRC, its risk factors, and screening modalities, a culturally tailored evidenced-based outreach and education intervention was implemented.

The Screen to Save (S2S) initiative was implemented in racial/ethnic and rural populations in collaboration with National Outreach Network (NON) and Comprehensive Partnerships to Advance Cancer Health Equity (CPACHE) programs. NON is a national network of Community Health Educators (CHEs) aligned with National Cancer Institute (NCI)-designated Cancer Centers (CCs). CPACHE are partnerships between a CC and a minority-serving institution (MSI) with, among other components, an Outreach Core and a CHE. Throughout the rest of the document, the CHEs, their collaborators, and partners will be referred to as the S2S Collaborative. CHEs recruited participants from the catchment areas of CCs and areas served by participating MSIs from CPACHE. Many of the CHEs at the 42 sites reflect the demographics of the populations served. The CHE serves as an intermediary between the community and health/social services and is a culturally adept team member who informs individuals about health conditions and facilitates expanded access to services across the care continuum. CHEs are ideally suited to deliver educational outreach to increase knowledge about CRC because they are well trained in community health education, contributed to the evidence-based National Institutes of Health Center to Reduce Cancer Health Disparities (NIH CRCHD) S2S Toolkit, and have established trusting partnerships for health promotion with the communities they serve. The aim of this community-based effort was to improve and expand access to CRC information, and to provide the opportunity for culturally sensitive discussions about colorectal health and early detection procedures. Finally, the S2S Collaborative implemented efforts that sought to direct and encourage screening uptake using CHE-facilitated connections to care and services.

Community outreach and education models have been shown to be a powerful tool for community engagement on issues of health and health disparities (14, 15). Specifically, CHE, community health worker (CHW), and patient navigator (PN) programs have been critical. They provide education and link medically underserved individuals to financial and advocacy resources to address barriers to care (16). The CHEs'/CHWs'/PNs' close understanding of the attitudes, beliefs, and practices of diverse and medically underserved populations has been increasingly responsible for improvements in the effectiveness of screening and reduced time to diagnosis and care efforts. For example, in a peer-reviewed study focused on a primary care setting serving predominantly racial/ethnic populations, screening rates following physician recommendation were compared for participants who did and did not receive patient education and navigation services (17, 18). Higher rates of screening completion were noted for the navigation group. In an article examining the effectiveness of a lay CHW intervention, Pap test and mammography screening completion at follow-up was higher among low-income Hispanic women in the intervention versus the control group (19). These findings are similar to the preceding on navigation services. The promotora (CHW) model has been tested in randomized trials. In a two-group randomized trial, Arredondo and colleagues (20) showed bilingual/bicultural promotores can positively influence physical activity and preventive screening behaviors among Latinos in faith-based settings. In view of the documented benefits of CHE/CHW/PN approaches in the literature, the Community Guide to Preventive Services recommends the use of community outreach and education strategies to increase colorectal cancer screening at the population level (14). The Guide also notes that there is a gap in community-based strategies to increase colorectal cancer screening and reduce structural barriers to screening utilization targeting medically underserved communities including racial/ethnic minorities. Accordingly, S2S, with its focus on increasing awareness of colorectal cancer, expanding access to and availability of colorectal cancer information and early detection procedures, and encouraging screening uptake using facilitated connections to care for racial/ethnic and rural populations, represents a step toward filling that unmet need.

S2S is a national initiative, implemented by the S2S Collaborative, to increase awareness and knowledge of CRC and promote uptake of U.S. Preventive Services Task Force (USPSTF) screening recommendations (21) in racial/ethnic and rural populations. To facilitate a national evaluation of the two-phase initiative, CRCHD, in conjunction with the NCI Office of Communications and Public Liaison (OCPL), developed a toolkit that was provided to all participating sites. The toolkit included: (i) a one-page initiative overview; (ii) an outreach plan template and strategies for engagement; (iii) an educational PowerPoint presentation with key CRC messages that NON CHEs could adapt and culturally tailor to their target populations; (iv) a pre- and post-educational activity survey with instructions for data collection and data security; and (v) NCI-approved messaging regarding CRC along with suggested communication channels including social media (e.g., Twitter and Facebook).

