Reducing Cancer Burden Through
Community-Based Research
September 28, 2007
Eugene J. Lengerich, VMD, MS
Associate Professor
Department of Public Health Sciences
Department of Health Policy and Administration
The Pennsylvania State University
Director, Community Outreach and Education
Penn State Cancer Institute
Objectives
Provide an update on ACCN research
initiatives (today)
Provide an overview of ACCN and NACN
Review NACN community-based initiatives
Review recent surveillance information
Appalachia Community Cancer
Network
(ACCN)
The Appalachia Community Cancer Network
Supported by the National Cancer Institute’s
Center to Reduce Cancer Health Disparities
1 U01 CA114622 (2005-2010)
Appalachian Areas of 7 States
KY, MD, NY, OH, PA, VA, WV
Principal Investigator
Mark Dignan, PhD, MPH
University of Kentucky
Regional Principal Investigators
KY – Nancy Schoenberg
OH – Electra Paskett
PA – Eugene Lengerich
VA – Jim Bohland
WV – Pamela Brown
Cancer Sites
Colorectal
Cervical
Lung/Tobacco
Breast, especially late
stage at diagnosis
The Appalachia Community Cancer Network
Supported by the NCI’s Center to Reduce Cancer Health Disparities
1 U01 CA114622 (2005-2010)
Northern Appalachia Cancer
Network
(NACN)
The Northern Appalachia Cancer
Network (NACN)
A Region of the Appalachia Community Cancer Network
A community-academic partnership to develop, test and
implement evidence-based interventions intended to
reduce the burden of cancer in rural, medically
underserved communities of PA and NY
Established in 1992
Three primary strategies
– Community-based participatory research with 10 cancer coalitions
Among the longest-running network of community cancer
coalitions in the U.S.
– Practice-based research with rural primary care providers,
specialists, and hospitals
– Surveillance research
NACN Advisory Committee
Composed of Community Representatives
(n=10) and State & Professional
Representatives (n=13)
Role:
– Advise NACN
– Facilitate community-based participatory research
– Represent coalitions
Expectations:
– Meet face-to-face once each year of the five years of
the cooperative agreement
– Meet via teleconference in the other three quarters of
each year
Community Partnerships
on the NACN Advisory Committee
Action Health Cancer Task Force (PA)
Allison Clark – Community health
education
Nicole Hockenbrock – Community health
education
Chautauqua County (NY) Partners for
Prevention
Laurie Adams – Community health and
education
Elk County Cancer Coalition (PA)
Paulette Schreiber, CRNP – Health care
and cancer screening
Greene County Cancer Coalition (PA)
Carolyn Wissenbach – Community
education and training
Indiana County Cancer Coalition (PA)
Charlie Shoemaker – Health care
administration
Coalition for People Against Cancer,
Clearfield County (PA)
Mary Day – Cancer education and
outreach
Lawrence County Cancer Coalition (PA)
Marcia S. Anderson -- Adult literacy
Crawford County Cancer Coalition (PA)
Dawn Moshbacher, BA, BSN –
Community health
Wyoming County Cancer/Tobacco
Partnership (PA)
Valerie Ann Bell, RN, BSN -- Cancer
prevention, education, and screening
Delaware County (NY) Cancer Coalition
Jeanne Darling – Rural community
education
Professional and State Representatives
on the NACN Advisory Committee
Cancer Education, Outreach, and Policy
Julia Bucher, RN, PhD
PA Cancer Control Consortium
Rural Hospitals and Networks
Aileen Galley, ACSW, LSW
Administrative Director, Mt. Nittany Medical Center
Statewide Education, Training, and Outreach
Marilyn Corbin, PhD
Associate Director, Penn State Coop. Extension
Cancer screening outreach and recruitment
Heather LeBlanc, BS
NY Department of Health
Rural Health Disparities and Health Networks
Lisa Davis, MHA
Director, PA Office of Rural Health
Continuing Education for Health Professionals
Luanne Thorndyke, MD
Associate Dean, PSU
Clinical Trials Education and Training
Linda Fleisher, MPH
Program Director, NCI CIS (Fox Chase)
Cancer Screening Services and Rural Health
Louann Weil, MPH
Director, Cancer Screening, Family Health Services
Cancer Genetics, Tobacco, and Lung Cancer
Philip Lazarus, PhD
Associate Director, Penn State Cancer Institute
Professor, PSU
Health Services Research
Carol Weisman, PhD
Professor, PSU
Health Communication Research
Roxanne Parrot, PhD
Professor, PSU
Social Marketing and Health Communication
Christy Widman
Partnership Program Director, NCI CIS (Roswell Park)
Public Health
Kathleen Zitka, MPH
PA Department of Health
Topography: The Northern Appalachia Cancer
Network and the Penn State Cancer Institute
Susquehanna HS
Wyoming Valley
Mount Nittany and
University Park
Pittsburgh
Lehigh Valley
Lewistown
Hershey
Philadelphia
NACN Update:
RE-AIM
350
300
Outreach only
250
200
Education only
150
Outreach and
Education
Screening
#
100
50
0
2002 (n=402)
2003 (361)
2004 (384)
RE-AIM Evaluation
Glasgow RE, Vogt TM, Boles SM (1999) Evaluating the public health impact of health promotion
interventions: The RE-AIM framework.American Journal of Public Health, 89:1323-1327.
