Opening Doors

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From Paths of Progress Fall/Winter 2014

The Ongoing Effort to Reduce Disparities

by Saul Wisnia

 

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Francisco Baez was a perfect candidate for a colonoscopy. He was in his early 60s with a family history of colon cancer; his brother had died of the disease at age 48. Baez's primary care physician scheduled him to get the screening several times, but Baez — a native of the Dominican Republic who did not speak English — never showed up for the procedure.

"I was afraid, because of what people had told me about the test," Baez says through an interpreter. "Even after I started having pain, I didn't want to go until I met Oscar [Sanchez]."

Oscar Sanchez was Baez's patient navigator at Dana-Farber/Brigham and Women's Cancer Center (DF/BWCC). In this role, Sanchez provided weekly consults at two facilities — the Southern Jamaica Plain Health Center and the Brookside Community Health Center — both located in Boston's Jamaica Plain neighborhood, where Baez lives. Sanchez met with Baez several times to help allay fears about his colonoscopy appointment. He explained the importance of the procedure in detecting cancer early, assured Baez the discomfort was far less than he envisioned, and even arranged for rides to and from the appointment with the help of DF/BWCC social workers and interpreters.

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The knowledge and confidence that Francisco Baez (right) gained in meetings with patient navigator Oscar Sanchez (left) prompted Baez to get a colonoscopy — which revealed his cancer.

Then, when the screening revealed a large tumor in Baez's colon, Sanchez was by his side for each step of his surgery and chemotherapy.

Stories likes Baez's among individuals from diverse racial and ethnic background are not uncommon. Minority groups, especially blacks and Latinos, maintain a disproportionately higher burden of colorectal and other cancers, and experience significant inequities in related mortality. Research demonstrates that this disparity can be linked to the fact that members of these minority groups are less likely than whites to undergo screening that would lead to a cancer diagnosis at an earlier and more treatable stage of disease. Such disparities underscore the need to raise awareness about cancer prevention, screening, early detection, and survivorship.

This is precisely what Dana-Farber's recently completed three-year Community Health Needs Assessment and the Institute's Cancer Care Equity Program (CCEP) are focused on doing. A key component of Dana-Farber's mission is to promote public health among medically underserved populations. This is approached through a "social determinants of health" framework by considering factors that affect cancer risk and mortality such as poverty, housing, education, employment, and health behaviors.

The Needs Assessment highlights the diversity of Dana-Farber's priority neighborhoods of Roxbury, Mission Hill, Dorchester, Mattapan, and Jamaica Plain, as well as many of the broad socioeconomic challenges and health care access barriers facing their residents. Individuals living in these communities reported being challenged by issues that go beyond cancer, such as inadequate availability of nutritious food, lack of a safe outdoor environment for physical exercise, high rates of unemployment, lack of affordable housing, community violence, and experiences of racism and discrimination within the health care system.

"Despite long-standing efforts by the city of Boston, civic leaders, and the area's academic medical centers, there continues to be a significantly higher cancer mortality for blacks compared to whites in Boston, which underscores the importance of our community-based work focused on reducing cancer disparities," says Anne Levine, MEd, MBA, vice president of External Affairs at Dana-Farber. "Dana-Farber has built a portfolio of community-based outreach and engagement activities over the last few decades, and while challenges persist, we continue to focus on the imperative to reduce the cancer burden in our surrounding neighborhoods and ensure that each patient who walks through our doors receives equitable, patient-centered care."

As part of Dana-Farber's broad-based efforts to improve health equity, the Institute's Community Benefits Office oversees a variety of comprehensive programs including sun safety education and screening, HPV and cervical cancer education, and tobacco control treatment. "The challenge we have is bringing all these programs and services to a level where they become embedded in the community," said Magnolia Contreras, MSW, MBA, director of Community Benefits at Dana-Farber. "We are making a long-term commitment to be part of the fabric of these communities."

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Left to right: Magnolia Contreras, MSW, MBA, Anne Levine, MEd, MBA, and Elizabeth Gonzalez Suarez, MA, help lead DF/BWCC’s work to reduce cancer disparities.

Peer Support

One key initiative — Open Doors to Health — is a peer support program focusing on improving screening rates for cervical, breast, and colon cancers, in addition to promoting other primary cancer prevention behaviors. Through well-established partnerships with housing developments in Roxbury, the program meets residents where they live and seeks to address key socioeconomic factors that have an effect on cancer risk such as a lack of outlets for physical activity and an unhealthy diet.

Research shows that minority groups have a disproportionately higher burden of cancer, and they can experience significant inequities in related mortality.

Statistics from Dana-Farber's Community Health Needs Assessment support these efforts: 72 percent of Boston residents consume less than adequate daily amounts of fruits and vegetables, and more than 55 percent of residents do not participate in adequate physical activity. The high cost of nutritious foods, the lack of supermarkets in some neighborhoods, and the limited access to safe outdoor environments for physical exercise are all factors.

"Our research has taught us that people respond best when encouraged by their peers, so we trained residents living in the housing developments to teach other residents about the importance of cancer screening and invite residents to participate in activities to keep active and healthy," says Elizabeth Gonzalez Suarez, MA, director of Community Health Practice for Dana-Farber's Center for Community-Based Research. "We also provide technical assistance to an organization that owns many of the affordable housing units to make changes in the housing environment that promote walking and consumption of fresh vegetables, such as establishing walking clubs and farmer's markets."

