The AVON Foundation Comprehensive
Breast Center at Grady:
Clinical, Research and
Navigation Successes
Sheryl G.A. Gabram, MD MBA FACS
Professor of Surgery, Emory Winship Cancer Institute
Director, AVON Comprehensive Breast Center
Georgia Cancer Coalition Distinguished Scholar
Kimberly R. Jacob Arriola, PhD MPH
Associate Professor
Rollins School of Public Health of Emory University
PI, AVON Foundation Community Education &
Outreach Initiative
History of Breast Cancer: Emory
z 1937: 1st cancer clinic in
United States, $50,000
donation from CEO Coke
z WCI rebuilt in 2003:$72m
z P30 NCI designation
“It always gave me pleasure to do something for somebody without being
asked to do it . I don’t like to be asked. I didn’t want to be given credit.”
Robert W. Woodruff
Grady Health System
z 1892: Atlanta
Constitution editor
Henry Grady supported
vision of quality hospital
care for the poor
z 953 beds, 10
neighborhood clinics
z Georgia Cancer Center
for Excellence
Why we exist…
Network of Strength Executive Director
Joya Harris MPH Emory 2000
Emory: Public Health Spring 2009
Underlying Causes of the Black-White
Racial disparity in breast cancer mortality: a
population based analysis
zNCI SEER 244, 786 ♀ from 1990-2003
zPurpose: to evaluate racial disparities in BC
outcome using rate ratios B/W ♀ for
incidence, mortality and hazard rate
– Sub-comparisons done for ER-status
– Rate ratios allowed comparison of trends
Menashe I et al: JNCI 2009;101:993-1000
NCI Biostatistics Branch, Division Cancer Epi
Results
zFrom 1990-2004, incidence RR stable (age
specific incidence rates BW lower)
zMortality ↓: B 36 to 29/100,000 ♀
W 30 to 22/100,000 ♀
zIrrespective of ER status, hazard of BC death
higher in BW vs WW (controlled for age dx, stage,
grade year and SES)
z
Especially in first few years after diagnosis
Menashe I et al: JNCI 2009;101:993-1000
Racial Disparities in Cancer Survival among
randomized clinical trials patients of SWOG
z19,457 pts (11.9% AA): 35 SWOG phase III
z10 year OS AA vs CA
– 68% vs 77% early stage pre-menopausal BC
– 52% vs 62% early stage post-menopausal BC
– 13% vs 17% for advanced ovarian CA
– 6% vs 9% for advanced prostate CA
zAA worse survival with uniform stage, Tx, f/u
Albain KS, et al: JNCI 2009;101:984-992
Reasons for Cancer Disparities
Environment
(Social, System factors)
Genetics
(Biology)
Lifestyle
(Behavioral)
Gabram SGA, Lund MJ et al: Br Can Res Treat 2006;100 suppl 1 S97
Gabram et al: Cancer 2008:113:602-607
Breast Imaging
z2005: Delays 6 months
zMammography task force
zIncrease in overall growth from 11,942 to
14,835 imaging studies for 2005-2006
zFrom 2005-2008, 35% growth
11,942 →16,140 studies!
Gabram SGA, et al: Br Can Res Treat 106. Suppl 1 S260-261.
