# Presentation: 162598

## Urban Latino African American Cancer (ULAAC) Disparities Project at Centinela Freeman Regional Medical Center

**Michael L. Steinberg, MD, FACR**
*Principal Investigator*
**David Khan, MD**
*Co-Principal Investigator*
**David Huang, MD**
*Co-Principal Investigator*
**Nicole Harada, CCRC**
*Clinical Research Coordinator*

## Our Team

**Principal Investigator**
- Michael Steinberg, MD
**Co-Principal Investigators**
- David Khan, MD, Radiation Oncologist, CF
- David Huang, MD, Radiation Oncologist, CF
- Nell Forge, PhD, MPH, Assoc. Behavioral Scientist, RAND
- Allen Fremont, MD, PhD, Assoc. Natural Scientist, RAND
- Oscar Streeter, MD, Radiation Oncologist, USC
- Mack Roach, MD, Radiation Oncologist, UCSF

## Cancer Disparities Research Partnership (CDRP) Program RTOGToronto, Canada

**Program Update**
**June 2006**

## Status of Clinical Trials

- 7 Trials Open
- 5 NCI Sponsored Trials
- 1 NCIC Sponsored Trial
- 1 Community-Based Trial

## Trials Open

| Name of Trial | Name of Sponsor |
| --- | --- |
| Prostate Patient Profiles Project (P4) | Louis Warschaw Prostate Cancer Center @ Cedars Sinai |
| RTOG 0413 | National Cancer Institute |
| RTOG 0232 | National Cancer Institute |
| RTOG 0321 | National Cancer Institute |
| NCIC CTG MA.20 | National Cancer Institute of Canada |
| RTOG 98-04 | National Cancer Institute |
| RTOG 0315 | National Cancer Institute |

## Trials Pending Approval by WIRB

- Cancer Post Treatment Survey – *Exemption*
- Rand/ULAAC Patient Navigator Survey – *In progress*
- RTOG 0123 – *In progress*
- RTOG 0214 – *In progress*
- RTOG 0116 – *In progress*
- S0424 – *In progress*

## Trials Accrued

## Accrual to Trial by Ethnicity

## Accrual to Trial by Gender

## Accrual to Trial by Residence

**Los Angeles (90008 – 90047)****	****Inglewood (90301 – 90305)    Gardena (90249)**
**Torrance (90250)****	****	****Culver City (90230)                Marina Del Rey (90292)**
**Sun City (92586)**

## Clinical Trials – NCI & Device Sponsored

## Reasons for declining clinical trial

## Publications and Presentations    

- “Implementing a Lay Patient Navigator Program to Reduce Barriers for Minority Patients’ Access to Cancer Care and Clinical Trials: Essential Steps and Initial Challenges”** **
***Manuscript  resubmitted***
- “National Leadership Summit on Eliminating Racial Disparities in Health”
** *****January 9-11, 2006, Washington, D.C******.***
***“***Prophylactic Post-Operative Antibiotics for Prostate Brachytherapy*”**** ***
***Presented at the 2006 ASCO Prostate Cancer Symposium***

## Publications and Presentations    

**“****Developing a Lay Patient Navigator Program Addressing Barriers to Care and Participation in Clinical Trials”**
***Presented at  the REACH 2010 Conference, May 17, 2006***
**“****Preliminary Results and Evaluation of MammoSite® Balloon Brachytherapy for Partial Breast Irradiation for Pure Ductal Carcinoma in Situ: A Phase II Clinical Study**** ****”**** **
***Presented at the American Society of Breast Surgeons Meeting, April 2006***
**“****Using Telesynergy® to Improve Access to Clinical Trials at an Underserved Community Based Hospital**”
-  ***Submitted to ASTRO, November 2006***

## Publications and Presentations

**A Lay Patient Navigator Program as Part of a Clinical Trials Infrastructure in a Community Hospital Serving Minority and Low Income Patients **
***Submitted to Cancer Health Disparities Summit 2006, Bethesda, MD, ***
***    ******July 17-19, 2006***
**The Use of Lay Patient Navigators to Improve Quality of Care and Accrual to Clinical Trials for Radiation Oncology Patients Who Are Minorities or of Low Socioeconomic Status**
***Accepted for oral presentation at  ASTRO 2006,   Philadelphia, PA, ***
***    ******Nov. 5-9, 2006***
**The Urban Latino African American Cancer (ULAAC) Disparities Project: Implementing the NCI-Radiation Research Program Model**
***Cancer in African Americans - Challenges and Opportunities the Cleveland Clinic Taussig Cancer Center, May 11-13, 2006***

## Update on Partnership Relations

- Centinela Freeman
- USC
- UCSF
- RAND

## USC/Norris Cancer Comprehensive Center

- Mentoring Institution
- Guidance and oversight in clinical trial infrastructure
- Collaboration of clinical trials
- MammoSite DCIS Trial (completed)
- P53 Trial ( in development )
- High Risk Prostate Cancer ( in development )
- Collaboration of tumor boards and case conferences
- Weekly combined tumor boards

## Cancer Disparities Research Partnership (CDRP) ProgramRTOGToronto, Canada

**Process Evaluation:  **
**Overview**
**RAND Corporation**

## Overview of RAND Activities

- Navigator focus groups
- Development of patient surveys and interview protocols
- Fostering research opportunities
-    (e.g. ACTION)
- Assistance on manuscripts
- Provider and staff interviews

**Notes:**
Refer to each  a sentence or two of elaboration, for Fostering Research opportunities , refer them to ACTION program PDF sent around, 

## Process Evaluation

- Assess whether the project’s goals and objectives have been operationalized and implemented as intended.
- Identify areas where adjustments are needed to increase the program’s effectiveness and efficiency.

