Background: At John H. Stroger Hospital of Cook County in Chicago’s West Side, up to 300 patients are diagnosed with later stage (3 and 4) breast cancer each year. That’s nearly twice as high when compared with state and national rates. To improve breast cancer prevention and expand services throughout underserved patient populations in Cook County, the hospital realized it needed a new approach to reach more patients to detect breast cancer before it develops into later stages. With help from a collaboration between the American Hospital Association’s Institute for Diversity and Health Equity (IFDHE) and Blue Cross Blue Shield of Illinois (BCBSIL), Stroger Hospital moved forward with its Breast Cancer Risk Identification, Screening, and Prevention (bCRISP) initiative to increase patient access. Among the many program goals include providing patients access to cancer risk assessment and genetic services. The bCRISP initiative aims to reach at least 200 Black and 150 Hispanic women. In this Spotlight Feature interview, Pamela S. Ganschow, M.D., describes the approach and strategy behind bCRISP and how it’s designed to make a difference.

Why did your hospital decide to move forward with this new initiative?

Evidence-based guidelines exist for the early detection and prevention of various cancers among individuals at increased risk for cancer, but uptake and dissemination of these evidence-based practices is limited. For example, fewer than one in five individuals meeting criteria for hereditary cancer syndromes are referred for genetic testing, which can identify many who are at moderate to high risk for certain types of cancer and create opportunities to help lower the risk of cancer developing. Studies show that the disparities in accessing these services is even more pronounced in minority populations.

“The COVID-19 pandemic has highlighted what we at Cook County Health have known about the disparities that disproportionately affect certain populations in terms of access to high quality care and ongoing preventative health care.”

We at Cook County Health decided to move forward with the bCRISP initiative to increase access to these evidence-based breast cancer risk management and genetic counseling/testing services for traditionally underserved patient populations throughout Cook County.

What is the goal of your program and how do you anticipate your efforts will impact patients?

The major impact of this program will be on the timely identification of minority women at increased risk for breast cancer, through genetic testing and other risk factor assessments. Early detection will enable individualized risk management strategies including chemoprevention, risk reducing surgeries and alternate screening strategies that can reduce breast cancer mortality. As mentioned above, we want to provide access to cancer risk assessment and genetic services in our safety-net health care system to at least 200 Black and 150 Hispanic women, reaching as many as 400 patients per year. Many who would benefit are of low socioeconomic status. We’re also looking to reduce the average time from referral-to-cancer genetic test results to three weeks or fewer for patients with newly diagnosed breast cancer or progressing metastatic disease, whose genetic test result would impact immediate treatment decisions (e.g., surgical or poly-ADP ribose polymerase “PARP” inhibitors).

In addition, we’re aiming to increase the weekly number of risk intakes performed by reducing the average time for staff to obtain an initial intake assessment, from 45 minutes down to 20 minutes through the implementation of innovative and electronic risk assessment tools that can be administered online, over the phone or in clinic.

In the area of education, we also want to educate at least 100 medical trainees. They would include medical students, residents, genetic counseling students, physician assistants, and physicians on cancer risk assessments and hereditary cancer through didactics, clinical rotations and grand rounds.

If you have a community partner, please share how your community partnerships support efforts to build this new program?

We do have a great community partner to help facilitate bCRISP. We work with the Metropolitan Chicago Breast Cancer Task Force, now called Equal Hope.

Equal Hope’s mission is to save women’s lives by eliminating health disparities in Illinois, originally through the lens of breast cancer. They’ve now expanded to eliminating health disparities regarding other conditions, including cervical cancer, with the goal of eliminating inequities related to prevention, screening, diagnosis, treatment and survivorship for all women. They are assisting us in reaching out to patients outside of our health system by screening women for family histories and detecting potential hereditary cancer syndrome.

Does a clearer understanding of socioeconomic conditions impacting patients and other barriers to health equity help you build a better program? How?

Yes. There are multiple barriers that have been identified to obtaining breast cancer risk assessment services, especially among populations of low socioeconomic status. These include, but are not limited to, financial expense, lack of physician referral, and lack of awareness among patients about the impact on screening/prevention and treatment options for them and for their at-risk family members.

Our program has been built to address these barriers through:

• Securing financial assistance to help cover the cost of counseling and testing for appropriate/eligible patients.
• Providing timely access to cancer risk assessment and genetic counseling for patients and their family members and discussing the impact of testing on screening, risk reduction and treatment options.
• Individual health behaviors adopted after the program initiation.
• Educating medical trainees on how to identify, refer and manage patients at increased risk for cancer.

“Achieving health equity requires valuing all individuals and populations equally, recognizing and rectifying historical injustices, and providing resources according to need.”

Underserved populations have long faced logistical barriers to access timely screening, diagnosis, treatment and even basic primary care. Logistical difficulties include not only getting an appointment for screening tests, such as mammograms, but also getting time off from work, transportation issues, as well as finding care for children or other dependents.

COVID-19 has highlighted what we at Cook County Health have known about the disparities that disproportionately affect certain populations in terms of access to high quality care and ongoing preventative health care. With the ongoing coronavirus pandemic, we have seen a marked decrease in screenings and we’re concerned that this will further contribute to disparities in breast cancer stages at presentation and outcome.

Mammograms and other cancer screenings are not only safe but also very important. We caution people not to neglect their ongoing health needs, including cancer screenings, and to pay attention to any other medical problems during the pandemic.

What information would you share with others about advancing health care equity within their organization?

I would begin by sharing a common definition of health equity, which I would describe as the assurance of the conditions for optimal health for all people. Achieving health equity requires valuing all individuals and populations equally, recognizing and rectifying historical injustices, and providing resources according to need.

I would also share that it is important that decision makers at your institution embrace the understanding of upstream drivers of health inequity, including systemic racism and other social inequities including class, gender and sexual orientation. Consider identifying institutional policies that may be perpetuating these inequities and advocate for new ones that combat racism while promoting respect and transparency. Ensure that diversity is achieved in leadership and in the workforce. Addressing health equity is much more than screening for social determinants of health.

Advancing equity in health care requires organizations to rectify historic injustices that have resulted in significant disparities in racial and ethnic disease outcomes. It also involves collective contributions of additional health care resources, beyond what many institutions are currently doing now. Safety-net health care institutions, which have historically cared for racial and ethnic minorities, continue to experience significant financial constraints resulting in limitations to essential resources such as staffing and wrap-around services. This can result in inadequate care for populations that often need greater resources to achieve optimal outcomes. In addition, many health care organizations continue to discriminate based on insurance status, disproportionately impacting non-white populations.

Increasing access to high-quality comprehensive care close to home for low-income families and communities of color cannot be the responsibility of one or a handful of institutions. Hospitals should either share in the provision of this care directly or contribute financially, or both.

I would add that we cannot rely solely on the limited infrastructure of community-based health centers to provide primary care without also ensuring equal and high-quality access to evidence-based specialty services and diagnostic/treatment services. Securing these commitments will begin to contribute in a meaningful way to the reduction of disparities and provide true equity in health care beyond what is often seen as token efforts on the part of many institutions.