A systematic way for researchers,
practitioners, and policy makers to
evaluate health behavior interventions
Reach
Efficacy/
Effectiveness
Adoption
Implementation
Maintenance
Participation
by residents
Impact on
residents
Providing
the
programs
Fidelity of the
programs
Establish a
routine/norm
NACN 2002-2004
Data from Kluhsman, et al, Prev Chronic Disease, 2006
Reach
Efficacy/
Effectiveness
Adoption
Implementation
Maintenance
Participation
by residents
Impact on
residents
Providing
the
programs
Fidelity of the
programs
Establish a
routine/norm
96
screening
initiatives
Trend:
2002:n=22
2003:n=35
2004:n=39
Ongoing
technical
assistance
[Subsequent
trainings on
evidencebased
programs in
2005, 2006,
2007]
14
community
changes (e.g.,
new contracts
for low/no cost
screening;
increased clinic
hours for
cancer
screenings)
3,981
residents
offered
screening at
96 screening
initiatives
1,951
residents
accepted
screening
$183.79 per
screening*
* (Grant Total Cost)x(96 Screening Initiatives) / ((371 Education and Screening Initiatives)x1951 Screenings).
Assumes 0 benefit for community changes and 0 cost for outreach and development initiatives.
NACN Update:
CRC Survivorship
Percent Who Ever Had a Sigmoidoscopy or
Colonoscopy, PA Adults 50 Years and Older,
1995-2006
70
60
+ 1.8% / year
50
30
20
10
0
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
Percent
40
Year
Design
• Design:
• Pre-post, multi-level, community intervention study
• CBPR approach
• Outcomes:
• Individual-level: Knowledge and beliefs in public
health and CRC-survivorship among individual
members of coalitions and partnerships
• Community-level: Presence and content of
community plans and resource directories for CRC
survivorship
• Analysis
• Change in knowledge and beliefs – McNemar’s
test (p<0.05)
• Content analysis by multiple reviewers (n=3)
Study Schema
Technical Assistance from NACN / PSCI / ACS
Recruit and
Prepare
(Proposed 6
coalitions)
Train on
Colorectal
Cancer
Survivorship
and Process
for Plan
Development
(Conference 1:
May 2006)
Assess
Barriers &
Needs;
Develop Plan
ASSESSMENT
Public health and
survivorship knowledge and
beliefs
Revised 5/11/06
Present CRC
Survivorship
Plans and
Resource
Directory
Disseminate,
Implement, and
Research
(Conference 2:
October 2006)
ASSESSMENT
Knowledge and beliefs;
Survivorship Plans and Resource
Directories
Participation
Recruited
– 11 coalitions (8 in PA; 3 in NY) and 4 hospitals (all in
PA)
– 32 individuals at initial conference (range 1-4 per
coalition/hospital)
MD’s; RN’s; Health Educators
Hospital Administrators
Survivors
Completed
– 11 coalitions and 3 hospitals (93.3%)
– 16 of 32 individuals at initial conference returned to
second conference (50.0%)
CRC Survivorship Assessments and Plans
Appalachian
Counties
n = 14
Barriers, Assets and Plans
Perceived
Barriers
Community
Assets
Planned to
Enhance
No.
%
No.
%
No.
%
Access to or Knowledge of Community
Resources
13
92.9
10
71.4
14
100.0
Psychosocial Care
12
85.7
14
100.0
12
85.7
Transportation Services
12
85.7
3
28.6
7
50.0
Treatment-Related Care
11
78.6
8
57.1
13
92.9
Primary Health Care
8
57.1
3
21.4
10
71.4
Financial Assistance and Health Insurance
7
50.0
5
35.7
6
42.9
Colorectal Cancer Screening
6
42.9
0
0.0
7
50.0
Care Givers Support
3
21.4
2
14.3
4
28.6
Language, Culture, Low Literacy
3
21.4
1
7.1
3
21.4
Healthy Life Styles
2
14.3
0
0.0
4
28.6
Genetic and Familial Risk
1
7.1
0
0.0
4
28.6
Disability
0
0.0
0
0.0
2
14.3
Specific Area of Colorectal Cancer
Survivorship
NACN Update: Recruitment to
Mammography through Food
Pantries, Indiana County, PA
Design:
Community- and evidence-based intervention in food pantries with pre-post assessment of
screening mammography in Healthy Woman Program
Result: Of the 302 age-eligible women, 158 (52.4%) were in need of scheduling a
mammogram. Of the 158 women, 138 (87.3%) received a mammogram as a result of the
adapted Tell A Friend® Program. Three (2.2%) women were diagnosed with breast cancer
and received treatment. The number of breast cancer screenings provided to underserved
residents increased by 46 (28.2%) during 2005.
