Dismantling Inequities in Colorectal Cancer Screening and Outcomes

April 15, 2024

Information

Yale Cancer Center Grand Rounds | April 12, 2024

Speaker: Dr. Folasade May

ID11584

To CiteDCA Citation Guide

00:00Good morning, everyone.
00:01We'll go ahead and get
00:03the festivities started.
00:04So we are just absolutely delighted to
00:08welcome Doctor Folasade May back to Yale.
00:11So Doctor May graduated cum laude from
00:13Yale University with a degree in molecular,
00:15cellular and developmental biology.
00:17She attended the University of Cambridge to
00:20study epidemiology and International health,
00:22earning a Master's of Philosophy
00:24in Epidemiology,
00:24and attended Harvard Medical School.
00:27During her Gastroenterology fellowship
00:29at UCLA, she earned a PHD
00:31in Health Policy and Management from the
00:34UCLA Fielding School of Public Health.
00:36Her doctoral dissertation addressed Black
00:38white disparities in colorectal cancer
00:40incidents, screening and outcomes. Dr.
00:42May's lab engages in health services,
00:44research and quality improvement
00:45related to population health,
00:47preventive medicine, and health disparities.
00:49The labs research spans several areas
00:51from the epidemiology of disease and these
00:53these risk factors to implementation
00:55science to improve disease outcomes.
00:57As Director of the Melvin and
00:59Brendan Simon Gastroenterology
01:00Quality Improvement Program,
01:02Doctor May also overseas the portfolio
01:04of quality improvement projects at
01:06UCLA Health to improve the quality of
01:08care for UCLA Health patients with
01:10gastrointestinal and liver conditions.
01:12Doctor May is passionate about improving
01:14awareness about preventive health
01:15and Health Equity and is involved in
01:17advocacy at the state and national
01:18level to develop and encourage policy
01:20to improve healthcare delivery.
01:21So we're going to do a quick photo with
01:25the presentation of the plaque.
01:27So again, we are so delighted to have
01:30Doctor May and welcome her back to Yale.
01:32Thank you so much for that introduction.
01:34Yeah, absolutely.
01:34And here we go.
01:35I'm happy
01:38to be in that photo. Thank you so much.
01:40I'll have to get the picture.
01:46Thank you. Thank you so much.
01:47We will mail this to you.
01:49So beautiful. Yeah.
01:50Thank you already.
01:51You don't need my eyes.
01:53These doors are your glasses too.
01:55Fantastic. OK.
01:56Well, thank you very much for
01:58that wonderful introduction and
02:00for the invitation to be here.
02:02It's an absolute honor to be here
02:03at the Yale Cancer Center today
02:05and to speak with all of you.
02:07And I'm actually really excited
02:08to see so many people live in the
02:10audience on a Friday morning.
02:11So thank you for weathering the weather
02:14and for coming to meet in person.
02:16And thank you as well for those of you
02:18online who I know are listening in,
02:19I am going to try and keep my
02:21eye on the chat and the Q&amp;A.
02:22So if you do have questions,
02:24please add those there.
02:26Also, if you're here live in the audience,
02:28please interrupt me if anything's unclear.
02:29If you have any questions.
02:31Today,
02:31I'm going to be talking about inequities
02:34and colorectal cancer screening and outcomes,
02:36which is what a large majority
02:37of the work is in my lab.
02:39I'll start by here just providing
02:43my disclosures.
02:44And since we are at Yale,
02:46I have to start with a few stories.
02:48So I was very honored to receive
02:50this invitation to come here today.
02:52I was thank you.
02:53But I I also was excited to share
02:56about the work that we're doing.
02:58And it also gave me a time to some
03:00opportunity to reflect because
03:01it's actually been 20 years
03:03since I've been on this campus.
03:05I graduated from Yale undergrad in 2002.
03:08I came back two years after
03:09that for a conference and then
03:11I haven't been back since.
03:12This is actually a picture of my
03:14parents who trusted me leaving
03:16Los Angeles to come to the East
03:18Coast for the very first time.
03:19I've never even visited to become
03:21an undergrad here at Yale.
03:23That young man is my brother
03:25who's now much taller than me.
03:27So this is them dropping me off
03:29at old campus in August of 1998.
03:31I had an extraordinary 4 years here.
03:34I say that they were the years
03:36that helped me become who I am.
03:39That's me studying rigorously in my
03:42dorm room here in in Farnham Hall.
03:44I played on the JV volleyball team here,
03:46wasn't tall enough to play varsity.
03:48And then there's some pictures
03:50as well from my last week at Yale
03:52when I went through graduation.
03:54So I really think of Yale as
03:55kind of the beginning.
03:57I think,
03:57as many of us do think of college
03:59as the beginning of your adulthood,
04:00your opportunity to think independently.
04:03This is where I became impassioned
04:05about global health, social justice,
04:07medicine and research.
04:09And for me this is kind of a full
04:11circle moment to be back here.
04:12I was got in a little early yesterday
04:13and got to walk around campus.
04:15So I also want to thank you
04:17for the opportunity
04:18to do that. So with that context,
04:20where am I now?
04:22So as mentioned, I work at UCLA Health.
04:25After my time at Yale,
04:26I spent some time in the UK and then
04:28I was in Boston for a long time,
04:30maybe a little too long.
04:31And then it got very cold and we
04:33had our first child and we said,
04:34you know what,
04:35California's looking pretty good right now.
04:37So we went back to to California.
04:39My husband's from Northern California,
04:41I'm from Southern California,
04:43and I did my GI fellowship at UCLAUCLA
04:46has this amazing opportunity.
04:47I know there's a similar program here.
04:49It's called the STAR program
04:51that gives fellows.
04:52So these are people who have finished
04:54their internal medicine training.
04:56I had left MGH after my
04:58internals medicine training,
04:59thinking I wanted to do research,
05:00but I hadn't had a chance to do
05:02an MDPHD program and kind of
05:04regretted that I never did that PhD.
05:06So when I got to UCLA,
05:07we had this STAR program where you
05:09can actually do a PhD at the same
05:11time as your clinical fellowship.
05:12So as I did my GI fellowship,
05:15I received a PhD in Health
05:16Policy and Management,
05:17which is really a health services
05:19degree and really from that point did
05:22never look back from doing research.
05:24I was able to start the May lab in 2015
05:28and I became the director of quality
05:30for our health systems in GI in 2016.
05:32So right now this is kind
05:34of how I split my time.
05:36I do spend a lot of time
05:37running a research program.
05:38I do include the quality improvement
05:40in the research bucket 'cause we
05:41do publish a lot of that work and
05:43then I do about 20% patient care.
05:45I am involved in running the
05:47STAR program now.
05:48So that's my way of giving back.
05:49And I also have some small
05:51involvement in global Health at
05:52our Global Health program at the
05:54David Geppen School of Medicine.
05:56In the lab,
05:57it's largely health services research.
05:59There is a heavy lean towards cancer.
06:00We're going to talk today about one
06:02of these cancers and HealthEquity,
06:04but we also do a lot of clinical EPI.
06:05As mentioned,
06:06I did an EPI degree before I
06:07even went to medical school.
06:09We run clinical trials including
06:10some of the big national GI clinical
06:12trials that are going on right now
06:14and and and have a lot of foothold in
06:17population health and how you roll
06:19out interventions across the health
06:20system which ties into the Qi work
06:24today. However, we're going to talk
06:26about one specific disease that I would
06:28say is the majority of my research,
06:29and that's in colorectal cancer.
06:32I'm going to start by talking about
06:34national trends in this disease,
06:35focusing on 2 areas that
06:37are high interest to me.
06:38Disparity is an early onset disease.
06:41And then we'll also talk about
06:43a colorectal cancer screening,
06:44screening disparities,
06:45including the challenges that we
06:47have and barriers to screening
06:49and potential solutions.