All toolkit and messaging content was derived from OCPL-approved sources of peer-reviewed and evidence-based content. Two sites translated the presentation and survey into Chinese, and 15 sites used the Spanish translation of the presentation and survey. All sites within the S2S Collaborative completed phase I requirements, meaning that the site conducted educational outreach and information dissemination activities on CRC and administered pre/post surveys to evaluate the effectiveness of the S2S intervention. S2S sites that elected to complete phase II complied with phase I requirements and linked outreach activity participants to medical providers/partners providing screening and follow-up care where appropriate. Connections to care may have included activities such as the distribution of fecal immunochemical test (FIT) or fecal occult blood test (FOBT) kits or colonoscopy referral. Administering a 3-month follow-up survey was also required for phase II participation. The educational outreach for phases I and II of the initiative occurred in parallel and began in March 2017 to coincide with National Colorectal Cancer Awareness Month. Data collection concluded in December 2018. Of note, select sites incorporated the use of an inflatable colon/colon walking tours, mini-colon exhibits, flipcharts/flipbooks, and videos/theatrical performances into colorectal cancer outreach activity implementation to enhance community engagement. Although the toolkits were culturally adapted for each target population, the CHEs were required to cover each of the designated CRC-related topic areas. Modifications to the surveys were not allowed except translation from English into Spanish and Chinese/Mandarin. Minor variations to the Spanish survey were allowed on the basis of specific language nuances from Hispanic/Latino (HL) subgroups (e.g., Mexican Spanish vs. Puerto Rican Spanish). Participating S2S Collaborative sites were geographically dispersed throughout the continental United States, Hawaii, Guam, and Puerto Rico.

CRCHD developed an 18-item knowledge survey to be administered before and after the educational presentation in phase I to assess change in knowledge. In addition, five items assessed intentions to speak with a health care provider (HCP), get screened, talk to family and friends about CRC, and eat healthier and increase physical activity.The true/false items covered knowledge of screening methods and guidelines and risk factors for CRC, including heritability. Survey questions were informed by existing instruments found in peer-reviewed literature and modified to be in alignment with the educational presentations. In addition, new items were constructed to reflect topic areas not covered in existing surveys. The initial set of items, developed by NCI, reflects important concepts regarding CRC risks and screening presented as part of the educational activity. These items were reviewed by a workgroup of CHEs within the S2S Collaborative credentialed with a master's degree or higher and extensive experience in both outreach education and cancer health disparities research. To validate the survey questions for clarity and readability, the final pre-, post-, and 3-month follow-up surveys were pilot tested with the intended target audiences in collaboration with this workgroup. In addition to the knowledge items, the survey contained information regarding participant demographics, CRC screening history, family history of CRC, and intentions to engage in healthful behaviors regarding CRC screening and prevention.

In some instances, the toolkit was culturally tailored to meet the needs of the racially/ethnically diverse target populations (22–27). Cultural adaptation is defined as “the systematic modification of an evidence-based treatment or intervention protocol to consider language, culture, and context in such a way that it is compatible with the client's cultural patterns, meanings, and values” (28).

Various studies have found that culturally tailored behavioral health interventions for racial/ethnic populations are highly effective (29). Some CHEs targeting Blacks/AA worked collaboratively with faith-based organizations and ensured that linguistic and literacy levels were adequate for their communities. A site targeting American Indians (AI) relied on trusted and already established community events to implement S2S. This site also incorporated an AI male to share his CRC screening testimonial to further encourage trust among community members. This approach relied on the cultural importance of story-telling within the AI community. Moreover, an innovative intervention within the HL community in South Texas relied on a theatre outreach program to reach their community through a culturally accepted novella-style educational program. In Guam, a video testimonial from a respected University of Guam faculty member, whose father had recently passed away from CRC, was produced highlighting the importance of CRC screening. This video was incorporated in the S2S community education intervention. S2S Collaborative sites targeting Asian communities relied heavily on cultural values of respect, including respect for elders and respect for medical authorities.

Although not mandated by this initiative, nine sites within the S2S Collaborative opted to pilot phase II, which required connections to care that were already in place at those sites. Different models of connections to care were implemented, including distribution of CRC screening tests, provision of colonoscopy referrals, partnerships with differing health care facilities (e.g., gastroenterology practices, Federally Qualified Health Centers-FQHCs), use of patient navigators, and support from community-based organizations. Phase II's 3-month follow-up surveys were developed by CRCHD, in conjunction with the CHE workgroup.

All sites within the S2S Collaborative obtained local institutional review board approval prior to participation in S2S. Deidentified survey data were entered into a database and a 10% random sample of all surveys was double entered for purposes of quality control and quality assurance.

