So, I'm Meredith Foster. I'm from the Chicagoland area. I'm actually a fight CRC ambassador, as I am a new stage 3 rectal cancer survivor since like April. So, I was diagnosed last July at the age of 41, so it took me quite some time. I had to fight to get my colonoscopy. But it's interesting. I noted the date today. A year ago today, I started my radiation. So, just kind of a nice full circle moment. So, yes, happy to take notes. Thank you. Yes. All right. Josephine, join us. Thanks. We're just doing some brief introductions. Okay, perfect. I'm Lisa Hall. I'm the Senior Director of Prevention and Screening with the Polar Rectal Cancer Alliance. And I'm originally from the East Coast, but I'm out of Arizona where I live. I'm Erica Sutton, Surgeon at Morehouse School of Medicine, but also a Founder of Surgery on Sunday News. Elizabeth Siemens. I'm a Health Services Researcher, Vice President of the Portland MGA American Medical Group Association based in Alexandria, but I live in Planned Parenthood. Ian Halberg, Ph.D. I teach Epidemiology by training, but I lead medical care for brain tumors. I'm Tom Kornegay. I am the Project Administrator for ASGE's CRC Screening Project. I'm a pediatrician by training, currently Medical Director at Primera Blue Cross out of Washington and Alaska, working with large employer groups. So we've been tasked with discussing patient-level interventions to improve follow-up colonoscopy. And I think in many ways, we're actually fortunate because this is one area where I think there's been some, you know, evidence. But I'd love to hear from you all. Again, Meredith is just going to take some notes for us. But what are some things existing, non-existing, aspirational? What can we work towards from a patient perspective to improve follow-up colonoscopy? So I would say that the community health worker model has been extremely strong in our part of the country to really sort of delivering a culturally appropriate message, but also to work with some of the elements of interestability that we're seeing. I would echo that, working with CHWs and CHRs when we're talking about tribal populations. And I think what I've been pleased to see over the last several years is that payers are actually employing community health workers as part of their workforce dynamic. And so I think their ability to reach in and really resonate culturally with various communities has been really, really effective. One of the areas there's a lot of, or a little bit more published work, is around navigation and navigators in different settings helping to navigate folks to the follow-up colonoscopy. And existing data, the effectiveness varies anywhere from like 5% to 20%, depending on the setting. Would you all consider navigators similar to the community health care model, or do you want to make that distinction? I think there's a distinction, but I think there are some things that transcend. But I think there's the need for them both in the continuum of care is distinctly important. And so I think, and then when we look at navigators, I think for my organization, really that navigation to screening versus navigation to care, support, and treatment across the continuum, I think is the additional opportunity for patients to be reached earlier upstream, as opposed to just when there's a diagnosis in terms of the navigator's role. And so that's really been important. So I wanted to just highlight a little bit. And I would have said years ago, I wouldn't have been able to pick out, oh, these are the differences. And now, as I'm becoming more familiar with community health workers, here are definitely some of the differences that I'm seeing and why. In our most recent grant, we were writing for separate roles for community health worker versus the navigator. It was helpful for us for the navigator to have a little bit more health care credibility and a little bit more knowledge of how health care systems work and how the referral process works and things like that, and the community health worker to have a little bit more relatability and connection to the community. And it used to be the same. I have found that it's been very helpful to have a navigator that is bilingual. And that is about the patients that we serve. It's about being in an expansion state and who's not included in an expansion state. And sometimes it's about geography and who's serving that area. So when we're in Kentucky, a navigator has to be bilingual. So bilingual navigator, navigator bilingual having more of that medical background expertise, even if they're not a physician per se, and the community health worker having more of the cultural concordance maybe. But I will say in certain states, Arizona being one of them, and I know there's a number of states that have really, from a state perspective, have really looked to amplify the legitimacy of the community health workforce. And so they've created certification programs, and they really focus on the education that those individuals are trained to really bring them more on par in that way. But I think there are distinct differences that are needed differences between the two. The CHES, the Community Health Education Specialist or something. And so we were funded by HHS for the COVID Resiliency Network and had to do those community health worker trainings and things like that. And so I fully recognize and support, you know, the trainings that work. We did a little more motivational interviewing, you know, in that setting. And I do want to, you know, to your point, Lisa, I think there was historically this impression that navigators were like, once you were diagnosed, and I think Jason had alluded to this, there's a conversation happening at Medicare right now around navigation. And I think this is a great opportunity for us, you know, as key opinion leaders to insert ourselves in those conversations to say, no, navigation really is throughout the cancer care continuum, right? Starting at like, you know, prevention, right, all the way through, you know, the test, the follow up, surveillance, etc, etc. So other thoughts? Well, I'm not going to leave at 3.30. So I'm jumping at my thought, if y'all don't mind. Meredith's already heard my spiel. So I'll repeat it again. We