Preventing Colorectal Cancer in Vulnerable Populations: A Former Harold Amos Scholar Searches for Solutions

    • April 22, 2014

The problem. Despite the proven effectiveness of screening for colorectal cancer, only about two-thirds of Americans ages 50–75 have the recommended screening tests, such as a colonoscopy. Screening rates among minority populations are even lower.

Yet colorectal cancer is the second-leading cause of cancer death among cancers that affect both men and women. About 10,000 lives could be saved each year if appropriate screening were offered to all who should have it, according to the Centers for Disease Control and Prevention (CDC).

“The people who still have not gone to screening have real barriers that are difficult for them to overcome,” explains Carmen E. Guerra, MD, MSCE, associate professor of internal medicine at the University of Pennsylvania’s Perelman School of Medicine. In additional to financial, logistical, and knowledge gaps, she says, “another barrier is attitude. There are patients who will not have a colonoscopy [because they have] a variety of negative attitudes, such as pain, embarrassment, and fear.”

An alumna of the Robert Wood Johnson Foundation’s (RWJF) Harold Amos Medical Faculty Development Program, Guerra has devoted her career as clinician, researcher, and administrator to helping vulnerable patients prevent colorectal cancer, or detect it early.

Getting her start. Guerra moved to the United States from Honduras with her parents when she was three years old. She grew up in Long Island City, New York—just across the East River from Manhattan—with her parents and younger brother. Because she and her family members were illegal aliens when they immigrated here, she learned the model of hard work and service to others from her family.

Her mother spent many hours cleaning apartments in Manhattan, while also devoting herself to the care of ailing friends and older people in her neighborhood. Of her father, who worked in factory maintenance during the week and pumped gas on weekends, she recalls, “I remember having to walk in cold winters to bring my dad lunch as he was pumping gas outside.”

Guerra enrolled in New York University, where she pursued an undergraduate degree in psychobiology, the study of the biological basis of human behavior. “Even to this day, I am fascinated by human behavior,” she says. “I think that it still defines my career and what I do.”

“Despite being presented with perfect logic, we sometimes behave irrationally. We understand the logic, we hear it, but sometimes we don’t act on it, and, in fact, we act in ways that undermine our health.

Two career paths beckoned to Guerra when she graduated in 1989: medicine and research. To choose the best fit, she volunteered in a research lab at Rockefeller University and also at several hospitals. “While I enjoyed the research I was doing on eating behavior in rats, I felt much more drawn to people. I realized that medicine would be the career that would merge my interest in science and my interest in serving others,” she says.

Her next step was a medical degree, which she earned in 1993 at the University of Rochester, where she also completed her medical residency. She joined the faculty of the University of Pennsylvania in 1996 as a full-time primary care physician with teaching responsibilities.

The research. Eventually, Guerra was drawn back to research, and completed her master’s degree in clinical epidemiology while continuing to teach and practice medicine.

Frustrated by the low rates of colorectal-cancer screening she was seeing in her practice, one of her early studies explored the connection between the attitudes, beliefs, and health literacy of Latino patients and their willingness to be screened. She published her results in the Journal of Health Communication (2005; 7:651–63) and the Journal of Health Care for the Poor and Underserved (2005; 1:152–166).

“I would ask: ‘You are 57, why haven’t you been screened?’ And they would say, ‘because my doctor hasn’t recommended it,’” recalls Guerra. “I realized that I wasn’t going to get anywhere unless I focused on the physicians.”

Of her Latino patients, Guerra learned, “They were screened when their doctor sent them and when their doctor didn’t send them, they weren’t screened.”

With an award from the National Cancer Institute, Guerra conducted interviews and focus groups with physicians to learn why they failed to recommend appropriate colorectal cancer screening. Among the reasons were lack of time during an office visit, particularly if there were other pressing medical issues to discuss; forgetfulness; a patient’s previous refusal to get the test; and language barriers. She published her findings in the Journal of General Internal Medicine. (2007; 12: 1681–88).

