Journal of Cancer Education
ISSN: 0885-8195 (Print) 1543-0154 (Online) Journal homepage: http://www.tandfonline.com/loi/hjce20
A multidisciplinary educational program to promote head and neck cancer screening Marianne N. Prout MD, MPH , Selma J. Morris MEd , Robert A. Witzburg MD , Christine Hurley RN & Sarbona Chatterjee MD To cite this article: Marianne N. Prout MD, MPH , Selma J. Morris MEd , Robert A. Witzburg MD , Christine Hurley RN & Sarbona Chatterjee MD (1992) A multidisciplinary educational program to promote head and neck cancer screening, Journal of Cancer Education, 7:2, 139-146 To link to this article: http://dx.doi.org/10.1080/08858199209528156
Published online: 01 Oct 2009.
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Date: 08 April 2016, At: 06:00
0885-8195/92 $5.00 + .00 © 1992 American Association for Cancer Education
J. Cancer Education. Vol. 7, No. 2, pp. 139-146, 1992 Printed in the U.S.A. Pergamon Press Ltd.
A MULTIDISCIPLINARY EDUCATIONAL PROGRAM TO PROMOTE HEAD AND NECK CANCER SCREENING
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MARIANNE N. PROUT, MD, MPH*; SELMA J. MORRIS, MEd*; ROBERT A. WITZBURG, MD†; CHRISTINE HURLEY, RN*; and SARBONA CHATTERJEE, MD† Abstract—An educational program to promote screening through primary health care for the squamous cell cancers of the buccal cavity, pharynx, and larynx as developed and implemented, and its impact on screening was documented. Providers of care for high-risk patients at seven inner-city health care sites in Boston were identified and targeted for training. Of the 327 providers who were targeted for training from December 1986 through June 1989, 261 (80%) attended educational sessions. Screening exams were documented on an average of 14.7 patients per targeted provider through December 1989. The educational program was associated with a large increase in documented screening for these cancers, compared with baseline rates. Several adaptations in the program were required, including a demonstration of efficient screening to address the concerns of these providers about time constraints. Variations in the quantity and quality of documented screening among health care sites were noted.
behaviors in the health care sites in such a way that patients at risk for head and neck cancers are identified, screened, and referred for followup as indicated. This program reached over 250 providers of health care and resulted in more than 7,000 documented screening exams in a 4-year period (1986-1990). Although this program was successful in accomplishing the behavioral objectives of increasing screening, it encountered obstacles previously reported in the emerging literature on implementing cancer prevention through physicians' offices4-5 as well as obstacles which may be specific to sites serving patients from lower socioeconomic groups.
INTRODUCTION An educational program to promote the screening of high-risk patients for head and neck cancers was developed, implemented, and evaluated in selected inner-city health care sites in Boston in response to the city's elevated incidence rates of these cancers.1 The program's goal was to enable primary health care providers to incorporate head and neck cancer screening into their routine care of patients at risk for these cancers. The strategy of integrating screening into routine health care was chosen after we documented both the use of health services by patients with advanced head and neck cancers in Boston prior to their diagnoses and also the low rate of screening in such services.2-3 Two main objectives were identified for the educational program: (1) to train the providers at each screening site; and (2) to change
BACKGROUND
Supported in part by NIH/NCI Grant #CA 40667 and ACS Grant #PBR-45. *Boston University School of Public Health and Boston University School of Medicine. †Boston University School of Medicine. Reprint requests to: Marianne N. Prout, MD, MPH, Boston University School of Public Health M-815, 80 East Concord St., Boston, MA 02118.
A brief overview of the development of the screening program is presented to provide the context for this report on the educational effort. The overall project began in 1985 and was funded by the National Cancer Institute's avoidable cancer mortality program with the objectives of developing, implementing, and evaluating a screening program for the squamous cell carcinomas of the buccal cavity, pharynx, and larynx (referred to as head and
139
M. N. PROUT et al
140
neck cancers in this paper). The selection of health care sites for screening was based on interview data collected from newly diagnosed patients with these cancers during the first two years of the project.2 The screening exam in-
cluded a systematic oral mucosal examination as advocated by Mashberg,6 modified to include risk factor and symptom assessment. A screening form was developed, pilot-tested, and modified. This form (see Fig 1) was used
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ORAL CANCER SCREENING FORM
Male Female . Date Locatiorv/Site Provider t Risk Factors 1. Do you smoke cigarettes now?............... no 2. Did you ever smoke cigarettes?. no no 3. Do you use cigar/pipe/snuff/chewing tobacco? no. no 4. Do you drink alcohol now?.. 5. If no, did you ever drink alcohol? no B.
