Early Detection & Screening

Breast cancer is the 2nd leading cause of death in American women, only second to lung cancer. Screenings, increased awareness, and evolving treatment options have contributed to decreased breast cancer death rates. Identifying the biases and stigmas different minority groups experience may translate to increased early-stage breast cancer diagnosis and decreased late-stage diagnosis.

The following objectives and strategies address the necessity of shifting the efforts of providers, payers, cancer registries, policymakers, and patients to decreasing mortality in Non-Hispanic Black women, improved identification of women with a high-risk genetic mutation, and increasing the number of breast cancers diagnosed at earlier stages. The support of educational approaches tailored to providers is essential to address knowledge gaps and unconscious biases that contribute to poorer breast cancer-related outcomes.

Additionally, the support of integrative approaches to systems improvements in clinics and community-based organizations can lead to better screening completion rates and earlier stages at detection. Only by engaging and coordinating stakeholders from all levels of the health care system can necessary changes be made and successfully implemented, which will reduce the breast cancer burden in those who are currently bearing the brunt of suffering from this disease.

Objective 1:

By 2025, increase the percentage of breast cancers diagnosed at Stage 0/1 by 20%, from the baseline of 60% to 80% of total breast cancers diagnosed.

Data Source: CCR, 2017

Strategies

1. In areas of the state known to have higher rates of late stage diagnosis, support clinic-based programs such as client reminders with mailers/text messaging, nurse navigators to educate on screening, and Electronic Medical Records (EMR)-based provider reminders, which are proven to increase screening rates in women.

2. Support culturally and linguistically tailored educational programs on the benefits of screening in those populations with lower screening rates and higher rates of the late stage of diagnosis.

3. Support efforts to ensure mammography screening is offered without a co-pay, share-of-cost, or deductible and that increase awareness of the Every Woman Counts (EWC) program.

Objective 2:

By 2025, increase the percent of women who are referred for genetic assessment of a high risk for breast cancer due to hereditary/familial breast cancer syndromes from the baseline of 25% to 35%.

Data Source: NCI, PMID 30964716

Strategies

1. Using the CDC for Genomic Applications Toolkit for Public Health Departments as a guide, support programs to educate primary care providers and other clinic staff about hereditary and familial cancer syndromes, specifically about the importance of inclusion of a three-generation family history of cancer in each patient’s EMR, about the specific NCCN guidelines for appropriate referral for genetic testing and about updating this information on an ongoing basis.

2. Conduct investigations into referral patterns to genetic counselors for women with breast cancer and for women with family members with breast cancer who meet NCCN guidelines for testing, identifying specific barriers to completion of referrals due to e.g., shortage of available genetic counselors, patient willingness to complete a referral, etc.

3. Support CCR efforts to investigate adding reporting of germline genetic testing for breast cancer patients to cancer registry reporting forms.

4. Support efforts in clinics and through cancer registries to increase appropriate referrals for unaffected family members of women with known hereditary breast cancer syndromes to undergo cascade testing to determine if they are also carriers of hereditary breast cancer syndrome mutations.Conduct investigations into the geographic availability of hig- risk breast cancer surveillance programs, especially in those populations with lower rates of referral to such clinics.

Objective 3:

By 2025, reduce breast cancer-related mortality rates for Non-Hispanic Black women from the baseline of 17 to 12 per 100,000.

Data Source: CCR, 2017

Strategies

1. Increase access to breast cancer screening and treatment facilities for target populations which include identifying specific culturally relevant barriers that contribute to limiting access to screening and treatment for breast cancer.

2. Educate providers and target populations in FQHCs regarding EWC and current screening recommendations.

3. Engage community leaders in public service strategies to increase awareness of poorer breast cancer related outcomes for Non-Hispanic Black women.

4. Address root causes for racial/ethnic disparities in receipt of breast cancer treatment such as provider unconscious bias and develop educational programs to counteract this.