06:51And then I'll end with a couple
06:52things that I think are important
06:54as we move forward in this area.
06:57So I'm going to assume that
06:58everyone in here is not going to
07:00be too shocked by this slide,
07:02but many people are surprised to hear
07:04about the large burden of colorectal
07:06cancer in the United States and globally.
07:08It is the third most common cause
07:10of cancer for men and women in
07:12the United States and second most
07:14common cause of cancer related
07:15deaths in the United States.
07:17And even though we have very
07:19effective screening modalities and a
07:21national call for everyone at some
07:22point in their life to be screened,
07:25one in three adults in the US do not
07:27get screened for colorectal cancer,
07:29which is a problem that many of us have
07:32been trying to tackle since the 1990s.
07:35Some of us do consider colorectal
07:37cancer a success story.
07:38Since the mid 1980s,
07:39we have had a decline in incidence
07:41and mortality from this disease
07:43and you can see that on the figure
07:45that's up here on this slide for men,
07:47women and overall.
07:48We've had a drop in overall numbers
07:51looking at all age groups in this
07:53disease and we attribute that to
07:54the introduction of screening,
07:56to the uptake of screening and
07:58those who've participated,
07:59but also partially into some improvements
08:01that we've had in treatment and
08:03reduction reduction in risk factors.
08:05We do think that some of the reduction
08:07in smoking has contributed to some
08:09of the reduction in the number
08:11of polyps that we see and polyp
08:14progression to colorectal cancers.
08:16But I do want to mention that it's
08:18a success story with a caveat,
08:19a couple caveats.
08:20The first being that there were massive
08:23disparities in colorectal cancer.
08:25The group that has the highest incidence
08:28of colorectal cancer is our American Indian,
08:30Alaska Native population.
08:31Those two groups are often
08:33combined in national databases,
08:35including SERE because they're small,
08:37But I want to highlight that they
08:38are very distinct populations.
08:39And actually,
08:40if you separate it,
08:41it's the Alaska Native group that's largely
08:44driving this epiphenomena that we see.
08:47And then after that,
08:48we have black individuals in the
08:50United States having the second
08:52highest rates of colorectal cancer,
08:53then white Americans,
08:55then our Latino population,
08:57followed by our Asian and
09:00Pacific Islander population.
09:01So even though in the Asian,
09:03Pacific Islander population it's
09:04a relatively lower incidence
09:06and mortality than in white,
09:08black or Native Americans,
09:09I do want to say and
09:11highlight that for our Asian individuals,
09:14it's still the number 2 cause
09:16of cancer related mortality.
09:17So in all of these groups
09:19there's significant burden.
09:22We also know that we have similar trends
09:24for mortality of colorectal cancer.
09:26Now the bars here are going to
09:28be lower because we have fewer
09:29deaths than we have cases.
09:30But again we're going to see that
09:32the the largest number of deaths are
09:34going to be in our native communities
09:35followed by black individuals,
09:37white individuals, Latinos and then Asians.
09:41We also carry about state.
09:42We also care a lot about stage
09:44because for colorectal cancer,
09:46we know that if we can diagnose
09:47this disease at stage 1,
09:49the survival is over 90%.
09:51Survival at stage 4 is 13 percent or lower.
09:55So we do pay a lot of attention
09:56to stage at diagnosis.
09:57And when you look at distance
09:59stage at the time of diagnosis,
10:01we have the worst case for black
10:04individuals where 25% of cases
10:07are being diagnosed at a late
10:10stage five year survival.
10:12Similar disparities and trends
10:13where you have worse outcomes for
10:16black individuals and Alaska Native
10:18American Indian populations than
10:20you do in the other subgroups.
10:23The other caveat to the success story
10:25is the recent trend that we've seen
10:27at the for the age of onset of disease
10:29which we call early age onset disease.
10:32These are individuals who are diagnosed
10:34with colorectal cancer under the age of 50.
10:37Now,
10:37I'll tell you,
10:38it wasn't too long ago that I was
10:40an internal medicine resident
10:41and I was taught that colorectal
10:43cancer is the disease that you look
10:45for for people in their sixties,
10:4670s or 80s.
10:47I no longer teach that to
10:49my residents and fellows.
10:51This is the disease that we need to be
10:53aware of in people in their thirties,
10:5440s and 50s.
10:56And that's because of these
10:57different trends that we've seen.
10:59So if you look at individuals age 0 to 49,
11:03which is the first graph,
11:04we have increasing rates
11:06or incidents over time.
11:07We have some plateauing as well
11:09and individuals that are 50 to 64.
11:11This was a slope that 10 years ago
11:14was clearly downward and now we are
11:17seeing that even in middle-aged adults
11:19in their 50s and and early 60s that
11:21we don't see the huge of impact that
11:23we did up screening and treatment before.
11:25And the group that we're still seeing a
11:27big benefit is individuals over age 65,
11:30which again we attribute to higher uptake
11:32of screening and greater penetrance
11:34over time of screening programs.
11:36Mortality, we're seeing the same thing.
11:38Unfortunately,
11:39we're not seeing this downward
11:41slope and mortality,
11:43particularly with the under fifty group,
11:45we're seeing an upward swing and mortality.
11:47And even when you look at
11:50individuals over 65,
11:51there's some concern for plateauing.
11:53So this big success story that we've
11:55been touting is now at risk not only
11:57because the disparities that we see,
11:59but because of early onset disease.
12:01This is actually a publication that
12:03my Co wrote with some incredible
12:06colleagues led by Samir Gupta at UCSD,
12:08where we did an overview of
12:10early onset colorectal cancer.
12:12And we were able to show using CR data
12:14that when you look from 1992 to 2019,
12:17there's actually a notable shift
12:18in the proportion of individuals
12:21who are diagnosed with disease.
12:23I'll highlight first the
12:24group that is age 40 to 49,
12:26that's this darker red 5% of cases in 1992.
12:31And then in 2019 where we have
12:33the most complete SEER data,
12:34that population increased to 9%.
12:38Again looking at individuals 50 to 59,
12:41that population was about 12%
12:43in in 1992 and now is 21%.
12:47So these are profound changes
12:50in the epidemiology of disease.
12:52I'm also including here a slide on
12:55the demographic profile by race
12:57and ethnicity using the same data.
12:59As you can see in 1992 seventy 6% of
13:03cases were non Hispanic white individuals.
13:06That is dropped to 58% of cases
13:09in the 19 in 2019,
13:11probably even lower now if we
13:13actually had 2023 data and that is
13:16attributed to as you can see here
13:18an increase in the number of cases
13:19in Latino Hispanic individuals
13:21and non Hispanic American Indian
13:23Alaska Native individuals and also
13:25in non Hispanic black individuals.
13:30So in that context I want to talk a
13:31little bit about what's going on in the
13:33screening world and some of the work
13:34that we're doing to help close some
13:36of these gaps just to make sure that
13:39we are all starting on the same page.
13:41Colorectal cancer is very unique and that
13:44we have a precursor lesion called a polyp.
13:46So when I am doing a procedure
13:48see if I can use my mouse here.
13:51This is what a colon,
13:52this is what a normal colon looks like.
13:54When I'm in the colon with a scope,
13:56obviously it's can you see my pointer?
13:59No, you can't see my opponent.
14:01Let's see it.
14:01Does this work?
14:04I should have checked this technology
14:07before I tried using the mouse.
14:09It's not right. But I I'll I'll
14:11describe So the normal colon picture,
14:13that is a nice looking colon.
14:15As Doctor Lane knows, that's what we want
14:17to see when we're doing a colonoscopy.
14:19It's sparkly, it's pink,
14:21there's no polyps and about 50% of people,
14:24however, we're gonna see a polyp and in about
14:2725% of people those polyps are pre malignant.
