Improving the efficiency of integrated cancer screening delivery across multiple cancers: case studies from Idaho, Rhode Island, and Nebraska

BACKGROUND

Three current and former awardees of the Centers for Disease Control and Prevention's Colorectal Cancer Control Program launched integrated cancer screening strategies to better coordinate multiple cancer screenings (e.g., breast, cervical, colorectal). By integrating the strategies, efficiencies of administration and provision of screenings can be increased and costs can be reduced. This paper shares findings from these strategies and describes their effects.

METHODS

The Idaho Department of Health and Welfare developed a Baseline Assessment Checklist for six health systems to assess the current state of policies regarding cancer screening. We analyzed the checklist and reported the percentage of checklist components completed. In Rhode Island, we collaborated with a nurse-patient navigator, who promoted cancer screening, to collect details on patient navigation activities and program costs. We then described the program and reported total costs and cost per activity. In Nebraska, we described the experience of the state in administering an integrated contracts payment model across colorectal, breast, and cervical cancer screening and reported cost per person screened. Across all awardees, we interviewed key stakeholders.

RESULTS

In Idaho, results from the checklist offered guidance on areas for enhancement before integrated cancer screening strategies, but identified challenges, including lack of capacity, limited staff availability, and staff turnover. In Rhode Island, 76.1% of 1023 patient navigation activities were for colorectal cancer screening only, with a much smaller proportion devoted to breast and cervical cancer screening. Although the patient navigator found the discussions around multiple cancer screening efficient, patients were not always willing to discuss all cancer screenings. Nebraska changed its payment system from fee-for-service to fixed cost subawards with its local health departments, which integrated cancer screening funding. Screening uptake improved for breast and cervical cancer but was mixed for colorectal cancer screening.

CONCLUSIONS

The results from the case studies show that there are barriers and facilitators to integrating approaches to increasing cancer screening among primary care facilities. However, more research could further elucidate the viability and practicality of integrated cancer screening programs.

Analysis of genetic variation in the Belgian Blue cattle breed using DNA sequence polymorphism at the growth hormone, low density lipoprotein receptor, alpha-subunit of glycoprotein hormones and thyroglobulin loci

New DNA sequence polymorphisms were identified at four bovine autosomal loci: growth hormone, low density lipoprotein receptor, alpha-subunit of glycoprotein hormones and thyroglobulin. Assuming independent assortment between these polymorphisms, the probabilities to be heterozygous at these four loci are 0.48, 0.36, 0.10 and 0.77 respectively, within the Belgian Blue Cattle breed (BBCB). Nucleotide diversity was estimated, showing that animals from the BBCB are heterozygous for 1/1450 nucleotides, a value significantly lower than the 1/500 value found in man. Moreover, we have estimated that the mutation rate at the cytosines of CG dinucleotides is about 10 times higher than that for other nucleotides.

Differentiated carcinomas develop as a consequence of the thyroid specific expression of a thyroglobulin-human papillomavirus type 16 E7 transgene

The oncogenic properties of the high risk human papillomaviruses (HPV) E7 protein are attributed to its interaction with the retinoblastoma susceptibility gene product RB1 and other related proteins. We report here the generation of a transgenic model expressing the E7 oncogene of HPV16 in thyroid follicular cells, under control of the bovine thyroglobulin gene promoter. Transgenics develop differentiated and functionally regulated thyroid goitres, due to thyroid cell proliferation and accumulation of colloid. On the background of this colloid goitre, the mice develop foci of more actively proliferating cells that become invasive and ultimately tend to loose their differentiation. Old mice display secondary tumour nodules that mimic the various histological aspects of the human differentiated thyroid cancers: the follicular and papillary carcinomas. The development of totally undifferentiated carcinoma is in contrast exceptional. We conclude that RB1, and/or related proteins, are responsible for the strict negative control of proliferation that characterizes the thyroid cell of the adult. Inactivation of these proteins results in a continuous growth of the thyroid, without affecting its differentiation, function and regulation. Given the high frequency of progression to highly malignant phenotypes, the retinoblastoma susceptibility and related genes are good candidates as targets for mutations or deletions in early steps of human thyroid carcinogenesis. The search for such mutations in human thyroid cancers will test if this hypothesis holds true.

