When lung cancer is detected earlier in the course of the disease, treatment is more beneficial for patients. According to Anne Conners, MPH, MA, of MaineGeneral Medical Center and Maine Lung Cancer Coalition, community health workers (CHWs) play a critical role in implementing lung cancer screening programs, as evidenced by the success of a pilot program implemented in her home state of Maine.
Lung cancer is very common and is the leading cause of cancer mortality nationwide. But according to Ms Conners, this malignancy disproportionately affects residents of Maine due to the state’s high smoking rate (nearly 20% of residents smoke, well above the US average of approximately 14%), its rurality and geographic barriers to healthcare access, and its naturally occurring but mitigable environmental risks, particularly its high rates of radon (a leading cause of lung cancer).
“We’re ranked 11th in the country in lung cancer mortality, so we’re doing a good job of taking care of people once they are diagnosed,” she noted at the AONN+ 2020 Virtual Midyear Conference. “But a strong screening program really can make a big difference.”
The Maine Lung Cancer Coalition
Smoking is the key risk factor for lung cancer, so reducing tobacco use is the most impactful way to reduce the burden of this disease. “Every year in the US, half a million people die of tobacco-related causes, and for every person who dies, 30 people are suffering from tobacco-related illnesses,” she said. “So we really have our work cut out for us.”
The Maine Lung Cancer Coalition was established to decrease the burden of lung cancer through lung cancer prevention, early detection, and treatment efforts in the state. The coalition aims to establish the infrastructure required to implement and disseminate evidence-based best practices about lung cancer screening, and to facilitate the early referral and treatment of patients with lung cancer throughout Maine.
“Nationwide, one of the biggest problems is that we’re not currently reaching enough of the eligible population that can be screened for lung cancer. So we’re working hard to get the word out on the provider level, as well as on the general community level,” said Ms Conners. “If lung cancer is caught earlier (stage 0 or 1), outcomes are much better. But because most lung cancer is asymptomatic for a long time, this disease is getting caught in the late stages, when treatment is much less beneficial.”
Enter the CHW
A CHW is a frontline public health worker who is a trusted member of the community, and who typically has an especially close understanding of the community members served. This trusting relationship enables the CHW to act as a liaison between health/social services and the community and serves to facilitate access to services and improve the quality and cultural competence of service delivery.
Through a range of activities such as outreach, community education, informal counseling, social support, and advocacy, a CHW also builds individual and community capacity by increasing health knowledge and self-sufficiency. This engagement is not limited to patients and members of the community but extends to all involved stakeholders, such as providers, policymakers, and insurance providers.
“This knowledge and trusting relationship allows CHWs to link people in their community to services
and to motivate behavior change,” she said. “This is a peer, not someone looking down on them or talking down to them.”
As perhaps the most critical part of their work, Ms Conners and her colleagues employed CHWs as an extension of the healthcare team to reach their most vulnerable populations. Their community-based outreach strategy was built around 2 aims: first, to increase knowledge about lung cancer screening (many people are familiar with screening for breast cancer with mammograms but are unaware of screening methods for lung cancer, such as low-dose CT scans), and second, to increase the number of people referred to the Maine Tobacco Helpline.
“Nothing About Us Without Us”
In their first year of efforts, Ms Conners and her team developed a plan for outreach and community engagement. “We established a county-wide advisory group to look at the current state of messaging around smoking and lung cancer, as well as the future state,” she said. “This community engagement strategy was so foundational to the work we did.”
Their slogan was “Nothing About Us Without Us.”
“We didn’t want to impose this work on the community; we wanted to hear what they thought about lung cancer, and whether or not they thought it was a problem in their community,” she added.
She and her team assessed local environmental health policies, introduced themselves to members of the community, and disseminated surveys about knowledge, attitudes, and beliefs about lung cancer. These survey data were then used to develop the messages used in the implementation phase.
In years 2 and 3, they launched a Primary Care Pilot with the main goals of increasing screening among the eligible at-risk population and encouraging ineligible individuals to engage in risk-reduction activities such as tobacco cessation or in-home radon testing.
They were able to reach 1184 individuals through proactive CHW outreach, and more than one-third of patients engaged in some type of risk-reduction activity after inclusion in the pilot. Radon testing was the most common risk reduction, followed by tobacco cessation. She noted that the lung cancer screening criteria were quite narrow, but about 8.5% of people were referred for shared decision-making, and about 7% completed low-dose CT scans.
Approximately 42% of current smokers engaged with the CHWs, compared with 19.5% of former smokers. “This was surprising, because it’s very difficult to engage people who smoke, particularly older people who have been smoking their whole lives,” she said. “They’ve been lectured to for a long time, and they tend to turn off. This shows that a CHW engenders trust, and behavior change is possible even in this population.”
In years 3 and 4, the team established their Annual Reminder Pilot, which involved patients who were 13 months or more overdue for their annual scan. A control group of patients were sent passive letters reminding them to complete their low-dose CT scans, whereas patients in an experimental group received the same letter along with a call from a CHW. Among the latter group of patients, an impressive 86% completed a low-dose CT scan, compared with 19.6% of patients who only received the letter, Ms Conners reported.
Of 344 smokers who received low-dose CT scans, 215 received tobacco cessation counseling from a CHW, and 151 accepted a referral to the Maine Tobacco Helpline. “This is higher than the standard acceptance rate for referrals to quit lines,” she said. “These results really show the power of the engagement of CHWs.”