talked about it at lunch. This was a theme, I'd like to talk about a little bit about prep hesitancy, only because it's been a theme through almost all the presentations. There are a number of patients that avoid colonoscopy altogether. And in fact, even with a positive FIT test, or Cologuard test, there was, I think in your research, there was approximately north of 30% of patients that said, no, thanks, but I'm still not doing it. There was a recent survey by Doug Lex's group, just released this year, that indicated that the prep was, in the patient's perspective, the worst part of colonoscopy. And that was 71% of patients said that. 55% of patients said that it was also the number one barrier to them getting a future colonoscopy. So I feel the need to mention that because right now we have guidelines that are being formed. Two pieces. One is, I think there are much better preps out on the market now. I think they're thinking, you know, the big four liter jug. That's not the only option at this point. And I think that, you know, we can do better than the 85%. We can probably get to a 90% adequacy level that the Europeans use. And then just including some language and guidelines around accommodating patient preference for preps, because I don't think patients even understand that there's options available, right, in most gastroenterology offices. And I think they've heard the horror stories, and I think they can realize that, hey, there's options out there for you. Now, granted, I realize there may be access issues to those options. So what do you think would be the patient intervention for prep? So I hear choice and education around the options and education about what else? I think the cost, for example, to me, again, you're talking to a patient. I'm talking from a patient's perspective here. Okay, but it's, you know, okay, you're going to colonoscopy, and after the fact, we're going to let you know whether you owe any money or not, depending on what we find. I mean, that's my experience. Okay, so we're talking outside of prep. Right, no, well, I think from the prep side, the other issue I have is, you know, I've had, I guess, two or three colonoscopies now, but it's, you get an envelope with a little test kit, you take it home with you. But there's no context, so you don't really understand. I know I'm supposed, my primary care doctor told me I'm supposed to do this. I go home, you know, take the test, mail it in. And yeah, hey, you know, it's, now it's, you know, you're at that stage of life where you need a colonoscopy, but there's really no, ever any context provided for this whole, this whole continuum, right? It's just this, you know, I'm just following the doctor's orders because I trust my doctor to do what's best for me, but I don't have the context for everything that's taking place. So, I want to come back, I want to come back to this. But before we move on to that, are there any other interventions around the prep? Yeah, you think? Yes. So, I think patients need to be told the different options they do have for prep. One of the things I experienced is when I got, got all my prescriptions for my colonoscopy, get, go to the pharmacy and I get handed the big four liter thing. My husband who had had a colonoscopy, he got the little Suprex. So, I call my doctor, I'm like, what is up with this? Why do I, like, why do I get one and my husband gets another? Well, your, your insurance, you know, only covers this. And for me in my position, I said, I don't care what my insurance will cover or not. I want to know what my options are. I don't, if I have to go through this, I'm looking to try to do this in the most comfortable way possible. My anxiety level is already very high. And so, you know, my providers didn't even talk to me about, like, these are your options as far as your prep is concerned. And then I think too, normalizing prep. And I think it's probably something that's bigger than just a medical community. A lot of it should be, you know, how do we get it out there if it's on Instagram, on TikTok? Like, this isn't that, it's not that big of a deal. Like, this is what actually happens when you do your prep. You don't feel sick. You don't feel like, this is just what it is. Because I think there are a lot of misnomers around what it is to actually go through the prep process. Yes. Messaging around options and then messaging to the public to take away some of that mystery. Yeah. Well, and to see someone who's relatable, right? Like, this person looks, and they did it and they were fine. So here we go. Okay. This is very interesting because how many of you in your own practice or in practices you know, the provider even offers an option, like, and I'll speak only for surgeons, typically it's like, oh, this is the prep for Dr. Sutton's patients. But this is the prep for Dr. Ecole's patients. Like, even though the office might have three different regimens, you get handed the one that- Mike Gastro talked to me about the prep and my tolerancy and what he was, I was like, no, I have this. And that's it. He was like, oh, then this isn't going to work. This is the one we wanted. So we talked about like what my options were, which was really helpful in my decision. That's great. And that's not standard because I don't even talk to my patients about the prep. My nurse does. So my, you know, our nurse is the one who's like, here are the options that we have. And they usually say like, this is the difference, toes versus low volume, high volume. And this may cost you less. Like that conversation for our clinic happens with the nurses. So it's not standard. And we use one that involves all over the counter products and have had great preps. The Miralax Gatorade. And the patients love it, but I don't, but I do get the sense that they feel like they have a little bit more control as opposed to a prescription that they have to fill or they go lightly. And I personally like the Sudrup, but the staff has been giving them all the Miralax Gatorade version, and it's been going well. I didn't even realize there were options. I'm just telling you from my perspective, but like, you know, going for my physical, take this test, you're going to get a call. So I want to come back to Tom's