COMMENTARY

How One Drive-By Clinic Fought Declining CRC Screening Rates

Alan Lyss, MD; Armenta L. Washington, MS

Disclosures

July 30, 2021

Editor's note: This interview was originally published as part of MDedge's Blood & Cancer Podcast series. In this episode, guest host Alan Lyss, MD, subprincipal investigator emeritus for Heartland Cancer Research NCORP, spoke with Armenta Washington, MS, senior research coordinator at the Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania in Philadelphia, about her involvement in a drive-by program in which participants could receive a flu vaccine and a take-home fecal immunochemical test (Flu-FIT). This transcript has been edited for length and clarity.

Alan Lyss, MD: What was the original intention behind the Flu-FIT program?

Armenta Washington, MS: The Flu-FIT program is a best practice of the American Cancer Society. It's designed to increase colorectal cancer (CRC) screening among adults and to give healthcare providers an opportunity to promote this among their patients at the time of their annual flu vaccine.

Studies show that providing a home kit with instructions and a return envelope can increase CRC screening. What the Abramson Cancer Center did was combine Flu-FIT with the National Cancer Institute's Screen to Save CRC screening campaign into a socially distanced drive-by program.

Lyss: You presented your initial results with this Flu-FIT program at the American Association for Cancer Research (AACR) virtual meeting. Can you share what the screening rates for CRC have been?

Washington: The results of our second program are forthcoming. But in the prior program, 335 people registered, with 192 participants receiving a FIT (57.3%). Of those 192, 154 (80.2%) returned the kit; 141 had negative FIT results and 13 had a positive FIT. We worked with the individuals who had a positive FIT, navigating them back to their primary care physician. Some have had colonoscopy.

Designing an Oasis for the Underserved

Lyss: Why did you decide to do the drive-by Flu-FIT program during the pandemic?

Washington: At the height of the pandemic, approximately 90% of individuals were not showing up for colon cancer screening as well as mammograms. We were working on addressing this within the healthcare system.

But when the actor Chadwick Boseman died from metastatic CRC, Reverend Leroy Miles from the Enon Tabernacle Baptist Church here in Philadelphia was concerned about the risk of the general public and wanted to address the disparity within the African American community. As we know from research, African Americans are 40% more likely to die from CRC. This is one of the most preventable cancers, so that's why we decided to do it this way.

Lyss: Dr Norman Sharpless, director of the National Cancer Institute, has predicted that because of the pandemic-related drop-off in screening, we may be facing 10,000  additional cases of advanced breast and colon cancer 10 years from now. That certainly makes this a very worthwhile endeavor.

You've been involved in this program since the very beginning. What were the logistical steps involved in arranging drive-by Flu-FIT?

Washington: Enon, which is one of the largest Baptist churches in the Philadelphia region, had already been employing a drive-by model to engage the community. They were using it to distribute food and provide an array of health services, which included one of the first COVID-19 screening sites in Philadelphia for the African American community. They'd been engaging well over 14,000 individuals [in late 2020].

Enon decided to reach out to Abramson Cancer Center, the Einstein Healthcare Network, the Black nursing sorority Chi Eta Phi, and the City of Philadelphia's Health Department, and leveraged all of us collectively in this project.

They have an online registration process, which is how members of their congregation and the community participate in the events they were holding. They placed the Screen to Save questionnaire on their website, so once an individual went on to register they were taken straight to that. They completed a 14-item knowledge questionnaire and a five-item screening intention before and after watching a brief CRC screening educational video.

Once the individuals were registered, they had the option of choosing which of the three drive-by Flu-FIT programs they would attend in the parking lot of Enon.

Participants came in their cars and remained there while physicians provided instructions on how to use the FIT and answered any of their questions. If they wanted to, they could receive a flu vaccine from a nurse, and then drive off. Once they had completed the FIT, all they had to do was return it to a medical collection box placed in Enon's vestibule.

Connecting a Community While Remaining Socially Distanced

Lyss: Beyond the initial participation results, what have you learned from the entire endeavor?

Washington: For me, one of the biggest takeaways from this is that a socially distant drive-by Flu-FIT program is feasible, acceptable, and an effective way to engage the community. People were very thankful to us for providing this opportunity and for the educational component.

We also learned that this program could help mitigate the significant decline in CRC screening that occurred as a result of the COVID-19 pandemic. And it helps to reduce the burden of CRC in these diverse communities.

Lyss: What did you learn from the knowledge and intention score testing that you performed?

Washington: The knowledge and intention scores were pretty good at baseline because many of these individuals either had some college or were college graduates. So we must take that into consideration.

But for the most part, the baseline knowledge about CRC was high, with the exception of four items: risk factors for CRC, the frequency of FIT, the role of Lynch syndrome, and the relationship between physical activity and the risk for CRC.

We also found that after viewing the video, all knowledge scores increased except for one item related to the earlier discovery of CRC and its relationship to survival. All baseline intentions to discuss CRC and screening were high. After viewing the video, scores increased slightly.