## Process Evaluation: Methods and Stakeholders

- Focus Groups
- Patient Navigators
- Face to Face Interviews
- Patients
- Semi-Structured Interviews
- Community Providers
- DFMH/ULAAC Staff

## Focus Group Sessions:Content Areas

- Patient Navigator
- Role
- Motivation
- Skills
- Needs
- Patient
- Navigator Training
- Clinical Trials
- Perceptions

## Patient Instrument:Key Domains

- Patient Needs and Barriers
- Perceived Satisfaction
- Navigator Support
- Provider Care
- Self-Efficacy
- Cancer knowledge
- Empowerment

## Update on Telesynergy/Telemedicine

- Tumor Boards
- USC – Every Monday
- CFHS – Every Wednesday
- Training Sessions
- ULAAC Navigator Training Programs
- Meetings
- Investigator Meeting – Quarterly
- Medical Advisory Board – Quarterly
- ULAAC – Every Wednesday
**Increased participation with mentoring institutions**
**Increased participation with CDRP sites**
- Clinical Trials
**Collaboration with other CDRP sites**
- Patient consent (Speaking)
**Abstract submitted to ASTRO**

## Cancer Disparities Research Partnership (CDRP) ProgramRTOGToronto, Canada

**Patient Navigator Program**

## Training Program

## Active Navigators

## Ethnicity of Active Navigators

## Navigators Who Are CancerSurvivors

## Patient Navigation Data

**67% accepted navigation**

## Ethnicity of Patients Approached

**Percentage Breakdown: **
**71% African Americans, 13% Latinos, 11% Caucasians, 4% Asians, 1% Other**

## Ethnicity of Patients Accepting Navigation

**Percentage Breakdown: **
**67% African Americans, 71% Latinos, 55% Caucasians, 70% Asians, 33% Other**

## Ethnicity of Patients Declining Navigation

## Reasons for Declining Navigation

## 6 Most Common Barriers

## Solutions for Barriers

**Transportation**
- Taxi vouchers
- Variety of van services to accommodate patients with special needs
- Work with patients’ insurance carrier to provide transportation
- Navigators who are willing to drive patients to and from treatment
**Psychosocial**
- Match patients with navigators who are cancer survivors (matching type of cancer when possible)
- Increase frequency of comfort calls
- Referral to patient/family support groups and/or counseling
**Financial**
- Financial assistance organizations
- Food vouchers
- Salvation Army and Catholic Charities
- Utilities assistance
- Housing assistance and referral

## Solutions for Barriers

**Fear of Cancer**
- Provide linguistically appropriate, cancer-specific educational materials
- Accompany patients to cancer-related medical visits
- Encourage support group participation
**Caregiver**
- Referral to In Home Supportive Services
- Referral to Multipurpose Senior Services Program
- Referral to Comfort Keepers
**Language**
- Assign navigators who are culturally and linguistically appropriate
- Make sure translator is available at patients’ appointments
- ALAS Para tu Salud – a translation program based in Los Angeles, CA

##  Cancer Post-Treatment Survey

**Study Questions:**
**Are there quantitative differences between  patients who received navigation versus those who did not in various QOL domains?**
**Are there patient perceived quality differences in the two groups?**

##  Cancer Post-Treatment Survey

**Source:**
**	****RTOG A-5 Demographic Survey**
**	****FACIT and Model Questions**
**	****	****Domains Evaluated**
**	****	****	****Spiritual**
**	****	****	****Social/Family **
**	****	****	****Physical  **
**	****	****	****Emotional **
**	****	****	****Functional **
**	****	****Patient Centered Questions**
**	****	****Relationship Based Questions**

## Cancer Disparities Research Partnership (CDRP) ProgramRTOGToronto, Canada

**Milestones **
**and **
**Lessons Learned   **

## ULAAC Access Database

## ULAAC Access Database –Cancer Post Treatment Survey

## Quality Assurance Patient Evaluation of Navigator Services Structured Interview

## Centinela Freeman Community Foundation

- Established  Community Health  Foundation
- Mission: Establish Infrastructure to Support Access to Care and  Clinical Research in the Community
- Current Activities
- Recruited Executive Director
- Diabetes Screening and Care/Navigator Program
- High School Sports Trainer Funding
- Centinela Freeman Research Institute
- Nursing Academy
- Trains 72 RNs per year

## MSW Intern’s Role

- Provided navigation
- Conducted various in-services for navigators (basic training/orientation, self disclosure guidelines)
- Developed  prototype Patient Tracking Notebook
- Built resource guide for navigators
- Laid groundwork for Latino Cancer Support Group
- Spanish

## Lessons Learned 

- It takes 15 months to start navigating patients
- It takes at least 1 year to gather enough data for analysis of navigation
- It takes 18 months to start clinical trials
- Clinical trials applicable to our institution and patient population are not plentiful
- Community hospital infrastructure was not initially conducive to grant support...we had to create our own