The Cancer Moonshot Blue Ribbon Panel Report, published in October 2016, identified clinical and research opportunities to expand use of proven cancer prevention and early detection strategies to improve patient outcomes and recommended projects related to cancer genetic testing (Recommendation G).
Colorectal cancer (CRC) is the third most frequently diagnosed cancer and the second leading cause of cancer deaths in the general US population. Cancer screening programs are partly responsible for declining CRC incidence and mortality in the United States. Unfortunately, American Indians (AIs) have experienced either no change or an increase in CRC incidence and mortality, disproportionate diagnosis of late-stage disease, and poorer survival.
Low screening rates
Despite the effectiveness of CRC screening tests for average-risk adults, these tests are significantly under-utilized by AIs, especially compared to urban Hispanic whites, adjusting for socio-economic status and other factors. Nearly two-thirds (65%) of US adults are current with CRC screening per US Preventive Services Task Force (USPSTF) guidelines. However, based on the Indian Health Service (IHS) Government Performance and Results Act data, screening rates ranged from a low of 28.1% in the Phoenix Area to a high of 50.5% in the Oklahoma Area, and 35% in Tucson and 41.9% in the Albuquerque Area. Most Tribes possess remarkably few healthcare resources to address CRC screening disparities and face many issues that underscore the need to implement effective CRC screening interventions targeting AIs, while engaging them with culturally appropriate interventions.
Barriers to healthcare services
AI health care is significantly underfunded, with fragmented services where acute care needs take precedence over preventive health services. Likewise, many IHS facilities have insufficient staff and high provider turnover, which results in abbreviated patient-provider encounters and insufficient or disjointed communications. Other documented barriers to CRC screening among AIs include cost/insurance, fear, stigma, embarrassment, and transportation. These issues underscore the need to implement culturally appropriate and effective CRC screening interventions targeting AIs. There is little evidence of efficacious CRC screening interventions being disseminated or implemented among AI communities or through IHS- or tribally operated health care facilities.
As a parallel effort to the ACCSIS initiative, the “Dissemination of a Colorectal Cancer Screening Program Across American Indian Communities in the Southern Plains and Southwest United States” consortia, referred to as the AI CRC Consortia, was established to address the need for improved evidence-based CRC screening interventions in a critically underserved population. The long-term goal of this initiative is to enhance health equity through the reduction of CRC disparities in morbidity, mortality, stage-at-diagnosis, and increase survival among AIs.
The overall objective of the project is to leverage the tribes’ and researcher team’s previous successes with dissemination and implementation science to test the effectiveness of comprehensive, multi-level, and multi-component interventions to facilitate and navigate American Indians aged 45-75 years, to obtain a CRC screening exam and follow-up care. Through supplements to the Cancer Centers, the University of Arizona, University of New Mexico and the University of Oklahoma received funding for two years (FY2018, 2019) to build partnerships, obtain tribal and university IRB approvals, conduct mixed-method environmental scans, develop and implement navigator trainings, identify protocols to tailor/target intervention strategies, and pilot test preliminary interventions for increasing screening in each of the primary study sites. Since the pilot years, the three sites have implemented full-scale, multi-level and multi-component strategies to test the effectiveness of the interventions within many different healthcare clinics, including the Indian Health Services (IHS), Tribal, and Urban Indian (I/T/U) facilities in both rural and urban areas.
University of Arizona Cancer Center:
University of New Mexico Comprehensive Cancer Center:
Stephenson Cancer Center at University of Oklahoma: