# Presentation: 814137

## Methods to Overcome Barriers in Underserved Populations

- Dwight E. Heron, MD
- (on behalf of the Cancer Disparities Research Partnership)
- ASTRO Education Symposium
- November 6th, 2006

## CDRP Sites

- Laredo Medical Center
- Laredo, Texas
- Rapid City Regional Hospital*
- Rapid City, South Dakota
- Centinela Freeman Regional Medical Center*
- Inglewood, California
- New Hanover Regional Medical Center
- Wilmington, North Carolina
- Singing River Hospital*
- Pascagoula, Mississippi
- UPMC McKeesport*
- McKeesport, Pennsylvania
- *Surveyed site

**Notes:**
By way of introduction:  We surveyed four of the five CDRP site to obtain information on their approaches to community outreach, patient navigation and recruiting to clinical trials.  In addition we asked them to relate some of their successes and to provide ideas for improvement in the current program.

Each of the 5 CDRP sites were awarded the NCI grant to establish infrastructure and conduct outreach and accrue to clinical trials.  Awards were granted to the community hospital who started from ground zero having had no experience with nor establishment of grant research infrastructure.

That being said, what follows is an amazing set of accomplishments over the past 3-4 years

## Populations Served

| Site | African American | American Indian | Hispanic/ Latino | Indigent | Rural | Displaced  |
| --- | --- | --- | --- | --- | --- | --- |
| Cent. Freeman |  |  | 
 |  |  |  |
| Laredo |  |  |  |  |  |  |
| New Hanover | 
 |  |  |  |  |  |
| Rapid City |  | 
 |  |  |  |  |
| Singing River |  |  |  | 
 | 
 | 
 |
| UPMC McKee. | 
 |  |  | 
 | 
 |  |

**Notes:**
As you can see, the populations served by the 5 sites cover a broad spectrum of people who are known to be underserved.

## Approaches to Outreach

- Key Site Leaders
- Community Research Representative
- Outreach Nurse
- Health Educator
- Community Outreach Specialist
- Professional Development Specialist

**Notes:**
Credentials of key site leaders in outreach endeavors include....

## Approaches to Outreach

- Key Functions of Leaders
- Education
- Community events/meetings
- Church groups
- Health Ministries
- Hospital Employees
- Local Businesses
- Physicians
- Employ long-time community representatives from respective reservations or lay community

**Notes:**
Their functions reach a wide array of community members from hospital employees to community physicians.  Some novel approaches by the CDRP sites (Centinela Freeman and Rapid City) include employing community members who can liaise between the health professional and the community at large

## Approaches to Outreach (cont.)

- Key Functions of Leaders (cont.)
- Brochure & educational displays, including design of brochures for specific populations (i.e. Amish)
- Engages community partners already established in communities served to conduct outreach programs
- Tailor education programs for community groups (i.e. homeless)
- Engage community physicians in education programs with mentor(s)

**Notes:**
Specific functions include....

## Approaches to Navigation

- Navigator Requirements/Qualifications
- Registered Nurses (Rapid City)
- Lay Persons (Centinela Freeman & Singing River)
- Health Field Educated, Bachelor Level/Tumor Registrar (UPMC McKeesport)

**Notes:**
As can be seen, credentials of navigators vary among the four survey sites with each approach having significant effect as you will see in a later slide.

## Approaches to Navigation (cont.)

- Navigator Functions
- Support and guidance of patient & family
- Referrals to tribal, community & social support systems
- Coordinate services with physicians re: clinical trials eligibility
- Facilitate interactions & communications
- Advise patients re: ways to pay for care, transportation & other needed community resources
- Track interventions & outcomes

**Notes:**
Navigator functions include a fair amount of “social work” to assist patients in overcoming barriers to their health care.  This can be any barrier from transportation to a scheduled treatment site or assisting in obtaining child care to enable a patient to more easily get to the doctor

## Approaches to Navigation (cont.)

- Navigator Functions (cont.)
- Provides transportation for patients
-  – a critical issue in some service areas
- Serve as tumor registrars at 5 sites
- Refers newly diagnosed cancer patients to navigator program through physician
- Attends local health fairs to promote program to community
- Matches patients & navigators based on cultural, interpersonal, professional & peer characteristics
- Empowering patients to overcome barriers

**Notes:**
At UPMC McKeesport we are attempting to offer navigation services to patients as quickly as possible.  As tumor registrars, they notify the physician of record for the pathology immediately that a patient is eligible for navigation services.  More recently we obtained IRB approval to verbally consent patients due to the great distances some of our patients have to travel to the sites or delays eminent with mailing consents back and forth.

