Cost-Effectiveness of Multitarget Stool DNA Testing vs Colonoscopy or Fecal Immunochemical Testing for Colorectal Cancer Screening in Alaska Native People.

OBJECTIVE: To estimate the cost-effectiveness of multitarget stool DNA testing (MT-sDNA) compared with colonoscopy and fecal immunochemical testing (FIT) for Alaska Native adults. PATIENTS AND METHODS: A Markov model was used to evaluate the 3 screening test effects over 40 years. Outcomes included colorectal cancer (CRC) incidence and mortality, costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). The study incorporated updated evidence on screening test performance and adherence and was conducted from December 15, 2016, through November 6, 2019. RESULTS: With perfect adherence, CRC incidence was reduced by 52% (95% CI, 46% to 56%) using colonoscopy, 61% (95% CI, 57% to 64%) using annual FIT, and 66% (95% CI, 63% to 68%) using MT-sDNA. Compared with no screening, perfect adherence screening extends life by 0.15, 0.17, and 0.19 QALYs per person with colonoscopy, FIT, and MT-sDNA, respectively. Colonoscopy is the most expensive strategy: approximately $110 million more than MT-sDNA and $127 million more than FIT. With imperfect adherence (best case), MT-sDNA resulted in 0.12 QALYs per person vs 0.05 and 0.06 QALYs per person by FIT and colonoscopy, respectively. Probabilistic sensitivity analyses supported the base-case analysis. Under varied adherence scenarios, MT-sDNA either dominates or is cost-effective (ICERs, $1740-$75,868 per QALY saved) compared with FIT and colonoscopy. CONCLUSION: Each strategy reduced costs and increased QALYs compared with no screening. Screening by MT-sDNA results in the largest QALY savings. In Markov model analysis, screening by MT-sDNA in the Alaska Native population was cost-effective compared with screening by colonoscopy and FIT for a wide range of adherence scenarios.

Alaska Native Patient and Provider Perspectives on the Multitarget Stool DNA Test Compared With Colonoscopy for Colorectal Cancer Screening.

Objective: Alaska Native (AN) people have among the world's highest rate of colorectal cancer (CRC). We assessed perceptions of AN people and their health care providers of a new take-home multitarget stool DNA test (MT-sDNA; Cologuard) relative to colonoscopy. Methods: Cross-sectional surveys of AN people aged 40 to 75 years (mailed) and providers (online). Results: Participants included 1616 AN patients (19% response rate) and 87 providers (26% response rate; 57% AN people). Over half (58%) of patients preferred colonoscopy for CRC screening, while 36% preferred MT-sDNA. Unscreened patients were significantly more likely to state a preference for MT-sDNA than previously screened patients (42% vs 31%, P < .05) as were younger patients (<60 years old) compared with older patients (40% vs 30%, P < .05). Most providers thought that MT-sDNA would improve screening rates (69%), would recommend if available (79%), and be implementable (79%). Perceived barriers differed substantially between patients and providers in both type and magnitude. Leading colonoscopy barriers reported by patients were travel (44%) and bowel preparation (40%), while providers thought that fear of pain (92%) and invasiveness of the test (87%) were the primary barriers. For MT-sDNA, patients' belief that colonoscopy was better (56%) and not knowing how to do the test (40%) were primary barriers, while providers thought stool collection (67%) and having a stool sample in their home (63%) were leading barriers. Conclusions: This study found that MT-sDNA has potential acceptability among AN people and their health care providers. Both groups reported a willingness to use MT-sDNA and did not perceive major barriers to its use. This preference was especially true of unscreened and younger patients. The majority of providers indicated they would use MT-sDNA if available and that it would improve CRC screening rates. In this population, where colonoscopy access is limited, MT-sDNA has the potential to improve CRC screening adherence.

Invasive breast cancer among Alaska Native women in Alaska.

