Accruing to TMIST in Los Angeles’s Hispanic Community
From the First Quarter 2020 TMIST Study Updates Newsletter
Posted April 16, 2020
Metro LA, a city of about one million residents within the megacity of Los Angeles, is one of the most fruitful locations in the nation to recruit Hispanic women for a major mammography clinical trial. More than half of its residents are Latino, speak Spanish, and live by the rhythms of a Hispanic culture that founded the City of Angels 238 years ago.
Two major medical centers serve Metro LA. One is the combined Los Angeles County and University of Southern California (USC) Medical Center, known as the LAC+USC Medical Center (LAC+USC). It is a 600-bed acute care hospital owned and operated by the County of Los Angeles. It opened in 2008 to replace a hospital damaged in the 1994 Northridge earthquake. Most of LAC+USC’s patients are enrolled in Medi-Cal, California’s insurance program for the state’s indigent and otherwise uninsured.
The other medical center that serves Metro LA is the USC Norris Comprehensive Cancer Center and Hospital, adjacent to LAC+USC. These well-endowed facilities serve mainly privately insured and Medicare patients. They are part of the USC Health Science Campus, which also houses the Keck School of Medicine.
The USC Department of Radiology services both hospitals, according to Linda Hovanessian Larsen, MD, the principal investigator for TMIST at LAC+USC. Dr. Larsen, pictured at left, is a professor and chief of women’s imaging at LAC+USC and the Keck School of Medicine. The TMIST co-principal investigator is Mary Yamashita, MD, a clinical associate professor of radiology at Keck and director of the mammography clinic at Norris.
The Norris facility operates three breast tomosynthesis scanners. LAC+USC provides four 2D digital mammography systems. Larsen and her associates are excited about the opportunities TMIST gives to their low income, Medi-CAL patients. These women, only being screened with 2D mammography at LAC+USC, now have the potential to gain access to 3D tomosynthesis at the Norris Hospital for the first time.
As Larsen noted in an interview, USC’s radiology division has a long history of participating in significant mammography trials. It assisted with the American College of Radiology® Imaging Network (ACRIN) 6666 Screening Breast Mammography and Ultrasound Trial. It was part of two studies that evaluated imaging techniques to measure the response of breast cancer to neoadjuvant chemotherapy: ACRIN 6688 Phase II Study of F-18-FLT in Invasive Breast Cancer Trial and the I-SPY 2 Trial.
In August 2019, these sites began enrolling women in TMIST. At LAC+USC, shown here, 86 percent of the 121 subjects are Hispanic. A large portion is of Mexican descent, with others having family ties to Central and South America.
Larsen assigns much of the credit for that performance to clinical research coordinator Melissa Perkins. Her fluency in Spanish and her Hispanic background serve the program well. She grew up in a multi-ethnic household with a Mexican mother who taught her to speak Spanish.
“My Mexican heritage is an asset,” she said in an interview. “It helps make connections. I’m a little more relatable with Hispanic patients because of it.”
Perkins’ education also helps. She graduated from the University of California, Berkeley in 2018 with a Bachelor of Science degree in psychology and cognitive science. She then served as a research assistant for studies of clinical depression and mental illness at Berkeley for about 18 months before joining the LAC+USC trial.
Celes Alvarez, who was hired in February to assist Perkins, is also fluent in Spanish.
Larsen and Yamashita created a TMIST workflow to track the status of potentially qualified candidates from LAC+USC. It starts with appointment scheduling and extends to entering results in the TMIST database. Perkins has convenient access to this workflow for recruitment.
For new LAC+USC women randomized to receive tomosynthesis, Larsen and Yamashita provide the oversight necessary to ensure that they get to the Norris Breast Center without delays.
Many Hispanic women distrust medical personnel and programs. “They haven’t been involved in research studies before, so they question what we’re doing and whether our practices are safe and effective,” Perkins said.
One of their great concerns about TMIST involves breast tomosynthesis. While other TMIST sites have problems recruiting patients for fear of being denied access to tomosynthesis, some Hispanic women fear this newer technology may be untrustworthy and experimental. Perkins must answer many questions about potential side effects and provide reassurance that the relatively higher radiation exposure from breast tomosynthesis does not pose a danger.
Logistical issues come up frequently. Many Hispanic women in Los Angeles depend on public transportation, which can be slow and unreliable. Job conflicts can be difficult to overcome, especially for women who work long hours on multiple jobs. Finding child care is always a worry.
Similar concerns may factor into decisions not to provide blood draws and buccal cell testing during initial subject recruitment. “A blood draw involves transporting the person to another building and adding up to three hours to their appointment,” Larsen noted. “Most of the patients, to be honest, don’t want to participate as soon as we mention blood draws and tissue samples,” she said.
After the COVID-19 crisis subsides, Perkins hopes to implement program improvements to reduce its reliance on phone calls and meetings with potential volunteers on the day of their screening appointment. She and Alvarez are planning to reach out to primary care physicians and possibly to gynecologists for referrals. They would like physicians to provide women with a TMIST promotional flyer when they first remind them to schedule their annual screening mammograms.
Larsen feels fortunate that LAC+USC can participate in TMIST. She appreciates the dual benefit of helping to compare the clinical efficacy of breast cancer screening methods and giving patients potential access to 3D breast tomosynthesis. To those ends, she is striving to accrue as many women for TMIST as the LAC+USC program can possibly handle.
Editor’s Note to Participating Sites: Through the quarterly newsletter, the TMIST team brings you strategies and tactics that you might consider implementing at your own institution. We strongly encourage all TMIST site physicians and staff to consider submitting your own experiences for this regular series of helpful articles. If interested, please send an email to the TMIST staff.
TMIST is publicly funded by the National Cancer Institute (NCI), part of the National Institutes of Health, through the NCI Community Oncology Research Program.