In addition to Dana-Farber's broad foundation of outreach programs, it established CCEP in January 2012 to serve as a bridge between research and outreach efforts in addressing cancer disparities. The role of CCEP is to improve local outcomes through enhancing access among the medically underserved to the spectrum of preventative medicine, treatment, and clinical trials at Dana-Farber; unite and facilitate disparities-related research across the Institute; and strengthen established outreach and educational programs.

Through CCEP, Dana-Farber Community Cancer Care at Whittier Street Health Center was launched after more than a decade of partnering with Whittier — a federally qualified health center in Roxbury serving patients from 25 different countries — on early detection and survivorship initiatives. The program provides streamlined diagnosis, treatment, and education of underserved patients with suspected malignancies through the various stages of care. This clinical partnership is believed to be the country's first dedicated oncology space in an inner-city health center.

In this model, one member of a rotating group of DF/BWCC oncologists spends a day working with oncology nurse Ludmila Svoboda, RN, BSN, every two weeks in Whittier Street's fifth-floor cancer clinic, meeting with adult patients for screenings, consultations, and educational sessions in a sun-splashed locale dominated by tall windows. A mammography suite is also open at Whittier three days a week as a brick-and-mortar partner to Dana-Farber's Mammography Van, which has spent many years visiting locations throughout Boston offering mammograms and breast health education to women eligible for screening.

Focus on Diversity and Cultural Sensitivity

Cross-cultural education and workforce development are two internal efforts designed to strengthen Dana-Farber's efforts to lessen cancer disparities.

Through a highly successful program, area high school and college students from communities of color intern and are hired for summer jobs in various research, clinical, and support roles at Dana-Farber — an initiative that has already produced a half-dozen full-time hirings. And as the Human Resources department leads efforts to increase Dana-Farber's workplace diversity, patients report feeling more welcomed in an environment where they see staff who look like them.

Another effort focuses on cultural competency training for clinical staff. "It's not necessarily about race, ethnicity, or socioeconomic status, and which group a patient fits into," says Karen Burns White, deputy associate director of the Initiative to Eliminate Cancer Disparities at Dana-Farber. "It's about understanding all the possible barriers that might impact a patient, and keeping them all in mind when talking to and treating him or her as an individual."

The overall value of the Whittier Clinic is reflected in a powerful statistic: 50 percent of the patients seen there since its January 2012 opening have had a previous experience with cancer — or are diagnosed as the result of a visit. But as Christopher Lathan, MD, director of both Dana-Farber Community Cancer Care at Whittier Street and the Cancer Care Equity Program points out, the program's job doesn't stop there.

"We need to do more than just keep our doors open — we need to link care delivery to people in these communities, and make it easy for them to get to us," explains Lathan. "If we were not there it might take weeks for a patient referred for oncology care by a primary care doctor to get in for all the treatment he or she needs. At Whittier we can expedite the workup and get them connected to Dana-Farber right away."

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Christopher Lathan, MD (right), treats patients at Dana-Farber Community Cancer Care at Whittier Street Health Center, in Boston’s Roxbury neighborhood.

Collaboration and Analysis

Another key component of CCEP is the development of a health equities database, which is being designed to work in conjunction with Partners eCare, the new integrated electronic health and administrative information system slated to go live at Dana-Farber and Partners HealthCare hospitals next year. The database will allow for more targeted research and outreach efforts by including the ethnic and racial backgrounds of patients by disease and other demographics.

In addition, CCEP coordinates efforts for disparities researchers to collaborate by bringing together the various groups within DF/BWCC and their contemporaries at the Dana-Farber/Harvard Cancer Center that are working on health equity-related research and programs. Lathan leads quarterly meetings where colleagues from these institutions are encouraged to trade ideas and collaborate.

"Say you're a basic researcher interested in disparities among triple-negative breast cancer patients, but you don't typically work with social workers or other behaviorists," says Lathan. "Maybe there is someone well-versed in those areas that you can link up with to pursue a grant or research project."

New efforts such as the health equities database complement established initiatives like the patient navigator program that connected patient Francisco Baez to navigator Oscar Sanchez.

Patient navigators from Dana-Farber's Center for Patient and Family Programs and Services help address the needs of individuals from diverse backgrounds who have been diagnosed with or are at risk for cancer. They facilitate access to health care services, particularly for patients who may face challenges associated with low socioeconomic status, limited English proficiency, disability, or insurance status.

Navigators work with patients in specific programs at Dana-Farber and Brigham and Women's Hospital in addition to affiliated community health centers, and the impact of their work is clear. The colorectal cancer navigator program that helped Baez, for example, has demonstrated a reduction in the no-show rate of patients at screening and diagnostic appointments from 80 percent in 2008 to 16 percent, as observed among patients from two affiliated community health centers.

As a result, the "total trust" Baez feels for his care team — and his own successful treatment — has made him a vocal advocate for colonoscopies among his family and friends. His brother's cancer was not diagnosed until it was at a very advanced stage; he does not want this same misfortune for his other loved ones.

"I ask everybody their age, and if they are over 50, or having pain, I tell them they should be seen right away," says Baez. "My brother had pain but didn't tell his family. If he did, and if he had the same care I did, I think he would be alive today."

Paths of Progress Fall/Winter 2014 Table of Contents 

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