Symptoms (as answered by the patient) L. Do you have any soreness or pain in throat mouth ear.................................. jaw neck................................. teeth on swallowing 2. Has your voice changed?. 3. Is your, voice hoarse?..... 4. Have you felt any masses or lumps? 5. Have you had trouble swallowing?. 6. Have you had trouble chewing? 7. Have you lost >10 lb in the past 2 months?. 8. Have you coughed up blood?.
no no no no no no no no no no no no no no
yes ... pks/day yes pks/day which? ves yes... yes
. . . . . . . . .
yes yes yes yes yes yes yes yes yes yes_...
ves yes yes yes
yrs— yrs
when q u i t ? > 2 weeks' d u r a t i o n ? no y e s unknow ^^^_ m_^... ^^^_ ___ *_
—. _—
—— ——
how much? when?
Locate positive findings below:
physical Examination c. Shortness of breath
no . yes Hoarseness.............. no . yes. Nose: blood in nares.......... no . yes. Oral cavity: no . yes. caries blood in mouth no . yes, edentulous.............. no . yes. white patches... no . yes. red patches............. no . yes bleeding areas.......... no . yes tenderness no . yes mucosal lesion no . yes. Neck: pain no . yes masses.. , no . yes nodes no . yes - D. Were the above signs and symptoms the reason for this visit?.... no yes_ E. Conclusion (check one): Normal Abnormal, cancer not suspected F. Action (check one): None Refer for followup because of: required Screening exam Other
Abnormal, suspicious for cancer _ Exam not done Signature..
Figure 1. Oral cancer screening form.
Reason
Promoting head and neck cancer screening
141
Table 1. Criteria for a positive screen The following criteria and recommended actions have been established for "abnormal, suspicious for cancer sign and/or symptom" found at the time of primary screen. Criteria
Recommended action
Simple leukoplakia: white patch that does not scrape off
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Complex leukoplakia: mixed white and red patches Erythroplakia: red velvety patches Mucosal lesion with gross appearance of cancer Hoarseness or voice change persistent throughout the day for 2 weeks Mucosal lesion of uncertain type in high-risk anatomic area: floor of mouth, ventrolateral tongue
to prompt providers to screen, to promote a standardized exam, and to collect data for evaluation. Descriptive criteria for a positive screen were established in consultation with otolaryngologists and dentists and are shown in Table I. 7 The seven health care sites selected for screening included two community health centers serving the neighborhoods with the highest rates of these cancers in Boston, two outpatient clinics serving veterans, a large outpatient clinic and an inpatient medical service in the only municipal hospital in Boston, and the coordinated health services for homeless shelters in Boston. Six screening sites remain active; the seventh site closed after less than one year of screening when the clinic ceiling collapsed. Patient care was transferred to another screening site and the data for these two sites have been combined. At each site, patients aged 40 or over who had ever used any form of tobacco were eligible for screening. METHODS Development of educational programs The selection of providers to perform the screening was difficult. Our initial plan was to train nurses who triage patients to perform a screening exam as part of their routine assessment; this plan required training only a small number of individuals at each site. However, a citywide nursing shortage combined with
Careful oral examination Elective referral to ENT Immediate referral to ENT Immediate referral to ENT Immediate referral to ENT Immediate referral to ENT Immediate referral to ENT
budgetary cutbacks forced the elimination of such nursing positions at most locations. Therefore, providers and other personnel who would be involved in the screening and their level of training and experience were identified during an initial walk-through visit at each site. Educational programs were developed that could be easily adapted for different categories of medical personnel. The format of the initial educational program was a lecture and slide presentation to meet the objectives shown in Table 2. For physicians, the presentation was limited to 45 minutes with 5 to 10 additional minutes for discussion. For medical students, a half hour of skills practice was added, during which exams were demonstrated and observed by instructors. For nursing personnel, the educational program included an additional hour for review of the anatomy and pathophysiology of the head and neck region and a review of staging for head and neck cancers. A separate program was developed for clerical staff that emphasized the importance of their roles in supporting the early detection of cancers in their clinics by preparing the screening forms and arranging followup appointments for patients with positive screening exams. The initial education was reinforced by distributing and discussing summaries of the screening data every 6 months and by informing all clinic personnel when cancers were detected.
