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Dismantling Inequities in Colorectal Cancer Screening and Outcomes

April 15, 2024

Yale Cancer Center Grand Rounds | April 12, 2024

Speaker: Dr. Folasade May

ID
11584

Transcript

  • 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&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.