Ethnic Minorities: Empowering to Increase Colorectal Cancer Screening Through Community Outreach Kimlin Ashing PhD

Kimlin Tam Ashing, PhD, discusses Ethnic Minorities: Empowering to Increase Colorectal Cancer Screening Through Community Outreach


Ethnic Minorities: Empowering to Increase Colorectal Cancer Screening Through Community Outreach Kimlin Ashing PhD

By Kimlin Tam Ashing, PhD
Professor, Department of Population Sciences, City of Hope

Community outreach and engagement are truly at the heart of the work we do because we know that cancer disparities exist and persist. One way to address this issue is by engaging with community leaders, who are trusted informants and gatekeepers in the community and can help address the burden of cancer and its disparities.


What were the main objectives of your research, and how did you go about achieving them? 

One of the important things in engaging the community in cancer prevention and control is to work with them to identify their specific needs. Conducting an appropriate community needs assessment can help determine what those needs are, as well as identify the community's strengths and the cancers that we can quickly make an impact on.


One cancer that has emerged as a top priority is colorectal cancer, which unfortunately has been on the rise, even among younger individuals. We went back to the community and explained that this is a cancer where we could truly make a difference, as there is a low-cost screening available.


Fortunately, the US Preventive Task Force recognized the urgency of colorectal cancer screening and reduced the age from 50 to 45. By working with community partners and clinicians, including our federally qualified health clinic (FQHC) partners, community health leaders, and community advisory board, we were able to address this issue. Our media partner at City of Hope also played a key role in helping us launch a media campaign.


Can you describe the ethnic minority groups that you targeted with your outreach and engagement efforts, and why you chose these communities in particular?

Overall, our community outreach and engagement efforts are responsive to the ethnic diversity, as well as to those who are marginalized and minoritized within our catchment communities. The City of Hope is located in Southern California, and our catchment area includes four counties: Los Angeles, Riverside, San Bernardino, and Orange.


Our catchment area is home to a diverse population of 18 million people, with a majority population of Latinx and Asian ethnicities, while African Americans make up about 20%, and approximately 6% of the population is of other ethnicities. We are committed to targeting those who are medically underserved, as well as ethnic minorities, and those who are eligible for cancer screening. By doing so, we hope to make an impact by promoting regular screening, early detection, and ultimately, reducing the impact of treatment, as early discovery of cancer makes it highly treatable.


Our primary focus is on colorectal cancer, which was implemented during the Covid-19 pandemic. We realized that we could continue to target colorectal cancer screening, even during the pandemic, by providing home kits and stool-based kits for cancer screening.


What were some of the biggest challenges you faced in engaging these communities, and how did you address them?

Some of the biggest challenges we face are related to resources, right? We are working with very diverse communities with varying language capacities and competencies, along with my staff. Since we are targeting those who are medically underserved, the stool-based test is the screening option that is most available and suitable for this population. However, the instructions for these tests may only be available in English, and even then, the reading level may be too high for some.


Therefore, one of our first tasks was to work with our community partners, including advocates and a community advisory board, to translate and simplify the screening descriptions and guidelines for using the stool-based kits. We created infographics to demonstrate how to use the kits properly, so that the sampling is effective, and the timeline for submitting the samples to the lab is clearly understood. This will help us to have better return rates of the samples, and ensure that the samples are properly conducted.


These kinds of in-depth community efforts require us to partner with our community health leaders to help us translate and adapt these documents so that they are most easily understood and readily available and acceptable to the community.


Can you walk us through some of the strategies you used to effectively engage and educate members of these communities about the importance of colorectal cancer screening?

In order to reach the medically vulnerable community, we developed a multi-component approach while working with community partners. One of the approaches focused on a broad community campaign, which involved using social media and ethnically focused media. Many ethnic groups, particularly older individuals, still read newspapers and listen to radio broadcasts in their language. Therefore, we utilized these platforms to educate and raise awareness of colorectal cancer screening and provide information on clinics and services where they could get screened. This broad public media campaign was conducted in various languages, including Chinese, Korean, Spanish, and English. We targeted newspaper and radio outlets that reached these communities, as well as the African American community.