14:30Now when we're looking at a polyp,
14:32we often cannot tell which one of
14:34those has the opportunity or the
14:36likelihood to progress into cancer.
14:38So we typically take out all the polyps
14:40that we see during a screening colonoscopy.
14:43Unfortunately though,
14:44if these polyps are left to themselves
14:47after years and years and years,
14:49they can develop into colorectal cancer.
14:51And this is the progression that
14:53we're trying to stop when we do
14:55screening for colorectal cancer.
14:56So we have two opportunities
14:57with colorectal cancer,
14:58which is very different from
15:00many other cancers.
15:01We can find the polyps and take them
15:03out before they transition to cancer.
15:05What that means is that's less people
15:07hearing the words you have cancer,
15:09right, because they never had cancer.
15:12But we also have the opportunity of
15:14finding a cancer early enough that
15:15you have that 90% cure rate that the
15:18words are more you have stage 1 cancer,
15:21we likely can cure you hopefully.
15:23So again,
15:24there's the prevention and an early
15:27detection benefit of screening.
15:28We know that screening is effective.
15:30We actually have RCT data that
15:33supports mostly Gwyac FOBT and
15:35flexible sigmoidoscopy and that's
15:38been extrapolated to assume that
15:41there's RCT evidence to support
15:43studies like FIT and colonoscopy,
15:46which are similar methodologies.
15:47Right now the most common screening
15:50test in the United States is
15:51colonoscopy and some health systems.
15:53It's up to 85% of screening,
15:55but we're about 70% national.
15:57And then of the stool based
15:59screening modalities,
16:00FIT or fecal immunochemical
16:01testing is the most common.
16:03Those are supported mostly by
16:05a large observational studies.
16:07And also this really, I think,
16:08amazing figure that was produced
16:10by Anne Zauber,
16:11an epidemiologist and her group
16:13that showed that over time,
16:15the red line is the incidence
16:18of colorectal cancer.
16:19The blue line is the incidence
16:22of colonoscopy uptake.
16:24And as you can see in the United States,
16:25as we've been using more colonoscopy,
16:28that incidence line is coming down South,
16:30another kind of observational piece of
16:33data that shows this early success story.
16:36Now as I mentioned before though,
16:38we don't see this in our young adults
16:40because we don't screen our young adults.
16:43And these are data that were released
16:45and JAMA Network open where they
16:47did a projection or a modeling
16:49study that showed that because of
16:51this 51% increase in young onset
16:54colorectal cancer since 1994,
16:56colorectal cancer is actually
16:58predicted to be the leading cause
17:00of cancer related deaths for
17:02individuals aged 20 to 49 by 2030.
17:05And actually the report that
17:06was released by the American
17:08Cancer Society just last month
17:09suggests that we're quite,
17:10we're actually there where we're
17:12seeing it and particularly in men
17:14that colorectal cancer aged 20
17:15to 49 is the number one cause of
17:18cancer related deaths in women,
17:20it's #2 by 2030 will probably
17:22be there for both groups.
17:25This change in epidemiology is
17:27largely what prompted the change in
17:29the United States Preventive Service
17:31Task Force recommendations in 2021.
17:33These are looked at every few
17:35years and every year.
17:37Previously,
17:37the recommendation had been grade
17:40A to start screening at age 50.
17:42We now have a grade B recommendation
17:45that people fit 4945 to 49 should also
17:48be screened by for colorectal cancer.
17:50This matters because everything
17:52that's grade A or B by USPFTF
17:56is mandated insurance coverage.
17:58And This is why,
17:59even though the American Cancer
18:00Society said this back in 2018,
18:02it's just now that we're starting to
18:05screen all of our 40 to 4045 to 49 year olds.
18:08I'll highlight that this is
18:10for average risk individuals.
18:11If there's a family history of polyposis
18:13syndrome or hereditary syndrome,
18:14we're actually going to screen much earlier.
18:17These are the USPFTF recommended
18:20screening modalities.
18:21As I alluded to before,
18:22we've got stool based strategies
18:23and then we've got what we call
18:26direct visualization techniques.
18:27Among the stool based strategy
18:29there is high sensitivity FOBT
18:31which is mostly out of favor.
18:32We have fit which is the number one
18:34stool based strategy and then stool
18:36DNA otherwise known as Cologuard.
18:38You've probably seen the commercial
18:39with the cartoon in the little white
18:41box which is a growing in use and
18:43actually we just saw last month in the
18:46New England Journal the release of the
18:48data for the Cologuard version 2.0,
18:50which is a newer version of their
18:52test that performs slightly better.
18:55The direct variation techniques
18:56are also listed here.
18:58These are all acceptable
18:59ways to screen for colon,
19:00not for colorectal cancer.
19:02And I think what's most shocking
19:04is that despite the fact that this
19:05is a rising burden of disease,
19:07a concerning disease that
19:09is highly impactful,
19:10despite the fact that we have evidence
19:12that screening works and the fact
19:14that everyone should be screened,
19:15we still have a problem with
19:18only about 6067% of people being
19:20screened even when we have all of
19:22these options for our patients.
19:23So we still are trying to find ways to
19:26have more people participate in screening.
19:30When you participate in one of the
19:32screening tests that is not a colonoscopy,
19:34we don't have the opportunity to
19:36go in and grab those polyps or
19:39or biopsy those early cancers.
19:41So we do call those two step
19:44screening processes.
19:45So whether you're talking about FIT,
19:46Cologuard, FOBT or CT colonography,
19:49if a polyp is found or abnormal abnormality
19:52is found during one of these tests,
19:54it's actually required that you have
19:55the second step which is colonoscopy
19:57to complete the screening process.
19:59Now this seems obvious,
20:01right,
20:01but I work in settings where only
20:0318% of patients have that throughput from
20:06abnormal fit or abnormal stool based
20:10testing to the completion colonoscopy.
20:13Participation and screening varies
20:15broadly across patient demographics.
20:18These are data from the National
20:20Health Interview Survey.
20:20So the caveat here is that these
20:23are patient reported data.
20:24And if anything,
20:25we've found that when you look at EHR
20:27data versus patient reported data,
20:29the patient reported data actually
20:30is maybe a little higher.
20:31Patients like to report that they've
20:33done things that maybe they haven't.
20:34So we're going to take this with
20:36a caveat that that 59% at the top,
20:38we're probably even lower than
20:40that in these patients.
20:42And there's also a lot of misremembering.
20:43I mean, I can't tell you how many times
20:45I've asked a patient when did you
20:46have your colonoscopy and they said,
20:47oh, it was last year and then we
20:49look in the chart and it was six
20:51years ago and nowhere close, right.
20:52And it happens with the stool
20:54based test as well.
20:55So overall,
20:56we're not doing very well at
20:57the top of the chart at 59%.
20:59You'll see the differences by age.
21:01Of course just because we've just started
21:03screening our 45 to 49 year olds,
21:05we're going to have the lowest
21:06uptake in that group.
21:07But we also haven't been very well
21:09at a screen done very well at
21:10screening our 50 to 54 year olds.
21:12And prior to the release of the new guidance,
21:15a lot of us are focusing on those
21:1750 year old patients because those
21:19people were under screened as well.
21:21Males and females do pretty well,
21:24but we have seen, as I mentioned,
21:26big differences by race, ethnicity.
21:27I will highlight that in the last 10 years,
21:30the black white screening gap has narrowed.
21:34I I don't believe these data completely
21:36because when you look at EHR data,
21:38there's still more than a 1% difference,
21:40but it does signal that we've done
21:42a good job of closing that gap.
21:45But look at the other non white
21:47racial ethnic groups again.
21:49When we're looking at our native populations,
21:51Asian and Hispanic individuals, we do.
21:53We have a lot of work to do.
