Poverty

Arkansas is one of the most rural and impoverished states in the U.S., with rural, African Americans (AA) bearing a disproportionate burden of cancer and related outcomes. Due to the fact that rural AA are more likely to live in persistent poverty and experience poverty's adverse effects, the mortality and incidence rates for the four major cancers and all cancers combined in Arkansan AA are among the highest in the nation. These disparities in cancer-relevant outcomes are further compounded by decades of discrimination and racism. Despite the state's obvious need to advance cancer prevention and control efforts, there are no NCI- designated cancer centers that serve the state, nor a strategic plan to address cancer disparities among communities in rural persistent poverty counties. Without a formal, systematic plan for cancer research engaging communities in this high-need area of Arkansas, cancer prevention and control efforts will continue to be stymied in communities who desperately need treatment now. Our goal through this P30 supplement is to form a cross-cancer center partnership that leverages the infrastructure of Roswell Park Comprehensive Cancer Center (Roswell Park) and the University of Arkansas for Medical Sciences Winthrop P. Rockefeller Cancer Institute (UAMS/WPRCI) to programmatically advance a cancer control agenda to reduce cancer disparities experienced by rural AA communities in the highest need areas of the U.S. This study will simultaneously 1) gather clinic-, community-, and participant-level data to inform a strategic plan for cancer prevention and control; and 2) build sufficient capacity within institutions currently serving Arkansas rural persistent poverty areas to implement a systematic program of cancer research. We will use mixed methodology to characterize cancer-related factors in rural AA communities, ascertain the current cancer research capacity of healthcare clinics that serve the target area, and determine assets and gaps within institutions who serve these communities to implement cancer research. We will collect standardized survey data from 240 AA residing in rural persistent poverty counties, electronic medical records (EMR) data from three clinics that serve all 12 rural poverty persistent counties, and qualitative data from 12 in-depth interviews with clinic leaders and administrators. To build the area's capacity for cancer research in the target area, we will construct a Community Advisory Board (CAB) consisting of healthcare clinic and community leaders. Through engaging the CAB in all aspects of the study, we will build relationships between healthcare, community, and academic stakeholders to conduct rigorous cancer prevention and control research. This collaboration will be developed from already long-standing relationships with the healthcare system and rural AA community within our team, in addition to Roswell Park's innovative partnership with WPRCI/UAMS. This study will provide the necessary evidence base and partnership capacity to develop organized efforts (that have not yet been implemented) for cancer prevention and control in a high-risk population.

Nonmedical social determinants of health are increasingly recognized for their impact on cancer outcomes. In New Mexico, our research team found that 36% of population-based cancer survivors experienced food insecurity in the 12-months following diagnosis. Food insecurity, hosing instability, transportation challenges, and utility needs are social needs that are all associated with suboptimal treatment adherence and poor health related quality of life for cancer survivors. Unmet social needs are particularly prevalent in areas of persistent poverty, presenting substantial challenges for cancer control. The goal of the proposed project is to create and test a sustainable, multidisciplinary, bi-institutional collaboration between the University of New Mexico (UNM) and New Mexico State University (NMSU) together with community organizations and clinics in persistent poverty areas. The Research Partnership to Address Social Needs in Cancer Care (REPASO) will: 1.) Create an innovative, multidisciplinary social needs research enterprise to eliminate cancer outcome disparities in persistent poverty areas of NM. We will build relationships among interdisciplinary academic researchers and community partners to develop a common knowledge-base of strategies to address social needs, tailored to the unique, local context of persistent poverty counties. 2.) Develop the research infrastructure to track the provision of social services to, and monitor outcomes of cancer survivors in persistent poverty areas. We will build data collection and management capacity and provide training for community organizations and clinics to track the delivery of services and link to local data on cancer outcomes. The novel REPASO enterprise will enhance the capacity of the two major university systems in NM to investigate and address unmet social needs as contributors to observed disparities in cancer outcomes and develop the collaborative relationships and infrastructure needed for community organizations and clinics serving low-income and underserved populations in persistent poverty areas to implement and participate in the evaluation of evidence-based social needs interventions. Ultimately, addressing unmet social needs of cancer survivors in persistent poverty areas has strong potential for advancing cancer health equity by improving the well-being and quality of life of cancer survivors.

Colorectal cancer is the 4th most common cancer diagnosed and the 2nd most common cause of cancer death in the United States. The age-adjusted incidence of CRC in Philadelphia County – a persistently high poverty area– is nearly 25% above the national average. Guideline-based screening for CRC via colonoscopy or fecal immunohistochemistry (FIT) reduces CRC-associated mortality. Despite the proven benefit of regular colonoscopy, CRC screening completion rates remain only around 50% in Philadelphia County and are consistently 10-15% lower for African Americans than White individuals living in Philadelphia County. Adverse social determinants of health such as high poverty contribute to CRC screening nonadherence disproportionately for African American and other minority communities. Recognizing this, in 2011, Penn Medicine created a navigation program to increase access to screening colonoscopies for patients in underserved areas of West, South, and Southwest Philadelphia by providing services that reduce barriers to cancer screening, including transportation assistance and detailed instructions on bowel prep. Despite initial success in increasing colonoscopies, a key challenge in scaling this navigation program is identifying patient populations at increased risk of CRC, who may benefit most from timely navigation. Automated machine learning (ML) algorithms based on routine electronic health record (EHR) data accurately estimate a patient’s relative risk of CRC. High-risk individuals may be particularly motivated to comply with disease screening recommendations and be targeted with an effective but resource-constrained navigator program. The overarching goals of this Administrative Supplement is to support the Abramson Cancer Center (ACC) mission to increase colorectal cancer (CRC) screening completion among high-risk individuals living in a persistent poverty county by designing, conducting, disseminating and evaluating an electronic health record- based automated identification program to target effective, culturally-sensitive CRC screening navigation to individuals who have not completed an ordered colonoscopy or fecal immunochemical test (FIT). Specifically, the goals of this supplement are to: 1) Adapt a previously validated EHR-based machine learning algorithm to predict CRC detection by retraining the model using data from patients seen in primary care clinics serving zip codes with a high proportion of racial and ethnic minorities living in Philadelphia County, a persistent poverty county; and 2) Implement and evaluate the feasibility and effectiveness of an algorithm-based CRC navigation program to increase colorectal cancer screening among 344 patients seen at one of 7 primary care practices within Philadelphia county who are at high risk of CRC, have uncompleted colonoscopies. Together, these projects aim to increase evidence-based screening in order to reduce the burden of CRC among high-risk individuals living in a persistent poverty county by utilizing evidence-based, targeted, culturally-sensitive CRC screening navigation that in part addresses social factors that prevent colorectal cancer screening.

