The greater Denver Latino Cancer Prevention/Control Network

Prevention and research through a community-based approach

Authors


Abstract

The Latino/a Research & Policy Center (LRPC), at the University of Colorado (UC) at Denver and Health Sciences Center built the Greater Denver Latino Cancer Prevention Network, a successful cancer prevention network, in 6 Denver metro area counties. The Network consisted of 23 Latino community-based organizations, health clinics, social service agencies, faith-based groups, and employee-based organizations; 2 migrant health clinics; and 14 scientific partners including the UC Comprehensive Cancer Center, the Colorado Department of Public Health and Environment, and the American Cancer Society. The Network focused on 5 significant cancers: breast, cervical, lung, colorectal, and prostate cancer. The Steering Committee initiated a review process for junior researchers that resulted in 5 NCI-funded pilot projects. Pilot projects were conducted with various Latino populations. The Network developed community education and health promotion projects including the bilingual outreach play The Cancer Monologues. The Network's partnership also started and held 2 annual health fairs, Dia de la MujerLatina/Day of the Latina Woman, and annual health prevention summits. The Special Population Network (SPN) adapted and revised a clinical trials education outreach module that reached Network community partners. SPN partners recruited Latino/a students to cancer research through a6-week NCI training program held yearly at the UCHSC campus. The Network methodology of bringing together the Latino community with the scientific community increased the level of awareness of cancer in the Latino community and increased cancer research and the level of engagement of the scientific partners with the Latino community. Cancer 2006. © 2006 American Cancer Society.

The Greater Denver Latino Cancer Prevention/Control Network began as a funded project of the Latino/a Research & Policy Center (LRPC) at the University of Colorado at Denver. The project fit the LRPC's mission of improving the quality of life for Colorado Latinos through research and policy work. This NCI Special Population Network (SPN) 5-year project was the first large-scale multiyear endeavor of the LRPC. Significantly, the LRPC was established with Latino community-based leadership already forming a part of the Center's membership in the form of ‘community associates.’

In 2000, Colorado's Latino population represented 17.1% of the state's population and continues to be the State's largest minority group. The Colorado Latino population had grown 73.3% since 1990. Epidemiologic and clinical data established cancer as a significant health threat for Latino/as in Colorado. The Colorado Latino (male) incidence rate per 100,000 for all cancers combined was 480.4 between the period 1995 and 2000 when compared with the U.S. Latino combined cancer rate of 443 per 100,000. The Colorado Latina (female) incidence rate for all cancers combined was 364.6 between the period 1995 and 2002 when compared with the U.S. Latina combined cancer rate of 313 per 100,000.1

Further examination of Colorado cancer data revealed disparities among Latinos with specific types of cancer. Hence, the Network focused on 5 cancers: lung, breast, cervical, prostate, and colorectal. The lung cancer incidence rates for Latinas increased between 1991–1995 and 1996 by 27%.1 In the 1990s, the Colorado lung cancer incidence rate for Latinos (males and females) was lower than the rate for white non-Latinos (hereafter ‘white’). However, the time trend revealed that Latinas' annual percent change for lung cancer was significantly higher. The lung cancer incidence rate increased 2.4% per year in Latinas. The trend in Latina lung cancer mortality rates from 1992 to 2002 in Colorado was up ∼1.7% per year. While smoking prevalence rates for most ethnic groups are higher than what is mentioned in the Healthy People 2010 goals, Latinos were among those having the highest rates. In addition, 69% of Latino adults surveyed stated that their place of work had an official no-smoking policy for indoor public common areas, compared with 81% of white adults. However, there was a dearth of information in the literature regarding Colorado lung cancer mortality rates for Latino males and females. In Colorado, Latino/a smoking prevalence rates were significantly greater than Healthy People 2000 targets, yet there was a dearth of information regarding Latino smoking prevention practices.2, 3

Between the period 1995 and 1999, improvements in early detection of breast cancer were seen in all ethnic groups; however, tumor stage differentials were still apparent in African American, Latina and white non-Latina women. Less African American (66%) and Latinas (66%) than white women (73%) received a diagnosis of early-stage breast cancer.

In Colorado, the incidence rate of invasive cervical cancer in Latinas continued its 2-fold elevation above that of non-Latina white women, 110% higher during 1991–95 and 123% higher in 1996.1, 4 For Latinas in Colorado, the cervical cancer mortality rate was 81% higher than for non-Latina white women (1995–1999).

Early detection of prostate cancer for Latinos (74%) and African American males (70%) lagged behind that of white males (78%) during 1992–1996. The colorectal incidence rates during the period 1995–1999 were significantly higher (19%) for Latinos (68 per 100,000) when compared with the rates of white males (57 per 100,000). This rate is also higher than the national incidence rate for Latinos (53 per 100,000). Further, the 5-year survival rate for regional colorectal cancer for Latinos is 53% when compared with 62% for white males.

