Delaware Eliminates Racial Disparities in Colorectal Cancer Screening, Treatment

Fran Lowry

April 19, 2013

A comprehensive colorectal cancer screening and treatment program that targeted all residents of the state of Delaware eliminated disparities in screening and produced a "near elimination" of mortality differences between African Americans and whites.

The innovative program also equalized incidence rates and reduced the percentage of African Americans with regional and distant disease at diagnosis from 79% to 40%.

The results of Delaware's cancer control program are published ahead of print in the Journal of Clinical Oncology.

"The federalist model operates partly on the premise that the states are the laboratories for the rest of the country," write Stephen S. Grubbs, MD, a practicing oncologist with Christiana Care Health System's Helen F. Graham Cancer Center, Newark, Delaware, and colleagues. "This model is only helpful if we take the lessons from those laboratories to our own states and work with determined effort to fit them into our particular populations."

Main Reason for Success Is an Enlightened Government

The program began in 2001, when Delaware Governor Ruth Ann Minner established the Delaware Cancer Advisory Council to reduce the state's high rates of cancer incidence and mortality.

Dr. Stephen Grubbs

In an interview with Medscape Medical News, Dr. Grubbs said he believes the main reason for the success of the program was an enlightened government.

"The government, the hospitals, and physician providers looked at the problem and decided that if we all work together, use our resources properly, we can improve outcomes. This is a great example of cooperation and problem solving," he said.

Ruth Ann Minner is the first woman governor of Delaware and experienced the devastation of cancer when her husband died of lung cancer.

"When she started out as governor, she made doing something to change cancer outcomes in the state one of her main objectives. She assigned Bill [William] Bowser, an attorney, whose son is a cancer survivor, to head up a group of individuals who volunteered to come together and see how we could improve outcomes," Dr. Grubbs noted.

The volunteers were realistic about what they could accomplish, he said.

"We weren't going to solve every cancer issue on the planet in one fell swoop, so we looked for the low-hanging fruit, if you will, so that if we actually did something about it, we could show that we could make a difference. After a lot of discussion, we came up with the idea that if we had better screening for colon cancer, which was one of the least screened cancers, with a good screening device, and if we could get that provided for everybody in the state, that would change things," he said.

Cancer Treatment Universal in Delaware

After screening, the next logical step was to provide treatment.

"If you were uninsured or underinsured, you could get screened, and then if needed, the first 2 years of treatment, so in the end, basically for the last 8 years now or more, we've had universal cancer care, both screening and treatment, for colorectal cancer. That's what is so unique about this," Dr. Grubbs said.

This not only saved lives, it saved dollars, he added.

"We caught more cancers early, when lives could be saved and treatment would be less expensive. The message is that if people are smart about how they are going to utilize their healthcare dollars and get the job done, they will end up with better healthcare at a better price. You can change the outcome of cancer if you get everybody in line properly and are willing to work together and spend the resources properly."

The Little State That Could

The Delaware Cancer Advisory Council came up with 3 key recommendations, including universal screening, a provision to treat individuals with no health insurance, and removal of racial disparities in colorectal cancer.

Colonoscopy was promoted as the preferred screening method, and a nurse and care coordinator were deployed at each of the 5 acute care hospital sites and physician communities in the state.

In 2004, the Delaware Cancer Treatment Program was established with funding from the state legislature. Under the direction of the Delaware Cancer Consortium, the program covers the costs of cancer care for 2 years for the uninsured who are newly diagnosed if they meet federal poverty level criteria. In addition, special programs to reach the African American community were started.

All Goals Were Met

The results of the statewide campaign have been stellar, Dr. Grubbs told Medscape Medical News.

Colorectal cancer screening rates for all Delawareans aged 50 years and older increased from 57% in 2001 to 74% in 2009. Screening rates for African Americans rose from 48% to 74%, the same as whites, during the same period.

In addition to the reduction in the percentage of African Americans with advanced disease at the time of their diagnosis, the percentage of those with local-stage disease rose, from 16% in 2001 to 50% in 2009 (P < .001).

Incidence rates per 100,000 declined from 67 in African Americans and 58 in whites in 2002 to 45 for both in 2009 (P < .001), and the mortality for African Americans declined by 42%, almost equal to that among whites (P < .001).

"The results we achieved in Delaware can be replicated across the country," Congressman John Carney, a member of the Delaware Cancer Consortium, said in a statement. "Forming strong partnerships, ensuring access to care for all, and focusing on prevention is what really makes the difference."

"We're ecstatic with the results," said Dr. Grubbs, who is also a member of the Cancer Consortium. "This program, as we designed it, has met all the goals we set in terms of changing the outcome of colon cancer in Delaware."

Dr. Grubbs reports no relevant financial relationships.

J Clin Oncol. Published online April 15, 2013. Full article

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