San Antonio Breast Conference Symposium December 2007
Growth in Breast Cancer volume
parallels Mammography
AVON Breast Patient Care Review
Conference
zGoals
– Practice evidenced care: NCCN guidelines
– Provide similar care across providers
– Identify patients for clinical trials
zData: ≈ 267 patients presented/re-presented
in 2008 with documentation of discussions
Clinical, Correlative, Registry accrual:
Implemented 2007, Increased 2008
z2007
–
–
–
–
Neoadjuvant: EU822
TAILORx
Brachytherapy (B39 and registry)
NSABP B-42
z2008:
– 4 clinical trials + 2 correlativeregistry trials
2007: 15 patients, 10.4%
2008: 33 patients, ≈20%
Reasons for Cancer Disparities
Environment
(Social, System factors)
Genetics
(Biology)
Lifestyle
(Behavioral)
Gabram SGA, Lund MJ et al: Br Can Res Treat 2006;100 suppl 1 S97
Gabram et al: Cancer 2008:113:602-607
Racial Differences
in TN Breast Tumors
Lund MJ et al: Br Can Res Tr 2009;113:357-70
¾Population-based study
¾Eligibility – WISH*, Black/White females;
primary unilateral invasive breast cancer
¾Description – Age 20-54; N=831
3 Atlanta counties (Fulton, DeKalb, Cobb)
May 1, 1990-Dec 31, 1992
¾Tumor Population –Pathology samples centrally
analyzed for Tumor Markers
¾ N=479 [117 B, 362 W]
⇒ Weighted analyses
*Womens’ Interview Study of Health
Racial Differences in
Triple Sub-groups (%)
ER-PRHER2-
Overall
ER+PR+H ER-PRHER2+
ER2-
ER+PR+H
ER2+
Black *
29.5
46.6
56.2
38.7
6.8
8.7
7.3
6.1
White
21.7
64.4
6.0
7.7
* p-value < 0.001 for black vs. white women
60
50
40
%
30
Triple Negative Tumors
by Age
56.6 55.4
42.2 41.2 44.2
42.2
28.6
20
10
17.3
19.6 19.5
0
Black
20-34
White
35-39
40-44
45-49
50-54
Lund MJ et al: Br Can Res Tr 2009;113:357-70
Disparate racial benefits of
chemotherapy in breast cancer
¾ To evaluate the outcomes associated with different
chemotherapy regimens in a largely AA group with early
stage breast cancer
¾ Population-Based Cohort of all FEMALES, identified using
SEER cancer registry
¾ Diagnosed during 2003-2004 with primary, invasive
unilateral breast cancer: Follow-up through 12/31/2007
¾ Resident of Fulton/DeKalb counties of Metro Atlanta treated
at 3 EUH affiliated sites
AVON Foundation Supported
K. May: SABCS 2008 #2091
Patient Population
K. May: SABCS 2008 # 2091
Results
K. May: SABCS 2008 #2091
Conclusions
¾ ♀ with TNTs have a higher likelihood of short-term recurrence
and mortality than other tumor subtypes and no statistically
significant differences in outcome were noted for AA or CA ♀
treated with chemotherapy
¾ Despite similar treatment, AA ♀ with ER+PR+HER2- tumors
experienced higher recurrence and mortality rates compared
to CA women
¾ Reasons and Future Direction: AA ♀ develop luminal B/higher
RS on oncotypeDX, CYP2D6 poor metabolizers, or
compliance
K. May: SABCS 2008 #2091
Reasons for Cancer Disparities
Environment
(Social, System factors)
Genetics
(Biology)
Lifestyle
(Behavioral)
Gabram SGA, Lund MJ et al: Br Can Res Treat 2006;100 suppl 1 S97
Gabram et al: Cancer 2008:113:602-607
Rollins School of Public Health
AVON Community Education &
Outreach Initiative Team
K. Jacob Arriola PhD
Principal Investigator
W. Wilkins-Thompson PhD
Co-Investigator
Tamara Mason MPH
Project Director
28 Community Patient Navigators
11 Patient Navigators
Maquina Harris BA
Administrative
Assistant
Avon CEOI History
z November 2001-May 2002
– Dr. Otis Brawley conceptualized the program
z June 2002
– 44 lay people were trained as Community Health Advocates
z April 2003
– Avon Foundation Comprehensive Breast Center opened due to
capital investment monies from AF, GCC, and GMH
z December 2003
– 10 breast cancer survivors were trained to serve as PNs
z April 2006
– RSPH Staff assumed leadership and management of project
z August 2008
– CHAs were retrained and renamed Community Patient Navigators
Program Overview
zGoal:
– Raise awareness about breast cancer
– Increase mammography screening rates
– Enhance the process of receiving prevention and
treatment services at Grady Health System
zSeeks to give the AFCBC enhanced visibility
and community recognition within Atlanta
zWorks to build and maintain strong
partnerships with local CBOs that focus on
breast health/cancer
Use of Lay Health Advisors
zA variety of different names
– Lay health workers, community health advisors
/workers/advocates, natural helpers, promotoras
zUses members from the target community deliver
health education
zOften used with marginalized populations
– Promote cultural competence
– May help address issues of distrust of the HCS
– Inexpensive to recruit, train, and supervise
– May be used in a variety of different settings
Training Lay Health Advisors
zAnnual training
– Breast cancer statistics
– How to interact with/support patients
– How to manage stress/care for self
– How to host community events
zBimonthly continuing education
– Variety of topics selected based on programmatic
need & PN input
Program Volunteers
z Community PNs
– Dedicated to raising
awareness about the
benefits of early detection
– Host and participate in
breast health events
– Equipped with teaching
tools
– Charged with identifying 5
women per event who are
interested in getting a
mammogram
z Clinic PNs
– Presence in the AFCBC
Breast Clinics
z Make appointment reminder
phone calls
z Provide support to patients
who are first diagnosed
z Individual PNs
– Mental/emotional support
during/after appointments
– Links to resources
– Liaison between patients &
social workers
2009 Community Patient
Navigators
Process Data for CPNs
z 107 events in 2009*
– 5,674 people
z Locations*
– Grady health clinics /
hospital-49
– Health centers/clinics-16
– Churches-12
– Community orgs-11
– Schools-4
– Other-15
z Demographics (N=70)*
–
–
–
–
94% Women
93% AA
50% annual income < $20k
Highest education
z 16% < HS diploma
z 22% HS diploma
z 36% Some college
z Screening/interest forms**
– 96 completed
– 20 (21%) had mammogram
*1/1/09-6/30/09; **1/1/09-4/30/09
Effects of AVON Outreach and Internal
Navigation program on breast cancer
diagnosis
History
‰ 2001: 125 CHAs/20 Navigators
‰ 1,148 community intervention
programs and over 10,000
participants
Study
‰ Cross sectional study: 20012004
‰ 487 breast cancer cases in
registries
‰ 89% AA, 5% Caucasian, 2%
Hispanic, 4% other
30
25.8
25
19.2
20
15
12.4
12.6
10
5
0
Stage 0
Gabram SGA et al Cancer 2008:113:602-607
Stage IV
2001
2004
2009 Patient Navigators
Process Data for PNs
Clinic
z 26 hours/week x 26
weeks=676 hours
–
–
–
–
–
–
9B Breast
10B Infusion
3A Mammography
Patient calling
GYN clinic
Rad/Onc
Individual
z 173 patients served
56%
12%
12%
8%
7%
5%
– Telephone support
– Support during
appointments
– Home visits
– Self-Image Center
Jan 1-June 30, 2009
75%
13%
10%
2%
Outcome Evaluation
z Qualitative Methods
– Utilize textual data
– Assumptions
z Reality is socially constructed
z Variables are complex &
interwoven
– Purpose
z Contextualization,
Interpretation, Perspectives
– Approach
z Inductive
z Seeks pluralism, complexity
z Quantitative
– Utilize numerical data
– Assumptions
z Social facts have an objective
reality
z Variables can be identified/
relationships measured
– Purpose
z Generalizability, Prediction,
Causal explanations
– Approach
z Deductive
z Seeks consensus, the norm
Qualitative Evaluation Methods
zIndividual in-depth interviews with 18 patients
who were enrolled in the program
– Brief quantitative survey to capture patient
demographics
zResearch Questions:
– How does PN impact patients’ lives?
– What are the strengths & weaknesses of the Avon
Foundation CEOI PN Program?
Ford, Thompson, Mason, Rayton,
& Arriola, in press
Qualitative Results
z How does PN impact patients’ lives?
