St. Luke’s Mountain States Tumor Institute (MSTI) provides advanced cancer care to patients at clinics in Boise, Fruitland, Meridian, Nampa, and Twin Falls, Idaho. Spanning more than 180 miles across southwestern Idaho, MSTI cares for patients from rural areas and from metropolitan areas. Because of geographic isolation, many people in rural areas present at later stages of disease. In addition, large Hispanic populations in the rural counties of the state are not getting screened for cancers on recommended timelines.
“Reduce cancer healthcare disparities” is the first of seven pillars with which National Cancer Institute Community Cancer Centers Program (NCCCP) sites are tasked. These inequalities of care include access to cancer screening, treatment, and research. The staff at MSTI hopes to reduce disparities in care for their patients with help from their new contract as a member of the NCCCP.
Making it a reality
MSTI has “plans to beef up programs that are partly already in place but need greater funding, whether that is getting early screening with mammography at a greater intensity or getting more education within the communities,” said Paul G. Montgomery, MD, FACP, a medical oncologist. “There has been some education, there needs to be more. There has been some mobile mammography units going to rural areas, there needs to be more.” Funding from the NCCCP contract should help MSTI provide these additional services and “allow us to make an impact.”
The action plans start by analyzing data on their patients. These data show where MSTI needs to focus, including geographic areas and ethnic populations. Then, areas with disparities are targeted for what is needed. Montgomery gave this example: Geographic areas where patients disproportionately pre sent in the later stages of cancers can be targeted for patient education, hopefully leading to improved early diagnosis and screening.
To help get information and services out to people, MSTI plans to expand its services beyond the Boise clinic, where most of the specialized clinics are currently housed. With the high-risk breast cancer clinic, for example, all patients must travel to Boise. But, the plan is to expand into the Twin Falls area, which is about 130 miles away, and at a future date, perhaps into the Fruitland area, according to Jill Winschell, RN, a breast cancer nurse navigator.
Navigation services will expand beyond the new clinic. MSTI is currently looking to fill several positions for new navigators, starting with a navigator for the Twin Falls area and one for the Fruitland area in the western end of the Treasure Valley, which is home to a large Hispanic and rural population. A third breast care navigator will be hired for additional western Idaho locations.
“These rural navigators will be situated in those areas and begin to develop community resources and community outreach to occur directly in their communities,” said Winschell.
A second mobile mammography coach also is in the works. The current coach is booked every day, except when it is down for service, according to Winschell. “In fact, they have traveled up to Grangeville, which is 220 miles north. And we will be traveling into Oregon, which will be new for us.”
Disparities meet supportive care
Psychosocial and survivorship resources are expected to expand into all five sites as well, which will help MSTI embrace another of the NCCCP pillars—“ Enhance cancer survivorship and palliative care services.” In addition, “we have the opportunity to provide supportive oncology clinics to meet the advanced disease population,” said Alicia Rosales, LMSW, an oncology social worker.
A supportive care oncology clinic was opened in May in the Boise location. “It is not in replacement of the patients’ visits to their primary oncologist, but something that is linked in parallel,” said Dan Zuckerman, MD, medical director for the supportive care and survivorship clinics. With this clinic, patients who require help from multiple supportive disciplines now have a place to go. The clinic offers dietitians, social workers, and physical therapists. There are plans to increase psychiatric services by hiring someone with a specific interest in psychooncology. Although dedicated psychosocial onco l ogy personnel can be difficult to staff in rural areas, Zuckerman is hoping to use funding from the NCCCP for this purpose. This funding may also allow a supportive oncology clinic to open in each of the five sites. Rosales envisions a halfday clinic of survivorship and a halfday clinic of advanced disease patients, staffed by a multidisciplinary team. The clinics would offer a dietitian, a social worker, a psychiatrist, a pharmacist, a nurse practitioner, and referrals to financial counselors and physical therapists.
The rural location of its patients affects survivorship services as well. With patients in remote areas, survivorship services means “making sure that patients have the information, the resources, and the tools they need to empower themselves to lead healthy lives. We have to take into account that all of them may not have the opportunity to participate in exercise classes. We have to give them the information about how they can do it on their own in their own geographic setting,” said Rosales.
Patient education is a similar challenge. In the Hispanic community, many believe that cancer cannot be cured. “It is even harder when these groups of workers are spread over a large area, to be able to reach out and have them understand that cancer can be cured. A great deal of time and effort will be needed to communicate that early diagnosis is important,” said Montgomery. “We are hoping that we can do more community outreach and interaction with the people in those communities to deal with a lot of those disparities and get the rural and Hispanic population into the healthcare system in a timely manner,” echoed Winschell. MSTI employs both Hispanic and Spanish-speaking oncologists and nurses to help with these efforts.
Clinical trials and biospecimen research
NCCCP sites are also tasked to “increase participation in clinical trials,” and “participate in biospecimen re search initiatives to support personalized medicine.” Using funding from the contract, MSTI will be able to start a phase 1 clinical trial program within the next 2 years, “which will be a huge thing because there is no place in Idaho or in our surrounding area that offers phase 1 trials,” said Zuckerman. At current, MSTI accrues only to phase 3 trials, usually from one of the cooperative groups— Southwest Oncology Group, Radiation Therapy Oncology Group, National Surgical Adjuvant Breast and Bowel Project, Eastern Cooperative Oncology Group, and Cancer and Leukemia Group B—as well as to a limited number of industry-sponsored and investigatorinitiated phase 2 trials.
Biospecimen processing is already under way. In conjunction with Boise Veterans Affairs Medical Center and Boise State University, MSTI has broken ground on the building where biospecimens will be stored. “I think one of the things nationally is the NCI [National Cancer Institute] is trying to standardize how biospecimens are stored and to enable researchers from anywhere in the country to access these biospecimens,” said Zuckerman.
Meeting the challenge
“The challenge is not only to deliver best standards of care, but also to implement that across our multiple sites. Many of our patients cannot come into our main center in Boise, so our goal and our responsibility is to provide care in their own communities,” explained Zuckerman. Along with fellow NCCCP site Billings Clinic Cancer Center in Billings, Montana, MSTI hopes to meet the NCI’s challenge of providing the best evidence-based care to all Americans.