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Oby: From the campus of Harvard Medical School, this is ThinkResearch, a podcast devoted to the stories behind clinical research. I'm Oby, your host. ThinkResearch is brought to you by Harvard Catalyst, Harvard University's Clinical and Translational Science Center and by NCATS, the National Center for Advancing Translational Sciences.

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In the United States, Inflammatory Bowel Disease, commonly known as IBD, is being diagnosed more and more among minority groups than in previous years. Dr. Anyane-Yeboa, gastroenterologist and PI at the Implementation Science Center for Cancer Control Equity discusses her work to increase colorectal cancer screenings in underserved communities and the importance of leveling the playing field.

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Good afternoon. Thank you for joining us on the show.

Adjoa Anyane-yeboa: Thank you for having me. I'm honored to be here.

Oby: You are a gastroenterologist at Massachusetts General Hospital and an instructor of medicine at Harvard Medical School. Would you be able to walk us through your career path?

Adjoa Anyane-yeboa: Sure, absolutely. So it's been a long road, but I am currently practicing gastroenterology. So that's really everything in your GI tract, so esophagus, stomach, small intestine, large intestine. And so I decided I wanted to go into medicine probably late in high school. I initially thought I wanted to do policy, but I recognized that it wasn't enough people, and I wanted more human interactions. And so I kind of went premed full force at that point.

I did my medical school, actually, in Cincinnati. I initially wanted to be a pediatrician, actually a peds cancer doctor, and then I eventually realized that sick kids with cancer, especially cancers that return and metastatic cancers and dealing with those kind of conversations and going to kids' funerals was not something that I could do regularly. So eventually I ended up going into adult medicine and then GI.

And so I chose GI because it was really what was just the most fun for me. So it was the thing that I would-- in my residency I would do my GI rotation and come home and do more reading and was excited to do presentations and to talk about it, and it felt like fun going to work. So I was like, wait a minute. I think this is it for me. So that's how I ended up in GI.

But after my GI fellowship, I also did what was called the Commonwealth Fund Fellowship in Minority Health Policy. So I kind of was like a full circle coming back to policy. And that was a program geared towards training individuals who are passionate about caring for historically marginalized populations and really advancing care delivery and working towards equity.

Oby: You said you went back, you kept reading about GI. You were-- it interested you. That's an interesting topic to get really passionate about.

Adjoa Anyane-yeboa: Yeah.

Oby: Is there anything else that comes up in there that you're like, yes, that's really what drew me towards GI?

Adjoa Anyane-yeboa: It's funny because when you're a resident, people-- and you're trying to figure out what you want to do, people say to think about and look at the people who are in those careers. Could you see yourself working with them? And so I considered cardiology. I considered adult hematology, oncology, and GI. And the people with the GI personalities, I just felt like I clicked with them the most. They were making jokes. I mean, if you're dealing with like poop and patients farting, like you can't be so serious, right? And so I felt like those were the people that I jived with the best.

And also what I liked about it is that it's a mix of procedures, a mix of inpatient, a mix of outpatient, and I'm somebody who can get bored really easily. So no day is like the last. For instance, tomorrow I might have clinic, and the next day I might be doing procedures, and the next day might be in the hospital. So it's kind of a nice mix that always keeps you on your toes.

Oby: Sure, thank you. That's great. Your research interests include gastrointestinal disorders in minority populations with a particular interest in inflammatory bowel disease or IBD. What is IBD?

Adjoa Anyane-yeboa: So IBD includes both ulcerative colitis and Crohn's disease. So they're immune-mediated diseases of the GI tract. So ulcerative colitis only affects the large intestine or the colon, so it causes inflammation in the colon. Patients might get diarrhea, bloody diarrhea, abdominal pain, et cetera. Actually, ulcerative colitis puts people at risk for colon cancer as well.

And Crohn's disease can affect anywhere from your mouth out your bottom, and it can cause a lot of different complications like narrowing of the bowel, obstructions or blockages, multiple surgeries, really a lot of morbidity and mortality that you can get from it. So ulcerative colitis and Crohn's are both considered IBD. They both have separate complications, and they're both chronic and really debilitating disorders.

Oby: And why are you choosing to focus specifically on minority populations with IBD?