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Table 2. Objectives for the initial educational session 1. Providers and other medical personnel will be able to identify patients at risk for head and neck cancers. 2. Providers will know the effects of stage at diagnosis on mortality and morbidity from these cancers. 3. Providers will be able to recognize symptoms potentially associated with head and neck cancers. 4. Providers will be familiar with the technique for performing a systematic exam of the oral mucosa. 5. Providers will know the descriptive criteria for a positive screening exam. 6. Providers will recognize the lesions and symptoms which are criteria for a positive screening exam. 7. Providers will know the procedure for followup of a positive screening exam. 8. Providers will be able to use screening forms to elicit risk factor and symptom information and to record signs, conclusions, and actions in a standardized format.
gram. (1) To evaluate the effectiveness of the program in reaching the targeted providers, attendance at each teaching session was recorded by project personnel. The number of providers targeted for the educational sessions was determined from lists of practitioners supplied by administrators at each screening site. (2) To evaluate the effects of the educational program on screening behavior, the quantity and the quality of screening forms completed at each screening site were assessed. Carbonless copies of screening forms were collected by project staff; data was entered and analyzed using FSP SAS (full-screen information processing) in the project offices. The number of completed forms and the frequencies of specific errors and omissions on the screening forms were summarized by health care site. The educational objectives of identification of at-risk patients, systematic assessment of symptoms and signs, and appropriate referral of patients with criteria for positive exams were assessed by reviewing screening forms to determine whether screened patients were aged 40 or over and had used tobacco products and whether the sections on exam conclusion and action were completed. The project staff discussed patterns of errors with medical supervisors as they became apparent, and therefore no quantitative assessment of errors was attempted.
Implementation of the educational program The initial educational program was incorporated into regularly scheduled educational courses for all provider programs except the homeless service, where special sessions were arranged. The programs were conducted at the onset of training periods for house officers and medical students in order to reach all providers at least once. Medical students were taught during a physical diagnosis course scheduled at the onset of the third-year medRESULTS icine clerkship; four staff were required for each two-hour session, which was repeated Table 3 summarizes the attendance at edevery 3 months. Programs were conducted in ucational sessions at the 6 active screening clinics on five successive days each July to sites through June 30,1989. The overall attenreach new houseofficers and attending physi- dance of targeted providers was high, 80%, cians. These programs were scheduled the with a range of 63% to 100%. Table 3 also inhour before clinics to promote the immediate dicates the average number of patients screened use of screening skills. Presenters included not per targeted provider at each site from Deonly staff from the research project but also cember 1986 through December 1989. providers at each health care site. InduceTable 4 categorizes problems with the comments for attendance included refreshments pletion of screening forms and indicates the and continuing education credits. personnel responsible for completing that part of the form at each site. The providers who Evaluation were expected to screen patients at these sites Evaluation methods were designed for each included medical students, house officers in of the two objectives of the educational pro- internal medicine training programs, attending
Promoting head and neck cancer screening
143
Table 3. Attendance and screening documentation by targeted providers Site
No. of attendees*
No. of eligible attendees
% attendance
Average no. forms/ targeted providerf
85 100 9 22 10 35 261
107 116 9 35 10 50 327
79 86 100 63 100 70 80
25.2 1.5 54.3 .8 90.7 6.7 14.7
1 2 3 4 5 6 Total
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•Attendance through 6/30/89. tBased on the number of completed screening forms on individual patients through 12/31/89. Exams were performed by attending physicians at sites 1, 3, 4, and 5, by house officers at site 1, by medical students at site 2, and by nurse practitioners at sites 1 and 3.
