Community Cancer Screening Program (CCSP)

Colorectal cancer is the third most common cancer among men and women in the United States, where the lifetime risk for developing colorectal cancer is about 1 in 20 (5%). Regular screening among adults aged 50‒75 plays an important role in both colorectal cancer prevention (by finding and removing precancerous polyps) and treatment (by detecting cancer early in its development). However, screening rates among these adults are often affected by patient barriers (e.g., fear of or embarrassment about the procedure, lack of information), provider barriers (e.g., difficulty identifying patients eligible for screening, reimbursement costs), and health system barriers (e.g., lengthy referral time, lack of health care access). Additionally, screening rates differ across patient populations, with lower rates occurring among minority racial groups, individuals lacking health insurance coverage, and individuals residing in rural areas of the country. Programs that employ multiple strategies to overcome the different types of patient-, provider-, and system-level barriers are needed in communities to increase compliance with colorectal cancer screening recommendations and reduce the impact of the disease.

The Community Cancer Screening Program (CCSP), operated by the Cancer Coalition of South Georgia, aims to increase cancer screening among low-income, underinsured, and uninsured patients aged 50-64 who access federally qualified community health centers in rural settings. The intervention's approach is based on the patient navigation framework, which accounts for the cultural, socioeconomic, and other factors that create patient-, provider-, and system-level barriers to cancer screening and lead to cancer health disparities. CCSP uses health navigators to overcome these barriers to colonoscopy screening. Health navigators collaborate with partnering clinics (e.g., health centers, hospitals, gastroenterology services) to implement CCSP program activities. These navigators:

-- Conduct chart audits to identify patients due for screening

-- Manage provider reminder systems that prompt health care providers to refer patients due for screening

-- Coordinate patient screening and follow-up services

-- Provide one-on-one patient education, call patients with appointment reminders, and assist patients in overcoming barriers to screening (e.g., transportation, costs)

-- Ensure that patient screening results are entered in patient charts and report back to providers on the use of screening services. In addition, to serve underinsured and uninsured patients who may not be eligible for government-funded health care, CCSP staff collaborate with gastroenterologists at outpatient and hospital-based endoscopy centers to secure their patients' colonoscopies at a reduced cost.

Health navigators, who have a bachelor's or master's degree in a social science (e.g., psychology, social work) and experience in case management, also must receive training by CCSP staff using the CCSP health navigator training curriculum. (Training outside of Georgia is conducted on a case-by-case basis and managed by CCSP.) The manual-driven curriculum includes 3 modules delivered in 13 sessions totaling approximately 16 hours of classroom training. Training includes lectures, discussions, and role plays and other hands-on exercises. Trainees receive a training workbook.

This program uses intervention approaches recommended by the Community Preventive Services Task Force: patient navigation services to increase cancer screening and advance health equity (Colorectal Cancer Screening - Colonoscopy Alone) and multicomponent interventions (Colorectal Cancer Screening - Colonoscopy Alone). This program also uses the following intervention approaches for which the Community Preventive Services Task Force finds insufficient evidence: one-on-one education interventions (Colorectal Cancer Screening - Colonoscopy Alone) and interventions to reduce structural barriers for clients (Colorectal Cancer Screening - Colonoscopy Alone). Insufficient evidence means the available studies do not provide sufficient evidence to determine if the intervention is or is not effective. This does not mean that the intervention does not work. It means that additional research is needed to determine whether the intervention is effective.

-- 16 hours for health navigator training

-- Approximately 40 hours per week for a full-time health navigator in more than one clinic (if the navigator is only responsible for work in one clinic, the position may be part-time

The intervention is designed for low-income, underinsured, or uninsured adults aged 50-64 living in rural areas.

The intervention is designed for implementation in rural clinical settings.

Required resources to implement the program include the following:

-- CCSP Navigator Training Manual

-- CCSP Navigator Training Workbook

-- Cancer Coalition of South Georgia CCSP Quality Assurance Checklist for Colonoscopy Screening Navigation

For costs associated with this program, please contact the developer, Denise Ballard. (See products page on the EBCCP website for developer contact information.)

A retrospective, quasi-experimental study compared colorectal screening outcomes among 13 federally qualified community health center clinics in Georgia implementing either the CCSP intervention or their usual standard of care procedures (the comparison condition) for 18 months. The three main outcomes examined were rates of colonoscopy referral, colonoscopy examination, and colorectal cancer screening guideline compliance. Patients in the intervention condition were from 4 clinics implementing CCSP, and patients from 9 clinics received the usual standard of care. Comparison clinics did not receive any support from CCSP and delivered their usual standard of care for colorectal cancer screening.

A total of 809 patients aged 50-64 were included in the evaluation. Of these, 67.1% were female; 62.9% were Black, not of Hispanic or Latino origin; and 37.1% were White, not of Hispanic or Latino origin. Analyses of colonoscopy referral and colonoscopy examination data were restricted to 767 of the 809 patients who were due for colonoscopy during the study period, whereas analyses of the guideline compliance outcome included the full sample of 809 patients. The analyses controlled for age and race and accounted for the use of electronic medical records, which was taking place in all four intervention clinics and four of nine comparison clinics.

Data abstractors reviewed electronic medical records and/or paper charts using a data abstraction form to record patient demographics, colorectal cancer history and risk factors, and colorectal screening and referral (i.e., colonoscopy, sigmoidoscopy, blood stool). All data fields related to the primary outcomes (i.e., colonoscopy referral and examination) were double-abstracted for quality control and double-entered by research assistants to minimize data errors. At the end of the study period, patients who had a colonoscopy in the past 10 years, sigmoidoscopy in the past 5 years, or blood stool test in the past year were considered compliant with recommended screening guidelines.

• Among patients due for a colonoscopy, those from intervention clinics were more likely to receive a colonoscopy referral than were those from comparison clinics (p<.001).

 

• Among patients due for a colonoscopy, those from intervention clinics were more likely to receive a colonoscopy examination than were those from comparison clinics (p<.001).

 

• At the end of the study period, patients from intervention clinics were more likely to be compliant with screening guidelines than were patients from comparison clinics (p<.001).