5. Support programs for the education of community-sponsored patient navigators who are culturally aligned with racial/ethnic subgroups.

6. Identify strategies for team-based breast cancer care for inclusion of multiple levels of staff/providers and for care across the breast cancer continuum.

In the past thirty years, cancer screening has greatly reduced cervical cancer incidence and mortality. Between 1988-2016, California’s cervical cancer incidence decreased by 37%, and mortality decreased 36%. Nevertheless, despite the risk reduction strategies, cervical cancer still ranks as the 12th most common cancer among California women (7.3 new cases per 100,000 women) and the 13th most common cause of cancer death (2.2 deaths per 100,000 women). Large racial/ethnic disparities in cervical cancer incidence and mortality persist in California. Among the four major racial/ethnic groups, Hispanic women have the highest incidence rate of 8.8 new cases per 100,000, African American women have the highest mortality rate with 3.0 deaths per 100,000 women.1-2 Asian-Pacific Islander women report the lowest rates of cervical cancer screening resulting in high cervical cancer incidence and mortality among some API populations.

Objective 1:

By 2025, decrease the percentage of women from all racial/ethnic groups ages 21–65 without a hysterectomy, who have not received a Pap and/or HPV screening test in the past five years from the baseline of 16.4% to 12.5%.

Data source: BRFSS, 2018

Objective 2:

By 2025, eliminate the disparity in cervical cancer incidence among non‑Hispanic Black and Hispanic women in California with known rates higher than non‑Hispanic white women and Asian/Pacific Islander, reducing cervical cancer incidence rates for all women to 6.5 per 100,000 women.

Data source: CCR, 2017

Objective 3:

By 2025, eliminate the disparity in cervical cancer mortality among non-Black Hispanic, Hispanic, and Asian/Pacific Islander women in California with known rates higher than non-Hispanic white women, reducing all cervical cancer mortality rates to 1.8 per 100,000 women.

Data source: CCR, 2017

Strategies for Objectives 1, 2, and 3

1. Begin cervical cancer screening for all women, particularly those with disparate cervical cancer mortality rates such as African American, Hispanic, Hmong, Filipino, and Vietnamese, at age 21. Women ages 21-29 should have a Pap test every three years. At age 30, women should be screened every three years with a PAP test alone, every five years with high risk human papilloma virus (hrHPV) testing alone, or every five years with hrHPV testing in combination with a Pap test (contesting).

2. Advocate for evidence-based, system-level interventions for all women, including enrollment into comprehensive health care coverage, screening navigation for those rarely and never screened, patient health care navigation, outreach using community health workers, and provider/organization-wide cultural and linguistic competency.

3. Support primary care practices and other clinics in developing and implementing system changes that improve cervical cancer screening, including electronic health record tools that help providers identify patients for cervical cancer screening and refer patients with abnormal test results for timely follow-up testing and treatment.

4. Educate women and providers about cervical cancer screening, including promotion of safety net programs (i.e., EWC) whose target populations are rare and never screened women (selected Asian/Pacific Islander, Native American, rural, disabled, and lesbian women). Increase understanding of confusing and frequently changing guidelines for cervical cancer screening.

5. Increase the use of evidence-based, provider-oriented interventions at every opportunity during patient care (provider assessment and feedback, and provider reminder and recall systems) to increase recommendation and delivery of cervical cancer screening services.

6. Support continued review of the efficacy of self-collected pap and HPV testing in women not being regularly screened, as well as primary HPV testing as a screening modality.

7. (Objective 3) For uninsured and underinsured women, particularly those women with disparate cervical cancer incidence and mortality rates noted above, promote and advocate for programs that cover cervical cancer screening, diagnostic, and treatment services.