Female breast cancer is the most common cancer diagnosed among Alaska Native (AN) women. We examined characteristics of and trends for female breast cancer among AN women. We assessed descriptive statistics, incidence trends (1969-2014), and cause-specific survival for female breast cancers recorded in the Alaska Native Tumor Registry. Results indicated that the majority of breast cancers among AN were diagnosed among women aged over 50 years, at local stage, and with Hormone receptor (HR)+/Human Epidermal Growth Factor (HER) 2- subtype. Five-year average incidence (95% CI) in the most recent time-period (2009-2014) was 145.0/100,000 (130.4, 159.5)); this was not statistically different from the previous time-period. Survival from breast cancer was high and varied by stage and cancer subtype. Hazard of death was greater among those diagnosed with regional/distant/unknown disease, relative to local disease (HR (95%CI): 4.65 (1.66, 12.98)), and higher among those with HER2-/HR- cancers, relative to those with HER2-/HR+ cancers (HR (95%CI): 6.59 (2.23, 19.49)). This study provides a comprehensive description of breast cancer among AN women, providing new and updated information on clinical and demographic factors, cancer incidence trends, regional variations and breast cancer survival. Abbreviations: AIAN: American Indian/Alaska Native; AN: Alaska Native; ANMC: Alaska Native Medical Center; ANTR: Alaska Native Tumor Registry; CI: Confidence Interval; HR: Hazard Ratio; ICD-O-3: International Classification of Diseases for Oncology - Third Edition; NHW - Non-Hispanic Whites; SEER: Surveillance, Epidemiology and End Results.

Improving the Health of Alaska Native People Through Use of a Policy Change Model and Capacity Building.

Public health training often includes program and education development but not policy, systems, and environmental (PSE) strategies. The Alaska Native Tribal Health Consortium's Good Health and Wellness in Indian Country program works to build tribal PSE change capacity. Trainings included community health assessment, facilitation and leadership engagement, policy and systems, and digital storytelling. From 2014 to 2017, 30 PSE changes were made: 3 tobacco-free healthcare organization policies; 2 tobacco-free tribal resolutions; 1 tobacco-free school district policy; 3 healthy food policies and environmental changes; 4 improvements in patient-provider communication; 13 prediabetes, obesity, and/or tobacco screening and referral policies; 3 improvements to health care facility signage; and 1 Baby-friendly Hospital application, protecting the health of 46,000 tribal community members. Targeted training and technical assistance moved tribal staff from a focus on direct services to population-based improvements. This increased self-efficacy may increase the sustainability of chronic disease public health efforts and improve tribal health.

Stool DNA Testing for Screening Detection of Colorectal Neoplasia in Alaska Native People.

OBJECTIVE: To assess the accuracy of a multitarget stool DNA test (MT-sDNA) compared with fecal immunochemical testing for hemoglobin (FIT) for detection of screening-relevant colorectal neoplasia (SRN) in Alaska Native people, who have among the world's highest rates of colorectal cancer (CRC) and limited access to conventional screening approaches. PATIENTS AND METHODS: We performed a prospective, cross-sectional study of asymptomatic Alaska Native adults aged 40-85 years and older undergoing screening or surveillance colonoscopy between February 6, 2012, and August 7, 2014. RESULTS: Among 868 enrolled participants, 661 completed the study (403 [61%] women). Overall, SRN detection by MT-sDNA (49%) was superior to that by FIT (28%; P<.001); in the screening group, SRN detection rates were 50% and 31%, respectively (P=.01). Multitarget stool DNA testing detected 62% of adenomas 2 cm or larger vs 29% by FIT (P=.05). Sensitivity by MT-sDNA increased with adenoma size (to 80% for lesions ≥3 cm; P=.01 for trend) and substantially exceeded FIT sensitivity at all adenoma sizes. For sessile serrated polyps larger than 1 cm (n=9), detection was 67% by MT-sDNA vs 11% by FIT (P=.07). For CRC (n=10), detection was 100% by MT-sDNA vs 80% by FIT (P=.48). Specificities were 93% and 96%, respectively (P=.03). CONCLUSION: The sensitivity of MT-sDNA for cancer and larger polyps was high and significantly greater than that of FIT for polyps of any size, while specificity was slightly higher with FIT. These findings could translate into high cumulative neoplasm detection rates on serial testing within a screening program. The MT-sDNA represents a potential strategy to expand CRC screening and reduce CRC incidence and mortality, especially where access to endoscopy is limited.

A Process Evaluation of the Alaska Native Colorectal Cancer Family Outreach Program.

