Dismantling Inequities in Colorectal Cancer Screening and Outcomes

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.