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5th Annual Early Age Onset Colorectal Cancer Summit - Session III

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5th Annual Early Age Onset Colorectal Cancer Summit - Session III: Earliest Possible Diagnosis and Treatment Through Timely Recognition of Symptoms and Signs of Young Adult CRC

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5th Annual Early Age Onset Colorectal Cancer Summit - Session III

  1. 1. EAO CRC delays in diagnosis and the consequences: Reducing late stage diagnosis and improving outcomes Whitney F. Jones, MD Founder, Colon Cancer Prevention Project Gastroenterology Health Partners, PLLC 5th International EAO CRC Symposium May 2-3, 2019. New York City
  2. 2. Financial Disclosures • Myriad – Speaker, Honorarium • Pfizer – Consultant, Fees • Premier Surgery Center – Physician Partner
  3. 3. Source: SEER 18 registries, 2005-2011. 33% 38% 26% 3% 40% 35% 20% 5% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% Localized Regional Distant Unknown < 49 years 50+ years Stage distribution: early vs. later onset
  4. 4. Stage distribution: early vs. later onset 33% 38% 26% 3% 40% 35% 20% 5% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% Localized Regional Distant Unknown < 49 years 50+ years Source: SEER 18 registries, 2005-2011.
  5. 5. Factors influencing sporadic advanced stage CRC at time of diagnosis – gap focus Can be changed • Improve awareness of symptoms • Seek medical help for symptoms • Reduce delays in definitive diagnostic evaluation Will not change • Tumor biology • Lack of family Hx • Screening program for sporadic (2019)
  6. 6. EAO CRC Tumor Biology: “Earliest stage” Dx wild card Case #1 : 48 yo healthy male • Painless rectal bleeding x 1 day, one episode, no FHx cancer • Diagnostic colonoscopy 2 days post onset symptom • 2.5 cm sigmoid pedunculated polyp • Path high grade dysplasia. Completely resected. • Genetic testing “not indicated” Case #2 : 24 yo healthy male • Painless rectal bleeding x 1 day, one episode, no FHx cancer • Diagnostic colonoscopy 2 days post onset symptom • 2.5 cm sigmoid pedunculated polyp • Path Invasive mucinous adenoCA involving margin of stalk • Preop Multigene panel test (-) • Single microfocus of tumor in 1/24 LN. Final stage T3N1M0
  7. 7. Sporadic 1. occurring at irregular intervals or only in a few places; scattered or isolated. 2.not happening or appearing in a pattern; not continuous or regular: 3. Synonyms: occasional, infrequent, irregular, periodic, scattered, isolated, odd, intermittent, uneven, spasmodic, random, fitful, desultory, erratic, unpredictable. https://dictionary.cambridge.org/us/dictionary/english/sporadic adjective: established
  8. 8. Sporadic 1. occurring at irregular intervals or only in a few places; scattered or isolated. 2.not happening or appearing in a pattern; not continuous or regular: 3. Synonyms: occasional, infrequent, irregular, periodic, scattered, isolated, odd, intermittent, uneven, spasmodic, random, fitful, desultory, erratic, unpredictable. https://dictionary.cambridge.org/us/dictionary/english/sporadic adjective: 4. Translation to EAO-CRC all adults > 21 established
  9. 9. Symptom presentation: established • Clinical complaints • Rectal bleeding ** • Change in bowel habits** • Unexplained abdominal pain, N, V • Unexplained weight loss, fatigue • Physical examination • Rectal exam - blood or mass** • Abdominal mass or pain • Laboratory results • Iron deficiency anemia • Thrombocytosis • Occult blood + • Calprotectin • Abnormal LFT’s https://bjgp.org/content/67/658/e336, Stapeley et al.