The community-based sample was recruited by the CHEs from communities in the areas served by the S2S Collaborative's participating sites. Potential participants were engaged via CHE verbal announcements at, for example, faith-based organizations (e.g., Spanish language masses), community clinics/FQHCs, barbershops/salons, and other partner agencies and community events; fliers; printed announcements in church bulletins; social media postings; and word of mouth. The requirement for the S2S Collaborative was that each participating NON site would provide a minimum of 100 completed pre- and post-test surveys, while participating CPACHE sites were expected to provide a minimum of 50 completed pre- and post-test surveys. The actual number of surveys provided by sites ranged from a low of 30 to a high of 466, with the majority of sites providing between 100 and 200 pre- and post-test surveys. Collectively, these sites conducted 347 educational sessions and administered 4,349 pre/post surveys. The analyses were restricted to those participants who were in the target age group of 50–74 years, resulting in a final sample of 3,183 participants who completed both the pre- and post-test surveys. Persons attending an educational session were not excluded because of age, as there is value in learning about CRC, prevention, and screening methods at an earlier age than recommended for screening by the USPSTF (21).

Descriptive analyses (frequencies and means) were conducted on the demographic information. Two-way ANOVA and paired t tests were conducted on the knowledge survey and behavioral intentions. A descriptive analysis was also performed on the 3-month follow-up data, which included statistics of follow-up rates and CRC screening methods. Data were analyzed using Stata version 14.0.

The characteristics of the sample are provided in Table 1. Nearly three-quarters of the sample were female. The sample comprises the following and contains large numbers of Asians (n = 329), Black/AA (n = 872), HL (n = 1,172), and NHW (n = 670), but small numbers of AI/Alaska Natives (AI/AN; n = 81) and Native Hawaiian/Other Pacific Islanders (NH/PI; n = 30). Nearly 30% of the sample reported having a college degree and nearly a quarter of the sample reported having less than a high school education. Educational attainment was not evenly distributed across racial/ethnic groups. Nearly 50% of NHW reported being college graduates compared with 37% of AA, 34% of AI/AN, 25% of Asians, 24% of NH/PI, and just 18% of HL. Conversely, 32% of both Asians and HL reported having less than an 8th grade education, compared with 10% of NH/PI, 3% of AI/AN, 2% of NHW, and 1% of AA [χ² (20) = 757; P < 0.0001].

Two-way ANOVA was conducted on each of the knowledge items at baseline. No gender differences were noted, so we report only on racial/ethnic differences in baseline knowledge. Significant ANOVAs were followed with Bonferroni post hoc test to determine differences among the racial/ethnic groups. The results of these analyses are shown in Table 2. Seventeen of the 18 knowledge items exhibited racial/ethnic differences that are statistically significant. In general, the seven items assessing knowledge of risk factors for CRC exhibited the greatest differences among the racial/ethnic groups, with Asians demonstrating the least amount of knowledge regarding these risk factors. These results have possible implications for the focus of future educational outreach events and what factors might be emphasized as part of the educational activity.

Paired t tests were conducted on the pre- and post-educational activity knowledge scores for each racial/ethnic group. As shown in Fig. 1, all racial/ethnic groups demonstrated a significant change in knowledge following the educational activity. A one-way ANOVA was performed on the knowledge change scores to determine whether there were racial/ethnic differences in the magnitude of change. A significant ANOVA was followed by Bonferroni pairwise comparisons to identify which racial/ethnic groups were significantly different from each other (Fig. 1). HL demonstrated the greatest increase in knowledge (mean change = 3.4 items) regarding CRC following the educational activity. This change was significantly greater than for Asians (mean change = 2.7 items; P < 0.01), AA (mean change = 2.7 items; P < 0.0001), and NHW (mean change = 2.2 items; P < 0.0001).

Intentions to engage in healthful behaviors related to CRC were assessed immediately following the educational activity. These behaviors included talking to a health care provider about CRC screening, getting screened for CRC, talking to family members/friends about CRC, eating healthier, and increasing physical activity. Items were worded as “Because of the educational activity how likely are you to…” engage in each of the measured behaviors. Responses were measured on a 4-point Likert scale ranging from strongly agree to strongly disagree. One-way ANOVAs were performed on each of the five measured intentions and post hoc tests were performed following a significant ANOVA to assess racial/ethnic differences. These results are presented in Fig. 2. Overall, NHW were least likely to report that they intended to adopt the assessed behaviors compared with all other racial/ethnic groups. Post hoc tests indicated that (i) Asians and HL were significantly more likely to talk to a health care provider about colorectal cancer screening compared with NHW (P < 0.05 for both groups); (ii) AA and HL were significantly more likely to talk about colorectal cancer with family/friends compared with NHW (P < 0.001 and P < 0.01, respectively); (iii) Asians and AA were significantly more likely to eat healthier compared with NHW (P < 0.05 and P < 0.01, respectively); and (iv) HL were significantly more likely to increase physical activity compared with NHW (P < 0.05). No other significant differences were observed.