– Improved knowledge about the treatment process &
breast cancer more generally
– Greater confidence in their ability to ask questions
– Informational, emotional, & spiritual support
Asking Questions
z I have plenty of confidence with [my PN]. When I
can’t explain for myself, I explain to her what I need
to ask the doctor, I try to explain it to her first. So
when the doctor comes in, she explains it to him
more clearly. And the doctor answers my questions
and sometimes I understand and sometimes I’m a
little confused because he speaks too fast. And I
don’t want to say because he is the doctor, you
know? So I ask [my PN] what he said and she
explains it to me slowly and I understand.
What are the Strengths &
Weaknesses of the Program?
z Strengths
– Relationship with PNs
– PNs are consistently
available
– PNs are BC survivors
z Weaknesses
– Enrollment into the
program
When [the doctor] told me that [I had cancer], I’m crying, I’m thinking
I’m going to die. What will happen to my future? What will happen to
my children? Everything together at the same time. I cried and the
doctor brought [my PN] to me and she comforted me. She told me I
had the same thing she had and that she lost her whole breast and
she’s okay and I was going to be okay too. She explained everything
and tried to calm me down. She supported me and encouraged me all
the time. For me, it was good. She is very good.
Limitations
zSocially desirable responding
– Great care taken to minimize this
zSmall sample size
– Generalizability was sacrificed for richer, detailed
accounts
Quantitative Evaluation Methods
zLongitudinal pre-post study
– Small study (N=61)
– 6-month follow-up period
zStructured interviews administered at AFCBC
z$15 monetary incentive
zAt follow-up
– 2 expired
– 13 were lost to follow-up
– 46 were retained in the study (78% retention)
Arriola, Mason, & Thompson, In
preparation
Change in Psychosocial Variables
Variable
Baseline
Mean (SD)
Follow-up
Mean (SD)
t
Social/Family Well-being
16.3 (4.3)
18.9 (4.9)
-3.9***
Emotional Well-being
18.4 (5.5)
20.2 (4.0)
-3.2**
Functional Well-being
19.8 (5.7)
20.4 (5.2)
-0.6
Social Support
81.4 (13.8)
80.5 (14.0)
0.6
Not able to get appt/too long of
a wait to see MD
1.7 (1.1)
1.6 (.8)
0.6
Not able to find an MD who
speaks language/gets culture
1.6 (1.1)
1.1 (.3)
2.9**
No transportation or $ for taxi
1.8 (.6)
1.5 (.6)
2.4*
Not able to get off from work
2.2 (1.4)
2.7 (1.5)
-2.0*
Not able to find childcare
2.7 (1.5)
2.9 (1.4)
-0.3
Perceived Barriers to health care
***p<.001; **p<.01; *p<.05
Limitations
zSmall sample size
– Limited power
– Inability to engage in multivariate analyses
zInability to make causal statements
– Lack of a control group
zNatural changes in quality of life are expected
throughout the treatment process
zLoss of 22% of participants to follow-up
Challenges
zStructural
– Working in a large, urban hospital
zProgrammatic
– Identifying newly diagnosed patients
– Volunteer stress & burnout
zPatient-level
– Multiple barriers to care
– Completing radiation
zSusan G. Komen for the Cure Intensive Patient
Navigation Program
Lessons Learned
zPatient navigation varies depending on
context
zOpen communication with all PNs
– Sensitivity to their well-being
zTargeting the program to those who need it
most
zCreating a level of community saturation that
is most effective
– Importance of patient follow-up
Overall Conclusions
zThe need for comprehensive programs to
eliminate breast cancer disparities is great
zPN offers a promising strategy that addresses
– Environmental factors
– Lifestyle factors
zPN may be an important part of a
comprehensive strategy to support marginalized
cancer patients
zThere are very real limits on how to study PN in
a hospital setting
“…If you want to go
quickly, go alone
If you want to go far,
go together…”
African Proverb
Many THANKS to …
z AVON Foundation
z Georgia Cancer
Coalition
z Sindab
z Susan G. Komen,
for the Cure
z It’s the Journey
z License tag Fund
z Lance Armstrong
Questions