Lisa McCooey and Christine Parker, The CT Dept. of Public Health Cancer Initiatives
January 4, 2009

Welcome to Yale Cancer Center Answers with Dr. Ed Chu and Dr. Ken Miller, I am Bruce Barber. Dr. Chu is Deputy Director and Chief of Medical Oncology at Yale Cancer Center and an internationally recognized expert on colorectal cancer. Dr. Miller is Director of the Connecticut Challenge Survivorship Program and is also the author of "Choices in Breast Cancer Treatment." If you would like to join the discussion, you can contact the doctors directly at canceranswers@yale.edu or 1-888-234-4YCC. This evening, Ed welcomes Christine Parker and Lisa McCooey, Co-Directors of the Comprehensive Cancer Program at the Connecticut Department of Public Health.

Chu
Christine, why don't we start off by discussing what the mission of the Department of Public Health is?

Parker
The mission of the Department is to enhance and look after the health and well being of all state residents. The mission of the Comprehensive Cancer Program is very specific, of course, to cancer, and it is to reduce the burden of cancer, and all of the illnesses associated with cancer, as well as morbidity and mortality associated with cancer. We have a very broad goal, which takes a lot of work.

Chu
When was the Comprehensive Cancer Program first established within the Department?

Parker
The Comprehensive Cancer Program was established in 2002. Prior to that, the Department had done a lot of work in very specific areas, particularly breast and cervical cancer programs, given that that was the focus the CDC had at that point in time.

Chu
As I understand it Lisa, this really was developed and established in coordination with the Centers for Disease Control.

McCooey
That is correct. Our first funding in 2002 was a planning grant, and approximately 3 years later we were able to secure implementation funding, which essentially just about doubled the amount of funding that we received from the Centers for Disease Control and Prevention.

Chu
What I found to be really very interesting about the whole program is that it is a broad coalition that initially was started by five founding members, is that correct?

McCooey
That is correct, and the whole premise for comprehensive cancer, in this case, is a public health approach; to provide coordination along the continuum of cancer care to reduce duplication and to have a more coordinated effort.

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Chu
Do each of the states in the United States have Comprehensive Cancer Programs built within their Departments of Health?

McCooey
That is correct. It is now a national program, and all 50 states have at least planning money, and most have implementation money.

Chu
Funding comes from the CDC, the federal government, the state government, a little bit of everything.

McCooey
It varies from state to state, and in many cases, all states have federal funding. In some cases, states are fortunate enough to have secured state funding as well as federal funding, and Connecticut is such a state where we have both federal and state funding.

Chu
I know that some states also get funding through the Tobacco Settlement, are we able to take advantage of the Tobacco Settlement? As I understand it, there are huge amounts of money that were made available.

McCooey
Historically, Connecticut has not been a state that has been dedicating their Tobacco Settlement dollars to public health and tobacco cessation activities. However, the 5.5 million dollars that the state legislature allocated to implement the state cancer plan in 2006, indeed is from Tobacco Settlement money.

Chu
Terrific, maybe we can review for our listeners what some of the main priorities of the Comprehensive Cancer Program are.

Parker
The priorities deal with all aspects of cancer and cancer care. We are looking at funding different entities that deal with preventing cancer, detecting cancer early on, providing quality treatment, powering and providing resources for survivors, and looking at what issues need to be addressed for end-of-life care. There are a lot of crosscutting issues, probably the most important being reducing health disparities. Specific projects, and two that are at this point in time priority projects for the state, are developing a Clinical Trials Network, as well as conducting a Pilot Colorectal Cancer Screening Program that will mirror how the Breast and Cervical Cancer Screening Program has been implemented in Connecticut.

Chu
It is interesting that you mentioned developing the Clinical Trials Network, because in fact, we here at Yale Cancer Center are very fortunate to have been awarded a grant from your program to help develop a clinical trial infrastructure to reach out to the

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community, community partners, and begin to work with them and educate them about the real importance of clinical trials and clinical research. I guess the real essence of this program is, how do we make available to all citizens in the state of Connecticut, the
access to state of the art cutting edge clinical trials?

Parker
We know that there is a dire need, not only on behalf of Connecticut residents, but on behalf of Connecticut's professionals, and clinical individuals to know that. They can access these clinical trials for their patient. We have a learning curve for the clinicians, Connecticut as a state, and the residents of the state.