Colorectal cancer is the fourth most common cancer and the second-leading cause of cancer death among men and women combined in California. In 2020, an estimated 15,530 new cases of colorectal cancer will be diagnosed statewide, and 5,480 will succumb to the disease. Screening can prevent colorectal cancer by detecting and removing precancerous growths at an early stage when it is easier to treat and outcomes are more favorable. Low-cost screening tests can prevent nearly half of all colorectal cancer cases diagnosed at a late stage. Despite being one of the most preventable types of cancer, one in four adults have never been screened for colorectal cancer, with underutilization more common among the Medi-Cal insured, uninsured, racial, and ethnic minorities. Additionally, there has been an increase in young-onset colorectal cancer (diagnosed under age 50). The following objectives with accompanying strategies detail the steps that can be taken to reduce the morbidity and mortality from colorectal cancer to address these disparities.

Objective 1:

By 2025, decrease the rate of late-stage diagnosis of colorectal cancer among those who are covered by Medi-Cal and the uninsured from the baseline of 71% to 64%.

Data source: CCR, 2017

Strategies

1. Explore adding colorectal cancer screening as a required reported quality measure for Medi-Cal Managed Care plans.

2. Implement FLU/FIT programs in California’s FQHCs.

3. Implement evidence-based strategies (EBS) in California’s FQHCs as outlined in Steps For Increasing Colorectal Cancer Screening Rates: A Manual For Community Health Centers and the National Cancer Institute’s Research-Tested Intervention Programs (RTIPS) website.

4. Clinics and health plans work with patient navigators/community health workers/promotores and implement other proven strategies to ensure appropriate follow-up of colonoscopies after a positive or abnormal Fecal Immunochemical Test (FIT).

Objective 2:

By 2025, increase the colorectal cancer screening rate among all Californians from the baseline of 70.8% to 80%

Data source: BRFSS, 2018

Strategies

1. Implement Evidence-based strategies as outlined in “Steps For Increasing Colorectal Cancer Screening Rates: A Manual For Community Health Centers” and the National Cancer Institute’s Research-Tested Intervention Programs (RTIPS) website.

2. Explore requiring the California Health Care Quality Report Card to report colorectal cancer (CRC) screening for all health plans providing care in California. All health plans should report their CRC screening rate for posting on the quality report card listed above.

3. Develop a FLU/FIT program in every clinic with colorectal cancer screening rates below 60%.

4. Develop clinic navigation to ensure all abnormal stool-based tests receive the required colonoscopy. The percent of abnormal stool testing that receive the needed colonoscopy should be a required quality measure for all health plans using stool-based screening tests.

5. Remove structural barriers (e.g., inconvenient clinic hours, lack of transportation, out of pocket costs, etc.) to CRC screening through the use of patient navigators/community health workers/promotores services.

Objective 3:

By 2025, decrease late-stage diagnosis of colorectal cancer among all Californians between the ages of 40 – 49 years from the baseline of 69% to 57%.

Data source: CCR, 2017

Strategies

1. Family history of CRC should be routinely asked and recorded in all adults to provide opportunities for earlier identification and screening of high-risk individuals, including with genetic testing, when indicated.

2. Encourage colorectal cancer survivors in all health plans and clinics to promote screening within their families.

3. Screening for hereditary cancer syndromes in patients with CRC should be done and include at a minimum a review of personal and family histories of all cancers.

4. Explore requiring genetic testing of removed colorectal cancers for DNA mismatch repair deficiency and/or microsatellite instability with the results reported to the CCR.

5. Health care providers should follow the ACS’s recommendations for evaluation of genetic risk in patients with a family history of colorectal cancer.