This article presents the results of a process evaluation of the Alaska Native (AN) Colorectal Cancer (CRC) Family Outreach Program, which encourages CRC screening among AN first-degree relatives (i.e., parents, siblings, adult children; hereafter referred to as relatives) of CRC patients. Among AN people incidence and death rates from CRC are the highest of any ethnic/racial group in the United States. Relatives of CRC patients are at increased risk; however, CRC can be prevented and detected early through screening. The evaluation included key informant interviews (August to November 2012) with AN and non-AN stakeholders and program document review. Five key process evaluation components were identified: program formation, evolution, outreach responses, strengths, and barriers and challenges. Key themes included an incremental approach that led to a fully formed program and the need for dedicated, culturally competent patient navigation. Challenges included differing relatives' responses to screening outreach, health system data access and coordination, and the program impact of reliance on grant funding. This program evaluation indicated a need for more research into motivating patient screening behaviors, electronic medical records systems quality improvement projects, improved data-sharing protocols, and program sustainability planning to continue the dedicated efforts to promote screening in this increased risk population.

Use of Tracking and Reminder Systems for Colorectal Cancer Screening in Indian Health Service and Tribal Facilities.

BACKGROUND: Colorectal cancer (CRC) is a significant cause of morbidity and mortality among American Indian/Alaska Native (AI/AN) people. Screening at recommended intervals can detect CRC in its early, most treatable stages, or prevent CRC through removal of precancerous polyps. However, CRC screening percentages remain low among AI/AN people. Reminder and tracking systems can be used to improve CRC screening percentages. PURPOSE: In this study we assessed the prevalence of CRC screening reminder and tracking systems in Indian Health Service (IHS), Tribal, or Urban (I/T/U) health facilities. METHODS: A telephone survey of randomly selected small, medium and large I/T/U health facilities nationwide was conducted. Three health facilities from each of the 12 IHS areas nationwide were selected from a list of I/T/U healthcare facilities that provide CRC screening or refer patients to another facility for screening, with the goal of having one small, one medium, and one large I/T/U health facility from each IHS area. RESULTS: Thirty-four facilities (94%) participated in the telephone survey between April 1 and September 24, 2010. All facilities used the IHS Resource and Patient Management System to manage their patient care, and 82% used the Electronic Health Record (EHR) version. Over half of these facilities (55%) performed in-office fecal occult blood tests (FOBT) collected during a digital rectal exam, all of which reported that they also sent FOBT cards home with patients. Fifty-three percent of facilities used an opportunistic, visit-based approach to CRC screening. Nearly a third (32%) of facilities reported using a reminder system to notify patients that they were due for CRC screening. Almost two-thirds (65%) of facilities used a reminder system to notify health care providers that patients were due for CRC screening. While 73% of facilities used a system to track whether patients were due for CRC screening, only 61% used a system to track patient results for CRC screening, and 42% used a system to track patients with a personal history of polyps or CRC. CONCLUSIONS: A majority of facilities performed in-office FOBT tests using a digital rectal exam, which is a practice that is contrary to national CRC screening recommendations. Additionally, the majority of facilities reported not using an organized system for CRC screening. Use of patient reminders was suboptimal. However, facilities did report use of provider reminders, tracking when patients were due for CRC screening, and tracking CRC screening results. As the EHR system becomes more widely used and established, I/T/U facilities could be encouraged to increase their use of the EHR tools available to aid in systematically increasing CRC screening percentages.

All-cause, cardiovascular, and cancer mortality in western Alaska Native people: western Alaska Tribal Collaborative for Health (WATCH).

OBJECTIVES: We determined all-cause, cardiovascular disease (CVD), and cancer mortality in western Alaska Native people and examined agreement between death certificate information and adjudicated cause of deaths. METHODS: Data from 4 cohort studies were consolidated. Death certificates and medical records were reviewed and adjudicated according to standard criteria. We compared adjudicated CVD and cancer deaths with death certificates by calculating sensitivity, specificity, predictive values, and κ statistics. RESULTS: Men (n = 2116) and women (n = 2453), aged 18 to 95 years, were followed an average of 6.7 years. The major cause of death in men was trauma (25%), followed by CVD (19%) and cancer (13%). The major cause of death in women was CVD (24%), followed by cancer (19%) and trauma (8%). Stroke rates in both genders were higher than those of US Whites. Only 56% of deaths classified as CVD by death certificate were classified as CVD by standard criteria; discordance was higher among men (55%) than women (32%; κs = 0.4 and 0.7). CONCLUSIONS: We found lower rates for coronary heart disease death but high rates of stroke mortality. Death certificates overestimated CVD mortality; concordance between the 2 methods is better for cancer mortality. The results point to the importance of cohort studies in this population in providing data to assist in health care planning.