Chu
That is interesting, and what we found is that there really is tremendous interest on the part of the health care providers throughout the state, for getting involved or having access. One of the obstacles is that they have very limited time, because, obviously, they are very-very busy taking care of patients, and so one of the things we are thinking about is, how can we relieve that burden by setting up a centralized infrastructure? It is a challenge, but I think it is a challenge that is clearly well worth the effort. Even here in the United States, which clearly has the best health care system in the world, somewhere between 20% and 40% of all individuals have access to any type of colon cancer screening, let alone the optimal gold standard for screening, and there are varying figures, but you folks should really be applauded for helping to develop such a program.

Parker
Thank you. We have done some research looking at individuals with health care coverage and their access to colorectal cancer screening. It is one particular cancer screening modality that is significantly underutilized, and we know there are several reasons for that. Education outreach certainly goes along with developing a colorectal cancer screening project, and we are making sure that all those components are included. You do not make colorectal cancer screening available and then expect that individuals will come. We need some very intense in-reach, outreach, and education. Those are all components of the program.

Chu
Lisa, you had mentioned trying to also focus on the minority and the underserved population, is there also a focus on trying to further develop colon cancer screening in that underserved population as well? We are finding that to be an issue right here in the local New Haven area.

McCooey
That is correct. We have contracted with the Community Health Center Association of Connecticut who overseas almost all, but not quite all, of the community health centers

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in Connecticut. They have recruited eight of their community health centers to participate in this project, and typically lower income folks access services at community health centers. We all know that, unfortunately, minorities are disproportionately included in the lower income socioeconomic group, so by going through local community health centers, we hope to be reaching the population in need.

Chu
One of the things we like to do on the show once in a while is to find out a little bit more about our guests and how they got involved in cancer, if you will. Chris and Lisa, give us a little bit about your background and how you eventually became Co-Directors of this program?

Parker
I started my professional career in hospital administration and worked with a radiologist, who, at that time, was president of the American Cancer Society. I saw the work that he did and it was impressive because he had such an impact on the state. I became involved as a volunteer with the American Cancer Society and then became one of their Directors. I then heard that the state was starting a cancer program, and desperately wanted to be part of it. So I did some informational interviews and eventually became part of a very new cancer program in Connecticut.

Chu
Great, terrific, and Lisa?

McCooey
I have to confess that I am a physician wannabe, when I was in high school my goal was to become a physician. I wanted to find a cure for cancer, as lofty as that sounds, that is what I really wanted to do. Somehow, my path got detoured along the way and I made my way to public health. When a position became open in the Breast and Cervical Cancer Early Detection Program at the State Health Department, I jumped at the chance and applied, and was fortunate enough to be hired. That was a number of years ago and I have been working in cancer, for the most part, since 1993.

Chu
Certainly being a part of this program has a significant impact on what happens in cancer care here in the State of Connecticut, but also throughout the country. You are actually following what you originally set out to do.

McCooey
I like to think so.

Chu
You are listening to Yale Cancer Center Answers. We are here in the studio discussing the role of the Connecticut Department of Public Health and the Comprehensive Cancer Program, and how this program can help to improve overall cancer care here in the State of Connecticut.

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Chu
Welcome back to Yale Cancer Center Answers. This is Dr. Ed Chu and I am here in the studio with our guests Christine Parker and Lisa McCooey from the Connecticut Department of Public Health. To start off this segment of the show, let's review some of the high priority programs that are run out of your office.

Parker
We have a number of them. We have the Connecticut Breast and Cervical Cancer Early Detection Program, we have the WISEWOMAN Program, and we have the Cardiovascular Disease Risk Reduction Program. We also have Comprehensive Cancer and Colorectal Cancer Screening Programs.

Chu
Let's review a little bit about what the Breast and Cervical Cancer Early Detection Program is. What's it all about?

McCooey
We receive funding both federally and from the state to provide breast and cervical cancer screening, diagnostic services, and treatment referral, to low income uninsured, or underinsured women. What we mean by underinsured are those women whose insurances do not cover the screening services. We have 17 contracted provider sites throughout the state, and approximately 120 satellite sites which are points of entry where women can come in, if they qualify for the program, and receive screening services. For most women that is it, that is all they need, but in the event that they do have an abnormal test result, diagnostic services are provided, and in the unlikely event that she is diagnosed with breast or cervical cancer, she is referred for treatment, as well as referred to the Breast and Cervical Cancer Treatment Act, which means Medicaid will pay for her treatment for the duration that she requires treatment.

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Chu
So, if in fact, unfortunately, a mass is diagnosed, say at the time of mammography, the diagnostic procedure would also be covered?

McCooey
That is correct.