Lung cancer is the leading cause of cancer deaths in the United States, killing approximately 142,670 people per year - more than colon, breast, and prostate cancers combined. For California, the American Cancer Society projects 10,210 deaths from lung cancer in 2020 (with 135,720 deaths nationwide). Recent advances in lung cancer detection and treatment include the advent of annual screening with Low-Dose Computed Tomography (LDCT) in high-risk individuals, shown to have a mortality benefit, and now recommended by the U.S Preventive Services Task Force (USPSTF), and the development of targeted therapies. Meaningful attempts to reduce lung cancer mortality rates in California should focus on:

1. Increasing the overall number of Low-Dose Computed Tomography Lung Cancer Screening Scans performed (per the USPSTF criteria);

2. Increasing access to those Low-Dose Computed Tomography Lung Cancer Screening Scans (per the USPSTF criteria) by minority underserved communities; and

3. Performing universal genetic, molecular, and comprehensive biomarker testing of all lung cancer tumors determines each patient's best therapies.

Objective 1:

By 2025, increase the number of lung cancer screening scans using low-dose computed tomography (LDCT) as indicated by the USPSTF from the baseline of 2,377 to 2,977.

Data source: American College of Radiology, 2018

Strategies

1. Estimate the rate of lung cancer screening in California by surveying health care organizations and using the CDC BRFSS lung cancer screening module.

2. Promote lung cancer screening through public outreach campaigns with state and local agencies and nonprofit organizations.

3. Implement physician and provider outreach on the importance of lung cancer screening and the need for accurate smoking history documentation to determine eligibility.

4. Decrease or eliminate copays for visits for initial lung cancer screening or follow-up procedures or tests.

5. Educate policymakers on the importance of including lung cancer screening as a metric for primary care providers.

Objective 2:

By 2025, increase the number of lung cancer screening scans in minority underserved communities using low-dose computed tomography (LDCT) as indicated by the USPSTF.

Data Source: TBD

Strategies

1. Identify and promote locations of hospitals and imaging centers that offer lung cancer screening LDCT within 20 miles of minority underserved communities.

2. Include e transportation services, including ride-sharing companies (e.g. Uber, Lyft), to lung cancer screening appointments under Medi-Cal insurance coverage.

3. Support screening of underinsured and uninsured individuals; develop lung cancer screening programs within county health systems (e.g., Los Angeles County Department of Health Services); and support accreditation of screening centers in close proximity to minority underserved communities.

4. Eliminate out-of-pocket costs for both screening LDCTs and follow-up LDCTs for all Medi-Cal insurance plans.

5. Explore requiring FQHCs to collect and record accurate smoking pack-year data and identify individuals eligible for lung cancer screening per USPSTF criteria.

6. Collaborate with state and local agencies to increase awareness of lung cancer screening and develop outreach programs and educational materials for both referring providers and the public, with a focus on addressing cultural/language/literacy barriers and stigmatization prevalent in minority underserved communities.

Objective 3:

By 2025, reach universal genetic, molecular testing, and comprehensive biomarker testing of all lung cancer tumors to help determine the best selection of therapies for patients.

Data Source: TBD

Strategies

1. Advocate for genetic/molecular/biomarker testing in all stages of newly diagnosed lung cancer patients, not just patients who are late stage (IIIB or IV).

2. Encourage participation of more patients in clinical trials, through patient and provider education. For example, provide patient and provider resources to programs that will assist with matching the patient to appropriate clinical trials (e.g., LungMATCH - https://go2foundation.org/resources-and-support/general-support/lungmatch/).

3. Inform and educate policymakers on the importance of eliminating pre‑authorization barriers currently tied to biomarker testing and delaying precision medicine to patients where time is critical and can be life-saving.

4. Advocate for national and local coverage determinations to expand comprehensive biomarker testing (e.g., next-generation sequencing) to all patients diagnosed with lung cancer including those patients where repeat testing is needed due to reoccurrence.

5. Collaborate with state and local agencies to increase awareness around genetic/molecular/biomarker testing including comprehensive biomarker testing and create outreach programs and educational materials to educate providers and patients of all relevant/current coverage policies in addition to the benefits of such testing and precision medicine.

6. Collaborate with state and local agencies to encourage research and data collection around genetic/molecular/biomarker testing to help build patient centered health outcomes and improve patient care. This could be achieved by providing clinical trials, and patient registry resources [e.g., https://www.lungcancerregistry.org].

