Studying the implementation of evidence-based interventions for

cancer prevention

Prajakta Adsul, MBBS, MPH, PhD

Assistant Professor, Department of Internal MedicineUniversity of New Mexico School of Medicine and

Comprehensive Cancer Center

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No disclosures to report

Outline

• Professional background

• What is implementation science?

• Ongoing collaborations with federal/national networks• CCCNP• CPCRN

• What is happening in New Mexico?• CRC moonshot• CHW toolkit• Cancer control plans

• How has COVID affected cancer screening?

• Future directions

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Professional Background

Clinical medicine

Public health

Cancer prevention

Implementation research

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Evidence-based interventions for cancer prevention

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Evidence base for screeningUnited States Preventive Services Task Force

Breast Cancer (2016)

Grade B 50-74 years Mammography Every 2 years

Colorectal cancer(2016)

Grade A 50-75 years Multiple tests Varies with test

Cervical cancer(2018)

Grade A 21-29 years Pap smears Every 3 years

30-65 yearsCo-testing or

hrHPV DNA as primary

Every 5 years

https://www.uspreventiveservicestaskforce.org/Page/Name/recommendations |6

Screening is a series of steps and can be influenced by factors at multiple socio-ecological levels

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Cancer Control Continuum

https://cancercontrol.cancer.gov/od/continuum.html|8

Multiple levels of influence on cancer care

Taplin, S. et al. 2012 |9

Complexity in studying implementation of screening

Uptake is dependent on behavior and delivery of services

Clinical and community settings

Multiple stakeholders

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Implementation research methods to study cancer screening

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Implementation research

“scientific study of the use of strategies to adopt and integrate evidence-based health interventions into clinical and community settings in order to improve patient outcomes and benefit population health”

NIH PAR -19 - 274|12

Implementation Research Methods

What?

Evidence Based

Interventions

How?

ImplementationStrategies

ServiceOutcomes*

EfficiencySafety

EffectivenessEquity

Patient-centeredness

Timeliness

Health Outcomes

SatisfactionFunction

Health status/symptoms

Implementation Outcomes

AcceptabilityAdoption

AppropriatenessCosts

FeasibilityFidelity

PenetrationSustainability

Proctor, E.K., 2009|13

Cancer screening implementation – collaborations with national networks 1. Comprehensive Cancer Control National Partnership (https://cccnationalpartners.org) 2. Cancer Prevention and Control Research Network (https://cpcrn.org/)

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Comprehensive Cancer Control National Partnership

Technical assistance as an implementation strategy for uptake of evidence-based interventions CRC Screening - 2015 - 11 state teams

HPV Vaccination – 2016 - 11 state teams

Expert presentations – brainstorming per local context – action planning

Total participants ~120 (including experts)

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Centralizing technical assistance

Evaluation using a survey showed: Improved knowledge and attitudes towards

use evidence-based interventions

Increased number of evidence-based interventions on the state action plans

Increased collaborations among state team members and across teams

Increased state level partnerships

Qualitative interviews

Mooreland-Russell, S., Adsul, P. et. al. ., 2019; Adsul, P., Chambers, D., 2019 |16

11 state teams that received HPV vaccination related technical assistance

11 state teams that received CRC screening related technical assistance

Cancer Prevention and Control Research Network (CPCRN)

National network of academic, public health, and community partners who work together to reduce the burden of cancer, especially among those disproportionately affected

Community-based participatory cancer research across its eight network centers, crossing academic affiliations and geographic boundaries.

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RURAL focus

Health Organizations

Cancer screening implementation – local collaborations1. Colorectal Cancer Screening Programs across American Indian communities (More information here:

https://www.cancer.gov/research/key-initiatives/moonshot-cancer-initiative/implementation/prevention-early-detection )

2. NCI funded CRC Screening Toolkit developed in NM3. Review of Cancer Control State Plans for colorectal cancer screening

(https://www.cdc.gov/cancer/ncccp/ccc_plans.htm)

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Cancer Moonshot – CRC in American Indian Communities

PI – Dr. Shiraz Mishra/ Dr Kevin English in collaboration with Albuquerque Area Indian Health Board

Rationale: AI/ANs are significantly less likely than non-Hispanic Whites to receive timely and risk- and age-appropriate cancer screenings, including recommended CRC screening. The short term goal is to enhance annual CRC screening using the fecal immunochemical test (FIT) using collaborative approaches with healthcare provider teams

Working with Santo Domingo and Jemez Pueblo

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Saving Lives - Increasing CRC screening in NM Hispanics

Finalized the toolkit and training through a multi-year process that incorporated community and stakeholder input (available upon request)

Educating CHWs and providing them with appropriate materials addresses some gaps to improve CRC screening rates; however, other barriers to screening among NM Hispanics remain

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Reviewing 4 corners state cancer control plans for CRC

How do they approach local data and statistics?

What are some of the evidence-based approaches that are being used?

How are they implementing these interventions, given some of the contextual barriers?

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COVID and Cancer Screening

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Impact of COVID

Electronic Medical Records at 39 health systems representing 190 hospitals in 23 states

Compared to 2017-2020 January, March 2020 the screening rate decreased by 86-94%

23https://ehrn.org/wp-content/uploads/Preventive-Cancer-Screenings-during-COVID-19-Pandemic.pdf |23

Role of telehealth, health equity concerns, etc.

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Seeing an increase in telehealth, but concerns about sustainability

Changing an approach to incorporate health equity, at times these are at crossroads

Rising COVID cases

Some guidance from national organizations like CCCNP -- https://drive.google.com/file/d/1gw4OBTUEa0W6_KEcLub5va6dr-

Re1Fuh/view

Recent guidance from National Colorectal Cancer Round Table (NCCRT)

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Silver linings?

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Prior to COVID, CRC screening rate in NM was at 49% in FQHCs and BRFSS shows 65% met USPSTF recommendations

April 2020 survey of NM FQHCs showed 50% of visits were virtual

Evidence on home-based cancer screening tests

Future directions

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CRC white paper

State cancer control plans review for CRC

Promoting home based tests for both cervical and colorectal cancer screening in FQHCs

Questions?

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padsul@salud.unm.edu

@PrajaktaAdsul