michael l. steinberg, md, facr principal investigator david khan, md co-principal investigator

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

Michael L. Steinberg, MD, FACRMichael L. Steinberg, MD, FACRPrincipal InvestigatorPrincipal Investigator

David Khan, MDDavid Khan, MDCo-Principal InvestigatorCo-Principal Investigator

Nicole HaradaNicole HaradaClinical Research CoordinatorClinical Research Coordinator

Our TeamOur Team

Principal InvestigatorPrincipal Investigator

– Michael Steinberg, MDMichael Steinberg, MD

Co-Principal InvestigatorsCo-Principal Investigators

– David Khan, MD, Radiation Oncologist, CF David Khan, MD, Radiation Oncologist, CF

– David Huang, MD, Radiation Oncologist, CFDavid Huang, MD, Radiation Oncologist, CF

– Nell Forge, PhD, MPH, Assoc. Behavioral Scientist, RANDNell Forge, PhD, MPH, Assoc. Behavioral Scientist, RAND

– Allen Fremont, MD, PhD, Assoc. Natural Scientist, RANDAllen Fremont, MD, PhD, Assoc. Natural Scientist, RAND

– Oscar Streeter, MD, Radiation Oncologist, USCOscar Streeter, MD, Radiation Oncologist, USC

– Mack Roach, MD, Radiation Oncologist, UCSFMack Roach, MD, Radiation Oncologist, UCSF

Cancer Disparities Research Cancer Disparities Research Partnership (CDRP) Program Partnership (CDRP) Program

Program Steering CommitteeProgram Steering CommitteeJanuary 20, 2006January 20, 2006Miami, FloridaMiami, Florida

Project Overview Project Overview

Status of Clinical TrialsStatus of Clinical Trials

12 Trials Open12 Trials Open

– 10 RTOG Sponsored Trials10 RTOG Sponsored Trials

– 1 Community-Based Trial1 Community-Based Trial

– 1 Device Trial1 Device Trial

Trials OpenTrials OpenName of TrialName of Trial Name of SponsorName of Sponsor Date openedDate opened

2003-02 DCIS2003-02 DCIS CYTYC (formerly Proxima)CYTYC (formerly Proxima) 11/30/200411/30/2004

RTOG 0229RTOG 0229 National Cancer InstituteNational Cancer Institute 12/29/200412/29/2004

RTOG 98-13RTOG 98-13 National Cancer InstituteNational Cancer Institute 12/24/200412/24/2004

Prostate Patient Profiles Prostate Patient Profiles Project (PProject (P44))

Louis Warschaw Prostate Cancer Center Louis Warschaw Prostate Cancer Center @ Cedars Sinai@ Cedars Sinai

09/08/200509/08/2005






RTOG 98-04RTOG 98-04 National Cancer InstituteNational Cancer Institute 12/07/200412/07/2004



Trials in DevelopmentTrials in Development

Melatonin TrialMelatonin Trial

Glutamine TrialGlutamine Trial

HDR as MonotherapyHDR as Monotherapy

Accrual to Clinical TrialsAccrual to Clinical Trials

120

1015

0

20

40

60

80

100

120

140

Patients Screened Eligible Enrolled

Clinical Trial QuestionnaireClinical Trial Questionnaire

Reasons for Declining Clinical TrialsReasons for Declining Clinical Trials

1 1

2

1

0

0.5

1

1.5

2

2.5

Lack of PCPSupport

PersonallyOverwhelmed

PreferredTraditionalTreatment

Problem withinsurance

Gender/Ethnicity of Patients of Gender/Ethnicity of Patients of Clinical TrialClinical Trial

1

4

3

2

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

African AmericanFemale

African AmericanMales

CaucasianFemales

Latino Males

Publications and Presentations 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 in review

““OMH OMH National Leadership Summit on Eliminating Racial Disparities in National Leadership Summit on Eliminating Racial Disparities in HealthHealth

January 9-11, 2006 Washington, D.C.January 9-11, 2006 Washington, D.C.