The number of lives lost from melanoma each year continues to rise. Five-year survival rates for people with melanoma depend upon the stage of the disease at the time of diagnosis, racial and ethnic differences, socio-economic status, and access to state-of-the-art treatment options for advanced disease. When melanoma is found and treated early, the chances for long-time survival are excellent. Therefore, early detection and screening are key to improving patient outcomes. The public and the healthcare community can play an important role in promoting early detection of melanoma by increasing awareness and early detection among highest-risk populations, including those of low SES and minority groups, promoting access to teledermatology and other screening technologies for those in need due to socio-economic or geographic reasons, and by providing knowledge about treatment options in regions of CA disproportionately impacted by late-stage diagnoses, in order to reduce mortality.

Objective 1:

By 2025, decrease baseline melanoma incidence rate in 16 counties with rates exceeding the baseline rate of 7.9 by 1 to 31.3 per 100,000.

Data source: CCR, 2017

Strategies

1. Establish a Melanoma Advisory Panel (MAP) with representation by academic, public and private dermatologists, county-based public health practitioners, and oncologists, primary care physicians (managing screening to referral), and survivor-advocate organizations. The MAP will guide the selection of specific strategies and activities to reduce melanoma incidence and reduction in stage at diagnosis.

2. Establish baseline demographics of the identified 16 counties, based on race, ethnicity, socioeconomic status, insurance status, medical home, access to dermatology specialists, and geographic location to identify common versus unique features to inform evidence-based interventions.

3. Develop a priority ranking and timeline for implementation of specific recommended evidence-based interventions using skin cancer outreach resources available through the NCI, the CDC, the Environmental Protection Agency, and those enacted through the novel Wipe Out Melanoma California initiative.

4. Develop a Melanoma Education and Planning document that will provide guidance for patients at the time of diagnosis on:

1) standard care for follow up;

2) recommended frequency of complete skin checks;

3) resources on the most up‑to-date treatment options; and

4) discussion of melanoma risk and prevention measures for family members.

Objective 2:

By 2025, decrease the incidence of thicker cutaneous melanoma (T3-T4) in 15 California counties with rates exceeding the state thickness-specific incidence and melanoma-associated mortality rates exceeding the state average rate of 16.07 by one to nine.

Strategies

1. Identify common versus unique features within the 15 counties to establish specific evidence-based interventions using available guidance on effective public health campaigns for reducing the incidence of melanoma, using culturally and linguistically relevant approaches for each region (using CCR/SEER data, OSHPD, CDC, HRSA).

2. Improve melanoma awareness and early detection among low socioeconomic and minority groups, focusing efforts on increased community engagement, education of health care providers and lay personnel, including implementing media campaigns tailored to reach the patients at highest risk of lethal melanoma, including older white men and those of lower socioeconomic class, across all racial-ethnic groups.

3. Increase access to tele-dermatology and other technologies to improve access to care for Californians with limited access to care due to socioeconomic or geographic limitations.

4. Conduct educational outreach to guide patients about the standard of care for their stage of diagnosis, new treatment modalities to consider, resources available for melanoma patients through academic medical centers, and options for participating in clinical trials.

In accordance with the United States Preventive Services Task Force, this chapter emphasizes whether men should be screened and when to be screened for prostate cancer. Screening must be offered in the context of the latest and best evidence on screening age and intervals and on risk-stratified approaches to the diagnosis of elevated prostate-specific antigen (PSA) tests and prostate cancer treatment. The primary aim of screening must be to diagnose aggressive, life-threatening prostate cancer early, and the aim of diagnosis and treatment must be to maximize benefits and minimize harm.

Previous controversies over the PSA test centered on the diagnosis and over-treatment of non-life-threatening prostate cancers led to declines in early detection and under-treatment of high-risk men, particularly African Americans.