Chu
That has been a big issue that we have faced here at Yale Cancer Center, where, with the generous support of the hospital, we have what we call the MammoVan. It goes out to some of the underserved areas and screening is done, but unfortunately, if in fact something suspicious is identified, there have been challenges in helping to finance the diagnosis and then the treatment. It sounds like this is a very nice opportunity, and a nice program that you have.

McCooey
It is a very nice opportunity. CDC made it very clear that that is exactly what they did not want to happen, so they made sure it is part of the program that diagnostic services be covered under federal funding, and then treatment for referral was a mandate.

Chu
I am just curious, approximately how many women per year undergo a breast cancer screening?

McCooey
We typically screen between 8500 to 9000 women per year.

Chu
Wow, so that is pretty significant.

McCooey
It is significant; however, it is still only approximately 12% to 15% of the women who are eligible for program services in Connecticut.

Chu
At the time that these women undergo breast cancer screening, do they also undergo cervical cancer screening?

McCooey
That is correct.

Chu
So again, you are hitting about 8000 to 9000 women in the state, but obviously you would like more. What number would you like to hit, if possible?

McCooey
We have estimates that over, or about, 50,000 women are eligible for the program. We would love to see all the women who are eligible, but obviously funding cannot allow us to do that.

Chu
Of those women that come for screening, what percentages are diagnosed with cancer?

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Parker
Unfortunately, I do not have those numbers in front of me, but I would guess that we diagnose maybe 50 breast cancers a year now, because part of the program philosophy, particularly with breast cancer screening, has been to have women come back according to the established guidelines for re-screening. We have many women who participate in the program for quite a number of years, and with thorough re-screening, if they are diagnosed with breast cancer, it is at a much earlier stage.

Chu
Christine, how do you get the word out to the community, and to your target audience, that services are available and that people should take advantage of those services?

Parker
The Department currently contracts with the 17 major program providers. These providers are the ones that subcontract with the 120 satellite sites. Part of our mandate to those 17 sites is that with the funding that we allow them, they have to hire an outreach educator. We have an outreach educator, public education coordinator, at the State Department of Public Health who is responsible for training the 17 state outreach educators to ensure that they have the tools necessary to reach the population. Not only that, but we have done some wonderful media in the past that has been very successful. We did a public service announcement where Meryl Streep did the voiceover years ago, and we allowed other states to use it. That was a very successful campaign, but we use every opportunity possible. There are so many programs where we are in collaboration, working to make sure that several programs are announced if we have a captive audience or there is a forum available to us.

Chu
Have you thought about using, or are you using, patient navigators? I know that at the Cancer Center we have been trying to reach out to the churches and the ministers to help us enlist these women at risk.

Parker
Yes, there are two projects that we are currently in the process of funding that do much of their work through the Face Faith Organization. We realize that we certainly need to be in those venues, but our outreach educators also do a lot with faith-based organizations; we have not missed that opportunity. I think the Department now has decided to allocate some larger funding to ensure that we are reaching as many women as we can through those venues.

Chu
Have you found that over time there is an increased understanding of the importance of these types of screening programs?

Parker
Absolutely, particularly when you see the utilization rates in Connecticut for both

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mammography and Pap testing. It is fairly high according to the Behavioral Risk Factor Surveillance System, and I think at this point in time colorectal cancer seems to lag behind. I think this is because it is more complicated, and there are several screening modalities that can be used. The prep test preparation, if you are having a colonoscopy, can be overwhelming. This is where we are really trying to explore the use of patient navigators within our community health centers, so that we are using that model to assist folks through what could be somewhat of a daunting procedure.

Chu
One thing to consider, because I know that with respect to colon cancer screening women are much less enthusiastic about going, it is about half of what males tend to do in terms of going for colonoscopy screening. In part, I think women tend to be maybe a bit more squeamish about the prep, but also, there is this general feeling that breast cancer, cervical cancer, and even ovarian cancer, are much more important, and occur more commonly than colon cancer. We do know, based on the numbers, that colon cancer is equal opportunity, and the incidence is really the same between males and females. I wonder if there is a way to link your colon cancer screening with the breast and cervical cancer screening, and get them right at that time that they are coming in for breast and cervical screening.

McCooey
That is our hope. Currently, the CDC has five demonstration projects for the Colorectal Cancer Screening Programs. We have done everything we can to make sure that our program is modeled using all the same tools, and collecting all the same data, so that if along the road the CDC does come out with additional colorectal cancer screening money, we will be in a perfect position to have all the pieces in place to apply.

Chu
There has been a great deal of focus placed on the minority underserved population, but another population that we are beginning to think more about at the Cancer Center is the elderly population, who tend to get forgotten amongst all that. I am just curious, are there any efforts to try to get the elderly population more actively involved in some of the screening programs?

