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March 8, 2022

How Delaware shrunk its cancer death rate over the last two decades

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    Over the past two decades, Delaware has significantly reduced its overall cancer death rate, and helped close racial disparities in cancer care, after implementing a program that expanded access to cancer screening and treatments, Yuki Noguchi reports for NPR's "Shots."

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    Delaware's approach to cancer care

    Two decades ago, Delaware had one of the highest cancer deaths rates in the United States—but an overhaul of the state's approach to cancer care in the late 1990s has helped it significantly reduce its cancer death rates.

    According to Noguchi, Delaware used funds from a 1998 tobacco settlement to set up universal cancer screenings and treatments for its residents. Under the state's "Screening for Life" program, all residents are eligible for free cancer screenings. And if cancer is found, the state will cover up to two years of treatment, even for undocumented or uninsured residents.

    Delaware’s cancer death rate, which was the second highest in the country in the 1990s, has since fallen to the fifteenth.

    Karen Knudsen, CEO of the American Cancer Society, said Delaware was able to implement its unified cancer care due to widespread support from politicians, physicians, community health centers, and patient advocates. "Having a state cancer plan is something they embrace, and that 20 years of work is starting to bear fruit," she said.

    The importance of patient navigators

    In addition to the screening and treatment programs, Delaware's approach includes the use of patient navigators. These navigators have played a critical role in helping the state reduce its cancer death rates, as well as narrowing racial disparities in some forms of cancer.

    Specifically, death rates from all cancers among Black men declined 26% from the period of 2003-2007 to the period of 2013-2017, and colorectal cancer mortality rates among Black men declined 37% during that same time.

    To reach underserved communities, Delaware identifies ZIP codes where cancer screening rates are lowest every five years. Navigators then target those areas, passing out flyers and setting up booths in grocery stores, laundromats, and religious institutions. Navigators also help patients schedule exams, arrange rides to appointments, work with insurance—and sometimes even act as a translator when needed.

    Mary Jo Vasquez, a patient navigator, said it takes time and effort to develop a relationship and rapport with someone who may be skeptical of the medical system. She added that people will often only approach her after seeing her multiple times in familiar places, like their grocery store or church.

    "They need to trust you," Vazquez said. "They have to learn that we're there for them, that we want to help them and that we're not going to abandon them."

    Separately, Nadya Julien, a family nurse practitioner who opened Tabitha Medical Care, a clinic that serves primarily Haitian and Latino immigrants, said having navigators on the front line is essential. According to Julien, navigators play more than just a logistical role in patients' care; they also help reduce patients' fears and support them through unfamiliar and potentially scary processes, such as screening or treatment.

    Julien said that having a navigator who can speak the patient's language and schedule appointments, who "can go to the house and pick them up and also be there with them to translate" gives comfort to patients.

    Overall, Stephen Grubbs, a medical oncologist and a founding member of the advisory council of the Delaware Cancer Consortium, said the state's cancer screening and treatment program has helped remove roadblocks to care and decrease the cost of cancer care. Because screening helps catch many cancers early, the needed treatments are generally less invasive and less costly, leading to better outcomes and reduced cancer costs overall.

    "This program has been so successful I think because it's built on data and evidence," Grubbs said. "... We took the barriers down, the navigators grease the system and made sure it all flowed through—that's exactly what it was."

    According to Knudsen, Delaware's widespread use of patient navigators underscores the importance of their role in cancer care, and there are now patient navigators nationwide.

    "Everybody knows it's the right thing to do," Knudsen said. "And I think there's a good, strong business case for it as well because of the lower cost of care for patients who are navigated."

    Currently, insurance does not cover navigation services, so cancer treatment centers and nonprofits typically pick up the cost. But Knudsen said she hopes that will change in the future, particularly after speaking to President Joe Biden at the White House's Cancer Moonshot announcement.

    "He did not specifically talk about navigators using that word, but he did talk about eliminating disparities and increasing access," Knudsen said. "What I hear when I hear that, I hear 'navigation.'" (Noguchi, "Shots," NPR, 3/7)

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