Implementation science is something Electra Paskett, PhD, is passionate about. Dr. Paskett is Director of the Center for Cancer Health Equity at the Ohio State University Comprehensive Cancer Center (OSUCCC). She is the Marion N. Rowley Professor of Cancer Research; Director, Division of Cancer Prevention and Control, Department of Internal Medicine, College of Medicine; Professor, Division of Epidemiology, College of Public Health; Associate Director for Population Sciences and Community Outreach at the OSUCCC.
The Center for Cancer Health Equity is the community outreach and engagement arm of OSUCCC. The 17-member staff, which includes patient navigators and community health workers, are matched demographically to the different populations served by the cancer center, which include underserved, minority, and marginalized populations. Center staff establish connections in the community and collaborate with more than 240 community-based organizations across the state to conduct outreach, education, screening, and provide continuum of care navigation. This provides support for patients from cancer prevention education through the screening process and includes help overcoming any economic and/or logistical barriers to receiving the recommended screening test(s). If there is an abnormal finding, the care continuum navigation process follows the patient through follow-up and treatment. “It’s a very close tie between the navigator who is at our center and the community health worker who works out in the community,” explains Dr. Paskett.
An overall population health concern is the ripple effect that the COVID-19 public health emergency (PHE) has had on cancer screening rates. In an editorial published in Science, NCI Director Norman E. Sharpless, MD, warned of the potential downstream consequences of the delays and decline in cancer screenings (due to COVID-related priorities for imaging services and healthcare staff, reduced schedules during Phase 1 closures, flatten-the-curve restrictions, and other factors):
There already has been a steep drop in cancer diagnoses in the United States since the start of the pandemic, but there is no reason to believe the actual incidence of cancer has dropped. Cancers being missed now will still come to light eventually, but at a later stage (“upstaging”) and with worse prognoses. . . . There can be no doubt that the COVID-19 pandemic is causing delayed diagnosis and suboptimal care for people with cancer.1
Further, the racial and ethnic populations that have experienced a disproportionate burden of COVID are also the populations that often are not having recommended cancer screenings. According to the recently-released American Association of Cancer Research (AACR) Cancer Disparities Progress Report 2020: “People who are not up to date with recommended cancer screenings are disproportionately found among segments of the US population that experience cancer health disparities, including racial and ethnic minorities.”2
In the context of the COVID PHE, moving the needle on cancer screening rates for Black and African Americans, Hispanic and Latinx populations, and other racial and ethnic minorities is more critical than ever. Cancer screening can help reduce cancer incidence, reduce incidence of advanced disease, reduce treatment-related toxicity and adverse events, and reduce cancer mortality.2
The AACR report concludes: “Identifying strategies to increase cancer screening awareness, access, and uptake among those for whom screening is recommended is an important step toward achieving health equity.”2
At the Center for Cancer Health Disparities, Dr. Paskett and colleagues design and conduct community-based participatory research studies with an implementation science focus. In a recent conversation with ACCC’s Research Review, Dr. Paskett described three studies: a large comparative effectiveness study of education on breast cancer screening that is nearing completion; a multi-year ongoing study underway with the University of Kentucky, West Virginia University, and the University of Virginia that focuses on cervical cancer prevention in Appalachia; and a study launching in October that aims to address higher death rates from breast cancer in African American women.
Nearing completion is the large CER study which recruited women from every rural county in Ohio and Indiana. Because all recruiting was done virtually, through Facebook, the COVID PHE did not slow the recruitment process. The study recruited women in need of breast, colon, or cervical cancer screening. “We recruited women 50 to 74 years of age, doing eligibility screening over the phone. We sent them a questionnaire to fill out and a medical release form. We got that back in the mail, and then contacted the clinic to get validated information on if they were up to date with screening. If they needed any combination of those three tests, they were randomized to one of three [study] arms. Group one received usual care. Group two received a DVD to take home and watch. The DVD provided education so that the participants could identify the test(s) needed and listen to vignettes from women from rural areas who faced similar barriers to obtaining screening. Group three received the DVD and a phone call from a navigator. For this group, the navigator, who was from a rural area, provided barrier counseling to identify and address the obstacles the women faced in completing the screening needed. The study is looking at which intervention was the most effective for the women.”
An ongoing, multi-year project will deploy implementation science research learnings to address cervical cancer prevention in the Appalachia area of Virginia, West Virginia, Ohio, and Kentucky. For this large grant-funded project, researchers are working with nearly 40 Federally Qualified Health Centers (FQHCs). “The first year we were doing some qualitative work, informant interviews, and finalizing our interventions,” Dr. Paskett explains. “We’re about ready to kick off our programs in the clinics next month. We’re now having to do all this virtually. We will be introducing three programs into the clinics that focus on cervical cancer prevention. The first one will be a program to help the clinics increase the uptake of the HPV vaccine. The second focuses on smoking cessation. The third is on cervical cancer screening including, for women who won’t come into the clinic for cervical cancer screening, mailed self-test kits.”
The three programs will be rolled out sequentially over one year, followed by teaching the clinics how to bundle all three into a cervical cancer prevention program. Half the clinics will participate this year, and the remainder will launch the process next year.
In October, the center will launch an initiative, funded by the American Cancer Society, Pfizer, and Pelotonia, focused on 12 counties in Ohio that have high death rates for African American women with breast cancer. The project will engage community partners and several interventions including the use of telephonic navigators to assist women in obtaining genetic testing counseling, accessing genetic testing, and mammograms. The OSUCCC Center for Cancer Health Disparities will provide education for the FQHCs on effective ways to focus on breast health and who, as well as how, to refer for genetic counseling and testing (if needed), mammography, and how to follow-up when a positive finding is reported.
Applying implementation science research to disparities in cancer screenings begins to address some of the barriers to coordinated care endemic in the fragmented U.S. healthcare delivery system. The AACR Cancer Disparities Progress Report 2020 notes that:
Increasing cancer screening rates alone will not eliminate cancer health disparities. We need to ensure that individuals whose screening tests show an abnormality receive follow-up testing and care in a timely manner.2
As Dr. Paskett explains, implementation science offers evidence-based practices for helping healthcare providers understand the next steps, make the linkages, and adopt or adapt best practices for integrating these into existing workflows “The clinics we’re working with, they want to provide the best care for their patients. They care about their patients. They want them to live a long time. But nobody teaches them how to do this.”
References
- Sharpless NE. Science. June 2020;368(6497):1290. DOI: 10.1126/science.abd3377.
- American Association for Cancer Research. Disparities in Cancer Screening for Early Detection. In AACR Cancer Disparities Report 2020. Available at https://cancerprogressreport.aacr.org/disparities.