Geographic variation in colorectal cancer incidence and mortality, age of onset, and stage at diagnosis among American Indian and Alaska Native people, 1990-2009.

OBJECTIVES: We characterized estimates of colorectal cancer (CRC) in American Indians/Alaska Natives (AI/ANs) compared with Whites using a linkage methodology to improve AI/AN classification in incidence and mortality data. METHODS: We linked incidence and mortality data to Indian Health Service enrollment records. Our analyses were restricted to Contract Health Services Delivery Area counties. We analyzed death and incidence rates of CRC for AI/AN persons and Whites by 6 regions from 1999 to 2009. Trends were described using linear modeling. RESULTS: The AI/AN colorectal cancer incidence was 21% higher and mortality 39% higher than in Whites. Although incidence and mortality significantly declined among Whites, AI/AN incidence did not change significantly, and mortality declined only in the Northern Plains. AI/AN persons had a higher incidence of CRC than Whites in all ages and were more often diagnosed with late stage CRC than Whites. CONCLUSIONS: Compared with Whites, AI/AN individuals in many regions had a higher burden of CRC and stable or increasing CRC mortality. An understanding of the factors driving these regional disparities could offer critical insights for prevention and control programs.

Comparison of fecal occult blood tests for colorectal cancer screening in an Alaska Native population with high prevalence of Helicobacter pylori infection, 2008-2012.

INTRODUCTION: Alaska Native colorectal cancer (CRC) incidence and mortality rates are the highest of any ethnic/racial group in the United States. CRC screening using guaiac-based fecal occult blood tests (gFOBT) are not recommended for Alaska Native people because of false-positive results associated with a high prevalence of Helicobacter pylori-associated hemorrhagic gastritis. This study evaluated whether the newer immunochemical FOBT (iFOBT) resulted in a lower false-positive rate and higher specificity for detecting advanced colorectal neoplasia than gFOBT in a population with elevated prevalence of H. pylori infection. METHODS: We used a population-based sample of 304 asymptomatic Alaska Native adults aged 40 years or older undergoing screening or surveillance colonoscopy (April 2008-January 2012). RESULTS: Specificity differed significantly (P < .001) between gFOBT (76%; 95% CI, 71%-81%) and iFOBT (92%; 95% CI, 89%-96%). Among H. pylori-positive participants (54%), specificity of iFOBT was even higher (93% vs 69%). Overall, sensitivity did not differ significantly (P = .73) between gFOBT (29%) and iFOBT (36%). Positive predictive value was 11% for gFOBT and 32% for iFOBT. CONCLUSION: The iFOBT had a significantly higher specificity than gFOBT, especially in participants with current H. pylori infection. The iFOBT represents a potential strategy for expanding CRC screening among Alaska Native and other populations with elevated prevalence of H. pylori, especially where access to screening endoscopy is limited.

Evaluating an Electronic Measure of Colorectal Cancer Screening at Indian Health Service Facilities, 2008-2010.

BACKGROUND: Colorectal cancer (CRC) is a leading cause of cancer mortality in American Indian and Alaska Native (AIAN) people, and incidence rates vary considerably among AIAN populations throughout the United States. Screening has the potential to prevent CRC deaths by detection and treatment of early disease or removal of precancerous polyps. Surveillance of CRC screening is critical to efforts to improve delivery of this preventive service, but existing CRC screening surveillance methods for AIAN are limited. The Government Performance and Results Act (GPRA) CRC screening clinical care measure provides data on CRC screening among AIAN populations. PURPOSE: The aim of this study was to evaluate the accuracy of the GPRA measure for CRC screening (sensitivity, specificity, positive predictive value and negative predictive value), determine reasons for CRC screening misclassification (procedures noted as screening when they were actually diagnostic exams), and to suggest opportunities for improving surveillance for CRC screening nationwide for AIAN populations. METHODS: Medical record reviews (paper and electronic) were compared to the GPRA-reported CRC screening status for 1,071 patients receiving care at tribal health facilities. A total of 8 tribal health facilities (2 small, 3 medium, and 3 large) participated in the study from the Pacific Coast, the Southwest, the Southern Plains, and Alaska IHS regions. Screening-eligible patients were identified using queries of the local electronic health record from January 2007 to December 2008, and medical chart reviews were completed at participating facilities from September 2008 to June 2010. RESULTS: Among 545 patients classified as screened by the GPRA measure, 305 (56%, CI: 52%-60%) had a false positive for screening as compared with medical record review. The overall sensitivity of the GPRA measure for CRC screening was 93% (CI=89%-95%) while specificity was 62% (CI: 59%-66%). The most common reasons for misclassification were for diagnostic or surveillance tests to be recorded as screening (67%), as well as medical record miscoding (18%) due to miscoding, charting errors, screenings performed outside the IHS, testing for a non-screening purpose, and categorization of patients as screened when a test had been ordered but not actually completed. CONCLUSIONS: This study found that the GPRA CRC screening clinical measure overestimates the true screening rate due to the inclusion of diagnostic and surveillance exams, especially colonoscopy, as well as misclassification errors. The results of this study suggest a need to more accurately use the ICD-9 diagnostic code V76.51, which was associated with frequent coding errors. In combination with other programmatic efforts that focus on screening average- risk, asymptomatic American Indian and Alaska Native persons, improving the coding used for CRC screening may help to more accurately detect decreases in AIAN CRC incidence and mortality.