thing. So we have three things, interventions, community health workers, navigation, prep, we kind of a couple of spokes. So Tom, you were talking about, you know, just nobody prepared. By the way, I get this. My primary care doctor's busy, you know, got to see the next patient and got a 15 minute window to get all this done. So I get it. I think, you know, in his mind, he says, okay, well, you know, we're checking all the right boxes here. I'm just, the observation here is that there's no context for me other than to kind of figure this out. And after you've been it through it twice, and I'm like, okay, I understand what this, you know, how the process works, but it's not until now and you're getting involved in this project. I actually understand, you know, all of this. I wish I wish every patient could hear. Well, again, I think, I think for ASGE and other stakeholders to begin to more proactively address some of these issues, educate people through social media, whatever mechanisms, the fact that our choices, the fact that, you know, hey, insurance is, or isn't going to cover this, you know, you know, you're, you're going to face a surprise bill or you're not. I mean, you know, again, I, I literally, you know, I, you, you ask your doctor, what's this going to cost me? Well, I can't tell you until we're done. And so I see what's, you know, there, and I don't, things may have changed since, you know. I want to hear about colon cancer screening five years before you're due, 10 years before you do. So earlier. I can remember the gentleman's point around, you know, whatever screening age you set, the communications got to be five years before that. I thought that was a really important insight. I mean, we should take a page out of immunizations, right? So that our most successful in our project on HPV immunizations is the clinic that when the baby comes in, here's a book, here's all the immunizations you're going to get until you're 17. So I was imagining something for prevention, you know, maybe not when you're 12, but you know, as you become an adult, here's what happens. Here's when you have to start doing pap smears. Here's when you do a mammogram. Here's when you do a colonoscopy. A book of the screening tests that we need to do. At least planning the seed. And then maybe some information behind each of those, you know, like what even is a colonoscopy? And again, the average person still thinks that it's a, it's a, you're, you're not at risk until you're 50. So why would I care about this when I was 18 or 20 or 25? It's like that baby book, but starting at 18, right? Also because there's high risk people. So they need to know too. They can start to maybe ask the questions of their family or to understand family history. But that goes back to, as I was listening to the presentations today, the importance of in which I didn't hear a lot of here, but the importance of really helping to create a more educated healthcare consumer so that they can also advocate for their own healthcare as they, you know, experience the healthcare system. And I think that's good plays into that because if I have that up front, I'm coming into the doctor's office and I'm asking for these things, even if they're not being told that I'm right, you know, I'm on schedule for this. Yeah. Oh, well, do I have any other choices for my prep? Right. Now you know that there's. Exactly. See, and I think that's part of the transition that's taking place because in my lifetime, it's, you know, just do what the doctor tells you and to now taking a more individual role, like a more active role in my own healthcare. But that's, that takes time to get from A to B because now it's like, yeah, okay. And it's, it's on me now. I have to take a more active role to understand how this process works, but. But then what is the, what is the age appropriate, you know, Katie Couric of our generation, you know, Terrence Howard, Luke Perry's, you know, with a spotlight, a spotlight shines brightly momentarily, you know, on this. I mean, so I think there've been folks, but probably not the same level of impact that Katie Couric has had. I mean, Jimmy, Jimmy Kimmel had his colonoscopy done, you know, on screen. Ryan Reynolds. Ryan Reynolds and his friends just do it. And they just had Terry Crews do it. Obviously when Chadwick Boseman, you know, passed away like that for the black community, I literally had all, everybody, family, friends, everyone calling me like, what is going on? You know, but I think the difference, I don't know, and maybe you all could speak to this, the Katie Couric effect seemed to be like sustained for a while, whereas now it's just like a spotlight and then it's gone. And it may be like, I think that's part of our time. Yeah, I think it's the inability to hold attention. But I think a couple of thoughts, like one is that, you know, I think the more self-service tools we have, the better because people are kind of, you know, in their moment, it's like, I need to go look up something, you know, they want to have that there. And I think that would also help, especially our primary care providers, you know, say, oh yeah, this, you know, some catchy site. Oh yeah, you go to that. It'll explain to you your options and your prep and what all about colonoscopy. People want videos, short two, three minute videos, just, yeah, just to capture that. And then you can capture this, well, who kind of looks like me, who might think like me. And the videos you want to capture these educational things that we are discussing. How'd you decide, or, you know, what was PrEP really like, you know, those kinds of things. They actually, they showed a video at the Southeastern region conference. I can't recall, but I wish every patient could have seen the video. Maybe it's hard for some patients to watch, but if you really want to understand, you know, that was in three minutes, taught me more about colonoscopy than all the rest of this. Right, they actually showed it. I was going to bring that up too, because I was at the same conference. And for PrEP, do you remember after that? Because they showed a good PrEP. Everyone else is like, I'm going to do my PrEP perfectly. I can't do anything with this. Well, I think patients have to