  10. 10. Studies suggesting delays in diagnosis impact stage of disease in EAO-CRC Study Type Sx onset to Eval MD eval to dx Delay associated with more advanced stage? 2018 CCA NTY Survey n= 1622 63% > 3 mo 27% > 3 MD 71% stage 3, 4 suggestive 2015 Bowel cancer Uk.org NTY Survey N=400 28%> 3 mo 56% < 6 wk 56% > 3 GP visits 20% > 5 GP visits Eval < 2 GP visits stage 1 56% stage 4 33% suggestive Cl Gastro Hep 2017 Chen et al Retrospective case control. N = 253 Vs > 50 yo Sx duration 90 vs 60 P <.01 Eval time 31 v 22 d P <.05 Stage 3, 4 had shorter duration of Sx v stage 1,2. Not suggestive Biomed Res Intnl. 2015. Siminoff et al Retrospective MDO’s N= 252 patients n/a Each additional MD doubles MDO risk <50 independent risk factor for MDO No final stage info supplied Amer J Surgery 2016. Scott, et all Retrospective case control. N = 56 < 50 yo 121 d > 50 yo 21 d P < .001 Symptom  Tx < 50 217 d >50 58 d P < .001 No difference in stage at diagnosis Not suggestive
  11. 11. Figure 1 https://June 2016Volume 211, Issue 6, Pages 1014–1018 RB Scott et aldoi.org/10.1016/j. https://doi.org/10.1016/j.amjsurg.2015.08.031amjsurg.2015.08.031R https://doi.org/10.1016/j.amjsurg.2015.08.031
  12. 12. EAO-CRC Awareness: 0 5 10 15 20 25 30 35 40 45 50 Stage 1 Stage 2 Stage 3 Stage 4 Bowel Cancer Awareness vs CRC Stage at Dx % Awareness https://bowelcancerorguk.s3.amazonaws.com/Test%20images/NeverTooYoungreport2015.pdf NOT Established
  13. 13. Breaking out of the Echo Chamber: Sporadic EAO-CRC Research Awareness Action 100% 0% Epidemiology ReactiveClinicians < 50 population PCP? Spec? Etiology 5-10%?
  14. 14. Timeline of delays: Months 3-12 months 1-2 months Awareness of sx (vs. knowledge of importance of sx) Make appt 1 month(?) PCP/Frontline Provider Specialist  scope Dx Tumor Biology Onset of Sx
  15. 15. Timeline of delays: Months 3-12 months 1-2 months Awareness of sx (vs. knowledge of importance of sx) Make appt 1-2 months PCPFrontline Provider Specialist --> scope Dx Tumor Biology Onset of Sx - Onset of Sx - Awareness of sx and importance of sx - Make appointment Dx 2-4 Weeks 2 Weeks GOAL Weeks
  16. 16. Timeline of EAO-CRC and Sporadic CRC Messaging: BOGO 40yr 45/50yr Current Message Package 18-21 years 40 45-50 >75
  17. 17. Timeline of EAO-CRC and Sporadic CRC Messaging: BOGO 40yr 45/50yr Current Message Package Family history + test  Lifestyle modification  ID + evaluate symptoms  Early Message Package 18-21 years 40 45-50 >75
  18. 18. Conclusions: Gap 2. Sporadic EAO–CRC Delayed Diagnosis Delays in diagnosis may contribute to advanced stage diagnosis, not conclusive BOTH low population >> low provider awareness THE major contributors Effective knowledge around and messages for prevention and earliest stage diagnosis already exist. Not delivered on time or with adequate frequency Awareness/action resources messaging: Fully integrated, emphasized and delivered to > 21 adult population, proportionate to anticipated incidence trends
  19. 19. Delayed Sporadic CRC Diagnosis Patient Awareness of symptoms Recognition of need for evaluation Patient Delay in seeking medical attention Delay in actually getting medical evaluation Provider Awareness gap - MDOs Primary care  Specialist
  20. 20. Awareness Gap for Sporadic EAO-CRC Researchers Epidemiology (Not Etiology) GI/CRC Primary care Acute care ER Ob-Gyn General population Others Health systems, Medical education, Insurers, Employers, Medicaid 100% 50% ~25% <10%<10%
