native cancer 101: module 9: chronic conditions and cancer kathleen ragan, bs, ches linda...

Native Cancer 101: Module 9: Chronic Conditions and

CancerKathleen Ragan, BS, CHES

Linda Burhansstipanov, MSPH, DrPH (Cherokee Nation of Oklahoma)

Native American Cancer Initiatives, Incorporated

Linda U. Krebs, PhD, RN, AOCN, FAAN, Oncology Consultation, Education and Advocacy Network (OCEAN)

Kerri Lopez, BS, Tolowa Nation, Northwest Portland Area Indian Health Board

Paulette Baukol, BS, Mayo Clinic, Rochester, MN

Dana Kontras,RN, Mayo Clinic, Jacksonville, FL

Audience Response System (the Keypads)

(TP)

Turning Point Keypads

Lanyard that goes

around your neck

These are NOT

calculators and need to be returned

to the faculty at the end of the session

please

Audience Response System (ARS) – keypads

This is how we vote on different items and issues

Although the keypads are “anonymous” (we don’t know who uses which keypad); but we would like you to use the same one throughout the workshop

You do not need to “point” the keypad (like a TV remote control)

You will see a counter on the screen that shows how many people have “voted” on any item

You press the number on the keypad that best describes your answer (use “0” for “10” on the keypad)

Demographic items(TP, 6)

What is your gender?

1 2 3

38%

0%

63%1. Male

2. Female

3. Don’t want to answer

brthyr5

About How Old are You?

1 2 3 4 5 6 7 8 9

0%

38% 38%

13%

0%0%0%

13%

0%

1. 81 and older

2. 65-80

3. 50-64

4. 41-49

5. 31-40

6. 21-30

7. 13-20

8. Under 12


What is Your Primary Race?

1 2 3 4 5 6 7

75%

0% 0% 0%

13%13%

0%

1. American Indian / Alaska Native (AIAN)

2. Pacific Islander

3. Asian

4. African-American

5. Non-Hispanic white (Caucasian)

6. Other

7. Don’t know / Don’t want to answer

Are you Hispanic, Latino or Chicano?

1 2 3 4

0% 0%0%

100%1. Yes

2. No

3. Don’t Know / Not sure


How Much Schooling have You Completed?

1 2 3 4 5 6 7 8 9 10

0% 0%

13%

25%

13%

0%

25%

0%

13%13%

1. Elementary (kindergarten to grade 6 / grade school)

2. 7th , 8th , or 9th grade (middle school)

3. 10, 11, or 12th grade (no degree)

4. High school graduate / GED

5. Technical school /apprentice training

6. Some college (no degree)

7. College AA degree

8. College BA, BS degree

9. Masters’ degree

10.Doctorate or more

Role2

Which of the Following Bests Describes You?

1. Community leader

2. Community member

3. Student

4. Teacher / Faculty

5. Researcher / Scientists

6. Healthcare provider (MD, RN, etc.)

7. Outreach recruiter

8. Cancer patient, survivor

9. Other

10. Don’t know / Don’t want to answer

1 2 3 4 5 6 7 8 9 10

13%

38% 38%

0% 0%

13%

0%0%0%0%

4 Pre-Session Knowledge Items

Which is an example of an “acute” condition?

1 2 3 4 5

13%

25%

13%

25%25%

1. Cancer

2. Arthritis

3. Trauma (car accident)

4. Diabetes

5. Don’t know / Not sure

What is the cause of most (~90%) of all cancers?

1 2 3 4 5

38%

13%

0%

50%

0%

1. Family history

2. Smoking for 5 years

3. Being exposed to radiation

4. Lifestyle and physical environment


If a “breast” cancer cell spreads to the kidney, what is the new cancer called?

1 2 3 4 5

14% 14%

0%

71%

0%

1. New primary cancer

2. Recurrent breast cancer

3. Breast cancer

4. Kidney cancer


Which is NOT part of the “triple triple” threat of diabetes among American Indians?