physicians, nurse practitioners, and nurses. Screening of low-risk patients, especially those who had never used tobacco, was noted at several sites and resulted in increased attention to risk assessment in the training program. The educational program was also modified in response to providers' concerns about time. First, the tobacco questions were changed from "do you smoke now or did you smoke within the past two years" to "do you now or did you ever," in response to complaints that patients would take 10 minutes to report all attempts at smoking cessation. Second, demonstration of a three-minute screen was included in our teaching sessions. Third, incremental initiation of screening was recommended, so that providers were asked to screen three to four patients per clinical session rather than all patients. At site 5, the pro-
viders decided to split the screening steps so that nurses collected risk factor and symptom data while physicians performed the exams. DISCUSSION Recommendations for integrating cancer screening into routine health care are reasonable based on the high frequency of health care visits by patients in need of cancer screening.8~1S Since current rates of cancer screening by physicians are suboptimal, effective methods to increase such screening are being studied.4'16"19 The challenges to changing practice behaviors of harried providers of inner-city health care to incorporate routine cancer screening are especially daunting. The acute and chronic shortage of nursing and clerical
Table 4. Problems in screening form completions Patient selection on risk factors Site 1 2 3 4 5 6
Excluded women
Included age 5>13'17 In these inner-city settings, providers repeatedly complained of time constraints. These time constraints were acknowledged and addressed in our educational program after the pilot phase. However, the screening of large numbers of low-risk patients seems incongruous with concerns of providers about the time effectiveness of this screen. We are now studying additional factors which may be associated with varying levels of provider compliance. The effectiveness of this particular educational program in reducing late-stage head and neck cancers will be determined in future years based on cancer registry data; the evaluation by cancer endpoints will be both lengthy and difficult.21 The long-term effects will depend upon not only the immediate change in provider behavior, but also the persistence of such behavior change, the transmission of such behavior to future providers, and the efficacy of such behavior. We are beginning to evaluate the persistence of screening behavior as the project's formal funding and activities cease. This educational program was implemented specifically in health services reaching socioeconomically disadvantaged individuals. Low socioeconomic status has been associated with excess cancer mortality, in part because of poor access to health services, especially preventive health services.22"24 Training providers to incorporate cancer screening efficiently into ongoing services may benefit patients already in care and may permit a low-cost approach to population-based screening.25
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REFERENCES
1. Massachusetts Department of Public Health: 19821985 Special Report: Cancer incidence in Massachusetts. Boston, MA: Division of Health Statistics and Research, 1988. 2. Prout MN, Heeren TC, Barber CE et al: Use of health services before the diagnosis of head and neck cancer among Boston residents. Am J Prev Med 6:77-83, 1990. 3. Lynch GR, Prout MN: Screening for cancer by residents in an internal medicine program. J Med Educ 61:387-393, 1986. 4. Battista RN, Lawrence RS, (eds): Implementing preventive services. Am J Prev Med 4(4):1-194, 1988. 5. Glynn TJ, Manley MW, Cullen JW, Mayer WJ: Cancer prevention through physician intervention. Semin Oncol 17:391-401, 1990. 6. Mashberg A, Barsa P: Screening for oral and oropharyngeal squamous carcinomas. CA 34(5):3-10, 1984. 7. Prout MN: Early detection of head and neck cancer. Hosp Prac 22(11A):111-118, 1987. 8. American Cancer Society: Guidelines for the cancerrelated checkup: Recommendations and rationale. CA 30:4-50, 1980. 9. U.S. Preventive Services Task Force: Guide to Clinical Preventive Services. Baltimore: Williams & Wilkins, 1989. 10. Canadian Task Force on the Periodic Health Examination: Periodic health examination. Can Med Assoc J 121:1193-1254, 1979. 11. Robinson WA: Malignant melanoma as a model for cancer education and prevention. J Cancer Educ 5:85-89, 1990. 12. Howard J: "Avoidable mortality" from cervical cancer: Exploring the concept. Soc Sci Med 24:507-514, 1987. 13. Ford D, Whelton P, Gordis L (eds): Frontiers in disease prevention. J Gen InternMed4(6):S1-S139, 1990. 