key: cord-0721126-xticxdpr
authors: Risendal, Betsy; Hébert, James R.; Morrato, Elaine H.; Thomson, Cynthia A.; Escoffery, Cam N; Friedman, Daniela B.; Dwyer, Andrea J; Overholser, Linda S.; Wheeler, Stephanie B.
title: Addressing COVID-19 Using a Public Health Approach: Perspectives From the Cancer Prevention and Control Research Network
date: 2021-02-23
journal: Am J Prev Med
DOI: 10.1016/j.amepre.2021.01.017
sha: 55f86dfe3f6d4fb12d5f1d82731b3ffc60143280
doc_id: 721126
cord_uid: xticxdpr

nan

The U.S. response to the coronavirus disease 2019 (COVID- 19) pandemic has entailed challenges related to testing, case management, and community-level mitigation. 1 Community spread of infection continues and U.S. COVID-19 mortality leads the world, exceeding 300,000 deaths as of early winter 2020. Sustained prevention and control efforts are urgently needed.

The "war on cancer" declared in 1971 2 led to significant investment in new technologies, medicines, and structural resources that have significantly reduced cancer mortality and dramatically increased the number of cancer survivors. 3 Although cancer is primarily a chronic condition and COVID-19 is an acute infectious disease, both benefit from multilevel public health strategies directed at the patient, provider, community, healthcare system, and policy formation level. Both cancer and COVID-19 also share a common set of barriers to care related to social determinants of health. Lessons learned from decades of cancer prevention and control can illuminate proven strategies relevant to the current COVID-19 crisis, especially as it moves into the long-term management phase. The impact of these strategies has further been amplified through the rapid integration of research evidence into practice using implementation science approaches that could similarly improve the COVID-19 response. 4 

Both COVID-19 and cancer prevention and control must address primary prevention, screening, diagnosis, treatment, and survivorship, while also addressing racial, ethnic, and socioeconomic disparities. Racial/ethnic disparities in cancer survival, for example, are largely attributable to poverty, delayed screening, differences in provider care recommendations, and lack of access to the latest treatments. 5 Similarly, emerging evidence indicates people of color are more likely to die from COVID-19 for many reasons that are preventable. 6 As the evidence for effective strategies to treat and manage COVID-19 accumulates, the potential to increase disparities also increases because access to these advances is unlikely to be equally distributed across all groups.

Additionally, established underlying risk factors such as poor diet, sedentariness, lack of insurance, and other factors related to healthcare access, 5 along with stress and poor sleep, 7 would be expected to work synergistically to amplify outcome disparities in both cancer and COVID-19.

Thomson and colleagues utilized the Quality of Cancer Survivorship Care Framework 8 to describe potential strategies for addressing the challenge of cancer survivorship care delivery and cancer-related disparities in the COVID-19 era. In the current paper, the focus is on the outer rings of the Framework, which mirror the multilevel socioecological model of public health 9 to illustrate additional opportunities for effective actions. Institute's Surveillance, Epidemiology and End Results (SEER) Program. The resulting standardization and centralization of cancer registry data were key to the identification of disparities in mortality resulting from late-stage diagnosis, leading to targeted funding and support for breast, cervical, and colon cancer early detection programs to reach vulnerable populations. 10 These registries could serve as models for rapidly evolving COVID-19 surveillance systems such as the NIH COVID-19 Cohort Collaborative (ncats.nih.gov/n3c).

Continuing support for expansion of this COVID-19 registry could be instrumental in moving toward a population-based case ascertainment system and standardized data collection protocols for important factors such as race/ethnicity not yet present with COVID-19 surveillance. 11 

Policies and laws regarding face coverings, gatherings, and the operation of businesses during the COVID-19 era have been communicated by a complex and confusing web of various state and local officials, creating a haphazard and lackluster response in many communities. Similarly, in the absence of federal regulations, states historically implemented an array of tobacco control strategies with varying results. States that made larger investments with integrated approaches in health communication campaigns and comprehensive tobacco-free policies have seen larger declines in cigarette sales as well as greater reductions in the prevalence of smoking among both adults and youth. 12 Similar coordination in responses and resources are needed to ensure that COVID-19 policies do not perpetuate or exploit existing disparities across communities.

Early Detection Program support programs to increase preventive screenings. Offering low-and no-cost screenings, reduced time and distance to service locations, expanded clinic hours to meet client needs, and modifying administrative procedures such as scheduling and referrals are evidence-based strategies deployed in these cancer control programs to reach and sustain services for the most vulnerable. 13 Continued expansion of efforts to improve the accessibility of COVID-19 testing combined with implementation of these approaches will require additional resources to replicate in the pandemic response.