21:55So this is where a lot of our work
21:56focuses on in the underserved,
21:57not just our black community but our
22:00other groups that are have low rates as well.
22:02I think I also hear put a lie
22:04where where you're born matters.
22:05So our immigrant populations
22:07have very low screening rates.
22:08And then also what how your
22:10insurance type is going to be a
22:12large predator for screening.
22:13So when I talk about inequities and
22:14when I talk about underserved, yes,
22:16for me it did start with black,
22:17white,
22:18and that's what my dissertation
22:19was on for my PhD.
22:20But it really has expanded
22:22to include Latinos,
22:24which is a group that we're seeing
22:26the highest rise and early onset.
22:28It also includes individuals
22:30who are Native American.
22:32I'll talk about one of
22:33the products that I have
22:34in the Tribal Nations and it also
22:35gives people who are foreign born and
22:37also who have insurance types that are
22:40barriers to them getting screened.
22:44The why. This is complicated and I could
22:47spend an hour talking about the why,
22:49but I've tried to just distill
22:51it into a quick slide here on
22:53social determinants of health.
22:54There are conditions about your life
22:56that make it more or less likely for
22:59you to participate in your healthcare.
23:01You can boil it down to competing demands.
23:03I I tend to find that a lot of our
23:05underserved populations have so
23:07many health and non health competing
23:09demands that getting screened for
23:11a preventive getting a preventive
23:13screening test for a cancer or disease
23:16they don't have is off the table.
23:18But the the more specific reasons
23:20for screening have been populated
23:23through a myriad of studies.
23:25This, I thought, was really interesting.
23:28This is Kaiser Family Foundation data,
23:30which I love all the data that
23:32they release online.
23:33They looked at the number of adverse social
23:36determinants of health by race and ethnicity,
23:39and they found that at the first bar,
23:41if you're a black individual,
23:42you have 16 worse,
23:43on average social determinants of
23:45health than a white individual.
23:47And you can see for Latinos it's similar,
23:50but even Asian,
23:51our native populations and our
23:54native Hawaiian populations as well.
23:57So this is,
23:57this was I think a nice way to quantify
23:59these competing demands that happen
24:01in life and to kind of at baseline
24:04try to understand why it is that when
24:06you have four children at home and
24:08elderly parent to take care of four
24:10jobs trying to put food on the table,
24:12don't even have a primary care provider.
24:13The idea of getting screened for
24:15colorectal cancer is not even on
24:17on the list of priorities for
24:19you that day or year or month.
24:21We've done a lot of work in this area.
24:22I'm going to populate this slide
24:24and this also combines work from
24:26colleagues in this area where
24:28we've tried to look at barriers
24:29to screening on a multi level.
24:31I like to look at it as patient
24:33provider health system and policy.
24:34What struck me most about this work when
24:36I started doing it was that everyone
24:38wanted to talk about the patient problems,
24:40right.
24:40The patient being the problem.
24:41The patient won't get screened because the
24:43patient has this and that and these barriers.
24:46But let's that's also highlight
24:47that there are provider factors.
24:49So that second box here,
24:51there are data that show that when you
24:54when you survey primary care providers,
24:56they don't know that there are disparities
24:59in colorectal cancer or they don't
25:00get the screening guidance right.
25:02They don't know that we've
25:04lowered the screening age.
25:05We know that your practice setting matters.
25:08The number one predictor,
25:09in fact,
25:10for whether a person is to get screened
25:12for colorectal cancer is whether or
25:13not their primary care doctor talked
25:15to them about a director directly.
25:17This is one of the first papers that
25:19I published with Brandon Spiegel.
25:20And when you look at ethnic and
25:22racial minorities,
25:23that odds ratio is even higher.
25:25So a, a trusted provider telling a
25:27patient to get screened is one of the
25:29most important predictors and that's
25:31not happening more in those groups.
25:33And again I could spend an hour just
25:35on the slide because we know that
25:36there's so many barriers and This
25:38is why a lot of the work that we do
25:40in this area is about multi level
25:42interventions where we're trying to
25:44pick at many of these barriers in one
25:47go with a multi component intervention.
25:50A couple things I do want to highlight.
25:51So policy because we talk a lot
25:53about patient provider system,
25:54but I also throw policy in there because
25:55I think for a long time there were
25:57policy barriers to getting screened.
25:59So the ACA, which I am a fan of,
26:01actually eliminated issues like
26:03copay and mandated coverage for
26:05preventive services that had a
26:07huge effect on disparities,
26:09not just for colorectal cancer
26:10but other cancers as well.
26:12And then we've been done some work
26:13on the state and national level.
26:14We had a law that we got past two
26:16years ago about removing barriers
26:18to colorectal cancer screening,
26:20which removed copay.
26:21Believe it or not,
26:22if you had a colonoscopy for
26:24screening and I took out a polyp,
26:26you would get a charge.
26:28It's like that's the purpose of the test.
26:31So we finally convinced Congress
26:32that that didn't make any sense
26:34and they removed those co-pays.
26:36This is work that's been
26:37championed for years,
26:38but that law went through
26:39I think 2 1/2 years ago.
26:40So there are also policy things that have
26:43to be addressed for us to close these gaps.
26:46I'll talk about those strategies next
26:48and how we address these barriers.
26:50And this really pulls us into the
26:52field of implementation science,
26:53which is,
26:54is,
26:55is kind of what we could we consider where
26:58health service the research is going to.
26:59So in health services research,
27:01we're trying to understand
27:02how to get the best care,
27:03the best quality of care to all people
27:06equitably and through health systems or
27:08other sources of healthcare delivery.
27:10And a lot of that leads up to
27:13effective implementation science.
27:14In implementation science,
27:16especially related to disparities,
27:17our first goal is to understand the
27:19extent of the disparities which we've
27:21talked about mechanisms and barriers,
27:23why we have the disparity and
27:25particularly for screening.
27:27We just looked at that slide and
27:28then we want to come up with
27:30evidence based solutions to those
27:31disparities and then we want to
27:33disseminate and scale them so that
27:34everyone has access and everyone
27:36has improvement in those outcomes.
27:37So that's what leads us towards
27:39these interventions that are multi
27:40level at the individual provider,
27:42health system and policy level.
27:44And more recently,
27:45we've had interventions that
27:46are also queued into community.
27:48And that's another level of the work
27:50that we do now because I came along
27:52at a fortunate time where the giants
27:54have been working in this field for a
27:56long time. We've learned a lot.
27:58And now we're at a place where we
28:00actually know pretty much what works.
28:02It's just trying to tailor it for the
28:04appropriate population and scale it.
28:05And we know, for example,
28:07that when we look at effective interventions,
28:09did it light up?
28:10Yes, there are certain there are
28:12certain goals that you want and
28:14how you design your intervention.
28:15You want it to target multiple levels.
28:18As I mentioned,
28:19you want to address barriers at
28:20all those levels which leads to
28:23a multi component intervention.
28:24You want them to be culturally tailored.
28:26Particularly interventions that involve
28:28patient education where all of the
28:31individuals on the pamphlet are are
28:32appear white or a pure male are not
28:35going to appeal to people who come
28:37from brown or black populations or
28:39underserved populations for example.
28:41So culturally tailoring the language,
28:43the examples, the settings,
28:45the people,
28:46and then also you want to work
28:48closely with the stakeholders.
28:50I think we come from unfortunately a
28:54history since probably the beginning of
28:56time where we've come into places and
28:59decided what's best for the people there.
29:02And this is more around coming into
29:04a place acknowledging that you're
29:06coming within with expertise,
29:07but that those people understand
29:09the community best.
29:10So when we develop interventions,
29:12we sit down with our community
29:13leaders and we say,
29:14what do you see as the problem
29:15and how would you fix it?