## Approaches to Clinical Trials

- Due to the nature of the unique populations served by the various CDRP sites surveyed, each sites’ strategies were explored

## Approaches to Clinical Trials (cont.)

- Rapid City
- Intensive orientation to various tribal health councils conducted
- Discussions, radio interviews
- Designed novel trial reducing treatment times that appealed to populations living extreme distances from medical facility
- Cultural sensitivity & relating treatment terms in meaningful language context

**Notes:**
Cultural sensitivity to acceptance of clinical trials was crucial for each of the sites.  Intensive outreach led to intensive orientation to the various communities and ultimately to clinical trial accruals.  

Rapid City overcame great obstacles with regard to IRB approvals, however, the design of a trial to reduce treatment time was specifically suited to the American Indians who traveled great distances to the medical center

## Approaches to Clinical Trials (cont.)

- Centinela Freeman
- Developed strategy to overcome barrier of general distrust of population to trials
- Used lay navigator to discuss navigation & trials upon first visit
- Navigators provided the bridge necessary to health professionals to reach the community

**Notes:**
Again outreach was key for Centinela Freeman who then used lay navigators to bridge to the community

## Approaches to Clinical Trials (cont.)

- Singing River (progress delayed by Katrina)
- Provided major follow up care post Katrina for 15 NCI protocol patients (Kiessler AFB Clinic was destroyed)
- Established track record
- All new consults screened for clinical trial appropriateness
- Full time research nurse & clinical research associate dedicated to program – RN also conducts outreach in the community & addressing clinical trials

**Notes:**
Despite the ravages of hurricane Katrina, Singing River was only slightly better off than Kiessler AFT Clinic, when they inherited 15 clinical trial patients from Kiessler during this time of crisis.  They have since accrued 6 additional patients to date.  Outreach approaches are ongoing at this site.

## Approaches to Clinical Trials (cont.)

- UPMC McKeesport
- Established RTOG affiliation for UPMC centers (3 of 5 sites)
- Work closely with two other health systems to advise on appropriate trials to offer
- Give physicians “ownership” of the trial
- Posted information in patient waiting rooms
- Worked with community partner to stimulate interest in and overcome distrust of clinical trials
- New clinical trials supplement will provide staff needed to increase these efforts

**Notes:**
Having five sites within it’s own program, UPMC McKeesport has 5 times the outrreach efforts being conducted.  Some approaches are detailed here, including assisting with establishment of infrastructure to conduct trials at each of these sites.  A very successful approach thus far has been that of physician ownership.  One of the community site physicians was made PI of a local trial giving him “ownership” and thereby incentive to accrue.  Dr. Stefanic has accrued 4 patients onto his trial within 3 months.  We will continue with intensive support system in place at McKeesport with the addition of a clinical research nurse coming on board in the very near future.

## Successes

- Major inroads into American Indian community by Rapid City
- Resilient program demonstrated by Singing River recovery from Katrina
- Immediate entry into communities via established partnerships by UPMC McKeesport
- Flexible & adaptive programs demonstrated by all with regard to communities served while maintaining scope

**Notes:**
Key to the programs has been the ability to grow with the community in responding to their needs for information regarding cancer treatment.  Each site had been through a learning curve in establishing its infrastructure that has paid off in every sense.  The most critical measure of this success that we have at hand is.......

## Successes (cont.)Accruals to Trials

| Site | Clinical Trials | Behavioral & Genetic Trials | Navigated | Total All Accruals |
| --- | --- | --- | --- | --- |
| Centinela Freeman | 26 |  | 208 | 249 |
| Singing River | 21* |  | 353 | 359 |
| Rapid City | 48 | 883 | 172 | 1103 |
| UPMC McKeesport
 | 20 | 34 | 261 | 315 |
| Totals | 115 | 917 | 994 | 2026 |

- *includes Kiessler follows ups post Katrina

**Notes:**
The numbers – which speak for themselves.  For just four of the six funded sites the numbers are quite phenomenal considering each of these sites had 0 patients on clinical trials at the time of program initiation.  These numbers translate into a whopping 122,500% increase!

## Advice

- Recommend 12-18 months start-up funding for programs initiated in community hospital setting followed by 18 months closure/ analysis period increasing program period to 7-8 years.
- Partner institutes should be invested & pro-active in guiding new programs particularly with assistance related to administration, regulatory & financial issues
- Institution should provide support & opportunity for community representatives to be adequately trained

**Notes:**
The road traveled to achieve this success was not without bumps large and small.  A few tips that might smooth this process are included here from the sites who contributed to this survey.