As noted above, nine S2S sites participated in this education and outreach initiative to assess follow-up with CRC screening. The demographic characteristics of the follow-up sample are provided in Table 3. It should be noted that a single site contributed just over a third of the follow-up sample; thus, results are skewed toward the characteristics of that site. Compared with the baseline sample, the follow-up sample is more HL (60% vs. 37%), less educated (34% vs. 25% had less than a high school education), and more likely to indicate Spanish as their preferred language (44% vs. 27%).

All participating sites reported existing partnerships with multiple HCPs, including FQHCs and safety-net hospitals that provided care and services (e.g., processing FIT/FOBT results and conducting colonoscopies). In addition, all the sites distributed FIT kits at the educational events. Three of the sites had a nurse navigator in attendance to facilitate a direct colonoscopy referral for persons at greater than average risk for CRC. If a positive result was obtained from the FIT/FOBT test, the health care facility that processed the kit referred the individual to no-/low-cost colonoscopy at a partner facility. Positive colonoscopies were referred to the CC or medical school of the participating site.

Three-month follow-ups were conducted with 441 participants in the target age range of 50–74 years. These 441 participants were those who agreed to be contacted for follow-up and whom the CHEs at the nine sites were able to recontact after the 3-month follow-up period. Forty-five percent of this sample (n = 200) had never been screened for CRC. Of those who had never been screened, 50% (n = 99) obtained CRC screening during the 3-month follow-up period. In addition, 109 participants who were due for screening or were out of compliance with USPSTF (22) CRC screening recommendations obtained CRC screening. Therefore, a total of 208 participants, or 47% of the follow-up sample, obtained CRC screening during the follow-up period. The majority of those who obtained screening during the 3-month follow-up period were screened by FIT/FOBT, 79% compared with 21% who obtained a colonoscopy. At the time of the follow-up, 82% (n = 171) of this group had obtained the results of their screening tests.

S2S is an outreach and educational intervention focused on CRC education and screening. The current initiative is unique in that all S2S Collaborative sites were provided the evidence-based S2S Toolkit that was culturally and linguistically tailored for the diverse ethnic groups targeted. The Toolkit included a CRC educational PowerPoint with screening information, resources, standardized pre- and post-educational activity surveys, and approved CRC messaging. This standardization allowed for direct comparisons of the pre- and post-educational activity survey data across the S2S Collaborative.

The common data elements and standard messaging allowed for pooling of data across sites, which then provided sufficient power for statistical analyses, including comparisons among racial/ethnic groups. The S2S initiative confirmed that culturally tailored CRC education facilitated by CHEs is an effective way to increase CRC knowledge, screening awareness, and screening intentions in racial/ethnic and rural populations. Findings align with prior research indicating that culturally tailored interventions and CHE implementation strategies improve information acceptability and influence positive health behavior uptake (20, 30–37). Incentives for programs that address and support increased screening by leveraging community partnerships, streamlining data requirements, and utilizing culturally relevant resources are essential for sustainability and the reduction of disparities. Indeed, the present effort could not have taken place without the NON and CPACHE infrastructure and the trusted partnerships that CHEs have nurtured within their communities, both of which facilitated participant recruitment in the implementation of this CRC screening intervention.

S2S findings demonstrate a significant change in knowledge and behavioral intentions following the educational activity participation, including the intent to speak with an HCP and friends/family about screening and to adopt healthier eating and routine exercise (Fig. 2). For the nine connections to care sites in phase II, dissemination of cancer-related information at educational events with FIT/FOBT kit distribution or referral for colonoscopy and associated follow-up care led to substantial increases in screening compliance and follow-up. Identifying partners that can provide clinical care for low to no cost is essential for ensuring that those who engage in screening and receive an abnormal result can be treated. In many instances, the CHEs included providers from the CCs in the outreach activities to promote increased levels of comfort and trust between the HCPs and the community. There are, however, several limitations to consider when interpreting the findings observed. This was an intervention that involved convenience samples of persons who chose to attend the educational events provided by the CHEs; consequently, all persons attending these events received the education. Thus, it is not possible to say that the intervention was successful compared with no intervention or an alternative intervention. For the phase II data, sample participants were those who agreed to be followed and then responded. Finally, this effort did not include analysis of the cultural adaptions. This would be the next step to better understand specific elements of an intervention that motivate persons to obtain appropriate CRC screening.