Mortality trends among Alaska Native people: successes and challenges.

BACKGROUND: Current mortality rates are essential for monitoring, understanding and developing policy for a population's health. Disease-specific Alaska Native mortality rates have been undergoing change. OBJECTIVE: This article reports recent mortality data (2004-2008) for Alaska Native/American Indian (AN/AI) people, comparing mortality rates to US white rates and examines changes in mortality patterns since 1980. DESIGN: We used death record data from the state of Alaska, Department of Vital Statistics and SEER*Stat software from the National Cancer Institute to calculate age-adjusted mortality rates. RESULTS: Annual age-adjusted mortality from all-causes for AN/AI persons during the period 2004-2008 was 33% higher than the rate for US whites (RR = 1.33, 95% CI 1.29-1.38). Mortality rates were higher among AN/AI males than AN/AI females (1212/100,000 vs. 886/100,000). Cancer remained the leading cause of death among AN/AI people, as it has in recent previous periods, with an age-adjusted rate of 226/100,000, yielding a rate ratio (RR) of 1.24 compared to US whites (95% CI 1.14-1.33). Statistically significant higher mortality compared to US white mortality rates was observed for nine of the ten leading causes of AN/AI mortality (cancer, unintentional injury, suicide, alcohol abuse, chronic obstructive pulmonary disease [COPD], cerebrovascular disease, chronic liver disease, pneumonia/influenza, homicide). Mortality rates were significantly lower among AN/AI people compared to US whites for heart disease (RR = 0.82), the second leading cause of death. Among leading causes of death for AN/AI people, the greatest disparities in mortality rates with US whites were observed in unintentional injuries (RR = 2.45) and suicide (RR = 3.53). All-cause AN/AI mortality has declined 16% since 1980-1983, compared to a 21% decline over a similar period among US whites. CONCLUSION: Mortality rates and trends are essential to understanding the health of a population and guiding policy decisions. The overall AN/AI mortality rate is higher than that of US whites, although encouraging declines in mortality have occurred for many cause specific deaths, as well as for the overall rate. The second leading cause of AN/AI mortality, heart disease, remains lower than that of US whites.

Giant inflatable colon and community knowledge, intention, and social support for colorectal cancer screening.

INTRODUCTION: Colorectal cancer (CRC) is the second-leading cause of deaths from cancer in the United States. Screening decreases CRC deaths through early cancer detection and through removal of precancerous lesions. We investigated whether a health exhibit consisting of a giant inflatable colon was an effective educational tool to increase community members' knowledge, intention, and social support for CRC screening and prevention. METHODS: Alaska adults (N = 880) attending community events statewide from March 2011 through March 2012 completed a short survey to assess knowledge about CRC, intention to get screened, and level of social support before and after walking through a giant interactive model of a human colon. The survey used a combination of open-ended questions and a Likert scale, where 1 was "very unlikely," 2 was "somewhat unlikely," 3 was "neutral," 4 was "somewhat likely," and 5 was "very likely." The model depicted CRC stages from normal tissue to advanced adenocarcinoma and displayed signs with CRC prevention tips. We used the McNemar test and paired sample t tests for univariate analyses. RESULTS: Respondents significantly improved their CRC knowledge (P < .05), intention to get screened (mean score increased from 4.3 to 4.5, P < .001), and comfort with talking to others about CRC screening (mean level of comfort increased from 3.8 to 3.9, P < .001). Multivariate analysis showed no significant differences by sex, age, or race for improvements in CRC screening knowledge, intention, or comfort. CONCLUSION: Interactive exhibits can improve public knowledge and interest in CRC screening, which may lead to increased CRC screening rates and decreased CRC incidence and deaths.