Linkage relationships among 20 genetic markers in cattle. Evidence for linkage between two pairs of blood group systems: B-Z and S-F/V respectively

Five bovine paternal half-sib pedigrees for a total of 527 individuals were typed for six blood group systems: A, B, F/V, L, S, Z; for nine biochemical polymorphisms: ADA, MPI, PGM-3(slow), NP, Gc, Pi2, Tf, Ptf1 and Ptf2; and for restriction fragment length polymorphisms at five autosomal loci: Tg, GH, LDLr, BoLA-DQ and BoLA-DY. Two of the pedigrees were informative for segregation at the 'muscular hypertrophy' locus, and one was informative at the coat colour determining 'roan' locus. Linkage analysis was performed between all markers. Linkage was demonstrated between the S and F/V blood group systems (z = 3.11), adding one locus to the previously identified linkage group VII (LGVII) [Pi-2 and S], the most likely order being Pi2-S-F/V with maximum likelihood recombination rates of 0.208 and 0.211. Also shown to be linked were the blood group systems B and Z (z = 5.7, theta = 0.245). We confirmed the observation previously made by Andersson et al. (1988) of a high recombination rate between class II genes DQ and DY, suggesting either a larger physical distance between those genes than expected from comparative data, or the presence of a 'recombinational hotspot' in the bovine major histocompatibility complex. No linkage was found either with the 'muscular hypertrophy' locus, or with the 'roan' locus. However, these two loci could be excluded from respectively 1.7 and 2.5 Morgans of the bovine genome.

On the use of DNA fingerprints for linkage studies in cattle

To find a marker for the bovine "muscular hypertrophy" gene and for the "roan" locus, we have typed six cattle pedigrees totaling 540 animals for nine blood group systems, for 12 biochemical markers, for RFLPs at four loci, and with five probes revealing multilocus DNA fingerprints. Segregation analysis of the fingerprint bands showed that, in cattle, a fingerprint probe will reveal a mean of 7.6 clearly resolvable bands, behaving as simple, highly informative Mendelian entities characterized by a mean mutation rate of +/- 1/4500 gametes. For one of the bands, we observed a "mutation burst" generating germline mosaicism. Because some of the fingerprint bands were allelic or corresponded to clustered minisatellites, a mean of only 5.7 independent loci is explored per probe. Fingerprint bands revealed by different probes also show a clear propensity for close linkage, pointing toward nonrandom distribution of minisatellite sequences or the existence of minisatellite clusters. Although this reduces the power of fingerprints for linkage analysis substantially, we were able to demonstrate genetic linkage between fingerprint bands and at least three of the classical markers, to exclude the roan locus from 4.5 Morgans of the bovine genome with the DNA fingerprints and for an additional 2.5 Morgans with the classical markers, and to identify a solid candidate marker for the bovine muscular hypertrophy gene, yielding a lod score greater than or equal to 2.84 without any obliged recombinant.

Comparaison du climat marin de Grande-Rivière (baie des Chaleurs) avec celui d'autres stations de la côte atlantique

Temperature variations of surface waters at Grande-Rivière have been studied in order to describe the marine climate of the region and to show anomalies between 1938 and 1962. Monthly averages of surface temperatures at Grande-Rivière vary between −1.5 and 14.0 C from February to August, respectively, yielding an annual mean of 5.0 C. Temperatures of surface waters are lower than 4.0 C during approximately 6 months of the year. Monthly averages are always higher at Entry Island than at Grande-Rivière and higher at Borden than at Entry Island. Summertime difference in temperature reaches 3.0 C between Entry Island and Grande-Rivière and 5.0 C between Borden and Grande-Rivière. Warm or cold years at Borden and at Entry Island are not necessarily warm or cold at Grande-Rivière.Heat exchanges at the surface and between layers and advection of heat are taken into consideration to explain the local variations of the marine climate at various parts of the Gulf of St. Lawrence. Long-term variations of surface water temperature at Grande-Rivière are compared with those observed at other points along Canada's east coast. Such variations at Grande-Rivière are similar to those of the waters off Nova Scotia. However, they seem to be different from those of other areas of the Magdalen Shallows where warming continues over a longer period than at Grande-Rivière.