SummaryA Harlem-based breast examination center affiliated with Memorial Sloan-Kettering Cancer Center assists patients age 50 and older in getting colonoscopy screening for colorectal cancer. Taking advantage of the opportunity presented by breast cancer screening (a "teachable moment" when the patient is likely receptive to a message about screening), the program uses medical assistants and nurse practitioners to do the following: identify eligible patients, provide them with education on the importance of screening, conduct a pretest medical evaluation, set up an appointment for a colonoscopy at a local community hospital, and provide followup support as needed. The program enhanced access to and interest in colorectal cancer screening in a population of low-income, ethnic minority women who otherwise have limited knowledge about and opportunity to receive such services.Suggestive: The evidence consists of post-implementation data on the percentage of eligible patients receiving a colonoscopy and the reasons for nonparticipation among those choosing not to receive screening services.
Developing OrganizationsMemorial Sloan-Kettering Cancer Center
Date First Implemented2003
The initial pilot study ran from July 2003 through October 2005.
Patient PopulationThe program serves women age 50 and older, most of whom are minorities. During the pilot study, more than 90 percent of the women were African American (49 percent) or Hispanic (43 percent).Gender > Female; Vulnerable Populations > Impoverished; Racial minorities; Women
Problem AddressedScreening rates for colorectal cancer remain low, particularly in minority populations that face multiple obstacles to obtaining such services. Lack of regular screening leads to low survival rates, as cancers often are not detected until they reach an advanced stage. Breast centers represent a potential—but largely untapped—opportunity to initiate and support the colorectal cancer screening process with minority women.
- Low screening rates, especially among minorities: No more than half of Americans in need of colorectal cancer screening receive it,1 with rates being lower in minority communities.2,3 Major obstacles to screening among minorities include lack of insurance, communication barriers, distrust of and/or poor satisfaction with the health care system (driven in part by the lack of minority providers), and inadequate infrastructure.2
- Low survival rates: Low screening rates translate into low survival rates. In 2008, colorectal cancer accounted for nearly 50,000 deaths, making it the second most deadly type of cancer in the United States.4 Five-year survival rates average between 47 and 62 percent nationwide,5 but minorities tend to fare much worse, with approximately 20 percent of those diagnosed with colorectal cancer surviving for 5 years in minority-dominated communities such as Harlem.6 Mortality rates have fallen in recent years among white males and females, but not among African Americans.2
- Unrealized potential of breast centers: Despite facing many of the same obstacles outlined above, most minority women receive regular mammograms and Pap smears, often at specialized breast centers that provide such services free of charge to those without insurance. For example, a survey found that 80 percent of Harlem women age 50 to 65 have had a mammogram,7 a figure only slightly below the 85 percent of all American women age 40 and older who have had one.8 Consequently, breast centers could serve as an effective venue for introducing and promoting the benefits of cervical cancer screening to a population already familiar with and accepting of the concept of screening. To date, however, few breast centers discuss the issue with patients or help to facilitate access to colorectal cancer screening.
Description of the Innovative ActivityA Harlem-based breast examination center assists patients age 50 and older in getting colonoscopy screening for colorectal cancer. Taking advantage of the opportunity presented by breast cancer screening (a "teachable moment" when the patient is likely receptive to a message about screening), the program uses medical assistants and nurse practitioners to do the following: identify eligible patients, provide them with education on the importance of screening, conduct a pretest medical evaluation, set up an appointment for a colonoscopy at a local community hospital, and provide followup support as needed. More details on these key elements are provided below:
- Initial eligibility determination: A bilingual (English and Spanish) medical assistant from the local community screens all patients who come in for a breast examination to determine if they likely need colorectal cancer screening. As patients wait for their appointment, the medical assistant reviews their chart and asks a few brief questions. During the initial study, eligible participants had to be age 50 or older, with no history of colorectal cancer, and no recent colorectal cancer screening (defined as annual fecal occult blood testing for at least the last 3 years or a colonoscopy within the last 10 years).
- Education about screening, appointment for next step: For those who qualify, the medical assistant briefs the patient about the importance of colorectal cancer screening, using either English or Spanish as appropriate. The nurse practitioner conducts the breast examination, and then provides further information about the importance of colorectal cancer screening and attempts to secure consent to initiate the screening process. During the initial study, those interested signed a consent form (available in English or Spanish) to participate and filled out a questionnaire (with assistance if necessary) assessing their attitudes, beliefs, and barriers related to colonoscopy screening. To ensure that the process continues, the nurse practitioner makes an appointment for the next step—a separate prescreening medical evaluation (see next bullet). The patient leaves with a card documenting the date, time, and location for this appointment, which takes place in a separate building a few blocks away.