  21. 21. Studies suggesting delays in diagnosis impact stage of disease in EAO-CRC Study Type Sx onset to Eval MD eval to dx Delay associated with more advanced stage? 2018 CCA NTY Survey n= 1622 63% > 3 mo 27% > 3 MD 71% stage 3, 4 suggestive 2015 Bowel cancer Uk.org NTY Survey N=400 28%> 3 mo 56% < 6 wk 56% > 3 GP visits 20% > 5 GP visits Eval < 2 GP visits stage 1 56% stage 4 33% suggestive Cl Gastro Hep 2017 Chen et al Retrospective case control. N = 253 Vs > 50 yo Sx duration 90 vs 60 P <.01 Eval time 31 v 22 d P <.05 Stage 3, 4 had shorter duration of Sx v stage 1,2. Not suggestive Biomed Res Intnl. 2015. Siminoff et al Retrospective MDO’s N= 252 patients n/a Each additional MD doubles MDO risk <50 independent risk factor for MDO No final stage info supplied
  22. 22. make the diagnosi s?Chelsea L. Boet, MD Internal Medicine and Pediatrics Spectrum Health Medical Group Grand Rapids, MI
  23. 23. Early onset colorectal cancer 86 percent of patients diagnosed under the age of 50 are symptomatic at diagnosis, and despite this, they have a more advanced stage at diagnosis and poorer outcomes Related to delay in diagnosis Up to 35% of early onset colorectal cancer is associated with a known genetic mutation. Other medical issues can be risk factors for early colorectal cancer
  24. 24. Who sees the patient? The average early onset colon cancer patient has multiple visits, often with multiple different specialties, prior to diagnosis Primary care (internal medicine, family medicine, pediatric and adolescent medicine) OB/Gyn Emergency medicine Gastroenterology General or Colorectal surgery
  25. 25. Primary care physicians/providers Symptoms present prior to diagnosis Bleeding (rectal, melena, GI) Anemia Change in bowel habits Abdominal pain Weight loss Bleeding and change in bowel habits had a PPV of 14% With other symptom had increased PPV as well
  26. 26. OB/GYN Increased diagnosis of CRC during pregnancy related to delayed child bearing and increased early onset diagnosis. 1 in 13,000 pregnancies Delay in diagnosis associated with pregnancy? Anecdotal Symptoms consistent with hemorrhoids and pregnancy associated constipation Should be getting thorough gynecologic oncology family history. Family history of endometrial cancer raises concern for Lynch Syndrome
  27. 27. Emergent vs. non emergent diagnosis Over 20% of CRC is diagnosed as an emergency presentation. Over 95% of patients (both emergency and non emergency presenters) had consulted their physician in the 6-12 months prior to diagnosis, typically with non specific symptoms Emergency presenters are less likely to present to their doctor with relevant or red flag symptoms Relevant symptoms: abdominal pain, constipation, diarrhea, weight loss, fatigue Red flag symptoms: anemia, rectal bleeding, change in bowel habits
  28. 28. Emergency presenters are less likely to be treated with curative intent, and have decreased survival even when controlled for stage at diagnosis PCP visits present opportunity for earlier diagnosis Earlier, non emergent diagnosis, improves outcomes Presentation with typical red flag symptoms associated with more prompt evaluation and non emergency diagnosis of CRC
  29. 29. References Macrae, F. Colorectal cancer: Epidemiology, risk factors, and protective factors. UpToDate https://www.ccalliance.org/about/never-too-young/survey/2018-young-onset-colorectal- cancer-survey-report Ewing, M et al, Identification of patients with non-metastatic colorectal cancer in primary care: a case-control study. Br J Gen Pract. 2016 Dec; 66(653): Mork ME. Et al. High Prevalence of Hereditary Cancer Syndromes in Adolescents and Young Adults With Colorectal Cancer. J Clin Oncol. 2015 Nov 1;33(31):3544-9. Jane E. Rogers et al. The Treatment of Colorectal Cancer During Pregnancy: Cytotoxic Chemotherapy and Targeted Therapy Challenges. Oncologist. 2016 May; 21(5): 563–570 C Renzi, et al. Do colorectal cancer patients diagnosed as an emergency differ from non- emergency patients in their consultation patterns and symptoms? A longitudinal data-linkage study in England. Br J Cancer. 2016 Sep 27; 115(7): 866–875.