The last frontier: innovative efforts to reduce colorectal cancer disparities among the remote Alaska Native population.

BACKGROUND: The Alaska Native (AN) population experiences twice the incidence and mortality of colorectal cancer (CRC) as does the U.S. white population. CRC screening allows early detection and prevention of cancer. OBJECTIVE: We describe pilot projects conducted from 2005 to 2010 to increase CRC screening rates among AN populations living in rural and remote Alaska. DESIGN: Projects included training rural mid-level providers in flexible sigmoidoscopy, provision of itinerant endoscopy services at rural tribal health facilities, the creation and use of a CRC first-degree relative database to identify and screen individuals at increased risk, and support and implementation of screening navigator services. SETTING: Alaska Tribal Health System. PATIENTS: AN population. INTERVENTIONS: Itinerant endoscopy, patient navigation. MAIN OUTCOME MEASUREMENTS: AN patients screened for CRC, colonoscopy quality measures. RESULTS: As a result of these ongoing efforts, statewide AN CRC screening rates increased from 29% in 2000 to 41% in 2005 before the initiation of these projects and increased to 55% in 2010. The provision of itinerant CRC screening clinics increased rural screening rates, as did outreach to average-risk and increased-risk (family history) ANs by patient navigators. However, health care system barriers were identified as major obstacles to screening completion, even in the presence of dedicated patient navigators. LIMITATIONS: Continuing challenges include geography, limited health system capacity, high staff turnover, and difficulty getting patients to screening appointments. CONCLUSIONS: The projects described here aimed to increase CRC screening rates in an innovative and sustainable fashion. The issues and solutions described may provide insight for others working to increase screening rates among geographically dispersed and diverse populations.

Alaska Native adolescent views on cervical cancer, the human papillomavirus (HPV), genital warts and the quadrivalent HPV vaccine.

OBJECTIVES: To understand the knowledge levels, attitudes and perceptions of Alaska Native adolescent girls about cervical cancer, HPV, genital warts and the HPV vaccine. STUDY DESIGN: A qualitative study. METHODS: Seventy-nine in-depth interviews were conducted with adolescent females aged 11 through 18 years in 4 communities in Alaska. The convenience sample was recruited through word of mouth, posters and flyers distributed in community schools, medical clinics and stores. RESULTS: Many of those surveyed didn't know the purpose of a vaccine and were not familiar with basic knowledge about HPV, genital warts and cervical cancer. After learning about cervical cancer and HPV, most teens felt that someone their age had an average likelihood of contracting the diseases and that having the disease would be quite bad. Most teens said they were interested in vaccination. When asked if they would get a vaccine, older teens most commonly cited concerns about side effects or doubts about vaccine efficacy, while younger teens were afraid the shot would hurt. Most teens stated that they preferred to learn about health topics such as these through television programming, followed by the Internet, brochures and posters. CONCLUSIONS: The findings provide valuable information on how to inform adolescents about the vaccine and alleviate their concerns. The design of an educational campaign should vary depending on the age of the adolescents. For younger teens, distribution of information should be at school using a brochure or curriculum, while for older teens a web page may be more appropriate.

Comprehensive cancer control programs and coalitions: partnering to launch successful colorectal cancer screening initiatives.

Colorectal cancer control has long been a focus area for Comprehensive Cancer Control programs and their coalitions, given the high burden of disease and the availability of effective screening interventions. Colorectal cancer control has been a growing priority at the national, state, territorial, tribal, and local level. This paper summarizes several national initiatives and features several Comprehensive Cancer Control Program colorectal cancer control successes.

Alaska native mortality rates and trends.