Lay Patient Navigator PresentationLay Patient Navigator Presentation

“Prophylactic Post-Operative Antibiotics for Prostate Brachytherapy”

presentation at the 2006 ASCO Prostate Cancer Symposium at February 2006

“California Cancer Reach 2010 Conference” May 2006 presentation on Patient Navigation

Update on Partnership RelationsUpdate on Partnership Relations

Centinela Freeman Centinela Freeman

USCUSC

UCSFUCSF

RANDRAND

USC/Norris Cancer Comprehensive CenterUSC/Norris Cancer Comprehensive Center

Mentoring InstitutionMentoring Institution– Guidance and oversight in clinical trial infrastructure Guidance and oversight in clinical trial infrastructure

– Collaboration of clinical trialsCollaboration of clinical trials

MammoSite TrialMammoSite Trial

P53 Trial ( in development )P53 Trial ( in development )

High Risk Prostate Cancer ( in development )High Risk Prostate Cancer ( in development )

– Collaboration of tumor boards and case conferencesCollaboration of tumor boards and case conferences

Weekly Combined Tumor Boards (Telesynergy)Weekly Combined Tumor Boards (Telesynergy)

USC School of Social WorkUSC School of Social Work

Intern Training in Social Service Management of Intern Training in Social Service Management of Cancer the Patient and NavigationCancer the Patient and Navigation

Developed Personal Health Record for Patients Developed Personal Health Record for Patients

Support Group DevelopmentSupport Group Development

Program Enlarging in 2006/2007Program Enlarging in 2006/2007

University of California, San FranciscoUniversity of California, San Francisco

Primary RTOG Site Primary RTOG Site

Guidance and oversight in clinical trial Guidance and oversight in clinical trial infrastructureinfrastructure

Rand CorporationRand Corporation

Providing Evaluation Component of the Program Providing Evaluation Component of the Program

Program Development Recommendations Program Development Recommendations

Focus Groups with Stakeholders (Community Focus Groups with Stakeholders (Community Advisory Board Members, ULAAC Project Staff, Advisory Board Members, ULAAC Project Staff, Patient Navigators, Community Physicians)Patient Navigators, Community Physicians)

Navigator Focus Groups Navigator Focus Groups

ACTION: multi-system collaboration NIH grantACTION: multi-system collaboration NIH grant

Compliance Compliance

ClinicalClinical

Regulatory Regulatory

AdministrativeAdministrative

Compliance ProcessCompliance Process

Outside AuditOutside Audit

Update on Telesynergy/TelemedicineUpdate on Telesynergy/Telemedicine

– Tumor BoardsTumor BoardsUSC – Every MondayUSC – Every MondayCFHS – Every WednesdayCFHS – Every Wednesday

– Training SessionsTraining SessionsULAAC Navigator Training ProgramsULAAC Navigator Training Programs

– MeetingsMeetingsInvestigator Meeting – QuarterlyInvestigator Meeting – QuarterlyMedical Advisory Board – QuarterlyMedical Advisory Board – QuarterlyULAAC – Every WednesdayULAAC – Every Wednesday

– Clinical TrialsClinical TrialsCollaboration with other CDRP sitesCollaboration with other CDRP sitesPatient consent Patient consent

Navigator Training ProgramNavigator Training Program

46

39

7

0

5

10

15

20

25

30

35

40

45

50

Signed up for training Completed training No-Show

Navigator Training OutlineNavigator Training Outline

The 6-hour training program takes place over three days:The 6-hour training program takes place over three days:

– Day OneDay One

Brief introduction to the project Brief introduction to the project

The role of the navigator developed by examination of The role of the navigator developed by examination of the barriers to health care existing in the community the barriers to health care existing in the community

Vignettes and anecdotes of a typical patient Vignettes and anecdotes of a typical patient


–Day TwoDay Two

Discussion of the navigator/patient relationship, including initiating Discussion of the navigator/patient relationship, including initiating contact, offering services and empowering the patientcontact, offering services and empowering the patient

Recordkeeping is demonstrated at length, with emphasis on the Recordkeeping is demonstrated at length, with emphasis on the research nature of the project and the importance of adequate research nature of the project and the importance of adequate chartingcharting

Appropriate use of the Intake Form, Hours and Mileage Form, the Appropriate use of the Intake Form, Hours and Mileage Form, the S.O.A.P. Form, and the Medications ListS.O.A.P. Form, and the Medications List