  30. 30. Colorectal Cancer Detection: Raising Public Awareness
  31. 31. Outline • Colorectal cancer (CRC) incidence and age, NYC • Change in CRC death rate over time, NYC • CRC prevention and gaps in screening, NYC • Changing direction in public health • Provider tools and education • Public health detailing • Patient tools and media
  32. 32. CRC Incidence and Age, NYC, 2003-2015, New York State Cancer Registry Source: DOHMH analysis of data from the New York State Cancer Registry, 2003 - 2015
  33. 33. CRC Incidence Rates in NYC, All Races Combined, Ages 20 – 49 Years, 1975 - 2015 *The Annual Percent Change (APC) is statistically significantly different: all rates are age-adjusted. Reference: Van Beck et al. JNCI Cancer Spectrum 2018; 2(4)
  34. 34. CRC Incidence Rates in NYC, White Adults, Ages 20 – 49, 1975 - 2015 *The Annual Percent Change (APC) is statistically significantly different: all rates are age-adjusted. Reference: Van Beck et al. JNCI Cancer Spectrum 2018; 2(4)
  35. 35. CRC Incidence Rates in NYC, Black Adults, Ages 20 – 49, 1975 - 2015 *The Annual Percent Change (APC) is statistically significantly different: all rates are age-adjusted. Reference: Van Beck et al. JNCI Cancer Spectrum 2018; 2(4)
  36. 36. Note: All data are age adjusted. Source: New York City DOHMH analysis of data from Vital Statistics. Death/Mortality Data 2000-2016. 21.0 19.0 18.0 18.6 17.2 17.4 17.0 16.5 16.1 15.9 14.9 14.0 13.7 13.9 0 5 10 15 20 25 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Age-AdjustedDeathRateper100,000 Change in CRC Death Rate per 100,000 Population, All Ages, NYC, 2003-2016
  37. 37. Source: Analysis of data from the NYC Community Health Survey, 2003-2017. Data are age-adjusted. 41.7 52.2 55.2 59.7 61.7 65.6 66.0 67.5 68.6 68.5 69.0 69.9 69.9 68.5 69.9 0 10 20 30 40 50 60 70 80 90 100 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 TimelyColonoscopy(%) CRC Prevention: Timely Colonoscopy among NYC Adults Ages 50+ Years, 2003-2017
  38. 38. CRC Prevention: Colonoscopy by Age, NYC, 2017 Age % No colonoscopy in the past 10 years NYC CHS, 2017 People (N) 45 – 49 years* 71.7 320,000 50 – 74 years 31.0 644,000 75+ years 29.4 123,000 Source: DOHMH analysis of the NYC Community Health Survey 2017 To increase screening we will need a change in practice. *45 is the ACS recommended age to begin screening, but we have yet to see if it will be covered.
  39. 39. How to Change Direction in Public Health: the DOHMH Experience • Recommendations for healthcare providers • Healthcare provider tools • Public health detailing for PCPs • Colon cancer prevention public education • Colon cancer prevention media
  40. 40. DOHMH CRC Prevention Recommendations for Healthcare Providers: CHI, 2009
  41. 41. DOHMH Healthcare Provider Tools: DERS Forms
  42. 42. Public Health Detailing Approach • Allow at least 9-12 months for campaign development • Train knowledgeable and persuasive Health Department Representatives and teams • Disease content knowledge (DOHMH expertise) • Selling and communications skills • 12-20 week campaigns; target is 2 visits per contact per campaign • Assess current practice: tailor presentation to each contact • “Sell” key recommendations and offer supporting campaign-specific materials
  43. 43. DOHMH Public Health Detailing Action Kits • Clinical tools • Provider resources • Patient Education • Developed using best-practices and qualitative research methods • Expert interviews • Research existing campaigns/messaging • Provider interview • Consumer focus groups 2008 Action Kit
  44. 44. NYC DOHMH Key Recommendations for Change: Internal Medicine and Family Practice • Colon Cancer Screening 2004, 2006 • Refer patients aged 50 years, or with a family history of colon cancer, for a colonoscopy • Colonoscopy is the NYC–recommended screening method • Any screening method is better than no screening method at all • Colon Cancer Screening 2008 • Refer patients aged 50 years or patients aged 40 years with a family history of colon cancer for colonoscopy • Directly refer appropriate patients for colonoscopy rather than first sending patients to a gastrointestinal consultation Dresser MG et al. Public Health Detailing of Primary Care Providers Am J Prev Med 2012;42(6S2):S122–S134)
  45. 45. Public Health Detailing of Primary Care Providers: NYC’s Experience, 2003–2010 Year Target Neighborhood Clinical Sites Provider Contacts Provider + Staff Contacts Contacts per Site 2004 South Bronx, East & Central Harlem, North & Central Brooklyn 193 530 982 5 2006 Staten Island 254 599 1489 6 2008 South Bronx, East & Central Harlem, North & Central Brooklyn 189 413 1424 8 Dresser MG et al. Public Health Detailing of Primary Care Providers Am J Prev Med 2012;42(6S2):S122–S134) • DOHMH studied effectiveness of the CRC screening-focused Public Health Detailing Program in helping PCPs and their staff improve patient care