really, I mean, just, just their participation in the process is really important. I go back to PrEPs and I don't want to overemphasize that, but it's like when you understand that if your PrEP is really good and you're clear, I'm not going to have to see you for 10 years versus if it's not, you're coming back in a year. And I think when patients go, I think I'm going to do a good job with my PrEP. I have a question for you all. So we talked about these short videos. We talked about self-service tools. Like how do we disseminate that effectively to the world? Well, there are going to be different ways depending on your target audience, right? So I think, and I think 40 is probably when you start laying the groundwork for people that this is coming, right? So how do you start early educating 40? Where, where are they existing, especially online? Where, where are they existing? How can we capture them? And then, you know, beyond that, when we're, we're trying to target people who are 50 or 55 or like trying to figure out where, where do these people exist? How did they like to get their information? How compliant I was with any screening at 40, because I was busy raising my kids. Like, I think I'm, I think I went to the doctor and I'm hoping I got screened good. Yeah. But hopefully someone's like planting the seeds, right? That, you know, it's going to be an interesting approach to take kind of like, you know, back when they were teaching kids why it was important to wear seatbelts. So they told their parents to wear seatbelts. Maybe it's actually telling people in their twenties, you know, help your family. Do you have somebody that's over 45? They need to go get their colon. I mean, like give them something to do. So they're talking about it and then hopefully it'll carry through. I need to do this at some point. Take their moms to go get colonoscopy. Oh my gosh. You're done. Let's talk about this again. And the world will like our video a million times. Like who helps us and who helps that has a pleasure meeting everybody else here or anybody else needs to hop on the shuttle. Well, we kind of decided that because some people are leaving that we want to take a picture at three 30. Let's show me more time. Okay. Well we need 30 and then moderator got us together. We have intervention. We have intervention. All right. But before we, so you want us to come take two minutes, three minutes, three minutes. All right. So three minutes y'all. So what do you want ASD to do about these problems that we just talked about? What can the ASD do? I work with NFL for a different reason, but I could just ask them to do, you know, get a video producer. And to me, it's not just the development of the resource, but I think this has to be expanded to multi-stakeholders because if it's just an entity, you're never going to get the critical mass. You're never going to get the reach. Yeah. You know, it needs to be like a PSA type thing that can be, you know, leverage ASD to combine multiple stakeholders, right? Right. So just because ASD doesn't have $50 million to spend on advertising, but if ASD serves as a catalyst to get that message out and to provide that stakeholders to include influencers, which is the more generic way that I would say that, right? Because I've been in a room with many of these people before, and I will continue to love being in rooms with you all. However, if we're going to get the message outside of the usual cast of characters, then we need to look at influencers of current culture. Cool people and young people. Okay. And it sounds like organizations like the NFL, like targeting, you know, organizations, groups, spaces where the target screening demographic would potentially come be. And I would say maybe a smaller ask potentially is some of these things that have clinical credibility behind it to explain whether it's options, the procedure, whatnot, in like the most simplest forms possible that can be white labeled or co-branded, then health plans can take that and then push it out to employers and use that as a messaging. In the absence of that, I'm creating stuff like that. So you all can use it. Correct. Okay. Okay. And we would do the same. We would push it out to our 400 plus healthcare organizations and through the collaborative in other ways. Okay. If there's, I mean, I guess don't reinvent the wheel. No, but I think you also need to engage those stakeholders early on, because if you want them to buy into it, if not, it's just going to be an ASGE initiative. Like, okay, you know, whatever, that's their project. But if you, if they feel like their own this, then they, you know, that's why my recommendation, bring them in early, have them feel like they own this process as well. And then I think you're going to have better. I'm getting the sense that ASGE can definitely help with the development of products and you all can help us with the dissemination. Is there anything else? We talked about community health workers, navigators, is there a role for ASGE in those types of patient level interventions? I think, I think something that is, that talks about the prep options, you know, whether that is material that's available for every office, you know, a one page sheet for common options for prep, you know, because what we kind of learned here is that people are either doing whatever that doctor does or whatever that clinic does. Yep. Or they're going to do whatever their influencers. Yeah. I don't even think most people realize they have choices or options. Well, yeah, yeah. I mean, you think there's, there's so much advertising on TV about different drugs that you can ask your health care provider about. You don't see much of that around. The only thing I can think off off the top of my head is Cologuard that you see on TV. Right. But how do we empower people to go in and ask, well, what are my options? Yeah. What are, cause you don't know until you, until you're in that. And yeah. Yeah. Well, thank you all. This has been really productive. I appreciate your conversation. We are being summoned to go take a photo. So let's go.

patient-level interventions

follow-up colonoscopy

rectal cancer survivor

community health workers

patient education

early screening education