14. National Center for Health Statistics: The National Ambulatory Medical Care Survey: A reason for visit classification for ambulatory care. DHEW Publ. No. (PHS) 79-1352 (Vital and Health Statistics; series 2, no. 78). Washington, DC: Government Printing Office, 1979. 15. Robert Wood Johnson Foundation: Access to health care in the United States: Results of a 1986 survey. Special Report:3-12, 1987. 16. American Cancer Society: Survey of physicians' attitudes and practices in early cancer detection. CA 35:197-213, 1985. 17. Pommerenke FA, Weed DL: Physician compliance: Improving skills in preventive medicine practices. Am Fam Physician 43:560-568, 1991. 18. Battista RN: Adult cancer prevention in primary care: Patterns of practice in Quebec. Am J Public Health 73:1036-1039, 1983. 19. Battista RN, Spitzer WO: Adult cancer prevention in
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primary care: Contrasts among primary care practice settings in Quebec. Am J Public Health 73:10401041, 1983. 20. Green L., Kreuter M, Deeds S, Partridge K. Health Education Planning: A Diagnostic Approach. Palo Alto, CA: Mayfield Publishing Co., 1980. 21. Byar DP, Freedman LS: The importance and nature of cancer prevention trials. Semin Oncol 17:413-424, 1990. 22. Freeman HP: Cancer in the socioeconomically disadvantaged. CA 39:266-288, 1989.
23. Lerner M: Access to the American health care system: Consequences for cancer control. CA 39:289-295, 1989. 24. Retchin SM, Brown B: The quality of ambulatory care in medicare health maintenance organizations. Am J. Public Health 80:411-415, 1990. 25. Dunn V, Prout M, Thomas I: The use of clinical decision analysis in a strategy to reduce head and neck mortality. Presented at American Public Health Association, October 3, 1990.
ISSN: 0885-8195 (Print) 1543-0154 (Online) Journal homepage: http://www.tandfonline.com/loi/hjce20
A multidisciplinary educational program to promote head and neck cancer screening Marianne N. Prout MD, MPH , Selma J. Morris MEd , Robert A. Witzburg MD , Christine Hurley RN & Sarbona Chatterjee MD To cite this article: Marianne N. Prout MD, MPH , Selma J. Morris MEd , Robert A. Witzburg MD , Christine Hurley RN & Sarbona Chatterjee MD (1992) A multidisciplinary educational program to promote head and neck cancer screening, Journal of Cancer Education, 7:2, 139-146 To link to this article: http://dx.doi.org/10.1080/08858199209528156
Published online: 01 Oct 2009.
Submit your article to this journal
Article views: 5
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=hjce20 Download by: [RMIT University Library]
Date: 08 April 2016, At: 06:00
0885-8195/92 $5.00 + .00 © 1992 American Association for Cancer Education
J. Cancer Education. Vol. 7, No. 2, pp. 139-146, 1992 Printed in the U.S.A. Pergamon Press Ltd.
A MULTIDISCIPLINARY EDUCATIONAL PROGRAM TO PROMOTE HEAD AND NECK CANCER SCREENING
Downloaded by [RMIT University Library] at 06:00 08 April 2016
MARIANNE N. PROUT, MD, MPH*; SELMA J. MORRIS, MEd*; ROBERT A. WITZBURG, MD†; CHRISTINE HURLEY, RN*; and SARBONA CHATTERJEE, MD† Abstract—An educational program to promote screening through primary health care for the squamous cell cancers of the buccal cavity, pharynx, and larynx as developed and implemented, and its impact on screening was documented. Providers of care for high-risk patients at seven inner-city health care sites in Boston were identified and targeted for training. Of the 327 providers who were targeted for training from December 1986 through June 1989, 261 (80%) attended educational sessions. Screening exams were documented on an average of 14.7 patients per targeted provider through December 1989. The educational program was associated with a large increase in documented screening for these cancers, compared with baseline rates. Several adaptations in the program were required, including a demonstration of efficient screening to address the concerns of these providers about time constraints. Variations in the quantity and quality of documented screening among health care sites were noted.
behaviors in the health care sites in such a way that patients at risk for head and neck cancers are identified, screened, and referred for followup as indicated. This program reached over 250 providers of health care and resulted in more than 7,000 documented screening exams in a 4-year period (1986-1990). Although this program was successful in accomplishing the behavioral objectives of increasing screening, it encountered obstacles previously reported in the emerging literature on implementing cancer prevention through physicians' offices4-5 as well as obstacles which may be specific to sites serving patients from lower socioeconomic groups.