  46. 46. Self-Reported Changes in Clinical Practice: DOHMH Public Health Detailing Campaigns Year Measure Baseline Follow-up 2004 Recommends colonoscopy as the primary CRC screening method 26% 42% Has an office system in place to promote CRC screening 52% 62% 2006 Colonoscopy recommended 82% 97% FOBT (stool-based test) recommended 10% 1.5% 2008 Uses DERS referral form for screening 9% 16% Dresser MG et al. Public Health Detailing of Primary Care Providers Am J Prev Med 2012;42(6S2):S122–S134) CRC=colorectal cancer
  47. 47. DOHMH Colon Cancer Prevention Public Education
  48. 48. DOHMH Colon Cancer Prevention Media, 2019 • Targeted to NYC neighborhoods with high levels of CRC mortality • Bus shelter placement • Staten Island ferry • Ethnic newspaper ads • Radio announcements • Social media sharing • Translated to Spanish, Chinese, and for radio, Haitian Creole
  49. 49. Colon Cancer Prevention Media, 2019
  50. 50. Summary • Number of new cases of CRC each year is declining among New Yorkers ages 50+ • But it is increasing among ages 20 – 49 • Yearly deaths from CRC declined as screening increased • Screening at younger ages is a practice change • Change in public health practices may be facilitated by: • Recommendations for healthcare providers • Healthcare provider tools • Public health detailing for PCPs • CRC prevention public education • CRC cancer prevention media
  51. 51. Thank you! Questions?
  52. 52. 10 6 Tony Foleno Senior Vice President, Strategy & Evaluation, Ad Council President, Society for Health Communication 5th International EAO CRC Symposium May 2, 2019 LESSONS LEARNED: WHAT HAVE WE LEARNED FROM PAST PUBLIC HEALTH COMMUNICATIONS SUCCESS STORIES?
  53. 53. 107 Question: how can we harness the power of media, marketing & tech to advance our objectives?
  54. 54. Mission Identify a select number of significant public issues and stimulate action on those issues through communications programs that make a measurable difference in our society.
  55. 55. Integrated, Multi-discipline Process 109 Data & insights infuse the entire process.
  56. 56. We have our work cut out for us • Media fragmentation • Message clutter • Competition for donated media • The need for focus & clarity • Logic vs. emotion Smart planning helps us navigate these waters
  57. 57. 111
  58. 58. 112 Exposure Awareness Engagement Impact Donated, earned, owned, shared media Issue and campaign awareness Digital, social & website analytics Behavior change Campaign evaluation framework
  59. 59. What Works Research, Research, Research Measurable Objectives A Big, Single-Minded Idea A Clear Call-to-Action Creative Excellence – Don’t Settle! Relevance & Emotion A Media Mix That Is Both Broad and Deep Social Utility …and, of course, puppies.
  60. 60. Campaign Overview 115 Help achieve health equity by educating and inspiring black women to understand their risk. Engage women with information and tools that can promote early detection. Objective Black women, 30-45 years old (halo ages 45-55). Target Go to KnowYourGirls.org for the facts you need on breast health. Call to Action Black women in America are dying of breast cancer at rates 40% higher than white women. They are more likely to be diagnosed at later stages with more aggressive forms of the disease. The Issue
  61. 61. Our Strategic Imperative Shift her mindset from one of fear around breast cancer to empowerment around her breast health.
  62. 62. 360° Campaign Video Print & Outdoor Digital Social Radio Local activation
  63. 63. Results: May 2018 – March 2019 $18MM Donated/earned media 473MM Media impressions 10%  15% Visited a website for info about breast health 45% Campaign awareness (net) 25% 29% Discussed breast health with family & friends 26%  29% Talked to their doctor about their risk
  64. 64. 12 0 Tony Foleno SVP, Strategy & Evaluation tfoleno@adcouncil.org Thank you
  65. 65. EAO Summit Andrew Albert, MD, MPH – Medical Director, Digestive Health Advocate Illinois Masonic Medical Center May 1, 2019 5th International EAO CRC Symposium May 2-3, 2019. New York City
  66. 66. EAO- CRC National Clinical Alert: Symptoms & Signs Index Details: Degree of Urgency Compelling Statistics Overview of EAO Signs and Symptoms Statistics relevant to family history Ways practitioners can help
  67. 67. What Providers Can Do? • Educate the Public and Clinical Staff about EAO and Family History • Ob/Gyn, PCP, ER, Surgery, Occupational Health, Community Health • Early assessment with physical exam • Educate patients on “basics” of digestive health (Health Literacy) • Help all clinical staff members to understand importance • Success?!