McCooey
Not at this point, but we do realize what our eligibility criteria for the programs are where we are going to target our outreach efforts and education efforts. Of course with colorectal screening, we know that 75% of all colorectal cancers occur in individuals 50 years of age and older, so of course that is where we target our efforts. Also, we have the new position of the Outreach Public Education Coordinator, and we are excited to have this individual onboard. We will begin to expand those efforts beyond breast and cervical cancer and the WISEWOMAN Program, and begin to focus more on the Colorectal Cancer Screening Program for targeting the elderly.

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Chu
You mentioned the WISEWOMAN Program; can you tell us a little bit more about what that program involves?

Parker
WISEWOMAN is a complimentary program at the federal level for the Breast and Cervical Cancer Early Detection Program. It stands for Well Integrated Screening and Evaluation for all Women Across the Nation. It came out of CDC's division of physical activity and nutrition. The idea is, when you have a woman come in for breast and cervical cancer screening, you have a captive audience. We all know that the number one killer is really heart disease, so how can we capitalize on the fact that we have these low-income women coming in for their breast and cervical cancer screening services? How can we deliver cardiovascular health screening services to them? But more importantly, those women who are at risk, not those who require medication for high blood pressure, high cholesterol, or high glucose levels, but those women who are at high risk and who through perhaps change in their diet and change in their exercise, can improve their lifestyles and might decrease their risk for developing cardiovascular health disease. 9 of our 18 breast and cervical cancer screening sites are delivering WISEWOMAN services as well, and they do it through group inventions and through individual counseling to try to help women map out a way to improve their lifestyles.

Chu
Do you have a nutritionist involved in this program?

Parker
In some of our provider sites, yes, nutritionists are delivering the nutrition component of the program.

Chu
It is fascinating to me that when you look at the general principles behind good health, and general wellness, they go hand in hand with the general principles for good cancer care prevention.

McCooey
Correct.

Chu
So exercise, physical activity, tobacco cessation, don't drink alcohol heavily, and eat fruits and veggies, if you do all of those thing you will have much better health in general, and you will prevent the risk of developing cancer.

McCooey
That is correct.

Parker
We know that 35% of all cancers are directly related to diet. So what we are practicing in the cardiovascular disease program, we know will impact their cancer risk as well.

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Chu
It is important to emphasize that it is never too late to change, and go from bad behaviors to good behaviors?

McCooey
That is true.

Chu
Terrific. Thinking ahead, what are some of the new initiatives, new priorities, that you folks are thinking about in your program?

McCooey
The Cancer Partnership is certainly well aware that our cancer plan is ending this year, 2008, and has been, for the last year and a half, very active in coming up with another state cancer plan. That new state cancer plan will begin in 2009 and end in 2013. It will have all of the areas that I mentioned earlier. They will look at prevention, early detection, survivorship, end-of-life care, and health disparities. We have prioritized all of the objectives in the plan, and the plan will be ready to be implemented. The plan is an important infrastructure piece for the entire state, because once the plan is in place, all partners of the cancer plan, and the entities in our outside partners, work to really implement the plan because the plan is research and data driven. We know that it is what we will encourage all of our providers to follow. That has been one of the major initiatives, and now accessing funding to implement the plan will be a second priority for the Partnership.

Chu
Obviously funding is always the key, where do you see funding opportunities, especially given all of the financial difficulties that we hear about on the news and radio every day?

Parker
It is certainly going to be a challenge. We have a project director, if you will, for the Connecticut Cancer Partnership, Lucinda Hogarty, and she has been actively mapping out what her strategy is going to be to move the Partnership forward. I am sure one of her priorities is to explore alternative funding via foundations or other sources, because we all know that state and federal government is in dire straits. We are going to have to look elsewhere.

Chu
Obviously we know that what you two have been doing, and what the program is doing, is absolutely critical for the citizens here in the State of Connecticut. We look forward to having you back and hearing about the progress, and hopefully we can talk about some of the progress that we are doing with you folks on developing this Clinical Trials Network. You have been listening to Yale Cancer Center Answers. I would like to

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thank my guests Christine Parker and Lisa McCooey for joining me. Until next time, I am Dr. Ed Chu from the Yale Cancer Center wishing you a safe and healthy week.

If you have any questions for the doctors or would like share your comments, go to yalecancercenter.org where you can also subscribe to our podcast and find written transcripts of past programs. I am Bruce Barber and you are listening to the WNPR Health Forum for Connecticut Public Radio.