INTRODUCTION An educational program to promote the screening of high-risk patients for head and neck cancers was developed, implemented, and evaluated in selected inner-city health care sites in Boston in response to the city's elevated incidence rates of these cancers.1 The program's goal was to enable primary health care providers to incorporate head and neck cancer screening into their routine care of patients at risk for these cancers. The strategy of integrating screening into routine health care was chosen after we documented both the use of health services by patients with advanced head and neck cancers in Boston prior to their diagnoses and also the low rate of screening in such services.2-3 Two main objectives were identified for the educational program: (1) to train the providers at each screening site; and (2) to change
BACKGROUND
Supported in part by NIH/NCI Grant #CA 40667 and ACS Grant #PBR-45. *Boston University School of Public Health and Boston University School of Medicine. †Boston University School of Medicine. Reprint requests to: Marianne N. Prout, MD, MPH, Boston University School of Public Health M-815, 80 East Concord St., Boston, MA 02118.
A brief overview of the development of the screening program is presented to provide the context for this report on the educational effort. The overall project began in 1985 and was funded by the National Cancer Institute's avoidable cancer mortality program with the objectives of developing, implementing, and evaluating a screening program for the squamous cell carcinomas of the buccal cavity, pharynx, and larynx (referred to as head and
139
M. N. PROUT et al
140
neck cancers in this paper). The selection of health care sites for screening was based on interview data collected from newly diagnosed patients with these cancers during the first two years of the project.2 The screening exam in-
cluded a systematic oral mucosal examination as advocated by Mashberg,6 modified to include risk factor and symptom assessment. A screening form was developed, pilot-tested, and modified. This form (see Fig 1) was used
Downloaded by [RMIT University Library] at 06:00 08 April 2016
ORAL CANCER SCREENING FORM
Male Female . Date Locatiorv/Site Provider t Risk Factors 1. Do you smoke cigarettes now?............... no 2. Did you ever smoke cigarettes?. no no 3. Do you use cigar/pipe/snuff/chewing tobacco? no. no 4. Do you drink alcohol now?.. 5. If no, did you ever drink alcohol? no B.
Symptoms (as answered by the patient) L. Do you have any soreness or pain in throat mouth ear.................................. jaw neck................................. teeth on swallowing 2. Has your voice changed?. 3. Is your, voice hoarse?..... 4. Have you felt any masses or lumps? 5. Have you had trouble swallowing?. 6. Have you had trouble chewing? 7. Have you lost >10 lb in the past 2 months?. 8. Have you coughed up blood?.
no no no no no no no no no no no no no no
yes ... pks/day yes pks/day which? ves yes... yes
. . . . . . . . .
yes yes yes yes yes yes yes yes yes yes_...
ves yes yes yes
yrs— yrs
when q u i t ? > 2 weeks' d u r a t i o n ? no y e s unknow ^^^_ m_^... ^^^_ ___ *_
—. _—
—— ——
how much? when?
Locate positive findings below:
physical Examination c. Shortness of breath
no . yes Hoarseness.............. no . yes. Nose: blood in nares.......... no . yes. Oral cavity: no . yes. caries blood in mouth no . yes, edentulous.............. no . yes. white patches... no . yes. red patches............. no . yes bleeding areas.......... no . yes tenderness no . yes mucosal lesion no . yes. Neck: pain no . yes masses.. , no . yes nodes no . yes - D. Were the above signs and symptoms the reason for this visit?.... no yes_ E. Conclusion (check one): Normal Abnormal, cancer not suspected F. Action (check one): None Refer for followup because of: required Screening exam Other
Abnormal, suspicious for cancer _ Exam not done Signature..
Figure 1. Oral cancer screening form.