Estimates indicate that between 10 and 26 million Americans have lost health insurance since the COVID-19 economic crisis began. 14 The importance of healthcare coverage was illustrated in a 2019 study of the impact of the Affordable Care Act, which found larger increases in breast and colon cancer screenings in states that expanded Medicaid coverage as compared with those that did not. 13 Recent data indicate that hospitalization rates are 4-5 times higher among Latinx, Black, and American Indian/Alaska Native individuals, likely further increasing the impact of state-level policies regarding Medicaid expansion in the disparate burden of COVID-19. 16 Given the high reported costs of COVID-19 management in many settings, 17 attention must also be given to the financial burden of COVID-19 with a focus on the under/uninsured, the elderly on fixed incomes, and low-income populations most likely to be harmed financially.

Given the furious pace of scientific discoveries regarding the risks associated with the novel coronavirus, the importance of disseminating clear, compelling, and timely messaging is critical to individual informed decision making. Ensuring cultural relevance and plain language, and engaging target audiences in message development and testing, have been widely applied to cancer prevention and control with great success and can inform COVID-19 interventions. 18 Health literacy and language translation are other important considerations in developing targeted communication materials. To ensure plain language, it is recommended that materials designed are within a sixth grade reading level. 19 Given the disproportionate burden of poor COVID-19 outcomes among people of color, especially those in low-income neighborhoods with limited access to testing and healthcare services, it is critical that any health-related messaging is meaningful to the groups that need these services the most, including the diverse subgroups within Black, Hispanic, Asian, American Indian or Alaska Native, immigrant, and Spanishspeaking communities.

Screening/Testing and Treatment

As efforts and funding are being redirected to build public health infrastructure in response to the COVID-19 crisis, the community health worker/patient navigator workforce is a as a vital link between healthcare clinics and communities to provide resource coordination and reduce the disproportionate burden of COVID-19. This workforce addresses structural barriers through scheduling and referral assistance, linking to resources for transportation and translation, delivering patient education and reminders, and assisting with issues related to insurance coverage and linkage to care. 13 Many of the barriers to care addressed by community health workers/patient navigators are related to social determinants of health such as employment, poverty, housing, and transportation. 20 Notably, these social factors important in determining risk of cancer and poor cancer outcomes are also directly related to exposure to and transmission of COVID-19.

Although the long-term impact of a COVID-19 diagnosis is unknown, early data suggest that for many patients, even those with mild or moderate disease, relapsing symptoms and long-term effects may be common. Studies of the late effects of COVID-19 are needed to understand ongoing needs related to respiratory or other rehabilitative care. Survivorship care planning to ameliorate late and long-term side effects from a cancer diagnosis is recommended by CDC, the National Cancer Institute, and the American Cancer Society, and similar protocols may be needed to guide primary care physicians caring for COVID-19 survivors. Advocacy groups such as the American Cancer Society and Livestrong serve as models for what is needed with patient advocacy engagement in a comprehensive long-term response.

Decades of collaborative cancer prevention and control research in real-world settings can further guide research translation efforts and practical actions in response to the current pandemic.

Investigators from the Cancer Prevention and Control Research Network have partnered with safety net clinics, faith-based organizations, border and rural health organizations, regional and statewide health fairs, 2-1-1 call lines, and other community-based partners to reach at-risk groups. 21 Given many of the essential workers during the COVID-19 pandemic are from racial minority and low-income groups, employers, homeless shelters, food banks, and other community partners represent an especially important route for reaching these groups.

There is strong evidence to support the combined action within different sectors at multiple levels, including the family, workplace, community, and healthcare system to optimize prevention and control programs. For example, CPCRN researchers across multiple funding cycles and geographic locations collaborated with the CDC Colorectal Cancer Control Program and demonstrated that grantees can further increase screening rates by intervening at multiple levels. 22 Other CPCRN researchers implemented an evidence-based intervention for cancer survivors delivered by peers, confirming that not all programs need to be delivered in healthcare settings to be effective. 21 

Even with the existence of ample evidence, proven strategies in cancer prevention and control still require extensive effort to promote their adoption and implementation. Reducing community spread and risk for coronavirus infection depends upon disseminating coherent, evidence-based public health programs and scaling them out to local communities. RADx-UP is NIH's initiative to reach those disproportionately affected by COVID-19 by making testing resources readily accessible and partnering with communities. CPCRN members developed training and technical assistance activities (e.g., Putting Public Health into Action) to similarly bridge the gap between research and practice, and help program developers find and use evidence combined with capacity-building among practitioners that could serve as a model for RADx-UP and other related initiatives. 21, 22 Additionally, as innovations such as telehealth are adopted and disseminated during the pandemic, ongoing attentiveness is needed to ensure that disparities are not perpetuated or even amplified.

