Parkland-UT Southwestern PROSPR Center

Incubating progress: Talent + Technology + Teamwork

Cancer Center tackles complex challenge of boosting colon cancer screening among minorities, uninsured, underserved populations.

Background

Colorectal cancer screening — generally advised for people age 50 and older—saves lives. Yet research has indicated that only about 15 percent of those who lack insurance receive screening, compared with 50 percent of insured people, and rates for African-Americans and Hispanics lag substantially behind those for whites.

Thus, a key challenge in reducing colon cancer deaths is delivery of early detection and follow-up services to people who are inadequately insured and to minorities. Partnering with the community and local health systems, Simmons Cancer Center researchers are addressing that challenge and are setting an agenda nationally for colorectal cancer detection in the neediest of populations.

The Foundations

2009: Parkland Health & Hospital System, Dallas County’s sole “safety-net” health care provider for more than 1 million underinsured or uninsured people, adopts an electronic medical record, integrating data from its hospital, clinics, and health centers. The massive data pool provides a unique opportunity to investigate how to improve health care delivery in a highly diverse, low-income population.

Ethan Halm, M.D., and Celette Sugg Skinner, Ph.D.
Ethan Halm, M.D., and Celette Sugg Skinner, Ph.D.

2009: Cancer Center members Chul Ahn, Ph.D., Keith Argenbright, M.D., and Celette Sugg Skinner, Ph.D., study colon cancer screening among more than 20,000 patients ages 50-75 in the JPS Health Network, Tarrant County’s medical safety net. The findings indicate a need to simplify access to screening, laying the groundwork for a project testing different methods to encourage more people to get screened.

2011: A five-year, $6.3 million National Cancer Institute grant led by Dr. Skinner and Ethan Halm, M.D., establishes the Parkland-UT Southwestern PROSPR Center to more efficiently target and deliver screening for colorectal cancer. (PROSPR stands for Population-based Research Optimizing Screening through Personalized Regimens.)

The center is one of just three nationwide focused on colorectal screening, and the only one targeting a population that lacks health care resources. The PROSPR Center begins studying all aspects of colon cancer screening among a racially and ethnically diverse group of some 70,000 Parkland primary-care patients to identify opportunities to improve screening rates, follow-up, and other care.

The Translation

2009-2013: Cancer Center members lead a project involving about 5,900 people in Tarrant County that compares three means of engaging primary-care patients in screening: usual care, a direct invitation to receive a free colonoscopy, or a free fecal immunochemical test kit mailed directly to them. Participation rates rise to about 41 percent for people sent a test kit and 25 percent among those invited for colonoscopy, compared with just 12 percent for those receiving usual care. The findings have implications for public health policy-making.

2014: Led by Sandi Pruitt, Ph.D., a statistical analysis of patients in the Tarrant County study who received usual care indicates that factors related not just to patients but to their physicians, neighborhoods, and clinics are relevant in screening decisions. The work highlights potentially important avenues to boost screening rates, such as reminders built into clinic systems or neighborhood campaigns.

The Impact

2011: In a PROSPR project, two Parkland Community-Oriented Primary Care clinics in Dallas begin deploying the Cancer Risk Intake System, a bilingual touch-screen computer application that asks patients about personal risk factors and family history of colon cancer, using responses to generate personalized screening recommendations. As of May 2015, about 2,700 patients had used the program.

2013: The PROSPR Center implements a program, embedded in Parkland’s electronic medical record, that matches colonoscopic findings with follow-up care guidelines for surveillance and rescreening. The program ensures subsequent care is provided based on the individually determined risk of colon cancer in each patient.

2014: The PROSPR Center’s mission expands to include cervical cancer screening, an effort led by Jasmin Tiro, Ph.D., and Dr. Skinner. Additional funding supports initiatives such as a project to follow some 178,000 screening-eligible women in the Parkland system (24 percent of them African-American and 61 percent Hispanic). Rates of cervical cancer in Hispanic women are about 60 percent higher than in non-Hispanic Caucasian women.

The Future

Investigators are studying whether higher colorectal cancer screening participation rates found among patients mailed test kits will carry over into repeat screening and follow-up when needed. Also, a large CPRIT-funded initiative called C-SPAN (colorectal cancer screening and patient navigation) is partnering with agencies and institutions in 20 local counties to expand the test-kit mailing program to 165,000 underserved suburban and rural residents and to ensure access to needed follow-up care.

Building on infrastructure and insights developed through colorectal screening research, Simmons Cancer Center scientists are improving delivery of screening and preventive care in other malignancies, including liver and cervical cancers.

Meanwhile, new insights into the genetics of colon cancers may someday better guide screening and follow-up care among African-Americans, who face higher risk of the disease and are more likely to die from it. Work by a team of investigators that included former Simmons Cancer Center Director James Willson, M.D., has identified a set of previously unrecognized mutations in colorectal cancers among African-Americans, shedding light on biological differences in the disease that may help explain that group’s elevated risk.

Significant Publications

Gupta, S. et al. Screening for colorectal cancer in a safety-net health care system: Access to care is critical and has implications for screening policy. Cancer Epidemiol Biomarkers Prev 18, 2373-79 (2009).

Tiro, J.A. et al. Multilevel correlates for human papillomavirus vaccination of adolescent girls attending safety net clinics. Vaccine 30, 2368-75 (2012).

Singal, A.G. et al. Outreach invitations for FIT and colonoscopy improve colorectal cancer screening rates: A randomized controlled trial in a safety-net health system. Cancer 122, 456-63 (2016).

Tiro, J.A. et al. The colorectal cancer screening process in community settings: a conceptual model for the Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) Consortium. Cancer Epidemiol Biomarkers Prev 23, 1147-58 (2014).

Skinner, C.S. et al. Development of the Parkland-UT Southwestern Colonoscopy Reporting System (CoRS) for evidence-based colon cancer surveillance recommendations. J Am Med Inform Assoc (2015) [Epub ahead of print].

Colon cancer screening process diagram
Cancer Center scientists and colleagues have developed a model conceptualizing the colon cancer screening process. The model has been adopted by all PROSPR colon cancer sites to help guide future screening research (see Tiro et al., 2014).