Aims

Colorado cancer data provided the rationale to embark on cancer awareness and education programs to achieve Network health aims in the Latino community.5, 6 The Network sought to increase awareness among the Latino population of breast, cervical, lung, colorectal, and prostate cancer risk factors, as well as appropriate ages for cancer screenings, and to reduce sociocultural barriers to screening. It should be noted that the project addressed each cancer to varying degrees, based on the funding of pilot projects and the natural development of the Network. Thus we placed primary emphasis on breast and lung cancer prevention and research, while colorectal, prostate, and cervical received secondary attention through our many and varied outreach activities. Another aim was to increase the number of minorities and junior researchers participating in cancer research.

MATERIALS AND METHODS

Historical Perspective and Needs Assessment

Breast and cervical cancer awareness programs were prominent in this community, with mammography screening programs experiencing the most success. However, annual mammograms for women aged 40–50, and annual or biannual mammograms for women older than 50 years, were still being underutilized by Colorado Latinas. While intervention programs targeting Latinas demonstrated increased mammo graphy utilization, lack of knowledge and lack of physician referral were consistently shown to be significant barriers to screening.7–12 Other documented sociocultural barriers included language (Spanish-speaking), lack of insurance, fear of diagnosis,13 and lack of support from male partners in screening.14

During Phase I of the study, the SPN completed a literature review, conducted a Denver area community-based organizational analysis on cancer, built a community infrastructure, and organized and convened a Steering Committee with members from the scientific community and leaders from the Network community-based partners. Regular Network communications were also developed via a triannual newsletter, an e-mail list serve, frequent phone calls from the project's coordinator, and the Network Web site.

The SPN conducted a community-based organizational analysis on cancer through a survey of Network partners on their cancer activities. The scan resulted in the Greater Denver Latino Cancer Prevention Control Network Resource Guide. Published in each of the first 4 years of the project, the Resource Guide contained on a full page a summary of each community and scientific organization, its mission, size, percent Latino, percent Spanish-speaking, current cancer activities, as well as all pertinent contact information. The SPN distributed over 900 copies of the Resource Guide to the Network members for active use in promotion, education, and prevention.

This Resource Guide aided both community and academic partners. First, the community-based partners became aware of cancer activities by scientific partners, while scientific partners learned of the nature and types of varied activities of Latino community-based organizations. More important, over time, community and scientific partners were able to readily communicate with each other on cancer-related issues.15, 16 This led to many unanticipated and valuable collaborations among Network partners and assisted in initial discussions of pilot project proposals. For example, a Network community based member, never involved in cancer prevention activities, contacted a scientific member, the Komen Foundation, and started a successful application for funding. Other similar community based members contacted the Rocky Mountain Cancer Information Services and started providing Spanish-language cancer educational materials to their clients.

Building the Network Infrastructure

To more effectively combat cancer among Latinos, the Cancer Prevention and Control Network focused on the 6-county Greater Denver Metropolitan Area. There were 427,692 Latinos living in these counties (Boulder, Denver, Jefferson, Arapahoe, Douglas, and Adams), which represented 17.8% of the counties' population.17

Denver was chosen as the Network's major site because it provided access to a large urban concentration of Latinos (31.7% of the city's population,18 or 107,382) with both long-time Mexican American residents (e.g., over 4 generations of residence) and recent immigrants. Adjoining counties to Denver were included because of the large number of Latinos in these counties. Likewise, a number of major Denver-based health and social service nonprofit organizations agreed to support the study by facilitating access to Latino clients (Rocky Mountain SER/Head Start), parishioners (Our Lady of Guadalupe Church), and migrants (La Salud/The Health Clinics) (Table 1).

Table 1. Greater Denver Latino Cancer Prevention and ControlNetwork: 6-County Latino Population17
CountyLatino populationTotal population% Latino
Adams102,585363,85728.2
Arapahoe57,612487,96711.8
Boulder30,456291,28810.5
Denver175,704554,63631.7
Douglas8,886175,7665.1
Jefferson52,449527,05610.0
Total427,6922,400,57017.8

The Greater Denver Latino Cancer Prevention and Control Network

Building a successful SPN Network in a 6-county area rested on establishing collaborative relationships between greater Denver Latinos/as and health and social service organizations and agencies, and appropriate local, state, and national and federal government and nongovernment cancer-related organizations. The SPN built a Network infrastructure of up to 23 Latino community-based organizations, including health clinics, social service agencies, faith-based groups, and employee-based organizations serving Latinos, and focused on 5 cancers affecting Latinos in Colorado: breast, cervical, prostate, colorectal, and lung cancer.19 In addition, a Steering Committee lent guidance to the SPN throughout the project's 5 years and established the pilot project proposal format that ultimately resulted in 5 pilot project proposals being funded by NCI.