The evidence shows that we also need to work with systems that provide primary care. In our state, federally qualified health clinics are the bedrock of preventive care and primary care for our community. Therefore, we worked with several community partners to analyze their workflow and provider recommendation. We conducted a CME for the providers as part of this systematic health system quality improvement approach, where we provided medical education to remind them of the lower age for screening guidelines and how to best implement provider recommendations. This included educating all staff members, including front desk staff, as we recognized that all opportunities for patient interaction could be a force for good and a reminder for screening. We also provided clinicians with free continuing medical education to increase their adherence to the screening guidelines.


We also trained community partners and advocates on colorectal cancer screening, informed by the NCI's "Screen to Save" or the S2S program. This three-pronged approach ensured that the screening guidelines were understood and adhered to by clinicians, community advocates were educated and activated to promote colorectal cancer screening, and broad media announcements were made to raise public awareness of this essential cancer prevention screening.


What were some of the most important outcomes of your research, both in terms of the impact on the targeted communities and on the larger field of colorectal cancer screening and prevention?

We hope that screening and prevention of colorectal cancer can be prioritized in our policy and healthcare practices. This cancer has a screening method, colonoscopy, which can detect it at a very early stage, even before it becomes cancerous.

If we screen early, even with a stool-based test, and find an abnormal result, the patient can be quickly directed to early diagnostic screening and treatment to prevent further development of cancer and possibly even cure it if detected early.

We find that community clinics and partners are very willing to partner with us because they understand the importance of colorectal cancer screening and its impact on saving lives. Our community advocates also recognize that colorectal cancer has a significant impact on communities, especially the African American community.


We have seen examples of leading actors who died early due to colorectal cancer, and the community is aware and ready to partner with medical institutions and researchers to change these statistics. We can save lives, detect cancer at early stages, increase survival rates, and prevent morbidity and mortality with the available tools. We only need the willpower to make an impact on colorectal cancer prevention.


How do you envision your findings and strategies being used in the future to address disparities in colorectal cancer screening and outcomes among ethnic minority groups?

Colorectal cancer screening should be a standard of care for everyone above 45, or for those who have a family history that requires earlier screenings. We believe that a multi-focus approach, which involves a cancer center and the community, including FQHCs, is very feasible.


It can be easily implemented within the quality improvement standard of care, and it doesn't require a huge amount of resources. Provider reminders and education provided to clinicians were very valuable, as it increased their capacity and preparedness to recommend colorectal cancer screening, especially with the screening guidelines being moved lower to 45. It was a reminder of this important change within the guidelines.


We also found that our advocates are willing to partner with researchers and clinicians at cancer centers and research centers to save lives in their community, which is unduly impacted by disparities in cancer, including colorectal cancer.


We believe that it's an important recommendation, and we advocate not just to our community partners but also to community health clinics and leaders to engage in our effort to increase colorectal cancer screening. Hopefully, there will be increased funding to implement these kinds of interventions that have been proven effective in reaching minoritized and medically underserved communities. We find that providing education in the language and places where people have trusted community health education, such as local newspapers, low-cost health ads within organizations, local radio stations, and social media platforms, can be very effective in reaching those communities and increasing health behaviors, including cancer screening.


In light of your research, what changes do you believe should be made to current screening guidelines and protocols to better address the needs of ethnic minority groups? 

One of the things we know is that the guidelines have reduced the age for screening to 45. Educating the community in a language-friendly way is important. This means using tools such as infographics, not just text and words, for those with low literacy.


For the stool-based test, we provided an infographic on how to use the kits correctly and the timeline for returning them so that the samples would be suitable for testing. Simple approaches like this, which are language-responsive and use images and infographics, have been proven effective in reaching communities and reflecting their needs.


It's also important to ensure that the images used reflect the community's ethnicity, culture, and language. Providing data and information about the screening guidelines is important, but it should be done in a way that is responsive to the community's linguistic and cultural aspects.


Looking ahead, what are your next steps in this area of research, and what impact do you hope to have on the field of colorectal cancer screening and prevention?

We found that 80% of providers felt confident, educated, and prepared to recommend the screening test. Clinicians, providers, and physicians play a critically important role in this regard. It's important to remind physicians that every clinic opportunity, whether face-to-face or virtual, is an opportunity to remind their patients about cancer screening.


We also found that it's important to activate community educators, health workers, and gatekeepers, so they can be both educated and motivated to help their communities understand their risk for colorectal cancer and address the barriers and cultural components that prevent people from getting screened. We discovered that some communities face important barriers in terms of belief systems, not just for colorectal cancer, but for cancer screening in general. People may be looking for symptoms that aren't there, and cancer is usually asymptomatic until it's metastatic.