- Precolonoscopy medical evaluation and colonoscopy appointment: The nurse practitioner conducts a medical evaluation and general physical examination of the patient. He or she asks about family history of colon cancer and draws blood for several tests, including complete blood count, prothrombin time, partial thromboplastin time, and creatinine (unless results for these tests are available from the last 30 days). Those found to have an active medical problem that would preclude a colonoscopy, such as angina, heart failure, severe pulmonary problems, or uncontrolled diabetes or hypertension, receive a referral to a medical clinic or their primary care physician, with instructions to return to the center after receiving treatment. Those who qualify clinically for a colonoscopy receive a detailed explanation of the procedure, including how to prepare, what to expect during and after, and potential complications. During this visit, the nurse practitioner makes an appointment for the colonoscopy for the patient at a local community hospital, with the patient again leaving with an appointment card specifying the date, time, and location.
- Colonoscopy procedure: Patients receive a colonoscopy from one of three gastroenterologists at the local hospital, with results given after recovery from sedation. The gastroenterologist discusses needed followup screening, pathology results, and treatment as appropriate. Within 6 weeks of the procedure, a breast center staff member calls the participant to discuss any procedure-related complications and to ask about their colonoscopy experience.
- Followup with no-shows: A secretary at the breast center follows up with any patient who does not show up for the prescreening medical evaluation or the colonoscopy procedure. The secretary inquires as to why the patient missed the appointment and sets up another one.
Context of the InnovationThe world's oldest and largest private cancer center, Memorial Sloan-Kettering Cancer Center employs more than 11,000 individuals, including 768 attending physicians who work at Memorial Hospital. In 2009, the organization handled more than 23,000 inpatient admissions and over 500,000 outpatient visits. Established in 1979 as part of Memorial Sloan-Kettering's outreach program, The Breast Examination Center of Harlem offers free, high-quality care (including breast and cervical cancer screening, education, and counseling) to women in the Harlem community of New York City. The impetus for this program came from Moshe Shike, MD, a leader in the department of medicine at Sloan Kettering who has expertise in the early detection of cancer. The hospital had previously launched a program on cancer prevention, with a focus on historically underserved, minority communities that suffer from high rates of cancer mortality. Dr. Shike felt that an untapped opportunity existed to promote colorectal cancer screening to individuals coming to the center for breast examinations, who tend to be familiar with and accepting of cancer screening. Similar types of educational strategies (e.g., one-on-one counseling) had been shown to be effective in increasing screening rates for both breast9 and colorectal cancer.10
ResultsThe program significantly enhanced access to and interest in colorectal cancer screening in a population of low-income, ethnic minority women who otherwise have limited knowledge about and opportunity to receive such services.
Suggestive: The evidence consists of post-implementation data on the percentage of eligible patients receiving a colonoscopy and the reasons for nonparticipation among those choosing not to receive screening services.
- Enhanced access to screening: In a pilot study conducted over several years, 23.6 percent of 2,616 eligible women agreed to participate, and over half of those individuals (12.9 percent of the original 2,616) ended up receiving a colonoscopy. (The remaining participants failed to show up for either the precolonoscopy medical examination or the colonoscopy procedure.) Because many of the women receiving a colonoscopy lacked knowledge about colorectal cancer, medical insurance, and/or access to routine medical care, they likely would not have been screened in the absence of this program. Study participation and colonoscopy completion rates likely would have been higher if grant funding had been available earlier to pay for screening for uninsured women, because lack of insurance was a major reason why many eligible women declined to participate early in the study (such funding only became available late in the study). After grant funds became available, 68 percent of the 223 uninsured women offered the procedure free of charge had a colonoscopy.2
- High interest among nonparticipants: The program generated interest in screening among the vast majority of those who chose not to be part of the study. In fact, 22 percent of those refusing to participate wanted colorectal cancer screening but not as part of a research study. (Some individuals resist the idea of participating in research studies, with minorities being more likely to have such reservations.) Nearly a third (29 percent) expressed interest, but wanted to discuss the issue with their primary care doctor before undergoing screening (a discussion that likely would not have occurred in the absence of the program); some of these individuals likely ended up being screened. Financial issues represented a barrier to some individuals who otherwise wanted screening, with 23 percent choosing not to participate due to lack of insurance or the failure of the hospital offering the colonoscopy to accept their coverage. Overall, only approximately 10 percent of those who refused to participate did so due to a lack of interest in or time for such screening.2
Planning and Development ProcessKey steps included the following:
- Partnering with breast center: Dr. Shike met with leaders and staff at the Breast Center of Harlem to broach the idea. Center leaders and staff enthusiastically embraced the concept and agreed to participate.
- Securing grant funding: Dr. Shike applied for and received grant funding from the National Cancer Institute to evaluate the program's impact.
- Partnering with hospital and gastroenterologists: Dr. Shike approached leaders at North General Hospital (a community hospital in the middle of Harlem) and three gastroenterologists practicing at the hospital about being partners in the program. Memorial Sloan-Kettering had an established relationship with North Shore, having helped to secure philanthropic donations to set up a cancer prevention and treatment center at the hospital. The parties negotiated a $300 all-inclusive fee per procedure.