1 2 3 4 5

38%

0%

38%

25%

0%

1. ~ 3 times the risk of cancer

2. ~ 3 times the risk of heart disease and stroke

3. ~3 times the risk of kidney failure

4. ~3 times the risk of death


Cancer 101Basics and Background

Cancer 100 “Overview of Cancer” (Burhansstipanov)Native Navigators and the Cancer Continuum (NNACC) [NCMHD R24MD002811]

18

QUESTION: Why do you think we are taking time to talk specifically about cancer?

Because cancer is now the 2nd leading cause of death for AIs over 45 years old.Cancer is continuing to increase with AIANs even through the disease is becoming less common among whites.The primary reason for our continued increase is due to our daily behaviors

What we eat, drink and smokeHow we get physical activity


19

AIAN Patterns of Cancer

Different Types of Cancer by Geographic Region and Tribal Nation; such as:

Prostate cancer among northern plains comparable to African Americans and Whites More stomach, kidney and gallbladder among Southwestern tribal nationsMore CRC, breast and lung among AK, northern plains and southern plains


20

Examples of Different Patterns of Cancer Sites and Access

More cancers among AIANs who live in Alaska, Northern Plains and Southern Plains

BUT, even in Southwest, selected types of cancer continuing to increase and there are significantly more AIs living in SW than in other regions of US

Burden of disease is extreme

Average interval from biopsy (diagnosis) to initiation of cancer care is 6 months for AIAN women and 9 months for AIAN males


21

QUESTION: What is cancer?

A group of over 100 diseases in which abnormal cells

Divide without controlDon’t die when they should (Apoptosis)

Cancer: Is primarily a disease of older peopleOccasionally occurs in young people (e.g., childhood leukemia, cervical, testicular) But, the majority of cancers appear in people who are older (over 45)


22

What is cancer? (continued)

Cancers are identified by the place they originate within the body. For example:

BreastCervixColonProstatePancreasStomachBrainBladder


23

Normal Cells

Excerpt from the Kansas State University “coloring book”


24Excerpt from the Kansas State University “coloring book”

Cancer Cells


25

Cancer (CAN-sir)

Cancer cells have the ability to spread from one part of the body to another part of the body

When cancer cells go to another body part, they can begin to grow without control in the new location

But a breast cancer cell in the liver is still “breast cancer” (primary site)


26

Metastasis (ma-TAS-sta-sis)

This means that cancer cells have spread from one body part to another

The cancer cells spread from the "primary site" to other organs by traveling through the blood vessels or lymph vessels

QUESTION: What is thelymphatic system?


27

Diagnosis (die-egg-NOH-sis)The process and result of determining if the symptoms or evidence of cancer is really cancerQUESTION: What type of information does the provider need to make a diagnosis?

I had a mammogram 6 months prior to finding a lump and thought I was in the clear. … I give myself a self-breast exam and I located a knot. I went to the doctor and they proceeded with tests. …. they thought it was a cyst, but I still never thought it could be cancer…when the surgery was over the doctor told me it had grown to 9 cm.

Ruby WellsCherokee Nation of OK

Dx. breast 2001


28

Diagnosis (die-egg-NOH-sis)The Provider…

Asks about symptoms

Asks about medical history

Performs a physical exam

Orders tests and imaging procedures

Performs biopsy--to determine whether cancer cells are present

suspicious


29

Biopsy (bye-OP-see)

The physician takes a piece of tissue (a group of cells) from the growth or cyst

Sometimes these cells are cut, and other times they are "sucked" out with a needle (fine needle aspiration)

These cells are examined by a "pathologist”

A biopsy is a sure way to make a diagnosis


30

QUESTION: What is a Tumor (TOO-mer)

Normally, cells grow and divide to produce more cells only when the body needs them

This keeps the body healthy

Sometimes cells keep dividing when new cells are not needed

Or the cells do not know how to die (apoptosis)

These extra cells form a mass of tissue, called a growth or tumor


31

Tumor (TOO-mer)

This is a growth or mass formed by excess cells

A "benign" tumor is not cancer and it does not “become” cancer. It just stays “benign”

8 out of 10 tumors are not cancer (they are "benign")