29:16And then we try to adapt our science
29:18to those potential solutions.
29:20And I think that's what makes
29:22the most exciting brainstorming.
29:24That has led to a slew of
29:27interventions and we have,
29:28as I mentioned,
29:29policy interventions that have
29:31been very effective.
29:32There's been interventions at the healthcare,
29:34healthcare system level.
29:34A lot of those have to do with automation.
29:36So a lot of the work that I do
29:38with my Qi hat is about offloading
29:40primary care providers by automating
29:42screening for them and and prompting
29:44them to do things and taking
29:46steps and the number of of touches
29:48on the EHR away from them.
29:50We also have interventions that are
29:52focused mainly on the provider or
29:54her provider components and also as
29:56I mentioned communities and patients.
29:58So when we're building intervention,
30:00a lot of times we're looking at lists
30:02like these and we're saying OK where
30:03do we want to pull from each of
30:05these levels as we build our multi
30:06level intervention to address the
30:09specific barriers in that community.
30:13I'm going to adopt that thinking
30:15to the work we've done in
30:16federally qualified health centers.
30:18So just to make sure that everyone
30:20understands what these clinical settings are,
30:22these are community based.
30:24They provide only primary care or that's
30:27how the government has structured them.
30:29They get funding and resources to
30:31provide primary and preventive care.
30:33They take care of 30 million
30:35Americans in the United States.
30:37And although they have offerings
30:40for screening or cancer diagnostics,
30:42they won't typically have
30:44a specialist on site.
30:46And so those patients often have to leave
30:49the FQHC when they need specialty services,
30:52which makes it very tricky for those
30:53patients who need that level of care.
30:57When you look at screening
30:58rates for colorectal cancer in
31:00federally qualified health centers,
31:01which we really only have for the
31:03age group of 50 to 75 at this time,
31:06the screening rates are much lower
31:07than national screening rates.
31:08So yes, we've had some improvements over
31:10time in federally qualified health centers.
31:13The blue line's going up,
31:14but look how far below the
31:16national screening rate we are.
31:17And the national screening
31:18rate isn't that great,
31:18so that's not even our goal.
31:20So in these settings,
31:22we have underserved individuals,
31:24often brown and black,
31:25often uninsured, often low SES,
31:28and very often poorly screened,
31:31not just for colorectal cancer,
31:32but for pretty much any measure.
31:34And that's the challenge of the
31:35primary care providers in this setting.
31:37Going back to that problem that
31:39I'm also interested in which
31:40is completion of screening.
31:42They even when they do get screened,
31:44if that screening is abnormal like
31:46they they use a lot of stool based
31:48screening in these settings because
31:49it's easier for them to give out.
31:51Sometimes there's no opportunity
31:53to get a colonoscopy.
31:55So in some of the series we've done
31:57as low as 18% of the patients who have
32:00an abnormal fit get a colonoscopy,
32:02which as a fellow when I started
32:03looking into the problem drove me
32:05crazy and I said this is definitely
32:06where I'm going to do my research and
32:08we're going to talk about that today.
32:10So we I do this work in LA County
32:13which is a very interesting place
32:15to do work in underserved.
32:17Our county has 10 million people,
32:22we are majority minority.
32:24So 72% of Los Angelinos identify
32:27as being a person of color.
32:30And just in our county we have 49 FQHCS
32:33and someone told me there was a new one,
32:34so it might be 50 now.
32:36So this is an incredible
32:38setting to do this work.
32:40It's an incredible playground.
32:41We have 1.1 million people
32:43in FQHCS just in our county.
32:45And then I just go,
32:45I gotta drive 2 hours South to meet
32:47up with Samir Gupta and I've got the
32:49San Diego counties at my disposal as well.
32:51And we do a lot of partnership
32:52with San Diego.
32:53Our populations are similar.
32:55So at the Center for HealthEquity,
32:58which is at UCLA,
33:00in the UCLA Cancer Center,
33:01where I am one of the associate directors,
33:03we collaborate with federally
33:05qualified health centers.
33:06We develop advisory committees with them.
33:08We have ongoing clinic engagement.
33:10I have staff that literally just sit
33:12in an FQHC clinic for a week and just
33:14observe how care is administered.
33:16We perform key informant interviews.
33:19We sit in a conference room with the
33:21clinic leadership with a couple of
33:22their providers and we bring in a
33:24couple patients and an interpreter often.
33:26And we just talk about what's working,
33:27what's not working and this is how we
33:30help them develop multi level interventions.
33:32Again,
33:33focusing on their system workflow,
33:35focusing on their provider
33:37and staff and how to maximize
33:39efficiency and also how to educate
33:41and best inform their patients.
33:43I'm going to lean into one example
33:44with one of our main partners.
33:46This is the Northeast Valley.
33:47I'm going to call them Northeast
33:48Valley from here on out,
33:49but it's a large FQHC.
33:51They actually have 15 sites
33:53throughout Los Angeles.
33:54It would take me an hour and a half
33:56to drive from one site to another.
33:58That's how spread out this one
33:59FQHC is and they've got a lot of
34:02patients from different backgrounds.
34:03It is largely Latino,
34:0584% and largely uninsured with a with
34:09about 90% living below the 200% FPL we've.
34:13I haven't,
34:14but my center has been working
34:16with this FQHC for 13 years.
34:17The partnership was started by
34:19Doctor Rashan Bastani who was
34:20one of my mentors doing my PhD.
34:22They've done work in breast cervical
34:25HPV vaccination for kids in the clinic
34:27and then now with colorectal cancer.
34:30So beginning in 2018,
34:31which is when I started working
34:33with this clinic, I said,
34:35well, you know,
34:36I'm a gastroenterologist,
34:36I'm going to come into the setting
34:39and of course I'm going to look at
34:41colorectal cancer screening and
34:42their screening rate was about 51%.
34:44Then it actually dropped to 39% during
34:48COVID and 9% of their fits were abnormal,
34:51but only 20% were getting that
34:53colonoscopy for completion
34:54and they had no protocols.
34:56They had no screening program and no
34:58abnormal screening follow up program.
35:00So this was an incredible opportunity
35:01for me to come in with Doctor
35:03Bastani and talk to him about
35:04the work that they're doing.
35:05And over the last six years
35:07now we've done a slew of work.
35:09I know this slide's very busy,
35:11but I did want to summarize and and
35:13and try to explain the trajectory here
35:16because with colorectal cancer screening,
35:18it's a process of care for which
35:20you need all the components you
35:22need to screen more people,
35:24but then you need to recognize that
35:26those people need to be screened
35:27at intervals and so that's what
35:29we call repeat screening.
35:30And then you also need to recognize
35:32that those people who have
35:33abnormal screening need a certain
35:34line of care as well.
35:35So our three buckets of work at Northeast
35:38Valley have been in those three lines.
35:41We've done work in the blue box
35:43about increasing the screening rate.
35:45That first work,
35:46that work was first funded by TRDRP
35:48which is a tobacco related disease
35:51program that does funding but
35:53they were very interested because
35:55obviously tobacco relationship with
35:57colorectal cancer risk and that
35:58grant allowed us to do a cluster
36:00randomized trial greater than I
36:02think it ended up being 12,000
36:04patients and this was a multi level
36:06intervention mostly about their
36:07workflow is how can we help them
36:10reestablish their workflow in the clinic.
36:12We offloaded the primary care providers.
36:13We got the M as involved in
36:16handing out FIT kits.
36:17We got different levels non
36:19MD providers in the clinic
36:20involved and explaining the kit
36:22following up with patients and that
36:24was very effective in increasing
36:26their overall screening rate.
36:27Then we had a post doc
36:29who said OK that's great.
36:30The patient got screened once in 2018,
36:32they had to get screened
36:33again 9 to 12 months later.
36:35What How do we make sure that happens?