Geography:
Indiana County
Status:
Manuscript accepted for publication, Journal of Rural Health
Collaborators:
Marcy Bencivenga, BA
Susan DeRubis, MS, RN
Patricia Leach, MS, MEd
Lisa Lotito, BA
Charles Shoemaker, ARRT(R), (N), CNMT, MBA
Eugene J. Lengerich, VMD, MS
NACN Update: Integrated Colorectal
Cancer Program (ICCaP)
Approach:
Integrate community partnerships and evidence-based program education
with health care training and delivery
Objective:
Increase colorectal cancer screening and survivorship in the target area
Components:
Community partnerships
Evidence-based programs
South Central Pennsylvania Cancer Education Network
Cancer Information Service
Primary care practice improvement
Surgical and medical care delivery
Geography:
Central Pennsylvania –
Seven rural or urban counties from Lebanon to Centre County
Elevated ascending colorectal cancer rates
Status:
Begin January 1, 2008 for two years
NACN Update: Obesity Reduction in
Rural, Low-income Families through
Food Selection and Physical Activity
Design:
Family-based randomized intervention trial with pre- and post-behavioral and
biomarker measurement
Population:
Low-income, rural families
Home-based intervention
Geography:
Central Pennsylvania – Centre and Snyder Counties
Status:
Completed focus groups
Tionni Weinrich, MS, and J. Lynne Brown, PhD
Currently recruiting for intervention study
Tionni Weinrich, MS, and J. Lynne Brown, PhD
Collecting baseline anthropometrics, blood pressure screening,
questionnaire and biomarker assessment
Robin Taylor Wilson, PhD
Eugene J. Lengerich, VMD, MS
NACN Update:
Mapping of Cancer
Data:
Geocoded1997-2005 colorectal and prostate cancer cases in PA
Software and Tools:
Model cancer atlas
Star Plots
GIS analysis
Principal components
Status:
Geocoded prostate cancer data
Developed model atlas
Developing GeoViz toolkit
Collaborators:
Gene Lengerich, VMD, MS
Frank Hardisty, PhD
Mark Gahegan, PhD
Brenda Kluhsman, MSS
Alan MacEachren, PhD
Robin Taylor Wilson, PhD
Surveillance Update: Appalachia
Population Density
Rates, 2000
Population Change in
Appalachia, 1990–2000
1990
2000
Poverty Rates
Poverty Rates
Cluster Analysis of Hispanic Settlement
Barcus H. The emergence of new Hispanic settlement patterns in Appalachia. Professional
Geographer 2007:59(3);298-315.
General Health Disparities
in Appalachia
Basic Sociodemographic
Characteristics of the ‘Eight Americas’
Ame
rica
Description
Population
(millions)
Avg.
Income per
Capita
Percent
Completing
High School
1
Asian
10.4
21,566
80
2
Northland low-income rural white
3.6
17,758
83
3
Middle America
210.0
24,640
84
4
Low income whites in
Appalachia & Mississippi Valley
16.6
16,390
72
5
Western Native America
1.0
10.029
69
6
Black Middle America
23.4
15,412
75
7
Southern low-income rural black
5.8
10,463
61
8
High risk urban black
7.5
14,800
72
Murray CJL, Kulkarni SC, Michaud C, Tomijima N, Bulzacchelli MT, Iandiorio TJ, Ezzati M. Eight Americas: Investigating
mortality disparities across race, counties, and race-counties. PLoS Med 3(90)e260. DOI: 10.1371/journal.pmed.0030260.
Life Expectancy at Birth in the Eight
Americas (1982-2001)
Males
Appalachia
Females
Appalachia
Murray CJL, Kulkarni SC, Michaud C, Tomijima N, Bulzacchelli MT, Iandiorio TJ, Ezzati M. Eight Americas: Investigating mortality
disparities across race, counties, and race-counties. PLoS Med 3(90)e260. DOI: 10.1371/journal.pmed.0030260.
Review
Provide an update on ACCN research
initiatives (today)
Provide an overview of ACCN and NACN
Review NACN community-based initiatives
Review recent surveillance information