The Long Road to Recovery, Part III: Cancer Screening in the U.S. (ChristianaCare, Delaware)

At the end of 2021, Delaware—along with many other states—saw its COVID-19-positive cases rise precipitously with the influx of the omicron variant. Like many hospitals nationwide, ChristianaCare in Wilmington, Delaware, began to experience extraordinarily high patient volumes and announced its intention to “temporary postpone some non-urgent surgeries and procedures,” which had the potential to affect all patients, especially those receiving cancer treatment.

When Delaware released its annual cancer report in October 2021, Secretary of the Delaware Department of Health and Social Services Molly Magarik stressed not only the importance of early screening and prevention, but also her concern about the ongoing pandemic’s impact on long-term health. “The data show us clearly that early screening and prevention are critical for bringing down cancer mortality rates,” said Magarik in a statement. “Unfortunately, the COVID-19 pandemic has caused many people to delay cancer screenings and other preventive chronic disease care, and economically disadvantaged communities are typically impacted the most.”

The 2021 Cancer Incidence and Mortality in Delaware, 2013-2017 report, produced by the state’s Division of Public Health, found that Delaware had the nation’s 15^th-highest cancer mortality rate in all cancer sites combined, unchanged from the state’s 2020 report. Despite this, Delaware is achieving progress in curbing cancer incidence and mortality rates. From 2003-2007 to 2013-2017, all-site cancer incidence rates decreased for most of the state’s demographic groups. Non-Hispanic Caucasian males, non-Hispanic African American males, and Hispanic males saw incidence declines of 12%, 22%, and 12%, respectively. Among female state residents, Hispanic women saw a 9% incidence rate decrease, while non-Hispanic Caucasian females and non-Hispanic African Americans saw increases of 3% and less than 1%, respectively.

During the same time period, there was a 26% decline in the all-site cancer mortality rate among non-Hispanic African American men and a 16% decline among non-Hispanic Caucasian men. Female all-state cancer mortality rates decreased 12% among non-Hispanic African Americans, 15% among non-Hispanic Caucasians, and 12% among Hispanic females.

Taking Statewide Action

The Delaware Cancer Consortium, created by the state’s legislature in 2001, unites health, civic, government, and community-based stakeholders in statewide action to reduce the burden of cancer. The consortium focuses on overcoming barriers to cancer screenings, delivering affordable cancer treatment, and educating people about health risks and harmful behaviors to reduce cancer risk. An overarching consortium goal is to “aggressively promote screenings” for five cancers: breast, cervical, colon, prostate, and lung.

Underpinning this goal is the aim to reduce the number of cancers diagnosed at a late stage. The Delaware Screening for Life program is integral to the consortium’s mission. The program, a cooperative effort of the Delaware Division of Public Health and the U.S. Centers for Disease Control and Prevention (CDC), provides free cancer screenings to eligible state residents. With COVID-19 public health emergency restrictions and multiple studies revealing the unequal burden of the pandemic on the nation’s most underserved and vulnerable populations, it is no surprise that the pandemic has had a significant impact on participation rates in the Delaware Screening for Life program from 2020 to 2021.

“During that time period, we saw a 68% decrease in the number of cervical cancer screenings performed in [comparison to] the same time frame in 2020,” said Nicholas J. Petrelli MD, FACS, the Bank of America endowed medical director at the Helen F. Graham Cancer Center & Research Institute at ChristianaCare Health System. “From March 2020 to February 2021, colorectal cancer screenings decreased 73% and breast cancer screening dropped 58%. Now we’re catching up with those [screenings], and that’s pushing up the volume.”

Restoring Screening Rates

The Community Health Outreach and Education team at the Helen F. Graham Cancer Center & Research Institute at ChristianaCare is working hard to remove barriers to care and encourage patients to return to regular cancer screenings. Community connections and engagement are at the core of ChristianaCare’s commitment to improve cancer early detection and outcomes.

Founded in 1998, the Community Health Outreach and Education program is staffed by eight full-time nurse navigators/educators who work closely with community-based stakeholders, including an active group of volunteer promotoras. (As known as promotoras de salud, promotoras are lay community health workers in Spanish-speaking communities.) Because ChristianaCare’s relationships with diverse communities have strengthened and expanded over the years, the cancer center and health system are known and trusted providers. Bringing culturally appropriate health information and education into underserved communities where people live and work is key to this thriving, innovative team. But pandemic surges shuttered put many of the program’s highly successful community events on pause.

“But we didn’t just stop,” said Nora Katurakes, RN, MSN, OCN, manager of community health outreach and education at the Helen F. Graham Cancer Center & Research Institute. “We needed to keep moving, so we went back to some programs that we already had in place. We had to adapt.” Katurakes, who has served on the Early Detection & Prevention Committee at the Delaware Cancer Consortium since its founding, says pivoting in response to new community needs has been essential. Her outreach team has taken cues from the communities it serves on how best to disseminate the information community members are asking for.  

One such adaptation is the Health Outreach and Education Spanish-language Facebook page, which has more than 400 followers. With support from ChristianaCare’s marketing and communications staff, the Outreach and Education Team posts and responds to the concerns and questions of community members. During recent months, many of the questions have understandably centered on COVID-19 and related health concerns. “If someone in the community needs information, they will message us,” said Katurakes. “They may ask, ‘How do I get my [access to] the Screening for Life program back?’ ‘How do I get my insurance back?’ or ‘Where can I find rapid COVID testing?’”