36:37So she did RO three or she started the
36:40RO 3:00 and also had an internal seed
36:42grant to help us work on repeat screening.
36:45And with nurses work we were
36:46able to make sure the clinic was
36:48doing recall of the patients.
36:49Ends up being about every nine months.
36:51So they have a mental alarm that they're
36:53going to be due for screening every year.
36:56And then of course I
36:57came along and I said OK,
36:58well I'm the gastroenterologist
36:59again who does the colonoscopy.
37:01So I want to make sure all these
37:02patients who have abnormal
37:03results get a colonoscopy.
37:04And that work started with an
37:06NCIRO 3 where we proposed that
37:08we were going to look at the why,
37:11why is it that patients are
37:12falling out in this process.
37:14And we created this conceptual framework
37:16where we showed that there were nine
37:18things that needed to happen for an
37:20abnormal FIT patient to get a colonoscopy.
37:22And we,
37:23we quantified the fallout or the
37:25attrition at each step and we
37:27were able to assess that these
37:28primary care doctors were doing
37:30very good at seeing that there was
37:32an abnormal fit in the chart.
37:34They're actually doing very good
37:36at ordering the referral to GI.
37:38About 85 to 90% of referrals were
37:40going in and then everything
37:41was a disaster after that.
37:43The patients just they were either
37:45getting to GI and not doing the
37:47colonoscopy or they never got to
37:48GI or they would get to GI have
37:50an appointment and then the
37:51colonoscopy was not scheduled.
37:52So we knew that we had to focus not only
37:55just on the internal processes at the FQHC,
37:58but that kind of there was another
38:00level of this multi level at the
38:01GI practice level where we had
38:03to work on that connectedness.
38:05And we actually Beth Glenn and I
38:07wrote an RO one where we said OK,
38:09we're going to do a multi level
38:11on a multi level which is kind
38:13of crazy the first time.
38:14The review did not go well.
38:16NIH is like what are you talking
38:17about because we proposed doing a
38:19multi level intervention in an FQHC
38:21at the same time as doing a multi
38:23level intervention in several GI
38:24practices that see their patients.
38:26But guess what we got?
38:28Note,
38:28we got news 2 weeks ago that it got funded.
38:31So this is a very excited exciting
38:35multi level intervention.
38:37We're at Northeast Valley.
38:38We are finally going to be able
38:41to close this gap.
38:42We've done a really good job of of
38:45improving care at the clinic within the FQHC.
38:47But now we're going to be
38:49working very closely with
38:50GI providers in the LA and the larger
38:52LA community to make sure that those
38:54patients are connected to the GI clinics
38:56and make sure that those colonoscopies
38:58are completed and make sure that the
39:01reports get back to the FQHC, right.
39:03Because if it's not documented in the
39:06FQHCSEHR, it's as though it never happened.
39:08So part of it was a measurement problem
39:10to you and we just got the word that
39:13this was scored very well and we're
39:15doing all the paperwork and hopefully
39:17we'll get this work started very shortly
39:19and we're very excited about that.
39:21So for me, you know,
39:22the this work that we've done at
39:25Northeast Valley has been really
39:27because I think even as a PhD student,
39:29I understood community partnership,
39:30I understood what it was.
39:31I was starting to understand what
39:33it was like to effectively go
39:34into community settings and listen
39:36and learn and then intervene.
39:38But now I've had about 5 projects
39:39with them where I've been able
39:41to not only see that process,
39:42but see the trajectory across
39:44the screening spectrum,
39:45which has been an incredibly
39:47rewarding experience.
39:48And you can do this in anything, right?
39:49You can do this in breast cerebral
39:51cancer screening, the FQHC.
39:52You know, we asked them,
39:54what are your priorities?
39:55And they actually recently
39:55told us liver disease.
39:56And I was like, OK,
39:57that's not me,
39:58but we'll find someone who's got this
40:00expertise because they have the similar
40:02problem with chronic liver disease.
40:04As we know,
40:05it's become increasing burden in
40:06the United States particularly.
40:08In these populations and they can't
40:09get those patients into liver care
40:11or into transplant evaluation.
40:12So it is replicating that model
40:14once you've figured out how to
40:15do it well and effectively.
40:19This work also dovetailed because we I
40:21started this work in 2016 seventeen and
40:24it's been going on my entire career.
40:28It's lent opportunities into other settings.
40:32So one of the things that came
40:34up about four years ago was this
40:36opportunity from Stand Up to Cancer,
40:37which is a nonprofit organization
40:40that is about cancer awareness and
40:43also works with AACR to fund research.
40:45They made made an announcement a
40:47few years ago. I'll never forget,
40:49'cause I was sitting in my office
40:50and it said Stand up to Cancer,
40:52Colorectal, Cancer Equity Dream Team.
40:54And I said, well, that sounds like me.
40:58It sounds like someone wrote a grant for me,
41:02but I'm way too junior and there's
41:03no way I'm going to get this,
41:04you know, $8 million grant.
41:06So I just kind of deleted the e-mail.
41:09And I think a few weeks later,
41:10Andy Chan at MGH reached out and said we're
41:13thinking about applying for this grant.
41:15And I said that's great.
41:17And I said, yeah, I'll consult, I'll help.
41:18And he said, no, no, we want you to run it.
41:20And I said no.
41:23So what are you talking about, Andy?
41:24But again,
41:25another incredible opportunity where I
41:27started meeting with him and Jennifer Haas,
41:30we pulled the team together and it it
41:32kind of just made sense for for us to go in.
41:34And we were very fortunate to get
41:36awarded this grant. It's $8 million.
41:38It's same work that I just described to you.
41:40Did I do that?
41:42OK, I'm going to keep going.
41:44It's it's the same work that I
41:47described to you in Northeast Valley,
41:49but it's across the nation.
41:50So we picked FQHCS in three cities,
41:53Los Angeles, Boston and in South Dakota.
41:56Now why South Dakota?
41:57Because of the Tribal Nations.
41:59So we have this incredible opportunity
42:02to in a very careful way engage with two
42:06FQHCS and tribal nations of South Dakota.
42:09And we are doing the same thing.
42:10We're helping them improve their clinic
42:13infrastructure to improve their screening.
42:15We're helping them improve
42:16the repeat screening.
42:17And the part that is we're doing right
42:19now we're in the last year of the study
42:22is we are improving their follow up
42:24after Abnormal Fit and Cologuard testing.
42:26Those are the tests that are most
42:28commonly used in these settings.
42:30So this has been an incredible opportunity
42:32to kind of spread the work that we've
42:35learned in local FQHCS in Los Angeles
42:37to other parts of the country and to
42:40work with incredible investigators
42:41like Doctor Hawes and Doctor Chan.
42:44This work is wrapping up.
42:45So we're kind of hoping that Stand Up
42:47to Cancer will give us an opportunity
42:49to do to do more of it moving forward.
42:51I think I just have two more slides
42:53and then I'll have time for questions.
42:55I just want to leave with two things
42:56that I think are important to
42:58think about as we think about this
43:00field moving forward.
43:01I do think that we're just at the
43:02beginning of implementation science
43:04around colorectal, cancer, equity.
43:05And there are groups all over
43:07the country that are doing work,
43:09even much better work than
43:10what I just described to you.
43:11And I'm so excited because it's wonderful
43:13to come together at conferences and to
43:15be collegial with these individuals.
43:17And there's a couple things that
43:19we're noticing that make this work
43:21even more relevant to everybody.
43:23The demographics in the United
43:24States are changing.
43:25I don't think anyone in this
43:26room is surprised by that,
43:27but unfortunately a lot of others are.
43:30And where we look at our demographics
43:31in 1980 compared to data from 2020,
43:35we know that the proportion of
43:38individuals who identify as white,
43:40non Latino is smaller and we've got
43:42a larger proportion of Latinos,
43:45black individuals and Asian Americans.