  68. 68. Reality…. • MeetingClinic visit Educate Repeat MeetingClinic visit • Speaking to same patients again and again • Providers/PCPs aren’t engaged • Medical Community is very busy • We aren’t reaching the right people • We make assumptions about health literacy
  69. 69. Reality continued… “My Brother (33) Died of Colon Cancer, do I need to be checked?” How many of you know March is Colon Cancer Awareness Month (0/1000) “I’m so sorry Doctor, can you tell me what a colon is?”
  70. 70. Clinical Alert and Beyond… • Need to take Alert one step further! • Please share this alert with your colleagues (focus group) • Invite other colleagues to champion this alert (15,000 Gastroenterologists) • Share this information (beyond the Silos) • Corporate, Community, Health Fair, Place of Worship • Reach the bottom of the iceberg • Do something/anything different: message needs to reach those who matter most
  71. 71. Patient Awareness and Advocacy EAO CRC Summit, May 2-3, 2019 Erin Peterson Communications Director Colon Cancer Coalition @gyrig
  72. 72. 425 RESPONSES 429 total responses INTERNAL SURVEY OF EAO PATIENTSSpring 2018 WERE YOU AWARE THAT YOUNG PEOPLE COULD BE DIAGNOSED WITH COLORECTAL CANCER? NO or MAYBE: 72.7% YES: 27.3% 423 RESPONSES YES: 74.9% NO: 25.1% DID YOU HAVE SYMPTOMS THAT YOU IGNORED OR TRIED TO SELF-TREAT?
  73. 73. IF YOU HAD SYMPTOMS, WHAT WERE THEY? ● BLOOD IN STOOL ● RECTAL BLEEDING ● ANEMIA ● WEIGHT LOSS ● FATIGUE ● CONSTIPATION ● INCONTINENCE ● ABDOMINAL PAIN ● CHANGES IN BOWEL HABITS ● PAINFUL PASSING OF STOOLS ● CHANGES IN COLOR OF STOOL ● NARROWING OF STOOL ● UNRESOLVED BLOATING ● CONSTANT URGE TO HAVE BOWEL MOVEMENT 372 RESPONSES
  74. 74. WHAT MESSAGES ABOUT YOUNG ONSET COLORECTAL CANCER WOULD HAVE GOTTEN YOUR ATTENTION? 352 RESPONSES BLOOD IN YOUR STOOL DOES NOT ALWAYS MEAN HEMORRHOIDS BE MORE COMFORTABLE TALKING ABOUT BATHROOM HABITS HEALTHY LIFESTYLE DOES NOT EQUAL PREVENTION IN YOUNG ADULTS AGE IS NOT A FACTOR YOUNG, ATTRACTIVE PEOPLE TALKING ABOUT YOUNG ONSET CRC HEARING THE STORIES OF YOUNG PEOPLE WITH CRC MISCONCEPTION THAT SYMPTOMS ARE FOR OTHER ISSUES THAT IT’S A POSSIBILITY AND NOT A RARE CHANCE STATS AND RISE AND YOUNG ONSET COLORECTAL CANCER
  75. 75. WHERE WOULD YOU HAVE BEEN MOST LIKELY TO SEE AN AWARENESS MESSAGE? 333 RESPONSES ● FACEBOOK/SOCIAL MEDIA ● TV ● ONLINE ADS ● IN-APP ADS ● PUBLIC TRANSPORTATION ● MAGAZINE ADS ● MALL KIOSKS ● ADS IN PUBLIC SPACES ● DOCTOR’S OFFICES/MEDICAL PAMPHLETS ● MOVIE THEATER PREVIEW ADS ● ADS IN PUBS/BREWERIES ● YOUTUBE ● PODCAST
  76. 76. RECYCLING KIOSKSBoston, Sept. 2018 Public Spaces • $30,000 + in kind support • 27 million impressions 40 three-sided kiosks throughout downtown Boston for four weeks in September
  77. 77. METRO USBoston, Sept. 2018 Online & Magazine • $5,000 + in-kind support • 1.2 Million Impressions Included front & back page print ads, ¼ page print ads, and one-month digital 75% of readers under age 55. digitalsample Metrobackpagead Metrofrontpageheader,Sept.4,2018
  78. 78. Thank You & Questions Erin Peterson erin@coloncancercoalition.org ColonCancerCoalition.org

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