Adjoa Anyane-yeboa: Unfortunately, IBD is like many other diseases where minority populations face disparities. And so you see disparities in IBD across the spectrum from access to providers, to prevention in terms of vaccinations and other screenings, to utilization in the emergency room or the hospital, to treatment, to surgery, to mortality. And so for me, it's really important to focus on the patients and the populations that have been historically marginalized and left behind in an effort to level the playing field. So for me, the focus on minorities is really just to make sure that everybody has the best opportunity to be as healthy as possible and to really address some of those inequities that we see and level the playing field.

Oby: You are currently the principal investigator on a pilot study from the Implementation Science Center for Cancer Control Equity at the Harvard T.H. Chan School of Public Health which is focused on increasing colorectal cancer screenings in underserved communities. Could you talk us through this study and some of the other work being done at the Center?

Adjoa Anyane-yeboa: Sure, absolutely. So I'll take a step back. So the Implementation Science Center for Cancer Control Equity, which is a mouthful but also called ISCCCE for short, is one of the implementation centers that's been funded by the National Cancer Institute Moonshot Initiative. So really the mission, the overall mission, of ISCCCE is to improve equity in cancer screening outcomes through implementation of sustainable strategies. So the project that I'm leading is actually just one pilot project in ISCCCE, but there's multiple different cancer equity pilots. For instance, there's one in lung cancer, breast cancer, et cetera. But I am very passionate as a gastroenterologist about colorectal cancer, and that's why that's the project that I'm leading.

And so a little bit more about the project, so there are disparities that we see in colorectal cancer. So Black men and women locally and nationally have the highest incidence and mortality from colon cancer. In addition, patients at community health centers also face inequities as well. So when you think about screening rates that we see nationally, so our goal overall, the National Colorectal Cancer Roundtable a few years ago set our goal to be 80% in every community for screening. Unfortunately, we've never reached that anywhere. Nobody has reached 80%, but the National rate that we see is about 69% for screening. Community health centers is about 44%.

So there's really a lot more that we can do in terms of helping health centers get screenings, helping address barriers, and really addressing those barriers so we can enable people to get screened and then hopefully prevent colorectal cancer. Because the beauty of colorectal cancer is that it is preventable with screening. And so this specific project is in partnership with a few community health centers. So our first aim of the project is really a data-gathering aim, so to get the lay of the land, figure out how health centers are doing right now, look at their screening rates, what tests they're using, what populations are being screened, which populations aren't being screened.

And then our second aim is to work with four specific health centers with four distinct and unique populations. So we have solidified three of the health centers thus far but really to do focus groups to understand barriers to screening and unique barriers to screening at those specific health centers. So one of the health centers is Brockton Health Center. That takes care of a large proportion of Black patients. Codman Square as well, they also take care of a large proportion of Black patients. And then Duffy Health Center which actually has a large homeless population.

So we'll be doing focus groups at those health centers, and then from there in two health centers will be testing strategies to increase colorectal cancer screening rates. So in Brockton and in Codman Square, from the focus groups we're going to identify barriers, and then we're going to work with the health centers to rank the barriers to what's the biggest barrier that we face to what's not as big of a barrier? And then from that we're going to match those barriers to different implementation strategies. And again, using and working with the health centers to understand what strategies would work for them given their environment, given their resources, given the staff, given what they think is going to be feasible.

And so I think the beauty of this and really the most important part of this is the partnership and the partnership with the health centers and making sure that their voice is heard every step of the way. And so from understanding which specific barriers that they face and then working with them to list the barriers in order of priority and then figuring out from their perspective what strategies might be most effective to address those barriers given their environment that they're in. So it's really important to think about the partnership and work together to increase cancer screening in these health centers. And then one more thing, we chose Brockton and Codman because, again, they serve a large proportion of Black patients who face disparities like we talked about in colorectal cancer screening both incidence and mortality.

Oby: You talked a little bit about the community health care centers. Can you talk to us a little bit about what they'll be doing in this study, kind of what they're doing now, and what's to come with the community health care centers?

Adjoa Anyane-yeboa: It's giving the health centers the tools to create sustainable strategies and not coming in and like telling them what we think they should do and doing the work for them but really with what they have, how can we sustainably increase cancer screening so that when the grant money is removed that we can continue the work.