43:47And in certain parts of the country,
43:49it's a different proportion increase.
43:52This means that addressing disparities,
43:54addressing inequities,
43:55understanding what gets different
43:57groups to get screened or get
43:59testing is even more critically
44:01important because we think that this
44:03demographic shift will continue.
44:04So I I try to remind people that
44:06even though this is starting as
44:08equity or disparities in a small
44:09group of investigators,
44:10we all need to learn how to do
44:12this work if we really want to
44:14address this problem on a national
44:16level and similar problems.
44:17The other thing that's going to rock
44:19our world in colorectal cancer is
44:21non invasive screening tests that are
44:23on the verge of driving me crazy.
44:26So we are going to have an emergence
44:29of stool based testing and blood based
44:32testing that we hope will be helpful
44:35towards screening more individuals
44:38but have potential downsides as well.
44:41So why are we having so many more tests?
44:43It's because we're still stuck at
44:45less than 70% of Americans getting
44:47screened for colorectal cancer.
44:48There is a huge market to make tests to
44:50get more people screened and I I agree,
44:52I agree with that.
44:54I think that certain test types are going
44:57to appeal to different population groups.
44:59The other thing that is critical
45:01to note is that there's a big
45:03movement towards ease of testing.
45:05So that is why we're seeing the
45:08emergence of liquid biopsy and said
45:10the idea that when I send a patient
45:12to get a Chem 7 or ACBC every year,
45:14I can just check off a box for their
45:16colorectal cancer screening and
45:18they don't need to manipulate their
45:20stool or do a prep and take two
45:21days off for a colonoscopy, right.
45:23So there's amazing potential
45:25in these blood based tests.
45:27We saw the garden data that was
45:29released in New England Journal last
45:31month and raised a lot of excitement.
45:33I was quoted in the New York Times as
45:35saying that a prep for a colonoscopy
45:37was a horrible experience and this
45:38potentially could get rid of that,
45:39which isn't what I said.
45:41What I said was that what I was trying to
45:44say was that patients feel that way,
45:46but we have to recognize that these
45:48tests are different strategy, right.
45:50So I started this whole presentation
45:53by saying that the amazing power
45:55we have in colorectal is that
45:57we can prevent an early detect.
45:59These blood based tests are mostly
46:01early detecting and they're not
46:02even early detecting stage 1,
46:04They're early detecting stage 2:00.
46:06So we just have to recognize that this
46:08this motto that Brendan Spiegel taught
46:10me when I was a fellow that the best
46:12test is a screening test that gets done.
46:14I'm not sure I'm going to be
46:15saying that anymore, right?
46:16Because to me it's kind of apples to oranges.
46:19We have tests that prevent and early detect
46:22and now we have tests that early detect.
46:25My biggest fear and why I get to the
46:27the slide and bite my lip is that I'm
46:29excited about the technology and the
46:30the emergence of people in our field.
46:32But I'm nervous about the interpretation of
46:35these tests because I've run into harmony,
46:38harmony people, lay people,
46:40but also researchers and clinicians
46:42who don't even understand that
46:45we're shifting fundamentally from
46:47prevention to early detection.
46:49That potentially changes again the number
46:52of people that we say you have cancer too,
46:55right, which is what I started
46:57this presentation with.
46:58So I am excited.
47:00These are not yet recommended by USPFTF,
47:03but it's on.
47:04I I think that our whole field is going to
47:07change as those become more and more popular.
47:09I'm going to close out here.
47:11I think I'm going to just put
47:12this up here for a couple minutes,
47:13but I'm pretty sure I made all these points.
47:15I want you to leave understanding
47:17how common this disease is,
47:18but how preventable it is.
47:19I want you to understand that young adults
47:22need to be aware of getting screened
47:24and also symptoms and not ignore them.
47:27I want you to be aware that the
47:29screening guidelines changed and
47:30now we're screening at 45 and that
47:31despite all the work in this area,
47:33we still have profound disparities.
47:35What we're doing some work
47:36in that those areas,
47:37but a lot more has to be done and it
47:39really has to do with very sensitive,
47:41culturally tailored and
47:43targeted interventions.
47:45I'm going to end there and I'll
47:47just put my thank you slide up.
47:49Oh,
47:49my goodness.
47:50And I'm putting this up because that QR
47:53code is to my lab if you want to learn more.
47:55And then also I want obviously want
47:57to thank my partners and our funders.
48:00So thank you very much.
48:06Thank you so much.
48:07And what a fantastic talk.
48:09Happy to take questions.
48:11Now there's something in the chat too.
48:13So that was so fantastic.
48:16Thank you. Thank you.
48:19I have a question about the the
48:22research you're doing from the
48:24FQHC to the the clinics and you
48:29mentioned eight factors you
48:31have found that are the barriers
48:35to getting the 2nd screening.
48:38Can you just say like what is the
48:40primary barrier that you would think
48:42is from the system's perspective
48:43that is causing a challenge?
48:46I, there's a chance I have a slide.
48:48So I'm just going to,
48:50I have all these extra slides just in case.
48:52But I don't think that's one of them.
48:54So OK, what it is,
48:55it's not that there are 8 barriers
48:57because that's how I used to think
48:59of things as like whole barriers.
49:01What we did is we there are eight sets, OK.
49:03So what we did is we went into
49:05the clinic and we said,
49:06we went into the clinic and we said
49:09when a patient has an abnormal fit,
49:11what's the first thing that has to happen.
49:13And the the first thing that
49:16has to happen is that the,
49:18the doctor has to see the results, right.
49:19And believe it or not,
49:21there are cases where it's just sitting
49:22in the EHR and no one ever noticed it,
49:24right.
49:25So that's step one.
49:26And then the second step is the
49:28provider has to contact the patient
49:30and communicate the results.
49:31The third step is the provider
49:33and the patient have to come to a
49:36patient provider decision that a
49:37colonoscopy should be pursued and by
49:39the multi society task force Full
49:41disclosure and part of that task force.
49:43But our guideline says that 80%
49:45of patients at least who have an
49:47abnormal fit should be appropriate
49:48for colonoscopy.
49:49So the answer to that third
49:51step should be yes.
49:52Then the next step is the provider
49:54needs to place a referral.
49:55Then the next step after that is
49:57that the referral has to be processed
49:58and that was a step we didn't
50:00really acknowledge before because
50:01we just thought it, it just happens.
50:03But we realized that a lot of
50:05these referrals,
50:06they would call the insurer and
50:07the insurer would say no and then
50:09no one else would follow up.
50:10And so things were getting stuck there.
50:13And then this is what was
50:14really interesting in LA,
50:17the GI consultants were requiring the
50:20patients to have an in office visit and
50:23then a second visit for the colonoscopy.
50:27I talked to my colleagues
50:28in Boston and New York.
50:30Everyone was just taking those
50:31patients and putting them into
50:33Open Access and scoping them.
50:34But when we did our qualitative interviews,
50:37which a part of the the NIH
50:38grant I didn't go to with,
50:39the first aim was qualitative interviews.
50:41All of the private practitioners in LA were
50:43saying it's a disaster when we do that.
50:45These patients are coming from
50:46a setting where they haven't
50:48had procedures,
50:48they don't understand the prep,
50:50we have language barriers,
50:52they have comorbidities they're
50:53showing up with in a FIB.
50:55We can't do the procedure.
50:56It's getting cancelled day of so they.
50:59So in LA, particularly with
51:01this underserved population,
51:02it became very clear to me that
51:04I wasn't going to be able to get
51:05rid of that step because all of
51:06my colleagues were saying oh,
51:07if you get rid of that step,
51:08you'll get rid of this,
51:09you'll fix this problem.
51:10But we have not.