The final sample included small numbers of AI/AN and NH/PI. According to the 2010 census, over three quarters of AI/AN populations live outside of tribal areas, with 10 states having the largest numbers of AI/AN persons. In addition, there was a single CPACHE site in Hawaii and Guam. Therefore, the small number of AI/AN and NH/PI was largely a reflection of the location of participating sites and access to clinical care partners. The small numbers of AI/AN and NH/PI participants speak to the need for increased efforts toward collaborating with Native Nation, Native Hawaiian, and Pacific Islander communities.

In view of these findings, an important area of future research should be the implementation of connections to care as a required component of outreach and education. Promising models could then be adapted and used for other preventable/screenable cancers irrespective of race or ethnicity. Our goal is to move beyond examination and analysis of cancer health disparities to developing solutions that address them. Creating awareness of the challenges at each step along the continuum of cancer care helps providers consider how well they are serving patients in the context of the entire cancer experience. Unless patients can transit the continuum in a way that is patient centric and respectful of their values and priorities, their care will be suboptimal and health outcomes will suffer.

S2S, with its harmonized messaging/instruments and national sample, confirms that this culturally tailored community health education intervention can improve cancer knowledge and awareness of screening recommendations. Furthermore, this work preliminarily sheds light on how the inclusion of a culturally tailored intervention and the implementation strategy can improve information acceptability and influence implementation effects as seen in other community health education interventions (20, 30–37). In summary, this initiative provided compelling data to support the hypothesis that culturally tailored, standardized educational messaging, data elements, and data collection tools are effective in educational outreach to advance CRC knowledge among racial/ethnic and rural populations.In summary, the key takeaways are as follows: (i) Culturally tailored health communication strategies must be actionable. (ii) Connections to care are a required component in conjunction with outreach and education efforts. (iii) Standardized data collection instruments, toolkits, and data elements are essential to educational outreach on health topics.

No potential conflicts of interest were disclosed.

Conception and design: D.E. Whitaker, F.R. Snyder, S.L. San Miguel-Majors, L.O. Bailey, S.A. Springfield

Development of methodology: D.E. Whitaker, F.R. Snyder, S.L. San Miguel-Majors, L.O. Bailey, S.A. Springfield

Acquisition of data (provided animals, acquired and managed patients, provided facilities, etc.): S2S Collaborative

Analysis and interpretation of data (e.g., statistical analysis, biostatistics, computational analysis): D.E. Whitaker, F.R. Snyder, S.L. San Miguel-Majors, L.O. Bailey, S.A. Springfield

Writing, review, and/or revision of the manuscript: D.E. Whitaker, F.R. Snyder, S.L. San Miguel-Majors, L.O. Bailey, S.A. Springfield, S2S Collaborative

Administrative, technical, or material support (i.e., reporting or organizing data, constructing databases): D.E. Whitaker, F.R. Snyder, S.L. San Miguel-Majors, L.O. Bailey, S.A. Springfield

Study supervision: D.E. Whitaker, F.R. Snyder, S.L. San Miguel-Majors, L.O. Bailey