The available strategies to reduce the morbidity and mortality of COVID-19 shown in Table 1 are solidly grounded in real-world experience from cancer prevention and control efforts. With the recent availability of vaccines for COVID-19, implementing these policy, communication, and multilevel strategies from cancer prevention and control programs is of even more critical importance. For example, multilevel strategies in partnership with the healthcare system, schools, and community have had a positive impact on vaccination rates for human papillomavirus. 13 These strategies include many of the same activities outlined in Table 1 No financial disclosures were reported by the authors of this paper. QOL, quality of life.

Testing and Reporting System with Centralized and Transparent Oversight.  Provide sustained funding for a centralized testing registry in the CDC, similar to the cancer registry program to support states in implementing and reporting testing data  Disseminate rapid testing and publicly report regular and timely case counts, including outcome reporting to assist with the monitoring of impact of various control and prevention strategies  Standardize measurement of race and ethnicity to monitor trends and disparities

Actions and Policies.  Standardize and coordinate recommendations for face coverings, large gatherings and other operational protocols across local, state and federal policies  Monitor and track outcomes of policies across all levels to coordinate and improve response STRENGTHEN THE HEALTHCARE SAFETY-NET

 Reduce structural barriers to COVID-19 screening and testing through increased clinic hours, number and location of sites offering free or affordable services  Establish federal funding mechanisms to partner with states programs to deliver consistent, evidence-based prevention, testing and treatment opportunities  Promote state-level policies that facilitate increased health insurance coverage and affordable access to testing and treatment  Fund state Medicaid programs to provide testing and treatment services, especially among those newly unemployed or uninsured due to COVID-19; prepare for vaccine implementation

 Promote the use of consistent, evidence-based core messaging related to COVID-19 community mitigation strategies (including vaccines when available) in culturallyrelevant formats  Create a clearinghouse of theory and evidence-based messages, materials and interventions modeled after the CDC Community Guide and NCI Cancer Control Planet to promote evidence-based prevention and health promotion strategies relevant to COVID-19  Create immediate funding opportunities administered through the CDC to states to deliver and evaluate COVID-19 prevention and health promotion campaigns and programs to build an inventory and promote the use of effective evidence-based approaches for communication  Assure cultural, behavioral, language concordant and literacy-based adaptations of messaging for optimal impact on health behaviors 

Disparities.  Work with trusted delivery channels present in communities --such as, faith-based organizations, recreational districts, cooperative extension, advocacy groups, social media influencers --to deliver evidence-based, consistent education/health promotion efforts  Partner with employers to implement education and interventions, testing opportunities, and extend employee COVID-19 control efforts to home and family LEVERAGE MULTI-SECTORAL STRENGTHS AND PARTNERSHIPS

 Financially incentivize partnerships and multi-level interventions involving schools, employers, community-based organizations, primary care providers and other healthcare system providers to deliver individual-and family-centered messaging about risk reduction  Provide supplies to support COVID-19 control measures and support and fund prevention campaigns and contact tracing and testing through these outlets  Offer multi-level strategies to promote COVID-19 vaccine uptake (i.e., public education and vaccination in their communities (i.e., pharmacies, community health centers, colleges); media campaigns with provider recommendation

 Synthesize emerging real-world evidence for decision makers  Identify dissemination-ready strategies  Create immediate funding opportunities for academic, healthcare systems and community-based organizations to serve as COVID-19 prevention and control training hubs  Invest in infrastructure and best practices for telehealth for monitoring of COVID- 19 cases especially in those with underlying health conditions who are at high risk for complications  Support efforts for expanded, high-speed broadband connectivity services and cellular network expansion for remote health care capacity-building  Support innovation in testing including at-home options and pooled testing to expand reach to at-risk populations and reduce costs CDC, Centers for Disease Control and Prevention; NCI, National Cancer Institute.

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Successes and struggles in the war on cancer: an interview with Vincent DeVita, MD

Cancer statistics, 2020

Considering the intersection between implementation science and COVID-19. Implement Res Pract

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Factors associated with COVID-19-related death using OpenSAFELY

Inflammation: depression fans the flames and feasts on the heat

Developing a quality of cancer survivorship care framework: implications for clinical care, research, and policy

An ecological perspective on health promotion programs

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GA: HHS, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health

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Changes in breast and colorectal cancer screening after Medicaid expansion under the Affordable Care Act

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COVID-19 Hospitalization and Death by Race/Ethnicity

Substantial direct medical costs for symptomatic COVID-19 cases in the US

Educating patients with limited literacy skills: the effectiveness of printed and videotaped materials about colon cancer

Plain language: a strategic response to the health literacy challenge

Patient navigation: a community based strategy to reduce cancer disparities

The Cancer Prevention and Control Research Network: an interactive systems approach to advancing cancer control implementation research and practice

Impact of the Cancer Prevention and Control Research Network: accelerating the translation of research into practice