Improving cancer care at every step

Much of this work happens through close collaboration with the UNC Lineberger Comprehensive Cancer Center, the only public National Cancer Institute-designated Comprehensive Cancer Center in North Carolina. It is also strengthened by state funding that supports research innovation and expands access to evidence-based care across the state.

Where diagnosis happens matters

Caroline Thompson, PhD, MPH, associate professor in epidemiology, studies how patients move through the health care system and the circumstances around cancer diagnoses. Cancer can be detected through proactive screenings like mammograms; incidentally, like when someone has an X-ray following a car accident and it reveals cancer; or, most commonly, after patients begin experiencing cancer symptoms and seek medical care.

None of us can take on cancer alone.

Many patients, especially in rural areas, don’t have access to regular primary care and may go to an emergency room when they first experience these symptoms. Thompson’s team has found that receiving a cancer diagnosis in an emergency room is associated with worse outcomes, including delayed care and lower survival rates.

“We’re trying to understand patient journeys and generate data that health systems can use to optimize care and improve outcomes for those who receive an emergency room cancer diagnosis,” said Thompson.

New approaches to cancer screening

Many researchers in the Gillings School are working to make cancer screening more accessible.

Jennifer S. Smith, PhD, professor in epidemiology, has evaluated human papillomavirus (HPV) self-collection kit outreach as a means of reaching under-served women who may lack health insurance or have other barriers to in-office screening. HPV tests play an important role in early detection of cervical cancer since HPV is an essential cause of cervical cancer. Smith and her team found that at-home HPV self-collection outreach doubled screening uptake among under-screened women as compared to offering in-clinic scheduling assistance alone and that at-home HPV self-collection was cost-effective.

“Cervical cancer is highly preventable. We really want to increase life-saving screening by bringing tests to those under-screened. Mailing self-collection kits allows women to save time and screen themselves in the privacy of their own homes — leading to two-fold higher screening coverage in our My Body My Test trial,” said Smith.

Stephanie Wheeler, PhD, MPH, the Michael S. O’Malley Distinguished Professor in health policy and management, has supported multiple cancer screening projects throughout the state by partnering with community health center primary care practices through the CAPRICORN initiative and by evaluating the cost-effectiveness of these initiatives. These projects build capacity for evidence-based cancer screening in communities through training, technical assistance and electronic health record support. In one community health center clinic in northeastern North Carolina, this work yielded a more than 30 percentage point gain in colorectal cancer screening over the past 10 years (going from 34% to 65% screening).

“Our close partnerships with these important community providers serving low-income, underinsured and rural communities have helped increase use of evidence-based practices, build workforce capacity, and build the business case for focusing on screening quality improvement and linkage to follow-up care. We’ve seen meaningful improvements in cervical, lung and colorectal cancer screening and outcomes as a result — in the populations who need screening the most,” said Wheeler.

With colorectal cancer, screening barriers can be especially complex. Beyond the time and financial barriers that exist for other cancer screenings, colorectal cancer screening touches on aspects of the body that many people experience as private and sensitive, creating a layer of discomfort. Leah Frerichs, PhD, associate professor in health policy and management, leads efforts to make colorectal cancer screening more accessible, and to help communities understand their screening options. She partners with eight clinics throughout Robeson County on a digital platform that delivers text message reminders to patients who are due for a colorectal cancer screening. The text message alerts prompt patients to either schedule a colonoscopy or order an at-home stool testing kit, based on their preference.

Subtyping for precision treatment

Gillings School researchers are also working to ensure that once a patient receives a cancer diagnosis, they have access to the most robust information possible about their tumor subtype and best treatment options. Naim Rashid, PhD, associate professor in biostatistics, worked with UNC Health collaborator Jen Jen Yeh, MD, to create a computational tool for subtyping and classifying pancreatic cancer tumors. It uses machine learning to analyze expression levels of 16 different genes and then classifies the patient’s tumor into one of two subtypes, which then informs which first-line chemotherapy treatment is likely to be most effective. This allows patients to receive precision treatment and spares them from wasting precious time on cancer treatments that will be ineffective.

Gillings researchers are also working to identify which cancers are indolent, or slow-moving and unlikely to be harmful, so that patients can avoid unnecessary treatments or overly aggressive treatment. Subtyping that can identify indolent cancers often takes place in specialized labs at large medical centers, but Melissa Troester, PhD, professor in epidemiology, is studying how cancer subtyping can be done with the pathology images that are already part of standard cancer care. Pathology images provide a detailed map of the tumor and its surroundings that can be used to identify indolent subtypes, providing vital information to inform treatment. And because these pathology images are collected for every patient who is diagnosed, using them for subtyping could expand precision treatment options to all cancer patients, even those in smaller, less-resourced health care systems.

It takes a team approach

Cancer care is complex, but patients should never feel like they’re navigating it alone.

“None of us can take on cancer alone,” said Rashid. “It takes researchers, statisticians, surgeons, biologists, pathologists, nurses, patient navigators, and the patients and families themselves, all working together as a team to take care of one another as we fight cancer.”