Collaboration with Community Partners to Provide Breast and Cervical Cancer Services to the Underserved University of Texas Health Sciences Center at Tyler 1 Northeast Texas Public Heath District 2 Patti Olusola, MD 1 Sarah Low, MD 1 Michelle Parker, MD 1 Jessica Osizugbo, MD 1 Stephanie Taylor, CCPH 2

Background Breast cancer is the most common and cervical cancer is the 7 th most common cancer to affect women in the state of Texas. Many studies have proven that screening for breast cancers with mammograms 1,2 and cervical cancers with pap smears and HPV testing 3 decreases mortality related to these cancers. Underserved and uninsured women have a higher incidence of these cancers due to lack of access to these important screening exams. 4 Many community and non-profit resources such as Susan G. Komen Race for the Cure and the Breast and Cervical Cancer Services (BCCS) program are available to financially assist underserved or uninsured women obtain these exams; however, coordinating these funding sources with facilities and providers that perform the exam can at times be challenging.

Northeast Texas Region (Public Health Region 04) Population at Risk: 2,782,222 Cases: 3883 Mortality Rate: 20.8%

Northeast Texas Region (Public Health Region 04) Population at Risk: 2,782,222 Cases: 240

Project Desciption For the past few years, the North East Texas Public Health Department (NET Health) and the Family Practice Clinic at UT Health Sciences Center at Tyler (UTHSCT) began a collaborative effort to provide breast and cervical cancer screening services to underserved and uninsured women in the Northeast Texas region. NET Health uses funds from the BCCS program, funded by the Texas Department of State Health Services, and the Komen Race for the Cure through the local affiliate with money raised locally. This study retrospectively reviews the number of women who obtained cervical and breast cancer screening and follow-up services through the Family Practice residency clinic and UTHSCT. – The total number of women who received pap smears, HPV testing, and colposcopies through the clinic in the 3 years prior to the collaboration were compared with the total number of women who received these exams in the 3 years since the collaboration. – The total number of women diagnosed with cervical dysplasia or cancer in the Family Practice clinic through this program are reported. – The total number of women undergoing breast biopsy and receiving a breast cancer diagnosis through this program at UTHSCT are reported.

Collaboration Flowchart NET Health identifies women in the service area and confirms their eligibility for BCCS and/or Komen Women are scheduled screening mammograms in multiple different locations throughout the region including UTHSCT Women needing clinical breast exams, pap smears and pelvic exams are schedule by NET Health to be seen in the Family Practice Clinic by one of the resident physicians Women with abnormal screening pap smears are referred for colposcopy in the Family Practice Clinic Women requiring breast biopsy are referred to one of the radiology or surgical specialist at UTHSCT Women requiring cervical excisional procedure are referred to the Gyn specialist at UTHSCT NET Health assists women diagnosed with cancer in applying for government funded insurance or other programs to obtain the further medical care they require

Results Through our collaborative effort, a significant number of underserved and uninsured patients received recommended screening exams, needed biopsies and follow-up exams. Five women have been diagnosed with breast cancer and one with cervical cancer. The Family Medicine residency clinic has performed significantly more pap smears and colposcopies in the years since this collaborative program began.

Numbers of Women Receiving Services Through BCCS and UTHSCT Cervical Cancer Services Pap Smears – 527 HPV Testing – 221 Colposcopy - 90 Breast Cancer Services Mammogram – 554 Breast Ultrasound Breast Biopsy - 31

Abnormal Pap Smears

Colposcopy Results

Family Medicine Clinic Procedure Numbers

Challenges Collaborative efforts such as this one require an incredible amount of planning and communication. Some of the barriers to our program include:  Scheduling: some patients have to wait up to 2 months for their provider visits  Identifying Komen and BCCS patients in the clinic  Communicating results and recommended follow-up exams to patients and NET Health  Providers filling out required forms and getting copies to NET Health  Tracking patients that are “lost to follow-up”  Billing, coding, and reimbursement

Conclusions Overall the collaboration between NET Health and the UTHSCT Family Medicine Residency clinic is a “win-win” partnership. It has been very successful in providing needed breast and cervical cancer services to underserved and uninsured women in Northeast Texas. In addition, the Family Medicine residents have received invaluable patient care experience in the evaluation and management of breast and cervical health issues.

Future Directions  A Pubmed search using criteria of internship and residency AND (breast neoplasms OR uterine cervix neoplasms) AND (early detection of cancer OR mass screening OR prevention and control) did not reveal any similar studies that had been published in the literature.  It would be interesting to survey public health organizations and residency training programs in the country to see if other similar partnerships exist.  Our goal is to encourage collaboration in other communities to improve access to needed services for patients and increase educational training opportunities for residents.

References 1.Miller AB, To T, Baines CJ, Wall C. The Canadian National Breast Screening Study-1: breast cancer mortality after 11 to 16 years of follow-up. A randomized screening trial of mammography in women age 40 to 49 years. Ann Intern Med 2002;137: Moss SM, Cuckle H, Evans A, Johns L, Waller M, Bobrow L; Trial Management Group. Effect of mammographic screening from age 40 years on breast cancer mortality at 10 years' follow-up: a randomised controlled trial. Lancet 2006;368: International Agency for Research on Cancer. Cervix Cancer Screening. IARC Handbook of Cancer Prevention, vol. 10. Lyon, France: IARC Pr; Ward, E., Jemal, A., Cokkinides, V., Singh, G. K., Cardinez, C., Ghafoor, A. and Thun, M. (2004), Cancer Disparities by Race/Ethnicity and Socioeconomic Status. CA: A Cancer Journal for Clinicians, 54: 78–93.

Acknowledgements Special thanks to Stephanie Taylor and the NET Health staff for collaborating so effectively with our Family Medicine residency clinic. Thank you to Zeding Li for gathering data to include in our study.