RWJF connection. In 2005, Guerra received a $364,607 grant from the RWJF Harold Amos Medical Faculty Development Program. It provides four-year awards for postdoctoral research to physicians and dentists from historically underrepresented groups who are committed to developing careers in academic medicine and dentistry. See Program Results Report for more information about the Harold Amos program.

The RWJF grant helped make it possible for Guerra to conduct a clinical trial to see if curcumin—the active ingredient in turmeric, a key spice in curry—lessened the rate of cell proliferation in the lining of the colon (which is associated with precancerous polyps). The idea emerged from findings that colon cancer rates are lowest in India and other places where the spice is commonly used.

That research continues, and Guerra is optimistic that it “could become a very inexpensive intervention” that could be part of a broader menu of prevention options.

Patient navigation. Another promising approach is patient navigation. In 2011, with funding from the American Cancer Society and other organizations, Guerra launched a patient navigation program for residents over age 50 in West Philadelphia—a low-income and predominately African American area of the city. The residents invited into the program, offered at the University of Pennsylvania Health System, had already missed at least one colonoscopy appointment.

The navigator—who spends an average of 4 hours and 17 minutes per patient—takes patients through each step of the colonoscopy process. The navigator explains the importance of the test, schedules the test, arranges for transportation, and helps patients find an escort, such as a fellow church member, to accompany them on the test day. She also mails them the bowel-prep medication they must take the night before the test, along with an instructional DVD.

On the day of the test, the navigator meets each patient and the escort at the door and helps them with the paperwork. She will sit through the entire procedure with any patient who requests it and also helps interpret the findings. If a biopsy is needed, she will call patients to discuss those results as well.

This is a resource-intensive approach, but it brings the screening to those who need it. Among the 225 patients who had navigator-assisted colonoscopies in 2012 and 2013, 75 (33%) had at least one pre-cancerous polyp that could be removed, and three were diagnosed with cancer.

The business case. The health system actually loses money on the colonoscopies performed in the navigator program because the program is resource intensive and more than half of the cases are reimbursed at low Medicaid rates. But hospitals do earn revenue from the follow-up treatment that is required after a cancer diagnosis. As a result, Guerra estimates that the University of Pennsylvania Health System netted $79,000 in the navigation program’s first two years.

“If you say to people, ‘This is the right thing to do,’ you will get a lot of nodding heads but no action,” says Guerra. “But if you show a business case and it is the right thing to do, you get action.” She hopes that the Pennsylvania Health System will assume funding for the program permanently, beginning in July 2014.

The project, says Guerra, “has really made me ask: Do I need business training to survive in this new era in health care [where we are] being so scrutinized and held so accountable for cost-effective care?” After concluding the answer to that question was “yes,” she added another commitment—taking business classes at the Wharton School—to her already packed schedule.

RWJF perspective. The purpose of the Harold Amos Medical Faculty Development Program, launched by RWJF in 1983, is to increase the number of faculty from minority and other historically disadvantaged backgrounds who achieve senior rank in academic medicine and dentistry.

The program also supports one of RWJF’s major objectives: to increase diversification of the medical and dental professions and, as a consequence, improve the health care received by the nation’s underserved populations.

Of Amos program scholars, RWJF Senior Program Officer David M. Krol, MD, MPH, says:

‘‘Ultimately, we would like to see these individuals from historically disadvantaged backgrounds becoming full professors at prestigious institutions, putting out important, valuable work, looking at a variety of different issues—including how to decrease the disparities between rich and poor, majority and minority—while climbing the academic ladder.

Carmen Guerra is one of more than 180 Amos program alumni in academic medicine today. Her career and research exemplify the academic achievement and professional contributions that the program was designed to stimulate.

“The measure of the success of the program is the success of the individuals who participate in it and how they impact the culture of health in the United States,” says Krol.