More recent research charts a better course.

Key examples include statistical modeling and evidence from long-term cohort studies indicating that early PSA screening (starting at age 45) can prevent more cancer deaths when subsequent screening frequency is tailored (and usually greatly reduced) based on an initial baseline test. The combination of evidence of active surveillance's effectiveness to reduce over-treatment and rigorous statistical modeling showing a mortality reduction associated with PSA tests in African Americans must inform discussions with these high-risk men. Together, these innovations point the way to smarter screening and smarter (risk-stratified) treatment for the benefit of all men.

Objective 1:

By 2025, increase the proportion of average-risk men ages 45 years and older who have had an informed discussion about the advantages and disadvantages of their health care provider regarding prostate cancer testing by 5%.

Strategies

1. Educate men and their providers regarding the differences in prostate cancer risk. Those at higher risk include men of African ancestry, men exposed to Agent Orange, and those with blood relatives diagnosed with aggressive prostate cancer.

2. Work with primary care provider networks to encourage providers to obtain and act on the most recent data and tools that support how to best communicate with patients about their risk, the use of PSA testing, the importance of follow-up for elevated PSAs, and to prepare men in advance for the possibility of a low-risk prostate cancer diagnosis which would not require aggressive treatment and how to manage prostate cancer patients who are on active surveillance.

3. Encourage health care institutions to create, adopt, and implement practices and policies consistent with the latest best evidence on risk stratification in the diagnosis of PSA abnormalities and in the treatment of prostate cancer, and in the use of PSA testing including consideration of baseline tests.

4. Develop clear, concise, culturally competent and linguistically appropriate resources and useful facts regarding prostate cancer; make these available to all men and their families. Encourage men to have informed discussions to increase prostate cancer awareness.

5. Strive to unify the messages from cancer authorities using the latest best evidence on risk-based screening, diagnosis, and treatment.

6. Support funding for research and State level programs to improve risk-based testing, diagnosis, and treatment.

Objective 2:

By 2025, increase the proportion of African American men 45 years and older who have had an informed discussion with their health care provider regarding both the advantages and disadvantages of prostate cancer testing from 56.6% to 61.6% and from 28.3% to 33.3%.

Strategies

1. Educate African American men, their families, and their community that:

1) compared with other race/ethnic groups, they are more likely to have Prostate Cancer (PCa);

2) PCa strikes African Americans at younger ages and more aggressively;

3) once diagnosed, African Americans are more likely to die due to PCa unless it can be diagnosed at an early stage; and

4) diagnosed men can benefit from support groups, health care system navigation services, and support from other diagnosed men.

2. Work with primary care provider (PCP) networks to encourage providers to obtain and act on the most recent data and tools that support how to best communicate with African American patients about their increased risk of prostate cancer, all risks and benefits of PSA testing, the importance of follow-up for elevated PSAs, to prepare men in advance for the possibility of a low-risk PCa diagnosis which would not require aggressive treatment, and how to manage PCa patients who are on active surveillance.

3. Encourage health care institutions to create, adopt, and implement policies that require primary care providers to initiate discussions related to PSA testing to African American men, and for specialists to practice risk stratification in diagnosis and treatment, including active surveillance for patients with low-risk PCa. Inform safety-net patients, providers, and programs about the state-run and grant administered prostate cancer treatment program.

4. Develop clear, concise, culturally appropriate resources regarding prostate cancer and make these available to all African American men and their families to encourage men to have informed discussions to increase prostate cancer awareness.

5. Conduct events in the African American community that provide education about the high risk of prostate cancer for African Americans, the importance of being informed and empowered, and the nature and importance of follow-up. In addition, assist those who are unaffiliated to establish a medical home, and for others who have a primary care provider, to reconnect for ongoing preventive care.

6. Strive to unify the messages from cancer authorities using the latest best evidence specific to African Americans on risk-based screening, diagnosis, and treatment.