Asking communities to screen for something when they're not feeling sick or experiencing any symptoms can go against some cultural beliefs. That's why it's essential to work with community advocates to target these cultural beliefs that may serve as barriers to screening. We need to reach the community in a way that they can understand that screening only detects changes that are cancerous or already cancer, but that we can detect it early when it's highly treatable, even pre-curable. It's crucial to assure them that we have safe and effective screening guidelines, starting with the low-cost stool-based test that's readily available at community clinics.


The gold standard, of course, is the colonoscopy. We have effective treatments available, especially for colorectal cancer, which can be curable if detected very early. Providing people with hope in the context of colorectal cancer screening and prevention, and bringing all partners to the table including clinicians, health systems that serve these communities, and community and patient advocates, are important for changing the acceptability and uptake of colorectal cancer screening. Across the nation, we have poor rates of uptake of this very effective cancer prevention screening practice, despite having very effective treatments for early-stage colorectal cancer.


Activating communities is crucial. We must work with the medical community to remind patients of screening and to collaborate with community partners and advocates to raise awareness of screening guidelines and of genetic and family risk factors. This will help families feel more comfortable talking about their cancer risk and vulnerability. These conversations are vital to have with community advocates, leaders, and clinicians, so that the message is culturally appropriate and relevant, and given in a way that the public can understand and accept. This will increase colorectal cancer screening and help prevent late-stage detection, which has greater financial and medical impacts, as well as impacts on quality of life, especially for medically underserved and minoritized communities.


We must work with our multi-sectoral partners to get the word out and change the culture and belief systems surrounding colorectal cancer screening as cancer prevention.


Final thoughts about the Empowering Ethnic Minorities Colorectal Cancer Screening Trial

In addition to providers feeling more confident and prepared to recommend screening, our intervention increased screening rates by almost 10 percentage points. We were able to demonstrate its effectiveness, as we found that more than 5,000 individuals were screened, and our intervention resulted in an increase of over 500 persons who would not have been screened otherwise.


10 Key Takeaways from the Empowering Ethnic Minorities Colorectal Cancer Screening Trial

  1. Colorectal cancer (CRC) is preventable with screening but remains the second leading cause of cancer deaths in the US.

  2. The COVID-19 pandemic caused a substantial decline in CRC screening nationally.

  3. Ethnic minorities and safety-net systems underutilize CRC screening.

  4. City of Hope partnered with Federally Qualified Health Centers (FQHCs) and community and faith-based organizations to improve CRC screening among medically underserved communities.

  5. The multi-component intervention implemented between October 2020 and October 2022 included community outreach and education and clinic-based interventions.

  6. The multi-ethnic multimedia campaign reached 35.4 million impressions.

  7. Provider/staff training reached 150 medical providers, with >80% feeling confident they could get their patients to complete their CRC screening test and follow-up care.

  8. Among the 100 providers surveyed, >80% felt confident they could get their patients to complete their CRC screening test and follow-up care.

  9. Overall CRC screening rates increased from 45% to 52% before vs. after the intervention implementation period across the four FQHC sites.

  10. The site with the highest CRC screening rate (>62%) maintained steady rates over the observation period, whereas three sites with lower baseline rates showed greater pre-post improvements (average 15 percentage-point increase).


Kimlin Tam Ashing, PhD - About The Author, Credentials, and Affiliations

Kimlin Tam Ashing, PhD, is a professor and founding director of the Center of Community Alliance for Research & Education (CCARE) at City of Hope. She received her doctorate in clinical psychology from the University of Colorado Boulder and is a licensed clinical psychologist. Dr. Ashing is an advocate-scientist who focuses on advancing population health science and practice by developing and implementing evidence-based health improvement interventions that are culturally, clinically, and community responsive. She holds several national leadership roles in cancer research organizations, including the African-Caribbean Cancer Consortium, the National Advisory Council for the Asian Pacific Islander Native Hawaiian Cancer Survivors Network, and the Young Survival Coalition. She is also a scientific advisor to several organizations and a member of the Human Rights Taskforce. Dr. Ashing has published over 80 articles and book chapters, co-authored a book on living with breast cancer, and is a notable leader in examining health disparities, cancer inequities, survivorship, and quality of life.