A "malignant" tumor is cancer and can spread to other parts of the body


32

Benign tumors:

not cancer

can often be removed

in most cases do not come back

do not spread to other parts of the body

rarely a threat to life

Malignant Tumors

are cancer

cells abnormal

cells divide without control or order

enlarge “mass”

metastasize

Two types of tumors:


33

Cancer Develops Over Time

It is a result of a complex mix of factors related to:

Lifestyle (daily behaviors)

Environment

Heredity (~5-10%)

These are called risk factors

See Breast Risk / Health Protection Shield on NACR web site http://www.NatAmCancer.org

Mayo Clinic’s “Spirit of EAGLES Community Network Programs 2” [P.I. Kaur; U54CA153605] ; Northwest Portland Area Indian Health Board; Native American Cancer Initiatives, Incorporated (NACI) 34

Examples of “Risk Factors”

Foods and drinks we consume

Tobacco use

Lack of physical activity

Exposure to environmental contaminants

Spiritual distress

Social distress (dysfunctional families, neighbors or work settings)

“Once an Elder asked me what I smoked. So, I took out a cigarette. He measured it and said, ‘It’s such a small

thing that you let control you.’ I quit smoking that day.”

- Edward McCarty, Cherokee

Daily physical activity Healthy, low fat diet

high fruits and vegetables Maintain recommended body weight Limited to no alcohol No store-bought tobacco use

limit tobacco to ceremonial use only Follow cancer screening guidelines Knowing your personal risk factors

ex. history of polyps, exposure to cigarette smoke, or your family’s history

Behaviors that help “protect” the shield of health against cancer include:

Native American Cancer Research 303-838-9359 Fact vs. Fallacy36

“Cancer 101”

Bear (True) vs. Coyote Trickster (False)

5 items


The lifestyle our ancestors lived put them more at risk for getting cancer. Coyote / False

If a “breast” cancer cell spreads to the kidney, the new cancer is still referred to as “breast cancer” Bear of Truth

Ceremonial tobacco use is just as dangerous as habitual cigarette smoking.

Coyote / False


Cigarette smoking is the single most preventable cause of cancer in the US.

About 30% of all cancer deaths are directly related to habitual smoking. Bear / True

Coyote / False – Answer: 5-10%

About 25% (1/4) of all cancers are inherited from your parents.

Introduction to Chronic Conditions


QUESTION: Why is Understanding Chronic Conditions Important to AIANs?

Leading causes of death among adult AIANs

Leading causes of conditions that interfere with our daily quality of life

I want my grandchildren to live long, healthy lives like our ancestors. Today we forget how to act in ways

that honor those who came before us. Our ancestors didn’t have these diseases.

Anonymous AI, 2011

Objective 1: Distinguish between a health condition that is acute versus

one that is chronic.

41Mayo Clinic’s “Spirit of EAGLES Community Network Programs 2” [P.I. Kaur; U54CA153605] ; Northwest Portland Area Indian Health Board; Native American Cancer Initiatives, Incorporated (NACI)


Definitions

Acute (uh-KYOOT) condition: A condition or disease that begins and worsens quickly. Usually lasts less than a year. If managed well will resolve (or improve and become chronic).

What would be an example of an acute illness?

Examples of Common Acute Conditions

Cold or flu

Infection

Trauma (car accident, broken leg)

Allergic reactions



Definitions

Chronic (KRAH-nik) condition: A condition or disease that persists or progresses over a long period of time.

May have previously been acute Can be managed, but usually does not go away completely

What would be an example of a chronic condition?

Examples of Common Chronic Conditions

Heart Disease

Cancer

Diabetes

High blood pressure (hypertension)



Characteristics of Chronic Conditions

Lasts 1 year or longer

Requires ongoing medical care

Limits daily activities

Often interferes with one’s quality of life

“We tell each other what our blood sugar readings are.

And, we remind each other to take our medicine.”

– Gwen Barnett Muscogee (Creek)

Objective 2 Identify at least 3 common chronic conditions in AIAN

communities.

47


Common Chronic Conditions

The most common, costly, and preventable chronic conditions in the U.S. are:

Heart diseaseCancerDiabetesArthritisObesity

This is true for AIANs too

Examples of Other Chronic Conditions

Stroke

Substance abuse and addiction disorders

Mental illness

Dementia

Cognitive impairment disorders

Developmental disabilities

NOTE: Heart disease, cancer and stroke account for ½ of all deaths each year.

