researcher Gerard Silvestri, M.D., is a convert.
He's treated patients with lung cancer and researched lung cancer for three decades. But in the last few years, as he has worked with Hollings cancer disparities researcher Marvella Ford, Ph.D., and traveled to MUSC Health's new regional hospitals in rural locations like Chester and Marion, he's come to truly understand what holds back would-be patients from getting life-saving screenings, not just for lung cancer but for other common cancers.
"Wow," he said. A third of South Carolina counties are classified as rural, and 75% of South Carolina's counties include rural areas. This becomes hugely obvious once you leave metro areas like Charleston, Columbia and Greenville. "Some people don't have the gas money to come and see me, let alone get screening tests. Marvella has really made me a believer – you've got to meet people where they are," he said.
The two researchers have started teaming up, melding their medical and behavioral science expertise to get more people to screenings. Earlier this year, they led Hollings to receive a Stand Up to Cancer grant and become part of the Southeastern Consortium for Lung Cancer Health Equity, which has as one of its goals improving cancer outcomes and screening rates in medically underserved communities.
"Some people don't have the gas money to come and see me, let alone get screening tests. Marvella has really made me a believer – you've got to meet people where they are."Gerard Silvestri, M.D.
Now, they are co-leaders of a $1.2 million grant to Hollings from The Duke Endowment, with ambitious goals to increase screening rates for five cancers and expand biomarker research trials by working with the regional hospitals in Florence, Lancaster, Chester, Marion, Columbia and Kershaw and a new facility scheduled to open in 2023 to serve Lake City and Williamsburg County.
The Duke Endowment Grant establishes the Center for Cancer Equity and Engagement at Hollings, a center that will house this and many other health disparity initiatives.
"Ultimately, what we want to do is detect cancers earlier so populations that, historically, have had cancers detected late, now we're going to move that needle closer to early-stage detection," said Ford, the Hollings associate director for Population Science and Cancer Disparities. "And that, hopefully, will change the perception of cancer in these communities."
By increasing screenings and getting people diagnosed at earlier stages, when cancer is more treatable, she believes people in these underserved communities will no longer assume that cancer automatically means death. Instead, it will be seen as a disease that can be managed – and people will see that patients can survive and thrive for years after cancer treatment.
With several grants and programs at Hollings focused on addressing cancer disparities in South Carolina, the Center for Cancer Equity and Engagement will provide the infrastructure to support the many health disparity research initiatives, including the new Duke Endowment grant, the Leon Levine Foundation grant, the existing SC AMEN outreach program, and the Stand Up to Cancer grant.
"It gives us a home for all of the initiatives to make sure that we're addressing the five major cancer types in the state and that we're really developing programs and research and outreach and strategies to meet the needs of the state across those five areas," Ford said. "And we'll be able to plot the location of the initiatives on a map to make sure that we're really including all counties in South Carolina.
"It helps us to make strategic decisions about what to do next and which cancers need additional focus. We're here to serve the people of the state, and having this umbrella helps us to make sure that we're continually evaluating how well we're meeting the cancer needs of the state," she said.
Cancer health disparities in S.C.
For The Duke Endowment grant, the pair is focused on five cancers with high mortality rates in South Carolina: lung, breast, prostate, colorectal and cervical cancer. These cancers also have big differences in outcomes among populations, including:
- Black men in South Carolina are twice as likely as White men to develop prostate cancer and 2 1/2 times more likely to die from it.
- White women in South Carolina are more likely to be diagnosed with breast cancer at an early stage, and Black women are more likely to die from breast cancer.
- Black women are more likely to die from cervical cancer than White women.
- Black people have higher rates of colorectal cancer and are more likely to die from it than as White people.
- Black people are more likely to develop lung cancer at younger ages and with less of a smoking history than White people. Nationally and across all races, only 6% of people who are eligible for lung cancer screenings actually get the screening.
- People in rural and Southern states are more likely to smoke, yet lung cancer screening programs are concentrated in the Northeast, California and Florida, where rates of lung cancer are lower.
- In rural counties across the nation, a quarter of the population doesn't have access to a low-dose computed tomography lung cancer screening program within 40 miles.
Silvestri has been working over the last couple of years to get low-dose CT lung cancer screening programs established at MUSC Health's regional hospitals.
"We now have six lung cancer screening programs up and running in our Regional Health Network. And I'm really proud of that, honestly," he said.
The screening programs rely on an active partnership from all involved, including doctors at each of the sites who are willing to champion the cause and bring others on board; on-site nurse practitioners who run the regional programs and meet quarterly with the Charleston team; and the tumor board, which reviews any suspicious scans.
Although South Carolina has been sitting at the national average for lung cancer screenings, Silvestri hopes to soon see it leap upward in the rankings.
With this practical experience in setting up lung cancer screening programs, Silvestri and Ford are now using that experience to expand screenings for the other cancers covered by The Duke Endowment grant.
But they know that simply offering the screenings isn't enough. This is where Ford's expertise in employing evidence-based patient navigation strategies comes into play. Patients often need help overcoming barriers to screening, and nurse navigators will be trained at each site to do just that.
"Screening, by definition, means getting checked for disease that you haven't yet been diagnosed with. It's very easy to put screening off when you're dealing with all of these immediate life issues."Marvella Ford, Ph.D.
The barriers could be around a lack of transportation, need for childcare, inability to meet copays or to take time off work to get screened.
"Screening, by definition, means getting checked for disease that you haven't yet been diagnosed with. It's very easy to put screening off when you're dealing with all of these immediate life issues," Ford said.
In addition to the nurse navigators helping patients to figure out these issues, the program will also use telehealth wherever possible.
Telehealth was successfully used in the lung cancer screening program during the height of the COVID-19 pandemic, and this program will copy its approach. The navigators will use telehealth to meet with patients and identify barriers to screening as well as resources to overcome those barriers.
Clinicians will meet with patients for a first visit to talk about the patient's risks and determine together whether screening is right for that person. After the screening, the clinician will meet again with the patient by telehealth to talk about the results.
The goal is to conduct half of screens with the telehealth model by the fifth year of the program.
Biomarkers could transform cancer care
Another exciting part of the grant is the focus on developing cancer biomarkers, an area in which Silvestri specializes. If there were a blood test that could indicate the likelihood that someone would develop lung cancer, then people could get an initial screening at a regular doctor's visit, with a simple blood draw, he said. The patients at the highest risk for developing lung cancer would be encouraged to move on to a CT scan screening at regional centers.
To work toward this goal, the duo is establishing a program to collect blood samples to be analyzed for possible biomarkers of lung cancer. Hollings is working with two companies conducting multicenter trials to, first, identify potential biomarkers and, second, validate that these biomarkers can actually predict who will develop cancer. Silvestri is the national principal investigator for one of the trials.
These types of trials require tens of thousands of samples, Silvestri explained. Typically, one person out of every 200 to 300 who are screened will be found to have cancer, depending on which cancer you're looking for, he said. Therefore, to get enough samples of people who have developed cancer and to see how those samples differ from the people who didn't develop cancer, you need a lot of people in the study.
These are the types of transformative research and trials that are possible in Charleston – and now, across the state – because of Hollings' status as an NCI-designated cancer center.
"We really are extremely excited about being able to expand our research, and what's so great is that the people in those areas are thirsting for that," Silvestri said.
