1. Determining the Proper FIT: Strategies to Improve the Delivery of Fecal Immunochemical Tests among Southwest American Indian Populations, 2014, New Mexico Jasmine Jacobs, MPH Prevention Specialist Office for State, Tribal, Local and Territorial Support Centers for Disease Control and Prevention PHAP/PHPS Summer Training June 2, 2015 Centers for Disease Control and Prevention Office for State, Tribal, Local and Territorial Support

2. BACKGROUND Colorectal cancer & how it affects American Indians and Alaska Natives

3. Polyps in the colon may develop into colorectal cancer if not removed. Colorectal Health Education Flip Chart, Albuquerque Area Southwest Tribal Epidemiology Center

4. Routine Screening for Colorectal Cancer (U.S. Preventive Services Task Force and CDC)  Criteria  Asymptomatic  Ages 50-75 years  Average-risk  Tests  Colonoscopy every 10 years (many health professionals consider it the GOLD STANDARD)  Sigmoidoscopy every 5 years + fecal occult blood test every 3 years  Fecal occult blood test (FOBT) every year Guaiac-based fecal occult blood test (gFOBT) Fecal immunochemical test (FIT) Recommendation Summary. U.S. Preventive Services Task Force. October 2008. http://www.uspreventiveservicestaskforce.org/Page/Topic/recommendation-summary/colorectal-cancer-screening

5. If colonoscopies are so effective, why doesn’t everyone just get them?

6. Comparison of Colorectal Cancer Screening Tests ColonoscopygFOBTFIT Cost≤ $2,000~ $5-7 No. of SamplesN/A31-3 Clinician Requirements Specially-trained mid- to high-level providers Primary care providers and technicians Preparation Heavy laxatives 1 gallon of water Clear liquid or low- residue diet Avoid vitamin C, red meat, broccoli, turnips, oranges, mushrooms, apples, iodine, boric acid, Aspirin, Ibuprofen None Procedure Conscious sedation Invasive procedure May require missed work/school May require travel Must have companion None

7. Colorectal Cancer Issues for American Indian & Alaska Native Populations  Low colorectal cancer screening rates among AI/AN populations (Government Performance and Results Act, 2014) Government Performance and Results Act, 2014 http://www.ihs.gov/crs/documents/gpra/2015/2014EndofYearDashboard.pdfhttp://www.ihs.gov/crs/documents/gpra/2015/2014EndofYearDashboard.pdf Perdue DG, Haverkamp D, Perkins C, Daley CM, Provost E. Geographic variation in colorectal cancer incidence and mortality, age of onset, and stage at diagnosis among American Indian and Alaska Native people, 1990-2009. Am J Public Health,. 2014 Jun;104 Suppl 3:S404-14.  Colorectal cancer second leading cause of cancer death among American Indians/Alaska Natives (AI/ANs)

8. Disparities in Colorectal Cancer Incidence and Death Rates Perdue DG, Haverkamp D, Perkins C, Daley CM, Provost E. Geographic variation in colorectal cancer incidence and mortality, age of onset, and stage at diagnosis among American Indian and Alaska Native people, 1990-2009. Am J Public Health,. 2014 Jun;104 Suppl 3:S404-14. * = Statistically significant (P < 0.05) Rates per 100,000 persons

9. METHODS An attempt to improve colorectal cancer screening rates

10. Methods  Randomized controlled trial  Setting  3 Indian Health Service or tribally-operated health facilities in New Mexico  Participants  Ages 50-75  Not up-to-date with CRC screening  No history of CRC or total colectomy  Study groups  Group 1: Usual care  Group 2: Mail-out  Group 3: Mail-out + Community Health Representative (CHR) outreach

12. Why Community Health Representatives?  Trusted and familiar faces in community  Liaisons between community members and health clinics  Vast majority members of same tribe they work with  Already interact with many community members

13. RESULTS Which delivery mechanism worked best?

14. Distribution of Participants, by Facility GroupFacility 1Facility 2Facility 3TOTAL Usual Care25795214566 (43.9%) Mail-out13395133361 (28.0%) Mail-out + CHR13395133361 (28.0%) TOTAL523 (40.6%)285 (22.1%)480 (37.3%)1288

15. Group Distribution of FIT Kits, by Return Outcome GroupYESNOTOTAL Usual Care36 (6.4%)530 (93.6%)566 (43.9%) Mail-out*61 (16.9%)300 (83.1%)361 (28.0%) Mail-out + CHR † 68 (18.8%)293 (81.2%)361 (28.0%) TOTAL165 (12.8%)1123 (87.2%)1288 *Significant difference compared to usual care (P < 0.01) † Significant difference compared to usual care (P < 0.01), but no significant difference compared to Mail-out (P=0.44)

16. DISCUSSION What can we take away from this study?

17. Limitations  CHRs could not carry out all intended outreach due to staff turnover, competing priorities, etc.  We cannot determine if significant differences between the mail-out group and mail-out + CHR outreach group would have resulted, had CHRs performed all outreach  Results should not be generalized to all American Indian populations

18. Take-Away Messages  Directly mailing FIT kits to individuals eligible for CRC screening increases completion and access to CRC screening.  If used widely, this strategy could increase the percentage of AI/ANs who are up-to-date with CRC screening, potentially affecting CRC morbidity and mortality.

19. Acknowledgements  Community health representatives, laboratory directors, and all others who contributed to the project from the 3 participating tribes  Kevin English, DrPH – Director, Albuquerque Area Southwest Tribal Epidemiology Center (Principal Investigator)  Amanda Tjemsland – PHAP Class of 2013  Donald Haverkamp, MPH – Epidemiologist, CDC Division of Cancer Prevention and Control (PHPS Alumnus)  David Espey, MD – Medical Officer for Tribal Affairs, CDC National Center for Chronic Disease Prevention and Health Promotion *This project was realized with funding from the Centers for Disease Control and Prevention, in cooperation with the National Indian Health Service Division of Epidemiology and Disease Prevention.

20. For more information, please contact CDC’s Office for State, Tribal, Local and Territorial Support 4770 Buford Highway NE, Mailstop E-70, Atlanta, GA 30341 Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: OSTLTSfeedback@cdc.govWeb: http://www.cdc.gov/stltpublichealthOSTLTSfeedback@cdc.govhttp://www.cdc.gov/stltpublichealth The findings and conclusions in this presentation are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Jasmine Jacobs-Wingo JJacobs1@cdc.gov 505-232-9908 Centers for Disease Control and Prevention Office for State, Tribal, Local and Territorial Support

21. Video: “Procedures to complete an iFOBT” (e.g., Polymedco OC Light) Albuquerque Area Southwest Tribal Epidemiology Center