Mayo Clinic’s “Spirit of EAGLES Community Network Programs 2” [P.I. Kaur; U54CA153605] ; Northwest Portland Area Indian Health Board; Native American Cancer Initiatives, Incorporated

(NACI) 49

Burhansstipanov, Native American Cancer Initiatives, Inc. (NACI) subcontract to Mayo Clinic’s “Spirit of EAGLES Community Network Programs 2” [P.I. Kaur; U54CA153605]; Northwest Portland Area Indian Health

Board50Indian Health Service, Regional Differences in Indian Health, 2002-2003. Data from 1999-2001


Heart (Cardiovascular) Disease (CVD)

AIANs have the highest percentage (36%) of deaths from premature heart disease.

This is nearly 2½ times that of whites.

AIANs have more risk factors for CVD than do Non-Hispanic Whites

Obese

High blood pressure (21% to 41% AIs)

Commercial tobacco use (15 to 70% AIs)


Cancer

Now considered a chronic disease

Most common types among AIANs are:

Lymphoma

Lung & Bronchus

Colon & Rectum

Corpus & Uterus

Kidney & Renal

Breast

Ovarian

Pancreas

Cervix

Thyroid


Diabetes

Type 2 diabetes – caused by body’s resistance to the action of insulin and by impaired insulin secretion.

Most AIANs with diabetes have type 2

usually develops in adults but within AIAN communities it is no longer uncommon for diabetes to develop in children and adolescents.

A small number (2-4%) have type 1 diabetes.


Diabetes (cont)

The “TRIPLE TRIPLE” of diabetes in Native America

~3x risk of heart disease and stroke

3.5x risk of kidney failure

3x rate of death


Diabetes (cont)

Diabetes can be PREVENTED

Disease and early death is not inevitable.

It is never too late to change and improve health.

Family & community efforts are the key

7% weight loss from 150 min of activity per week and healthy meals can reduce the risk of

diabetes by > 50%


QUESTION: What is the relationship between Diabetes and Cancer among AIANs?

30+% of AI/AN over age 55 have diabetes

38% of AIANs (n-822) in “Native American Cancer Education for Survivors” survivorship program have both diabetes and cancer

Diabetes is associated with a 30% increased risk of colon cancer

Larsson SC et al JNCI 2005;97:22: 1679-87Larsson SC et al JNCI 2005;97:22: 1679-87

Objective 4: Describe how

co-morbidities impact cancer and

quality of life.

57Mayo Clinic’s “Spirit of EAGLES Community Network Programs 2” [P.I. Kaur; U54CA153605] ; Northwest Portland Area Indian Health Board; Native American Cancer Initiatives, Incorporated (NACI)


Co-Morbidities AND Cancer

Many older adults with cancer often have one or more other chronic conditions, such as:

Diabetes, heart disease, depression, arthritis, obesity, menopausal symptoms

All contribute to quality of life (ability of the individual to do everything they want to do body, mind, emotions and spirits)



Diabetes and cancer have similar risk factors (unhealthy diet, lack of physical activity, obesity)

Organs / systems damaged by diabetes include eyes / vision, nerves (peripheral), kidneys, immune system

Organs / systems damaged by cancer / cancer treatment include nerves (peripheral), liver, immune system



Survivors who have both diabetes and cancer have significantly more problems that can affect quality of life

Chemo medications may interfere with insulin management

Insulin management may interfere with absorption of chemo medications

Resulting in increased problems / side effects of both diseases


Concerns for people with chronic conditions AND cancer

Lack of information

Potential impact on:

Quality of life

Ability for self-care

Cancer treatment decisions

Cancer treatment outcomes

AIAN Cancer Survivors, Denver, CO 2009

How Can I Get Cancer Screenings?

Excerpt from Get on the Path for Breast Health Native American Cancer Research 1-800-537-8295; http://www.NatAmCancer.org; sponsored by Mayo Clinic’s Spirit of Eagles Communities Network Program 2 [NCI1U54CA153605]

Doctor recommendation or referral.

