By Anne Blythe
Kim Schwartz, chief executive officer of the Roanoke Chowan Community Health Center, never misses an opportunity to break into song — just ask her seven grandchildren, she quips.
No need to cue up an orchestra either.
Schwartz belted out the first lines of “Fly Me to the Moon” on a recent Friday morning inside a conference room full of UNC-Chapel Hill physicians, scientists and researchers. Her audience also included Arati Prabhakar, director of the White House Office of Science and Technology Policy.
Prabhakar was in North Carolina on Feb. 10, in part, to hear how federal grants have been used to strive for the Biden administration’s “Cancer Moonshot” goal of cutting cancer death rates in half over the next 25 years.
Shelley Earp, director of the Lineberger Comprehensive Cancer Center, a beacon for cancer research and treatment across the state, tapped members of his team to provide Prabhakar an overview of the work on tobacco cessation efforts, links to cancer and obesity, and early detection programs.
Not all of them used song in their presentations, as Schwartz did, so Prabhakar took a moment to acknowledge the Frank Sinatra-esque flourish.
“We have a theme song,” Prabhakar said as laughter erupted in the conference room.
Based in Ahoskie, Roanoke Chowan Community Health Center serves Bertie, Gates, Hertford, Northampton and Washington counties. They’re part of an 11-county region in northeastern North Carolina identified as “a hotspot” of colorectal cancer mortality in an American Cancer Society study published in 2015. Such a finding warranted prioritized screening intervention, according to the study.
Colorectal cancer is the second leading cause of cancer deaths in North Carolina. So health care workers inside and outside the hotspot areas got busy, trying to find and treat colorectal cancer earlier.
Colon cancer hotspot
Researchers found that in 10 of the identified counties near the Virginia border, an average of 55 people per 100,000 died from colorectal cancer. The overall county rate for the rest of the state was 45 deaths per 100,000 people.
A multitude of reasons were cited for the disparity. The congressional district that encompasses a large part of the rural region has been identified as one of the sixth poorest in the country, according to Schwartz.
That kind of intergenerational poverty can lead to health care access disparities and other systemic challenges that arise from unstable housing, lack of affordable transportation and fewer quick nutritional food options and safe exercise choices than in wealthier parts of the state.
Dan Reuland, a general internist and co-director of the Carolina Cancer Screening Initiative at the UNC-Chapel Hill Lineberger center, is well aware of the colorectal cancer disparities along the North Carolina-Virginia border.
The North Carolina screening initiative was founded in 2016 to focus research primarily on cervical, colorectal, liver and lung cancers. The SCORE program, or Scaling Colorectal cancer screening through Outreach, Referral and Engagement, was set up after that with an emphasis on improving screening rates for community health center patients.
President Joe Biden, whose son Beau died from brain cancer, rekindled interest in the Cancer Moonshot program last year, some six years after its initial launch. In addition to the goal of cutting the cancer death rate in half over the next quarter century, Biden said the country should strive to improve the lives of cancer survivors and those fighting the disease.
“Working on solutions to cancer is one of the most important things we can do, and these solutions are so important to the president and first lady,” Prabhakar said. “They have the conviction to tackle this, and that’s one of the reasons I took this job.”
The Moonshot money, Reuland told Prabhakar, “happened to come down at the perfect time.”
When the 2015 American Cancer Society study showed that instances of colorectal cancer were higher than otherwise could be explained by many factors in the northeastern part of the state, the Lineberger researchers leaned in with more focus.
“This is in our catchment area. What are we doing?” Reuland said the team asked.
‘Best test is one that’s done’
Schwartz and her team already had been trying to make colorectal screening more routine through outreach efforts. They doubled their screening rate within a year.
Reuland and his team used federal dollars to boost state funding from the University Cancer Research Fund to improve the accessibility and quality of screening.
They partnered with the Roanoke Chowan Community Health Center to get mail-in fecal immunochemical tests, or FITS, to patients older than 45 and pursue them aggressively to get them to return stool samples to the lab.
The researchers in Chapel Hill provided technical support to help determine who in that northeastern region was due for a screening, then make sure they get a kit and guide them through next steps if the lab test comes back positive.
The kits are mailed annually.
Unlike a colonoscopy, which is recommended at least once a decade for people over 45, the kits are more effective at the early detection of cancer if they are used at least once a year.
They are less expensive than a colonoscopy and do not require someone to perhaps take time off work to get to a health care facility that offers such procedures and have someone wait with them to drive them home.
FITS done annually are “a little less effective” than a colonoscopy in lowering the risk of undetected cancer, Reuland acknowledged. Nonetheless, he added: “The best test, colorectal test, is the one that’s done. They’re all way better than no screening.”
Three degrees of separation
Schwartz said part of the outreach at the Roanoke Chowan center has been to make patients more comfortable talking about the color of their stool. The center has developed charts and a “We’re Right Behind You” public relations campaign.
“I have seven grandchildren, so poop is in my life all the time,” Schwartz said. “What we did was we got everybody’s statistics out. We had shades of brown. What we did was try to normalize it.”
In a personal moment, Schwartz explained that most people in her region of the state know someone who has been touched by colorectal cancer. Her mother was diagnosed with the illness six years ago and died late last year.
As her voice choked with emotion, Schwartz showed Prabhakar that she wore her mother’s watch to the meeting to pay tribute to her.
“That is what came to the heart of our work, that every one of us … every single one of us, there’s less than three degrees of separation in this hotspot area,” Schwartz said.
Reaching the rural areas to make a dent in the cancer death rate is crucial, Earp said. In a state with 10.7 million people, Census estimates are that 4.6 million live in rural unincorporated areas.
Though much research is being done and many early-detection and prevention efforts are in the works in rural areas, Earp would like to see more movement of the needle on challenges that won’t go away overnight.
“These are long-standing problems,” Earp said.