Geographically Underserved Areas

Geographic disparities in cancer outcomes are considerable and continue to persist. With the rise of the COVID pandemic, rural and frontier, low-income, and health shortage areas are the least prepared to meet emerging needs caused by the pandemic. Data compiled from our parent grant can be uniquely used to inform what is known about patterns of disparities in these areas and provide insight about the future impact of cancer on the population. In this supplement, we propose to expand our linkage of the Colorado Central Cancer Registry and the Colorado All Payer Claims Dataset to specifically consider areas of High and Persistent Poverty, Frontier and Remote Areas (FAR), and Health and Professional Shortage Areas (HSPAs) in Colorado. We expand the scope of the linkage to incorporate the most current data including time before and after the start of the COVID-19 pandemic and the resulting statewide lockdown that considerably restricted access to routine preventive care as well as assessment of emergent conditions.

TIPS: Tool for Inherited cancer Predisposition counseling and testing Study (Point-of-Care Genetic Services) Identifying and providing appropriate genetic counseling (GC) and genetic testing (GT) services is critical to guide care for 5-10% of breast, colorectal, endometrial, pancreatic, and prostate cancer patients and up to 18% of those with ovarian cancer. There are, however, logistical barriers to accessing GC and GT services, given the shortage of credentialed genetic health professionals. This is particularly salient in rural populations and those living in persistent poverty. Consequently, strategies to streamline the delivery of GC and GT services could greatly improve access among these populations. Specifically embedding these services within the existing oncology care setting, referred to as ‘Point-of-Care’ (POC) testing, has shown great promise. Through an existing effort, we developed and tested a web-based 12-minute pre-test GC educational video aligned with national practice standards, which successfully increased knowledge and informed/empowered decision-making in the majority of patients. We have also built an electronic resource in REDCap through which patients may complete components of a GC visit in the comfort of their own home through automated collection of personal and family history and viewing of the GC educational video online. Through this supplement, we plan to study the implementation of this platform, to automate delivery of POC web-based GC services together with GT for inherited cancer, with a rural underserved population who otherwise have limited access to these specialized services. In addition, we aim to assess barriers and facilitators to and impact of this process on these patients and their providers.

The Aim to Screen Rural Health Supplement leverages the success of the parent Aim to Screen award by moving the touch screen program delivered in underserved urban safety-net clinics to an online delivered intervention with program team support available by telephone and positioned locally in rural southeast Kansas. To ensure sustainability, the project has and will continue to engage local stakeholders – patients, clinicians, and staff – to learn how to best implement the program to result in highest impact (colorectal cancer screening) with the lowest clinic burden. The study will be conducted with 100 patients eligible for CRC screening at the Community Health Center of South East Kansas (CHCSEK), a large rural safety-net primary care setting. Participants will complete an online version of the parent award touch screen program that includes a screening form, informed consent, a baseline survey, and they will receive information on CRC test options including a free FIT test. Three and six-month phone surveys will be completed with all participants. The primary outcome will be CRC screening completion at 6 months.    

This supplement study, titled “Picturing Supportt,” will take place in six counties located in rural Southern Illinois. It will examine patients’ supportive care needs during and after a colonoscopy procedure. Colonoscopies require more time and effort from patients than other cancer screening tests, and many providers require that a family member or friend accompany the patient to the procedure. Participants in this study will include patients and the family members or friends who support the patient. Participants will receive cameras to document and contextualize the support they give and receive before and after the procedure. The study will provide findings to identify unmet needs of rural patients and families and inform the development of appropriate clinic and health system tools to support patients and their families. The work will directly inform the intervention for the parent R01 and support both completion of CRC screening and follow-up of positive FITs.

The eastern portion of both San Bernardino and Riverside counties are very isolated, with residents traveling long distances to see a physician and not having access to cancer treatment available to Los Angelinos in our word-class academic hospitals. Key health issues facing our rural counties include obesity and diabetes. 
Here we aim to test the impact of e-community based intervention, Eat Move Live (EML) to improve healthy behaviors, reduce obesity and prevent diabetes. EML started as a grass-root collaboration between Duarte (Los Angeles County) Latina mothers of school age children, the Duarte Unified School District, and Latina investigators at City of Hope. The goal of EML is to build a community-centric program to reduce type-2 diabetes and cancer. EML was framed around the mother as the main caretaker of the family; by empowering mothers to be healthy, mothers can in turn play pivotal roles in improving the health of their families. Since its inception, EML has been adapted for non-Hispanic Whites and several Asian immigrant populations. 
In this supplement, we aim to develop and pilot-test an interactive e-version of EML. Standard lectures will be developed and video-graphed. The lectures will be broadcast at specific times with EML staff on-hand to answer questions to test the hypothesis that a 12-week EML e-intervention can be delivered to remote portions of San Bernardino and Riverside counties as to reduce hyperinsulinemia and cancer-promoting epigenetic damage and increase exercise.

Remote delivery of Exercising Together to Geographically Underserved Couples Coping with Cancer. Rural cancer survivors are at elevated risk for a variety of poor health outcomes, even many years after their cancer diagnosis, but are the least likely to have access to programs and resources to improve their health and well-being. Improving health behaviors, such as physical activity, can have a substantial impact on quality of life and survival in cancer survivors and their partners, but rural and poor adults, and particularly cancer survivors, have low rates of physical activity. Survivors living in rural areas and/or in poverty face many barriers to exercise, particularly facility-based, supervised programs which can provide a more effective, safe and supportive engaging environment than unsupervised training. However, delivery of supervised, group programs can be challenging because of limited resources in rural/poor communities. Because we have recently adapted our supervised, group exercise intervention programs to remote delivery due to COVID-19, we now have an opportunity to expand the reach of our studies to cancer survivors and their partners in geographically underserved areas. For this supplement, we will conduct a community readiness assessment to understand the needs of cancer survivors living in geographically underserved counties in Oregon to participate in an exercise trial, and then we will pilot test our remotely delivered, supervised, group-based exercise in a cohort of 30 couples coping with breast, prostate or colorectal cancer. If successful, this supplement could completely widen the scope of how structured evidence-based supportive care programs, like exercise, could reach cancer survivors and their partners regardless of their resources and access.