51:11We've just tried to streamline
51:12that step by doing better
51:14medical documentation and pre
51:16like pre procedural work.
51:19Yes.
51:19So Rachel Osaka,
51:21who's a colleague at
51:23University of Washington,
51:25she has a systematic review that's
51:27just about to come out that looked
51:29at effective interventions for fit,
51:30follow up and underserved.
51:33And they found, I think,
51:3513 interventions and all
51:37the body of literature,
51:388 of them were manuscripts,
51:41five were abstract conference abstracts,
51:42right So.
51:43And every single one but
51:46one involved the Navigator.
51:49So there there is really in
51:51these settings in particular,
51:52there's something about patient
51:54to human interaction and coaching
51:57someone through these eight or nine
52:00steps that's effective and important.
52:02Did I answer your question?
52:03Yes.
52:04OK.
52:05I want to also thank you for
52:07an amazing talk and thank you
52:09for really eloquently outlining
52:10how complex it is to develop
52:12interventions across all these levels.
52:14So thank you for being here.
52:17One of the things that I'm
52:18a huge fan of your work,
52:19but what I'm really sort of fanning
52:22over right now is your relationship
52:24with the Federally qualified health
52:26centers and acknowledging that,
52:27you know,
52:28a large majority of our at
52:29risk populations are being
52:31served in those settings,
52:32but yet we're not able to engage
52:34them in research regularly.
52:35So you outlined a sort of program
52:37that sort of has a longitudinal
52:39relationship with these centers.
52:41And I wonder if you can just help
52:44us understand what it really takes
52:46to maintain that relationship
52:47and engage those community,
52:49those groups,
52:49because I think that's where
52:50we miss the mark a lot.
52:52I think we miss the mark a lot.
52:53And I'm not going to sit here
52:54and say that I do this perfectly.
52:56I've had missteps,
52:58I would say that in everyone.
53:00But one of the FQHCS that I've worked in,
53:02the hardest part was trust building.
53:06So a lot of these settings I walked into,
53:09they had had experience with,
53:12with academic institutions,
53:14with investigators.
53:15They felt almost raped of
53:18their data in some situations.
53:20So a lot of that first year or so
53:22is like courting them like just
53:24showing up like we're here to.
53:26I said I have coordinators that
53:28just sit there and just watch and
53:29bring in breakfast and you know,
53:31just listen and learn.
53:33We are very pushy.
53:36Like I think as academics we don't
53:37realize and it probably is very
53:39efficient and effective people.
53:40You just were like in five
53:42states in the last
53:43two days. We are very efficient people
53:44and we like things like this and you
53:46go into those settings and you realize
53:48if you act like that it does not work.
53:50They just see you as a pushy person
53:51who needs to watch your agenda.
53:53So a lot of it is the trust building
53:55and the relationship building.
53:56The other, the second part that I
53:58would say answering your question
54:00is you have to have a really strong
54:02like stakeholder in the setting.
54:04For us it tends to at least start
54:06with the Qi director or someone
54:08who has that equivalent role and
54:09sometimes will migrate to someone else.
54:12We have one of the FQHTS that
54:13we're working with for the Stand
54:14Up to Cancer grant.
54:15It's actually a primary care provider.
54:16She just really decided
54:17that she loves this work.
54:19But you have to have buy in because
54:21that person helps change the
54:23culture of the institution and
54:24almost gives you cred about among
54:26all the other providers there.
54:28So that's been really important as well.
54:30But it's hard.
54:31I mean,
54:31we've gotten feedback from some of
54:33these settings that we were rude on
54:34certain days or I've gotten a call
54:36that my project coordinator came in
54:38there talking like she knows everything.
54:39You know, like you have to be,
54:40you have to be very careful.
54:42I mean, I I mean,
54:43I hate to say it,
54:44but even like the way we dress
54:45or the jewelry we wear,
54:46you can be very careful when you
54:48go into these settings and you
54:50have to be very aware of that.
54:51And then, and you have to understand,
54:52this takes time.
54:53I mean,
54:53I started doing this work and Gary
54:55Gitnick was the chief of my division.
54:57And I told him I want to do this work.
54:59No one does this work.
55:00But I'm going to need like
55:01five years to figure this out.
55:03And can you just pay me?
55:04Well, figure this out.
55:05And he was like, sure, yeah, we'll,
55:07we'll figure it out. We'll just pay you.
55:09And now it's paying off.
55:10But I mean, you have to have some.
55:12You have to be at an institution
55:13that's going to invest in people.
55:14And the time, I hope the answers,
55:16I can go on forever,
55:17but hope that answers.
55:21Hi, It's good to see you.
55:26Good,
55:28thank you. But with
55:32the stool based test, if you pick out
55:36polyps in you actually can with the fit.
55:39So the sensitivity for fit, for FIT,
55:42for advanced adenoma which is the polyps
55:45we care about is about 40%, it's for the.
55:49Yeah. So the sensitive is even
55:52higher for stage one through 4:00.
55:54So we actually think fit does a pretty
55:56good job of both the prevention,
55:58early detection, the Gwyak,
55:59the FOPG does not, it's like 12%.
56:01So though that's why those
56:02have come out of favor.
56:03Cologuard is, is 42%.
56:05I think the, the one point O,
56:08so those two newer test and
56:11then the Cologuard 2 point O,
56:13the one that they just released the Journal,
56:14the in New England Journal 3 weeks ago,
56:17that also has good sensitivity
56:19for Vance Adenovus.
56:20But it's just the liquid,
56:21the the blood ones that do not 13 percent,
56:2513%.
56:28Yeah. I mean, I, like you don't really
56:32believe that screening is being done
56:35as frequently as black Americans,
56:37as white Americans.
56:39But, you know, that's the idea you have.
56:41But clearly, you know,
56:43mortality is higher in black individuals.
56:46Yeah. So there's there's a problem
56:48after diagnosing and there's no
56:51question about that. Absolutely.
56:53You have thoughts about that? Yeah.
56:55So you know that I do have a slide.
56:57Do I have, do I have a minute?
56:58I have a minute to it.
56:59I have a minute. OK.
57:01So this, I'm glad you brought
57:03that up because we only talked
57:05about a piece of the problem.
57:06Right. So, oh gosh, no, I'm not.
57:11I'm using my minute to like
57:12scroll through slides.
57:13But this is the bigger problem, right,
57:15is that you have disparities at every box.
57:19So I've decided to focus on this box.
57:21But you could have,
57:22you could focus on any of those boxes.
57:24And recently we had a paper that came out
57:26in JAMA that showed differences but black,
57:29white differences in treatment.
57:30So when you look at guideline directed
57:34treatment for colon and rectal cancer,
57:36black individuals are less likely to
57:38get the NCCN guideline recommended
57:40treatment than white Americans.
57:42And that's after we we controlled
57:44for everything that was national
57:45data adherence
57:48adherence. So when you look at the
57:51their surgery, chemotherapy, radiation,
57:53particularly radiation for rectal cancer,
57:55the use of guideline appropriate
57:57treatment as laid out in the guidelines
57:59was lower in black individuals.
58:01So that it's the accumulation of
58:03disparities at every one of these boxes
58:05that's at 40% mortality difference
58:07that you're referring to. Yeah.
58:10And I this, this alone is a talk,
58:12right, 'cause I mean you could I'm
58:13we just talked about screening today,
58:15but there's differences in risk factors and
58:18lifestyle and also survivorship as well.
58:21When you look at like things like
58:23sexual dysfunction, Gu dysfunction,
58:25those are all different by race as well.
58:28I'd like to thank Doctor May again
58:33time and presentation today.
58:35Thank you so much.
58:36Thank you so much and thank
58:38you for the questions.
58:39And I'll stand here for a few
58:40minutes in case there are more.
58:41Thank you so much.