Reason
Promoting head and neck cancer screening
141
Table 1. Criteria for a positive screen The following criteria and recommended actions have been established for "abnormal, suspicious for cancer sign and/or symptom" found at the time of primary screen. Criteria
Recommended action
Simple leukoplakia: white patch that does not scrape off
Downloaded by [RMIT University Library] at 06:00 08 April 2016
Complex leukoplakia: mixed white and red patches Erythroplakia: red velvety patches Mucosal lesion with gross appearance of cancer Hoarseness or voice change persistent throughout the day for 2 weeks Mucosal lesion of uncertain type in high-risk anatomic area: floor of mouth, ventrolateral tongue
to prompt providers to screen, to promote a standardized exam, and to collect data for evaluation. Descriptive criteria for a positive screen were established in consultation with otolaryngologists and dentists and are shown in Table I. 7 The seven health care sites selected for screening included two community health centers serving the neighborhoods with the highest rates of these cancers in Boston, two outpatient clinics serving veterans, a large outpatient clinic and an inpatient medical service in the only municipal hospital in Boston, and the coordinated health services for homeless shelters in Boston. Six screening sites remain active; the seventh site closed after less than one year of screening when the clinic ceiling collapsed. Patient care was transferred to another screening site and the data for these two sites have been combined. At each site, patients aged 40 or over who had ever used any form of tobacco were eligible for screening. METHODS Development of educational programs The selection of providers to perform the screening was difficult. Our initial plan was to train nurses who triage patients to perform a screening exam as part of their routine assessment; this plan required training only a small number of individuals at each site. However, a citywide nursing shortage combined with
Careful oral examination Elective referral to ENT Immediate referral to ENT Immediate referral to ENT Immediate referral to ENT Immediate referral to ENT Immediate referral to ENT
budgetary cutbacks forced the elimination of such nursing positions at most locations. Therefore, providers and other personnel who would be involved in the screening and their level of training and experience were identified during an initial walk-through visit at each site. Educational programs were developed that could be easily adapted for different categories of medical personnel. The format of the initial educational program was a lecture and slide presentation to meet the objectives shown in Table 2. For physicians, the presentation was limited to 45 minutes with 5 to 10 additional minutes for discussion. For medical students, a half hour of skills practice was added, during which exams were demonstrated and observed by instructors. For nursing personnel, the educational program included an additional hour for review of the anatomy and pathophysiology of the head and neck region and a review of staging for head and neck cancers. A separate program was developed for clerical staff that emphasized the importance of their roles in supporting the early detection of cancers in their clinics by preparing the screening forms and arranging followup appointments for patients with positive screening exams. The initial education was reinforced by distributing and discussing summaries of the screening data every 6 months and by informing all clinic personnel when cancers were detected.
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Table 2. Objectives for the initial educational session 1. Providers and other medical personnel will be able to identify patients at risk for head and neck cancers. 2. Providers will know the effects of stage at diagnosis on mortality and morbidity from these cancers. 3. Providers will be able to recognize symptoms potentially associated with head and neck cancers. 4. Providers will be familiar with the technique for performing a systematic exam of the oral mucosa. 5. Providers will know the descriptive criteria for a positive screening exam. 6. Providers will recognize the lesions and symptoms which are criteria for a positive screening exam. 7. Providers will know the procedure for followup of a positive screening exam. 8. Providers will be able to use screening forms to elicit risk factor and symptom information and to record signs, conclusions, and actions in a standardized format.
gram. (1) To evaluate the effectiveness of the program in reaching the targeted providers, attendance at each teaching session was recorded by project personnel. The number of providers targeted for the educational sessions was determined from lists of practitioners supplied by administrators at each screening site. (2) To evaluate the effects of the educational program on screening behavior, the quantity and the quality of screening forms completed at each screening site were assessed. Carbonless copies of screening forms were collected by project staff; data was entered and analyzed using FSP SAS (full-screen information processing) in the project offices. The number of completed forms and the frequencies of specific errors and omissions on the screening forms were summarized by health care site. The educational objectives of identification of at-risk patients, systematic assessment of symptoms and signs, and appropriate referral of patients with criteria for positive exams were assessed by reviewing screening forms to determine whether screened patients were aged 40 or over and had used tobacco products and whether the sections on exam conclusion and action were completed. The project staff discussed patterns of errors with medical supervisors as they became apparent, and therefore no quantitative assessment of errors was attempted.