The biology of cancer and common types of treatment are discussed The biology of cancer and common types of treatment are discussed

Overview of clinical trials presented by one of the co-investigating Overview of clinical trials presented by one of the co-investigating physicians, including information on the benefits of trials physicians, including information on the benefits of trials participation to patients and the communityparticipation to patients and the community


– Day ThreeDay Three

Presentation on the Emotional aspects of cancer, sensitizing Presentation on the Emotional aspects of cancer, sensitizing the trainees to the fears and uncertainties cancer patient may the trainees to the fears and uncertainties cancer patient may face face

Presentation on the Barriers to trials participation in this Presentation on the Barriers to trials participation in this community are gathered from the participants’ point of view community are gathered from the participants’ point of view

Discussion about the benefits to trials enrollment are Discussion about the benefits to trials enrollment are reaffirmed as the trainees learn how to appropriately speak to reaffirmed as the trainees learn how to appropriately speak to their assigned patients about participation. their assigned patients about participation.

HIPAA presentation on patient confidentialityHIPAA presentation on patient confidentiality

Navigator TrainingNavigator Training

17

14

8

0

2

4

6

8

10

12

14

16

18

Group 1 Group 2 Group 3

Three training programs were conducted during the months of March (Group 1), June (Group 2), and September (Group 3), 2005. A total of 39 Navigators were trained.

Active NavigatorsActive Navigators

10

6

3

0

2

4

6

8

10

12

Group 1 Group 2 Group 3

Ethnicity of Active NavigatorsEthnicity of Active Navigators15

4

0

2

4

6

8

10

12

14

16

African Americans Latinos

Navigators Who Are SurvivorsNavigators Who Are Survivors

1

7

1

2

1

0

1

2

3

4

5

6

7

8

Esophageal Breast Colon Prostate Lung

Patient Navigation DataPatient Navigation Data152

93

3

56

0

20

40

60

80

100

120

140

160

Approached Accepted PendingDisposition

Declined

Reasons for Declining NavigationReasons for Declining Navigation42

12

1 10

5

10

15

20

25

30

35

40

45

Strong SupportSystem

Felt it was notneeded

MedicalBackground

Wanted noinformation at all

Patient Navigator Case LoadPatient Navigator Case Load

10

6

3

0

2

4

6

8

10

12

1-3 Patients 4-6 Patients 7-10 Patients

Chart Audit: “Barriers to Care”Chart Audit: “Barriers to Care”

Barriers to Care: Chart AuditBarriers to Care: Chart Audit

PT PT ID#ID#

DxDx BarriersBarriers Navigator Navigator AssignedAssigned

Date of Date of ReviewReview

Date Date closedclosed

Days Days openopen

Resources Resources IdentifiedIdentified

Did ULAAC Did ULAAC staff assist staff assist Navigator?Navigator?

009009 ColonColon 1. Transportation1. Transportation RJHRJH 04/29/0504/29/05 04/30/0504/30/05 22 Taxi Taxi voucher voucher programprogram

NoNo

2. Financial2. Financial RJHRJH 04/29/0504/29/05 04/30/0504/30/05 22 Beckstrand Beckstrand Cancer Cancer

FoundationFoundation

NoNo

6 Most Common Barriers6 Most Common Barriers

50

118

117 9

0

10

20

30

40

50

60

1

Transportation Fear of Cancer

Lack of Caregiver Financial Difficulties

Language Difficulties Lack of Psychosocial Support

Assessment and Effectiveness of Assessment and Effectiveness of Quality AssuranceQuality Assurance

Navigator Focus Groups (Rand source protected feedback)Navigator Focus Groups (Rand source protected feedback)

Patient Satisfaction Survey, compatibility and does the Patient Satisfaction Survey, compatibility and does the navigation process meet patient needs (patient perception of navigation process meet patient needs (patient perception of effectiveness) effectiveness)

Clinical Trials Questionnaire Clinical Trials Questionnaire

Telephone interviews with patientsTelephone interviews with patients

Compliance interviews (5%)Compliance interviews (5%)

CHALLENGES AND CHALLENGES AND OPPORTUNITIESOPPORTUNITIES

Evaluation of effect on trialsEvaluation of effect on trials

Pushing navigation earlier in the process of care (surgeons, Pushing navigation earlier in the process of care (surgeons, primary care, screening) primary care, screening)