Oby: That's amazing. We look forward to talking to you about how the study goes and hearing your findings. What inspired you? And you talked about this a little bit and kind of alluded to it in some of your other answers, but what inspired you to center your work around health equity?

Adjoa Anyane-yeboa: For me, it's the principle of justice and fairness. So based on historical injustices, there are populations that have been historically marginalized and have been left behind like we talked about earlier. And those populations often face ongoing inequities. And so really equity means giving each person what they need to be as healthy as possible, and it's really about leveling the playing field. And so equity can be looked at in many different ways in terms of many different demographic factors, but equity in terms of racial and ethnic minorities is what I focus on and really making sure that everybody has an equal opportunity to get the care they need and to be as healthy as possible.

Oby: Why is it important to increase and improve access for minority populations?

Adjoa Anyane-yeboa: It's really important to increase access and improve care to address inequities. It all goes back to the inequities. And really to improve access and to achieve equity, we really need to start thinking about the social determinants of health and where inequities stem from and what the root of the inequities are and really looking upstream rather than going downstream if we really want to improve outcomes for all. We also need to think about the contribution of systemic racism into inequities as well and really work on addressing these underlying factors that then lead to barriers and access to care.

And so if we improve access for minority populations, we can overcome some of the disparities that they might face, and we can really contribute to better care and outcomes for these populations. So we need to address the social determinants of health including systemic racism. We need to increase the diversity of the workforce. And we know that individuals who come from racial and ethnic minority backgrounds are more likely to do work in disparities research and more likely to work in underserved communities. And we know that having individuals who are working in these communities, we can work to achieve equity that way as well.

We also need to make sure that we're promoting those people, that we're mentoring them, and that we're sponsoring them. And that's why the work that ISCCCE is doing is really important with thinking about grant funding for minority researchers and for equity-based research and increasing money for this type of research because we know that this is historically underfunded. We also need to mentor and sponsor those people and put them up for promotion, and we need to think about creative ways to meet patients where they are.

We know that community health-center patients face barriers to specialty care, so really thinking about ways to be creative about the way we deliver health care in an effort to increase access and to improve outcomes and to make sure that everybody has the opportunity to be as healthy as possible. And so these are just a handful of places to start to address health inequities, to achieve the level of care and justice that really all patients and populations deserve.

Oby: That's amazing. I really love what you were just saying about meeting patients where they are I think about that in a lot of different sectors and industries that we can think of, and you started to explain a little bit about even what that looks like in your profession and your specialty. Can you give us a couple more examples of what that could look like or what it does look like when people think about the individual and how we can meet individuals where they are?

Adjoa Anyane-yeboa: Absolutely. So one thing that I think of is like the COVID-19 pandemic, right, and thinking about getting people vaccinated. And I remember I was on with-- I had a virtual visit with a patient who hadn't left her house in a year because she had so many co-morbid conditions, and she was so afraid of getting COVID. And so it wasn't that she didn't want to get vaccinated, but she was afraid to leave her house.

So an example in that situation of meeting patients where they are is actually Massachusetts has this program where they actually do at home vaccinations, right, and so even though I was seeing her for a GI complaint, I actually gave her the information for the home vaccination program. Because it's important to meet people where they are especially if they can't get to where you're delivering the care. So I think just thinking about ways to be creative and not waiting for patients to come to us but rather going to them.

Another example of that is mammography vans, so doing breast cancer screening with the vans coming to patients' houses or going to their neighborhoods, just finding different ways to be creative and making it easier for patients to access the care that they need versus requiring them to come to the ivory tower and look for parking and wait online and get validated. We need to think about ways to make it easier for patients to access care.

Oby: Thank you so much. It has been such a pleasure having this conversation with you. And sincerely, we look forward to having you back to talk about the findings of your study and what's next. So thank you.

Adjoa Anyane-yeboa: Thank you. It's been great chatting with you. This has been so much fun, and I can't wait to circle back and let how things are going.

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Oby: Thank you for listening. If you enjoyed this episode, please rate us on iTunes and help us spread the word about the amazing research taking place across the Harvard community and beyond. We are always looking to connect and collaborate with the research community and would like to hear from you. Please feel free to email us at onlineeducation.catalyst.harvard.edu to inquire about being a guest on the podcast.

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