- Training center staff: Dr. Shike met with nurse practitioners and the bilingual medical assistant on multiple occasions to educate them about the importance of colorectal cancer screening and to discuss various screening methods, potential problems, etc. He also trained them on how to answer the most commonly asked questions about colorectal cancer.
- Training nurse practitioners on patient preparation: Gastroenterology nurses trained the breast center nurse practitioners on how to prepare patients for a colonoscopy.
- Securing funding for uninsured: During the middle of the study, Dr. Shike secured funding from the American Cancer Society and individual donors to cover the colonoscopy procedure for uninsured women.
Resources Used and Skills Needed
- Staffing: The program requires one full-time bilingual medical assistant (a college graduate). Nurse practitioners perform program-related duties as part of their regular job responsibilities.
- Costs: Data on program costs are unavailable. Major expenses include salary and benefits for the medical assistant and payments to the hospital and gastroenterologists for uninsured women undergoing a colonoscopy.
Funding SourcesThe National Cancer Institute provided grant funding to cover the costs of the research study. Third-party insurers cover the cost of colonoscopy for insured women. As noted earlier, the American Cancer Society and individual donors provided funding to cover the costs of the colonoscopy for uninsured women during the study.
Getting Started with This Innovation
- Choose convenient venue within community: The program will be most effective if screening services can be offered at a familiar and convenient location for the target population. Although this program chose to use a local hospital, would-be adopters could also consider partnering with gastroenterologists who perform the procedure in their offices.
- Use culturally competent, friendly, and caring staff: Women will be more likely to accept screening if those trying to educate and persuade them speak their language, understand their culture and community, and treat them in a friendly, respectful, caring, and honest manner. As noted, the breast center hired a bilingual medical assistant from the local community to conduct the initial screen and broach the subject of colorectal cancer screening with patients. Center nurse practitioners also had experience in working with the target population, as they already provided breast and cervical cancer screening services to minority women.
- Do not overburden physicians: Breast center physicians likely lack the time or desire to discuss colorectal cancer screening with patients. Consequently, the program will be most successful if designed without the need for physician involvement.
Sustaining This Innovation
- Make process easy for patients: More patients will complete the screening process if they are guided through the steps. For example, in this program, the patient always leaves one step with an appointment in hand and complete instructions for the next step.
- Seek funding for uninsured women: The vast majority of uninsured women have access to free mammography screening through local clinics that have government or other funds to support the provision of such services. However, such funding frequently is not available for colorectal cancer screening, thus creating the need to approach foundations, local agencies, and others for ongoing philanthropic support.
- Consider additional support in overcoming barriers: Given the relatively significant number of "no-shows," would-be adopters might consider providing additional support to those who face barriers to attending appointments, such as helping them to secure transportation to and from the preprocedure evaluation or colonoscopy.
Contact the InnovatorMoshe Shike, MD
Memorial Sloan-Kettering Cancer Center
Department of Medicine
1275 York Avenue
New York, NY 10065
Innovator DisclosuresDr. Shike has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
References/Related ArticlesShike M, Schattner M, Genao A, et al. Expanding colorectal cancer screening among minority women. Cancer. 2011;117(1):70-6. [PubMed]
Centers for Disease Control and Prevention (CDC). Increased use of colorectal cancer tests—United States, 2002 and 2004. MMWR Morb Mortal Wkly Rep. 2006:55:308-11. [PubMed]
Shike M, Schattner M, Genao A, et al. Expanding colorectal cancer screening among minority women. Cancer. Epub 2010 Oct 25. [PubMed]
Doubeni CA, Laiyemo AO, Klabunde CN, et al. Racial and ethnic trends of colorectal cancer screening among Medicare enrollees. Am J Prev Med. 2010;38(2):184-91. [PubMed]
4 American Cancer Society. Cancer Facts and Figures 2008. Atlanta, GA: American Cancer Society; 2008. Surveillance, Epidemiology, and End Results-National Cancer Institute.
Freeman HP, Alshafie TA. Colorectal carcinoma in poor blacks. Cancer. 2002;94:2327-32. [PubMed]
Fullilove RE, Fullilove MT, Northridge ME, et al. Risk factors for excess mortality in Harlem. Findings from the Harlem Household Survey. Am J Prev Med. 1999;16(3 suppl):22-28. [PubMed]
Blackman DK, Bennett EM, Miller DS. Trends in self-reported use of mammograms (1989-1997) and Papanicolaou tests (1991-1997)—Behavioral Risk Factor Surveillance System. MMWR CDC Surveill Summ. 1999;48:1-22. [PubMed]
Legler J, Meissner HI, Coyne C, et al. The effectiveness of interventions to promote mammography among women with historically lower rates of screening. Cancer Epidemiol Biomarkers Prev. 2002;11:59-71. [PubMed]
Chen LA, Santos S, Jandorf L, et al. A program to enhance completion of screening colonoscopy among urban minorities. Clin Gastroenterol Hepatol. 2008;6:443-450. [PubMed]
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Original publication: May 11, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: May 01, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: April 24, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.