Need: Colorectal cancer (CRC), 2nd leading cause of cancer-related death in the US & TX (TX: At a Glance, ACS, 2020), has higher incidence and mortality in rural areas (Zhand et al., 2017), where poor access to healthcare may exist. TX is 47th among states in CRC screening (Joseph et al., 2018), with Hispanics lacking up to date screening (CRC in TX Web Report, TX DSHS, 2019), and black males disproportionately impacted by CRC (TX Cancer Registry). CRC screening is poor among the uninsured (Henley et al., 2020). TX has the highest age-adjusted incidence rate of hepatocellular (liver) cancer (HCC) (ACS, n.d.). HCC prevention includes risk factor assessment and testing for Hepatitis C (HepC), ...

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Need: Colorectal cancer (CRC), 2nd leading cause of cancer-related death in the US & TX (TX: At a Glance, ACS, 2020), has higher incidence and mortality in rural areas (Zhand et al., 2017), where poor access to healthcare may exist. TX is 47th among states in CRC screening (Joseph et al., 2018), with Hispanics lacking up to date screening (CRC in TX Web Report, TX DSHS, 2019), and black males disproportionately impacted by CRC (TX Cancer Registry). CRC screening is poor among the uninsured (Henley et al., 2020). TX has the highest age-adjusted incidence rate of hepatocellular (liver) cancer (HCC) (ACS, n.d.). HCC prevention includes risk factor assessment and testing for Hepatitis C (HepC), thought responsible for 50% of all HCC (CDC, 2019; Knight, 2018). A 23-county area of TX (16 rural) includes 18 counties successfully served by CPRIT PP180037, and 5 new East TX expansion counties with high rates of CRC (TX Cancer Registry) and no CPRIT HCC prevention programs. 17 of the 23 have a percentage of persons living below FPL exceeding the TX avg. 12 counties are >15% Black; 11 counties are >20% Hispanic. Rurality, low-income (LI), and race/ethnicity have been associated with poor screening rates (Ojinnaka, 2015) and may contribute to higher CRC incidence and mortality.

Expansion Strategy: PP220013 as proposed allows TX A&M Family Medicine Residency (TAMFMR) and School of Public Health to provide 3,835 evidence-based screening and diagnostic services (e.g., colonoscopy, fecal immunochemical test (FIT), and/or HepC testing) to 2,750 unique people, and provide >17,000 education, patient care, or navigation services - focusing on LI, rural and/or medically underserved (MU) populations. With CPRIT funding since 2011, TX A&M has established the Cancer Screening, Training, Education & Prevention Program (Texas C-STEP), using community health workers (CHWs) to enhance the ability of TAMFMR and clinic to provide screenings to uninsured/underinsured. In 2014, C-STEP expanded from 7 to 17 counties; PP180037 expanded to 21 counties, adding FIT. These grants provided more than 2863 colonoscopies (>62% to Blacks & Hispanics) and almost 1,000 FIT (>80% rtn rate). In response to RFA P-22.1-EPS, C-STEP will expand its geographic reach to rural East TX counties: (San Jacinto, Polk, Tyler, Jasper and Newton) and expand services to include increased CRC screening, and assessment for HCC risk factors, HepC testing, and liver diagnostics. Texas A&M, primary grantee, will provide colonoscopy, FIT, and HepC. Collaborating clinical providers across the service area ensure access to services for poor and health-disparate persons. New collaborator Tyler County Hospital & Clinic will provide FIT in the expansion region. Tomagwa Healthcare Ministries serves N. Harris, Waller & Montgomery Counties, providing FIT, Hep C testing and colonoscopy referral. Limestone Medical Center provides CRC screenings in northern service counties. New subcontractor CHI St. Luke's Health - Memorial Livingston will provide colonoscopy and FIT to East TX residents. C-STEP has a 10+ yr history with a network of 467 rural community partners (e.g., churches, agencies, food pantries, and civic leaders), providing outreach and education. Our CPRIT-trained CHWs educate, financially qualify, obtain referrals, assess knowledge to reduce screening barriers. C-STEP will schedule, educate and navigate patients, with positive findings to surgical evaluation, county indigent/hospital charity care programs, or foundation funding for reduced-cost treatment.

Goals: The goal is to provide CRC and HCC screening, prevention education, and patient navigation, to LI residents of 23 mostly rural TX counties or MUAs. If funded, >100,000 persons (public/professionals) will be reached indirectly. Specific goals 1-3 are: Clinical >2,750 LI, MU persons will receive 3,835 clinical services including colonoscopy (1,000), FIT (>1,567 tests completed of 2,375 issued), HepC testing (400), liver diagnostics (60). • Education/Navigation At least 6,130 persons (lay people & professionals) will be directly served with prevention education, and at least 3,485 unique people will receive direct, interactive navigation services over 4 yrs by C-STEP faculty, staff or CHWs, with >17,000 total culturally appropriate education/navigation services. • Training 60 family medicine resident physicians will receive training in screening colonoscopy over 4 yrs.

Significance/Impact: CRC and HCC are significant public health issues in TX, especially among rural and MU populations. Expansion funding allows TX A&M to leverage its rural partnerships to serve the state's most vulnerable counties. FMR graduates practicing in rural TX could impact 1000s of rural and MU, aid early detection of cancers and reduce cancer mortality. C-STEP provides a replicable model for training rural health professionals in cancer prevention to improve screening rates in health-disparate populations across the US & TX.

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