OBJECTIVES: This article compared mortality data (1999-2003) for Alaska Natives (AN), U.S. white residents (USW), and Alaska white residents (AKW), and examined changes in mortality rates from 1979 to 2003. METHODS: We used SEERStat* software from the National Cancer Institute to calculate age-adjusted mortality rates. RESULTS: The AN all-cause mortality rate was 40% higher (rate ratio [RR]=1.4) than the rate for both the USW and AKW populations. Based on comparisons with USW, the largest disparities in AN mortality were found for unintentional injuries (RR=3.0), suicide (RR=3.1), and homicide (RR=4.4). Disparities were also found for eight of the 10 leading causes of death, including cancer (AN/USW RR=1.3), cerebrovascular disease (RR=1.3), chronic obstructive pulmonary disease (RR=1.4), pneumonia/influenza (RR=1.6), and chronic liver disease (RR=2.0). In contrast, the mortality rate for heart disease among AN was significantly lower (RR=0.9) than for USW, and lower-though not significantly lower-for diabetes. Findings were quite similar when rates for AN were compared with AKW. AKW also had high rates of unintentional injury mortality and suicide compared with USW, but the magnitude of the difference was much less for AKW. From 1979 to 2003, mortality rates among AN declined 16% for all causes, similar to the USW decline of 15%. CONCLUSIONS: Monitoring mortality rates and their trends is essential not only to understand the health status of a population but also to target areas for prevention and evaluate the impact of policy change or the effect of interventions over time.

Development of a flexible sigmoidoscopy training program for rural nurse practitioners and physician assistants to increase colorectal cancer screening among Alaska Native people.

At the Alaska Native Medical Center in Anchorage, colorectal cancer screening rates improved dramatically with the initiation of a dedicated flexible sigmoidoscopy screening program staffed by mid-level providers. We describe the development and implementation of a program to train rural nurse practitioners and physician assistants in flexible sigmoidoscopy.

Alaska Native parental attitudes on cervical cancer, HPV and the HPV vaccine.

OBJECTIVES: To describe Alaska Native parents' knowledge of and attitudes towards cervical cancer, the human papillomavirus (HPV) and the HPV vaccine. STUDY DESIGN: This was a qualitative study composed of 11 focus groups (n = 80) that were held in 1 small village, 2 towns and 1 large urban centre in Alaska. METHODS: A convenience sample of Alaska Native parents/guardians was recruited in each community to participate in focus groups and to fill out a quantitative survey. RESULTS: While many parents had heard about HPV, most were unaware of its link with cervical cancer. The majority wanted to vaccinate their daughters because they had health and safety concerns; believed that vaccines work; had personal experiences with cancer; or believed that their daughters were susceptible to HPV. Reasons for refusal included general concerns about vaccines; a need for more information; a fear of side effects; wanting more vaccine research; and a fear of being in an experimental trial. CONCLUSIONS: The majority of parents were interested in having their daughters vaccinated. Acceptance of the vaccine was primarily based on a parent's desire to protect her/his child from cancer; while reasons for refusal revolved around trust issues and fear of unknown negative consequences of the vaccine.

Digital images for postsurgical follow-up of tympanostomy tubes in remote Alaska.

OBJECTIVE: To determine if video otoscope still images of the tympanic membrane taken in remote clinics are comparable to an in-person microscopic examination for follow-up care. DESIGN: Comparative concordance, diagnostic reliability. METHODS: Community health aide/practitioners in remote Alaska imaged 70 ears following tympanostomy tube placement. The patients were then examined in person by two otolaryngologists. Images were later reviewed at 8 and 14 weeks. RESULTS: Intraprovider concordance for physical examination findings was: "Tube in," 94 percent -97 percent (kappa = 0.89-0.94); "Tube patent," 94 percent -97 percent (kappa = 0.89-0.94); "Drainage," 90 percent -96 percent (kappa = -0.04-0.38); "Perforation," 90 percent -96 percent (kappa = 0.61-0.82); "Granulation," 97 percent -100 percent (kappa = 0.49-1.0); "Middle ear fluid," 88 percent -96 percent (kappa = 0.28-0.71); "Retracted," 83 percent -91 percent (kappa = 0.26-0.58). These agreement rates are similar to interprovider concordance when two otolaryngologists examine the same patient in person. Intraprovider concordance for diagnoses was 76 percent -80 percent (kappa = 0.64-0.71) and 77 percent -88 percent (kappa = 0.66-0.81) when poor images were excluded. Interprovider diagnostic concordance for the in-person exam was 89 percent (kappa = 0.83). CONCLUSION: Video-otoscopy images of the tympanic membrane are comparable to an in-person examination for assessment and treatment of patients following tympanostomy tubes. Store-and-forward telemedicine is an acceptable method of following patients post tympanostomy tube placement.