Preventing Liver Cancer in Native Communities by Promoting Vaccination and Screening Among Opioid Users

Overview

Liver cancer can be caused by long-term infections with hepatitis C virus (HCV) or hepatitis B virus (HBV). The opioid epidemic has increased the number of people who inject drugs in the United States, which may lead to an increased risk of HCV and HBV transmission through use of shared equipment.¹ These factors may contribute to the increase in liver cancer in the United States.²

Although the risk of developing liver cancer is low, surviving liver cancer is very difficult. For every 100,000 people, 8 new liver and intrahepatic bile duct cancer cases are reported, and 7 people die of these diseases, according to 2019 data from United States Cancer Statistics.³

From 1999 to 2015, American Indian and Alaska Native (AI/AN) people had the highest drug overdose death rates—22.1 per 100,000 in metropolitan areas and 19.8 per 100,000 in nonmetropolitan areas.⁴ The HCV-related death rate among AI/AN people in the Northwest is three times higher than the rate among non-Hispanic White people (19.6 versus 5.9 per 100,000).⁵ The liver cancer incidence rate among AI/AN people is two times higher than that of non-Hispanic Whites (11.9 versus 5.5 per 100,000).⁶

Demonstration Projects Help Promote Vaccination and Screening Among Opioid Users

CDC provides funding, guidance, and technical assistance to its National Comprehensive Cancer Control Program (NCCCP) recipients to create, carry out, and evaluate plans to prevent and control cancer. In 2019, CDC started a 3-year demonstration project, working with four NCCCP recipients to build sustainable partnerships with local organizations to improve knowledge and awareness of the link between injecting drugs and getting hepatitis and liver cancer.

Native Communities Take Action to Prevent Liver Cancer

The American Indian Cancer Foundation participated in a CDC demonstration project to put promising or proven liver cancer prevention strategies into action. The goal was to reduce the incidence of HBV and HCV infections and opioid overdose and decrease liver cancer rates among people who inject drugs.

Demonstration Project Strategies

Provider Education

The American Indian Cancer Foundation partnered with the Native American Community Clinic to—

• Develop and distribute a news brief email and three educational resources to educate clinic providers about hepatitis B, hepatitis C, and liver cancer.
• Work with the Mayo Clinic to develop and set up a webinar to educate community clinic medical staff about liver cancer incidence, risk factors, screening and prevention, and treatment.
• Collect data to track the number of emails sent; the number of providers who received the news brief email; the number of providers who participated in the webinar; and changes in knowledge, awareness, ability, and intent of participating providers to talk to their patients about HBV and HCV.

Comprehensive Syringe Services Programs

The American Indian Cancer Foundation partnered with the Native American Community Clinic to—

• Conduct community engagement and outreach, including distribution and collection of harm reduction materials.
• Provide mobile HBV and HCV screening and medical services during outreach events.
• Collect data to track hepatitis screening, treatment, and the distribution and collection of harm reduction materials.

Project Achievements

Provider Education

• 1 medical oncologist who specialized in gastrointestinal cancers, including liver cancer, from the Mayo Clinic presented the webinar and led a question and answer session with community clinic providers. The discussion focused on how community clinic providers can apply what they learned to their work.
• 11 community clinic providers received the news brief email and education resources. Educational resources were also provided to the clinic for continued dissemination to providers and patients.
• 7 providers completed the pre-assessment and 1 provider completed the post-assessment to assess changes in knowledge, awareness, ability, and intent.
• 12 of 14 invited community clinic medical providers attended the webinar, which improved the information provided in the news brief email and resources.
• 5 providers completed the pre-assessment and 6 providers completed the post-assessment to assess changes in knowledge, awareness, ability, and intent.

Comprehensive Syringe Services Programs

• 1 new data collection system was developed to monitor progress.
• 145 outreach events or locations were visited, including encampment street outreach events in South Minneapolis and onsite testing events at a local community clinic.
• 28 clients were screened for hepatitis B, 38 clients screened for hepatitis C, and 115 clients treated for hepatitis C during the project period.
• More than 100,000 clean syringes and other harm reduction materials were distributed outreach events, including encampment street outreach events in South Minneapolis and onsite testing events at a local community clinic.
• 39,135 harm reduction materials were collected over the course of the project.

Lessons Learned

• Getting providers to complete pre- and post-assessments for the webinar and news brief emails was challenging. Providing incentives, such as 1 free hour of administrative time or continuing medical education (CME) credits for participating, and requiring completion of the evaluation forms to receive the CME credits may help boost participation.
• When working with partners, being flexible and able to change plans when challenges arise is essential. Over the course of this project, the American Indian Cancer Foundation and the local community clinic worked together to overcome multiple challenges, including staff changes and the COVID-19 public health emergency, to carry out a successful demonstration project.