Using army of navigators in community outreachUsing army of navigators in community outreach

Using navigator for disaster preparednessUsing navigator for disaster preparedness

Testimonial method in training and in presentation of clinical Testimonial method in training and in presentation of clinical trials trials

CHALLENGES AND CHALLENGES AND OPPORTUNITIESOPPORTUNITIES

Ongoing Evaluation Will Provide Practical Information Ongoing Evaluation Will Provide Practical Information

– Elimination of barriers to care Elimination of barriers to care

– Quality assessmentQuality assessment

– Effects of navigation on accrual to clinical trialsEffects of navigation on accrual to clinical trials

Spawned from the ULAAC Grant Spawned from the ULAAC Grant

– Cancer CommitteeCancer Committee

– ACoS Accreditation with 7 commendationsACoS Accreditation with 7 commendations

– Tumor Boards case conferences weeklyTumor Boards case conferences weekly

– Community Outreach and health screeningsCommunity Outreach and health screenings

– Navigators outreach educating the community Navigators outreach educating the community about the benefits of clinical trials about the benefits of clinical trials

– Development of a Spanish Support GroupDevelopment of a Spanish Support Group

Media CoverageMedia Coverage

La Opinion article, November 11, 2005La Opinion article, November 11, 2005

– To Navigate Services in a Health System: The Patient Navigator To Navigate Services in a Health System: The Patient Navigator Program Helps Sort Through Obstacles that Make it Difficult to Program Helps Sort Through Obstacles that Make it Difficult to Treat CancerTreat Cancer

Inglewood Today article, October 12, 2005Inglewood Today article, October 12, 2005

– Taking Care of Business: The Urban Latino African American Taking Care of Business: The Urban Latino African American Cancer (ULAAC) Disparities ProjectCancer (ULAAC) Disparities Project

KCAL 9 news station (CBS)– December 7, 2005 2:00 PM, 3:00 PM, KCAL 9 news station (CBS)– December 7, 2005 2:00 PM, 3:00 PM, and 4:00 PM news ULAAC: New cancer Program Helps Patients and 4:00 PM news ULAAC: New cancer Program Helps Patients Navigate SystemNavigate System

http://cbs2.com/video/[email protected]://cbs2.com/video/[email protected]

Centinela Freeman Community Centinela Freeman Community FoundationFoundation

Mission Statement:Mission Statement:

“ “The mission of the Centinela Freeman Community The mission of the Centinela Freeman Community Foundation is to enhance the health and healthcare Foundation is to enhance the health and healthcare of South and Southwest Los Angeles by developing of South and Southwest Los Angeles by developing

and supporting healthcare education, medical and supporting healthcare education, medical research, and programs which improve access to research, and programs which improve access to healthcare for the citizens of our community.”healthcare for the citizens of our community.”

Centinela Freeman Community Centinela Freeman Community FoundationFoundation

Leveraging Off Previous Community Based Foundations … Formed New Leveraging Off Previous Community Based Foundations … Formed New FoundationFoundation

Establishing Infrastructure to Support Access to Care and Clinical Establishing Infrastructure to Support Access to Care and Clinical Research in the CommunityResearch in the Community

Current ActivitiesCurrent Activities

– Recruited Executive Director Recruited Executive Director

– Diabetes Screening/Navigator ProgramDiabetes Screening/Navigator Program

– Cancer Screening ProgramCancer Screening Program

– High School Sports Trainer FundingHigh School Sports Trainer Funding

– Nursing AcademyNursing Academy

– Low cost insurance supplement collaboration Low cost insurance supplement collaboration

““Still Too Separate, Not Yet Equal”Still Too Separate, Not Yet Equal” … A. Epstein… A. Epstein

Describing And Explaining Disparities Is Much Describing And Explaining Disparities Is Much Easier Than Devising Strategies To Reduce Easier Than Devising Strategies To Reduce Disparities Disparities

michael l. steinberg, md, facr principal investigator david khan, md co-principal investigator

Documents

cancer care

radiation oncologist

lay patient navigator

california cancer reach

patient navigators

patient navigationupdate

asco prostate cancer

racial disparities