Lyss: Did you learn anything from the original experience that guided how you did things for your second drive-by Flu-FIT program?

Washington: Yes. Where possible, special arrangements were made with a number of those who had not returned their kits. We engaged the participants by phone calls, text messages, and emails. We went as far as to visit their homes and leave kits in their mailboxes.

Some of those we were able to reach shared with us that they've followed up with their primary care physician and are in the process of being scheduled for colonoscopy, if needed.

Lyss: What next steps do you have planned with this project?

Washington: Enon is located in the northwest section of Philadelphia, but we see that there's a high incidence of CRC in south, southwest, and west Philadelphia. So we are going to expand our services into those communities.

We also hope to include other screenings, such as for diabetes, hypertension, and take-home tests for HIV. We also may want to evaluate the feasibility of a drive-by for the COVID-19 vaccine and FIT, once the priority groups are in alignment with local health department recommendations.

Building a Successful Drive-By CRC Screening Program

Lyss: It occurred to me that Enon must have a lot of credibility in the community, and that they are responsible for some degree of your great success with this program.

Washington: They're absolutely a very trusted partner in the community. They pride themselves on crossing the aisle to work with all different types of faith-based institutions and organizations serving the community. Once they give their stamp of approval, once Reverend [Alyn] Waller makes the announcement, most people absolutely will participate.

And Reverend Leroy Miles did share that at this point [as of April 2021], they've probably engaged well over 30,000 individuals with their work throughout the pandemic, and that those numbers have more than doubled.

Lyss: This is certainly impressive. What advice do you have for people who want to implement a Flu-FIT program at their own center? What things should they pay particular attention to?

Washington: Because we've been in the middle of a pandemic for over a year, we can sometimes overlook the number of hardships that individuals have been faced with. Many lost their employment and their health insurance. They're scrambling to try to figure out how to make it from day to day. Often in those types of situations they put their health on the back burner. This program means they have one less decision to make among all of the others they're juggling.

Navigation is another key component to this. For example, an individual who may have lost their job for the first time in 20 years doesn't really know how to navigate the waters of going into our city's health department, and doesn't have existing relationships with the nurses and administrators there. By being the liaison, we can help them navigate with that system or with a federally qualified health center.

Another thing that people really have appreciated is the fact that they're engaging with staff and faculty who look like them. It's important when they see an African American doctor walk up to their car, caring for them and answering their questions. People have a lot of reservations about getting a colonoscopy. When the doctor looks like them and can reassure them of everything, it's like they really respect and will honor what is being asked of them.

Logistically, you want to consider a central location that can accommodate the vehicles, because there's a lot of traffic that comes with this. You want to be respectful of the neighborhoods you're in, not bottlenecking the traffic, but also making sure you have the footprint to be able to pull this off.

You also want to be able to provide opportunities for those who don't drive. So, making sure that it's accessible by public transportation or that it's a place that people can walk up, because we do have people who also do that.

A Liaison Who's Here to Help

Lyss: In your AACR presentation, I think you mentioned that around 15% of your patients were uninsured and you had to navigate some of them through the maze of getting colonoscopy performed. People would call for colonoscopy and be put off for 3 or 4 months, at which point you had to intervene.

Washington: There were several cases, but two really stick out for me. One patient's husband was a member of the local union; he lost his job, and they lost their insurance. She needed to be navigated through a federally qualified health center and onto specialty care. The second patient worked for a local university that made some cuts and she also lost her insurance. I helped those individuals weekly, sometimes twice a week, talking to them, getting them connected into the services, making sure they got what they needed.

One of these individuals had her colonoscopy, and they found and removed polyps, which were not cancerous. Now, she had no intention of even participating in the FIT test; she had come to get a flu shot. But when she saw that this was going on, she thought, Well, why not? Once she took the test and found out that she was positive, and was navigated into the specialty care, she realized that she had a family history. So this was very important for her to do.

Lyss: Armenta, I want to thank you and congratulate you on your group's accomplishments for conducting the drive-by Flu-FIT program. It was really a tremendous amount of work. It seems like you've been involved in every facet, from concept design to implementation to patient navigation and now data analysis. You've been there from the beginning and through to the end.

Washington: We have lots of moving parts to this.

Lyss: I also want to tell you what a thrill it is for me to host a podcast on which a clinical research coordinator is the featured guest, because clinical research associates and research nurses are vital to all cancer clinical investigators during their professional lives. They certainly were to me. Without you all, cancer research is a frustrating and flawed endeavor. So, thanks for what you do.

Washington: I appreciate and thank you so much for that.

Dr Lyss was a community-based medical oncologist and clinical researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers, as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis.

Ms Washington is a research coordinator at the Abramson Cancer Center, Perelman School of Medicine at the University of Pennsylvania in Philadelphia. Through her work, she helps to build community partnerships with medically underserved communities.

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