The authors would like to humbly acknowledge and thank the S2S Collaborative for their contributions in the acquisition of data, and writing, review, and/or revision of the manuscript (Cary B. Aarons, Adrianna I. Acevedo-Fontanez, Terrance Adams, Toyin Adeyanju, Tim Ahles, Fredua A. Akosa, Roger Anderson, Debra Armstrong, Elva M. Arredondo, Marisha Artero, Claudia P. Barajas, Mary C. Beckerle, Rhonda S. Boozer-Yeary, Donna Branson, Katherine J. Briant, Mary Elizabeth Brooks, Carmenza Bruff, Brenda E. Bryant, Debbie L. Cadet, Kimberly Cannady, Veronica A. Carlisle, Marina Carrizosa-Ramos, Vivian L. Carter, Kevin D. Cassel, Eida M. Castro-Figueroa, Hilmarie Centeno, Chesley Cheatham, Moon S. Chen, Jr., Christina Ciecierski, Jomary Colon, Sofía Colón, Vivian Colon-Lopez, Cynthia Cortes, Diana Cortes, Jeralyn Cortez-Weir, José Cruz, Nicole Cruz, Julie Ha Thi Dang, Norma L. Dawkins, Cecilia DeGraffinreid, Jose DeJesus, Niyati Desai, Tressa P. Diaz, Marynieves Diaz-Mendez, Daphne Ellis, Eugenia Eng, Deborah O. Erwin, Betsy Escobar, Nannie Evans, Darla Fickle, Edwin B. Fisher, Nicole Fisher, Marian L. Fitzgibbon, Khaliah Fleming, Armida Flores, Marvella E. Ford, Cody Fredrick, Katie Ganey, Francesca Gany, Marisela Garcia, Juana Gatson, Darrell Gray II, Brooke Groneman, Betsy Grossman, Carmen E. Guerra, Rachael T. Leon Guerrero, Dolores D. Guest, Clement K. Gwede, Garrett Harding, Claudia Hardy, Rodney Haring, Lindsay Hauser, Grace C. Hillyer, Jacquelin Holland, Cheryl Holt, Deb Howes, Bin Huang, Karen Hubbard, Rachel Hunley, Inger Imset, Megan K. Inada, Kathye Jenkins, Maria Jibaja-Weiss, Julio Jiménez, Beth A. Jones, Karen Kim, Anita Y. Kinney, Helen Lam, Veronica Landa, Jennifer Lang, Nita Lee, Cristina Jiménez Lizardi, Ana Maria Lopez, Jomar Lopez, Carolina Lopez De La Torre, Jeff Lunsford, Upender Manne, Caree McAfee, Lorna McNeill, Cathy D. Meade, Diana Medina, Lemuel Melecio, Charlene L. Mitchell, Melinda Monge, Jane Montealegre, Jennyffer Morales, Michelle Moseley, Angelina G. Mummert, Teresita Muñoz-Antonia, Magdalena Nava, Elena L. Navas-Nacher, Laura Nervi, Jill Nery, Mary O'Connell, Tracy Onega, Jane Ostler, Rebecca Palacios, Neal A. Palafox, Rena J. Pasick, Electra D. Paskett, Tonya Pauley, Sneha Prabhu, Amelie G. Ramirez, Andria Reyes, Kim Rhoads, José Ríos, Darilyn Rivera, Erika Robers, Melinda L. Rogers, Jiana R. Salas, Kimberly Sanders, Katelyn Schifano, Jenna Schiffelbein, Karen M. Schmitt, Theron Scott, Doris Sempasa, Mayra Serrano, Julian Simon, Melissa Andrea Simon, Erin M. Solomon, Lilnabeth P. Somera, Karoline Sondgeroth, Marievelisse Soto, Leo Spychala, Wesley Stoller, Rick Strickland, Andrew L. Sussman, John Sweetenham, Ashley Teague, Beti Thompson, Cesille Torres, Roberta M. Troy, Cornelia Ulrich, Graciela Unguez, Susan Vadaparampil, Jaydutt Vadgama, Meghan Johnson Vance, Robin C. Vanderpool, Camille Vélez-Alamo, Anissa I. Vines, Srue Wakuk, Anne Washburn, Monica Webb Hooper, Brad R. Weiner, Christy Widman, Consuelo H. Wilkins, Ching Wong, James Zabora, and Eduardo Zamora). In addition, we would like to highlight the pivotal role that the National Outreach Network and the Comprehensive Partnerships to Advance Cancer Health Equity program played in outreach, S2S implementation, and generation of the core data set. We would also like to thank Hemosure® for providing FIT kits at no cost, and their commitment to the initiative. The authors would also like to acknowledge Dr. Mary Ann Van Duyn and CRCHD staff, both past and present, who contributed to S2S as part of official duty at NIH. The S2S initiative was supported by the following funding sources: P30CA043703, P30CA033572, P30CA054174, P30CA068485, P30CA069533, P30CA016056, P30CA177558, P30CA134274, P30CA016672, P30CA118100, P30CA016086, P30CA016058, P30CA016520, P30CA013148, P30CA093373, P30CA015704, P30CA076292, P30CA013696, P30CA138313, P30CA042014, P20CA157071, U54CA132378, U54CA137788, U54CA132383, U54CA132381, U54CA143727, U54CA143728, U54CA210962, U54CA156732, UL1TR001070, U54CA163071, U54CA163068, U54CA096297, U54CA096300, U54CA118948, U54CA132384, U54CA132379, U54A118623, U54CA143931, U54MD007598, U54CA202995, U54CA202997, U54CA203000, U24TR001579, UL1TR001450, UL1TR002243, R24HS022063, R2CA193088, R01MD005892.

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