The Community Health Outreach and Education team are a known source of reliable, accurate information for community members. To connect with as many individuals as possible, the team reaches out to specific racial and ethnic communities. For example, to serve the Asian community, the outreach navigator connects with people via the WeChat social platform, which has more than 500 participants, Katurakes said.

But growing these relationships takes time, added Katurakes: “You have to build trust over years, not just in a week. These were relationships [developed] before COVID, and now they are continuing. We’ve elevated them and—during COVID—we’ve been communicating about vaccines, back to screening, and re-enrolling in the Marketplace.”

Keeping the Momentum Going         

During the past 15 years, Delaware has achieved remarkable success in reducing colorectal cancer incidence and mortality rates. The Delaware Cancer Consortium reports that from 2001-2005 to 2011-2015, the state saw a 30 percent decrease in the colorectal cancer incidence rate (more than the 22 percent drop nationally). In 2011-2015, the colorectal cancer incidence rate among African Americans in Delaware was 43 per 100,000 people, lower than the U.S. rate of 48.7 per 100,000 people.

Importantly, Delaware has also been closing the disparity gap in colorectal cancer mortality rates. From 2003-2007 to 2013-2017, data show a 37% decrease in colorectal cancer mortality rates among non-Hispanic African American males and a 20% decline among non-Hispanic Caucasian males. In 2016, Delaware had the 12^th-highest colorectal cancer screening rate in the U.S.

Preventing the pandemic from upending this progress is top of mind for ChristianaCare and the Delaware Cancer Consortium. To keeping the momentum going, ChristianaCare executed a long-planned colorectal cancer awareness campaign from July 2020 through December 2020. As part of this outreach, the health system debuted a new online colorectal cancer risk assessment tool, which was widely promoted via social media. The free tool generates individual reports that indicate if a person is at low, medium, or high risk for colorectal cancer. The report urges individuals to share their screening results with their primary care providers. Those identified at high risk can ask for follow-up from the cancer center’s outreach oncology nurse navigator. Also included in the tool are ChristianaCare and community resources for quitting tobacco use, finding a provider, and contacting a nurse navigator.

ChristianaCare’s campaign and navigator outreach resulted in 422 completed assessments, Dr. Petrelli said. The assessment identified 333 individuals as at risk. Of those, 97 agreed to be contacted by a nurse navigator for follow-up. The campaign was repeated in March 2021 for Colorectal Cancer Awareness Month. ChristianaCare employees were included in screening outreach through the Caregiver Connect mobile app. Describing the Delaware cancer screening experience in The Cancer Letter in February 2021, Dr. Petrelli, Nora Katurakes, and colleagues wrote: “As a result of COVID-19, we found individuals sometimes felt the need to reschedule or change their choice of screening option. The key is to have a reliable contact to help navigate through these COVID times and not stop screening.”

Conducting Business, Not as Usual

Katurakes explains that as the outreach staff maneuvers through the still-shifting COVID-19 pandemic, they’ve been able to re-start a few community events, conduct virtual programs, and once again engage promotoras in educational activities. Among the established programs the outreach team conducted in fall 2021:

• “The Story of Brenda,” an education program focused on health equity and people with triple negative breast cancer

   

• Two community breast screening events, including one that brought 25 local senior center participants to the cancer center for mammograms

   

• A “pop-up” oral screening event planned with the ChristianaCare Department of Maxillofacial Surgery and Hospital Dentistry. Katurakes explained, “We had postponed our mouth and throat cancer screening last year because of COVID. So we decided to do what I’m calling a ‘pop-up’ event. For this, we worked with our transitional housing shelters in the city of Wilmington and with our department of maxillofacial and hospital dentistry.”

Katurakes said her team went to the shelter for transitional housing, where they screened nine women. Most of them are smokers, and two of them needed follow-up. “It doesn’t matter how many you reach,” said Katurakes. “People need help. These are women who need help to quit smoking and also need follow-up—one for thyroid and one for thickening in the mouth. So we’re going to continue that type of pop-up oral screening and move it to two of the other shelters next year.”

As the effort to return to original screening rates continues, capacity can be a challenge, said Katurakes: “We’ve found that whether it’s lung screening or breast screening—and somewhat for colonoscopy—there might be a delay in getting in, and that delay can vary.” This is despite the health system expanding hours to include evening and Saturday appointments. “People want to go where they’re familiar, and they have a great trust of our healthcare system,” said Katurakes. “So we want to accommodate them.”

Given the apparent staying power of COVID-19, Katurakes adds that providers need to adjust community health outreach rather than shut it down: “You can continue to do the work you’re doing; we just need to be mindful. We can’t just stop living. We just have to follow protocol. We’re going to have to learn how to live with COVID in our community.”

Headquartered in Wilmington, Delaware, the ChristianaCare health network includes outpatient services, home health care, urgent care centers, three hospitals (1,299 beds), a freestanding emergency department, a Level I trauma center, a Level III neonatal intensive care unit, a comprehensive stroke center, and regional centers of excellence in heart and vascular care, cancer care, and women’s health. A nonprofit teaching health system with more than 260 residents and fellows, ChristianaCare is continually ranked by U.S. News & World Report as a Best Hospital.