Implementation of the educational program The initial educational program was incorporated into regularly scheduled educational courses for all provider programs except the homeless service, where special sessions were arranged. The programs were conducted at the onset of training periods for house officers and medical students in order to reach all providers at least once. Medical students were taught during a physical diagnosis course scheduled at the onset of the third-year medRESULTS icine clerkship; four staff were required for each two-hour session, which was repeated Table 3 summarizes the attendance at edevery 3 months. Programs were conducted in ucational sessions at the 6 active screening clinics on five successive days each July to sites through June 30,1989. The overall attenreach new houseofficers and attending physi- dance of targeted providers was high, 80%, cians. These programs were scheduled the with a range of 63% to 100%. Table 3 also inhour before clinics to promote the immediate dicates the average number of patients screened use of screening skills. Presenters included not per targeted provider at each site from Deonly staff from the research project but also cember 1986 through December 1989. providers at each health care site. InduceTable 4 categorizes problems with the comments for attendance included refreshments pletion of screening forms and indicates the and continuing education credits. personnel responsible for completing that part of the form at each site. The providers who Evaluation were expected to screen patients at these sites Evaluation methods were designed for each included medical students, house officers in of the two objectives of the educational pro- internal medicine training programs, attending
Promoting head and neck cancer screening
143
Table 3. Attendance and screening documentation by targeted providers Site
No. of attendees*
No. of eligible attendees
% attendance
Average no. forms/ targeted providerf
85 100 9 22 10 35 261
107 116 9 35 10 50 327
79 86 100 63 100 70 80
25.2 1.5 54.3 .8 90.7 6.7 14.7
1 2 3 4 5 6 Total
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•Attendance through 6/30/89. tBased on the number of completed screening forms on individual patients through 12/31/89. Exams were performed by attending physicians at sites 1, 3, 4, and 5, by house officers at site 1, by medical students at site 2, and by nurse practitioners at sites 1 and 3.
physicians, nurse practitioners, and nurses. Screening of low-risk patients, especially those who had never used tobacco, was noted at several sites and resulted in increased attention to risk assessment in the training program. The educational program was also modified in response to providers' concerns about time. First, the tobacco questions were changed from "do you smoke now or did you smoke within the past two years" to "do you now or did you ever," in response to complaints that patients would take 10 minutes to report all attempts at smoking cessation. Second, demonstration of a three-minute screen was included in our teaching sessions. Third, incremental initiation of screening was recommended, so that providers were asked to screen three to four patients per clinical session rather than all patients. At site 5, the pro-
viders decided to split the screening steps so that nurses collected risk factor and symptom data while physicians performed the exams. DISCUSSION Recommendations for integrating cancer screening into routine health care are reasonable based on the high frequency of health care visits by patients in need of cancer screening.8~1S Since current rates of cancer screening by physicians are suboptimal, effective methods to increase such screening are being studied.4'16"19 The challenges to changing practice behaviors of harried providers of inner-city health care to incorporate routine cancer screening are especially daunting. The acute and chronic shortage of nursing and clerical
Table 4. Problems in screening form completions Patient selection on risk factors Site 1 2 3 4 5 6
Excluded women
Included age 5>13'17 In these inner-city settings, providers repeatedly complained of time constraints. These time constraints were acknowledged and addressed in our educational program after the pilot phase. However, the screening of large numbers of low-risk patients seems incongruous with concerns of providers about the time effectiveness of this screen. We are now studying additional factors which may be associated with varying levels of provider compliance. The effectiveness of this particular educational program in reducing late-stage head and neck cancers will be determined in future years based on cancer registry data; the evaluation by cancer endpoints will be both lengthy and difficult.21 The long-term effects will depend upon not only the immediate change in provider behavior, but also the persistence of such behavior change, the transmission of such behavior to future providers, and the efficacy of such behavior. We are beginning to evaluate the persistence of screening behavior as the project's formal funding and activities cease. This educational program was implemented specifically in health services reaching socioeconomically disadvantaged individuals. Low socioeconomic status has been associated with excess cancer mortality, in part because of poor access to health services, especially preventive health services.22"24 Training providers to incorporate cancer screening efficiently into ongoing services may benefit patients already in care and may permit a low-cost approach to population-based screening.25
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REFERENCES
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