In 2017, Texas had the highest incidence of liver cancer in the United States and ranked second in liver cancer-associated mortality and the highest incidence rates occur in South Texas. Between 2001-2015, Texas had an average annual increase in liver cancer incidence of 3.9%, the national average was 3.8% per year for the same period. The population in South Texas is 70% Hispanic, 87% of whom identify as Mexican Americans. The South Texas Hispanic population experiences socioeconomic and healthcare disparities, leading to disproportionately higher rates of infectious disease-related cancer, including liver cancer. Between 2012-2017, the liver cancer incidence and mortality rate were higher among the Hispanic population than non-Hispanic whites in Texas. Additionally, Mexican Americans have a seven-fold all-cause mortality due to chronic HCV- associated disease compared to non-Hispanic whites and non-Hispanic blacks. Chronic HCV infection is a major risk factor for liver cancer. Our long-term goal is that by addressing chronic HCV infection through secondary prevention measures, we can assuage the liver cancer disparity in South Texas Hispanics. To achieve this goal, this study proposes two specific aims: (1) use Replicate Effective Programs (REP) to implement the evidence-based STOP-HCC-HCV program in two clinic systems primarily serving low-income, underserved Hispanic communities in three South Texas persistent poverty counties; (2) evaluate the effect of the STOP-HCC-HCV evidence-based program through empirical analysis of patient use outcomes and stakeholder feedback. The counties selected for this proposal are Hidalgo, Starr, and Cameron Counties, located in South Texas and designated as a Persistent Poverty Area, Health Professional Shortage Area, and Medically Underserved Area. There is a tendency for the public health system in persistent poverty areas to be chronically neglected. This proposed intervention will provide sustainable infrastructure to two community clinics using teleconsultations, tele-mentoring, making improvements to workflow and navigation, providing educational resources, and a technical evaluation to improve the HCV screening, treatment, and cure rates. The STOP- HCC-HCV program significantly increased the proportion of South Texas baby boomers screened and treated for chronic HCV; by tailoring this program for use in novel populations, we can strengthen the primary prevention of liver cancer through secondary prevention of HCV and contribute to the national strategic goal of eliminating HCV. Additionally, the data collected from this program will inform the development of future preventive strategies directly relevant for the South Texas Hispanic population.

Lung cancer screening has been shown to lead to early detection and reduced mortality. While the uptake of lung cancer screening is lower than other cancers across the nation, it is disproportionately lower in underserved rural racial/ethnic minority populations, which are often those living in persistent poverty. Furthermore, rural communities and those with persistent poverty have elevated rates of lung cancer mortality. The majority of persistent poverty counties are located in the Southern U.S. and in nonmetropolitan areas. Despite disparities in lung cancer outcomes, little empirical investigative evidence exists as to the reasons for lung cancer disparities among people living in persistent poverty. To address this gap, we will increase the capacity to bring lung cancer control research initiatives to rural counties with persistent poverty in the South. The goal is to understand the multi-level factors impacting adoption of lung cancer screening in vulnerable communities and to enhance capacity in the area of cancer prevention and early detection. In partnership with three federally-qualified health centers (FQHCs) in rural counties designated as persistent poverty, we will identify the needs, barriers and facilitators to lung cancer screening at the patient, provider, and community-level and will provide educational interventions to help address the limited access to lung cancer screening in these communities. The patient populations served by these FQHCs are primarily African American and living well below the federal poverty level. We propose the following three aims: 1) conduct a multi-level environmental scan to assess patient and clinic needs, barriers, and facilitators to access to lung cancer screening among eligible individuals who reside in rural counties with persistent poverty; 2) identify eligible patients for lung cancer screening; and 3) strengthen capacity and implement an educational intervention about lung cancer screening targeted to patients and providers in federally-qualified health clinics and partner hospitals with low-dose computed tomography scanners. We will employ innovative community-engaged strategies to support capacity building and increase awareness and control, aligning with community needs. Careful investigation will identify barriers and facilitators to address lung cancer screening utilization. A key innovative aspect of this proposal is its community-engaged approach, which will help translate our empirical findings into the design of a patient and provider-oriented community-based lung cancer control program. This project is relevant to the mission of the National Cancer Institute since it focuses on establishing equity in lung cancer screening utilization. Our findings will inform the development of improved clinical strategies for the early detection of lung cancer and can lead to future initiatives in partnership with the communities at greatest need of lung cancer screening.