You can also ask your doctor to send you for a screening if you have symptoms (ex. breast lump).

Veterans Administration (VA) hospitals and clinics (for vets only).

Private insurance or Medicare can pay.

Check with local health department or clinics.

State, community programs may also pay for specific tests.

Contact local Community Health Educator/Worker.

Medicare

Excerpt from Get on the Path for Breast Health Native American Cancer Research 1-800-537-8295; http://www.NatAmCancer.org; sponsored by Mayo Clinic’s Spirit of Eagles Communities Network Program 2 [NCI1U54CA153605]

Medicare can pay for people 65 years of age and older: Mammogram once a year Pap Test once a yearCRC screening for people who do not have symptoms, are “at average risk” (compared to “high risk”), and are 50 and older*

FOBT once a year Sigmoidoscopy once every 4 years Colonoscopy every 2 years for “high risk” people

PSA blood test Lung screening (pays for diagnostic tests if you have symptoms)


“Chronic Conditions and Cancer”

Bear (True) vs. Coyote Trickster (False)

5 items


65

About 15% of AIANs have diabetes.

Coyote / False – Answer: ~30%

The “triple triple” threat for diabetes among AIANs is >3 times the risk of heart disease and stroke, kidney failure and death.

, Bear of Truth


66

“Chronic” conditions mean they last at least 5 years

Coyote / False – Answer ~1 year +

The most common chronic conditions experienced by AIANs are cancer, diabetes and HIV infection

AIANs have nearly 2½ times deaths from cardiovascular disease (CVD) than whites.

Coyote / False

Bear of Truth

67

Post Session Knowledge Items (TP)

4 items

Which is an example of an “acute” condition?

1 2 3 4 5

0% 0% 0%0%

100%

1. Cancer

2. Arthritis

3. Trauma (car accident)

4. Diabetes


What is the cause of most (~90%) of all cancers?

1 2 3 4 5

0%

14%

0%

86%

0%

1. Family history

2. Smoking for 5 years

3. Being exposed to radiation

4. Lifestyle and physical environment


Which is NOT part of the “triple triple” threat of diabetes among American Indians?

1 2 3 4 5

57%

14%

0%

14%14%

1. ~ 3 times the risk of cancer

2. ~ 3 times the risk of heart disease and stroke

3. ~3 times the risk of kidney failure

4. ~3 times the risk of death


If a “breast” cancer cell spreads to the kidney, what is the new cancer called?

1 2 3 4 5

13%

38%

0%

25%25%

1. New primary cancer

2. Recurrent breast cancer

3. Breast cancer

4. Kidney cancer


Cancer 100 “Overview of Cancer” (Burhansstipanov)Native Navigators and the Cancer Continuum (NNACC) [NCMHD R24MD002811] 72

Workshop Evaluation (TP)

5 items

(you won’t see the answers)


73E_undrst

Overall, how understandable was the presentation?

1 2 3

100%

0%0%

1. Very understandable

2. Fairly understandable

3. Not understandable


74E-useful

Overall this session provided useful information to me.

1 2 3 4

75%

0%0%

25%

1. I strongly agree

2. I agree

3. I don’t agree

4. I strongly disagree


75E_quality

Overall, what was the quality of the information content of the presentation?

1 2 3

100%

0%0%

1. High

2. Average

3. Low


76E_rec

Would you recommend this workshop to your friends or colleagues?

1 2 3 4

100%

0%0%0%

1. Yes

2. Maybe

3. No

4. Not Sure

E_rec

Would you be interested in attending another workshop?

1. Yes, on Breast Cancer

2. Yes, on Cervix Cancer

3. Yes, on Colon Cancer

4. Yes, on Lung Cancer

5. Yes, on Prostate Cancer

6. Yes, on a combination of cancers

7. Yes, on Genetics and Cancer

8. Yes, on Biospecimens and Biobanking

9. No

10.Not Sure/Don’t want to answer

Thank you for allowing me to

share this workshop

information with you

native cancer 101: module 9: chronic conditions and cancer kathleen ragan, bs, ches linda...

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