During Phase I, the SPN established an infrastructure for cancer awareness and education projects in the Latino community based on already extant associations, LRPC community associates, and past intervention and education activities, such as its 1990–1995 Latina breast and cervical cancer prevention work.10, 20–22

The Network's organizational structure emerged during Year 1 of the SPN and is depicted in Figure 1. The LRPC's Executive Director was the Network Principal Investigator and the Co-Investigator served as the Center's Assistant Director. Network partners were treated as equals,23 with both community and scientific partners contributing to the success of the Network.20

Figure 1.

Greater Denver Latino cancer prevention/control network organizational structure.

During the first 2 years of the project, Network meetings were held monthly. Network community partners were offered a stipend of $1000 per year for their participation in the Network. This incentive compensated partners for time spent at Network meetings and activities. Community partners were paid by the percentage of meetings attended, with full attendance garnering the full $1000; half, $500; and so on.

Pilot Projects

One of the goals of the Greater Denver Latino Cancer Prevention/Control Network was to develop junior investigator pilot projects in collaboration with the community-based partners to address cancer prevention and control among underserved populations. Of particular interest were proposals addressing cancer health disparities in Latino populations. There were 3 objectives for the pilot projects:

  • 1Encourage partnerships of community-based and research organizations for community-based participatory research
  • 2Mentor the research of junior and minority researchers interested in Latino cancer disparities
  • 3Collect preliminary data for the development of R01-type research projects

The first pilot project, entitled Chicano Theater for Cancer Education, tested the effectiveness of a cancer awareness play The Cancer Monologues that was developed during the Network's first year as a low-literacy cancer education activity. Cancer education training was provided by the NCI's Rocky Mountain Cancer Information Service to the actors. The pilot, conducted in Years 4 and 5 of the Network, used a preplay and postplay cancer education assessment, followed by discussion for a target audience of low-literacy underserved Latinos adults (aged 40 and older). The second pilot project proposal funded was an intervention study of middle-aged Latinos and smoking cessation. The study explored potential individual-level barriers that might need to be addressed and sociocultural values that might be incorporated in a tobacco cessation intervention study design. The pilot used semi structured, focused, group discussions among Latino smokers and family members of smokers aged 35–64.15 The final 3 pilots funded by NCI are discussed in the following text.

Recruitment of pilot proposals

The SPN initially sought only ethnic minority junior investigators as eligible applicants for the pilot projects. In subsequent years, eligibility was broadened to include any junior investigator interested in conducting Latino cancer disparities research. However, nonminority junior investigators were strongly encouraged to include in their research teams members from ethnic minority populations. Members from collaborating community-based organizations were included as part of the research team and listed as co-investigators.

Solicitation for pilot projects as an RFP began 5 months prior to submission to NCI. The RFP, developed by Dr. Espinoza and based on the model of a sister SPN, Redes En Acción/Networks in Action, was e-mailed to all scientific partners, including all 4 University of Colorado campuses and all other state universities. The RFP was also disseminated to the Colorado Minority Health Forum and was posted on the Network Web site.

Pilot project development and review

To familiarize pilot project junior investigators with the NCI's R01 criteria, the SPN required junior investigators to meet similar criteria in developing their proposals. All proposals, which began with a concept paper, were reviewed by the Network Steering Committee at several intervals in the 5-month development process.

The SPN purposefully made the pilot proposal review process transparent by opening Steering Committee review sessions to junior investigators. These meetings became more like working groups, with feedback provided to junior investigators as they developed their proposals, had drafts reviewed by the Steering Committee, and made requested changes.

RESULTS

Pilot Projects

All 5 funded pilot projects focused on various Latino populations: one centered on tobacco cessation (Dr. Levinson); the second assessed the Network's cancer education play (Dr. Espinoza); the third assessed Spanish-language breast cancer screening videos (Dr. Borrayo); the fourth assessed a Spanish-language breast cancer screening scale (Dr. Borrayo); and the fifth addressed informational needs of Latina cancer survivors (Dr. Sorenson).

Dr. Levinson's completed pilot project produced a forthcoming AJPM article What Keeps Some Latino Smokers From Using Pharmaceutical Aids to Quit?An Exploration. His research provides important findings that may lead to more effective ways for Latinos (aged 35–64) to stop smoking.16 Levinson et al. found that Latino smokers in this age group believed that NRT may be replacing one addiction with another and that personal efficacy, “getting one's life ‘right,’” can lead one to quit smoking.24

Dr. Espinoza's Cancer Monologues pilot provides for a pre- and postplay, test assessment of the audience's learning of the various cancers covered in the play. Her pilot will be completed in the summer of 2006. Dr. Borrayo's first pilot, Video to influence Latinas Participation in Mammography, tests 2 different Spanish-language videos on efficacy toward mammography screening; this pilot will be completed in the summer of 2006. Her second pilot, Scale to Measure Latinas' Breast Cancer Screening Beliefs, is a questionnaire scale development project on the influence of Latinas' cultural health beliefs. Finally, Dr. Sorenson's completed pilot Latina Breast Cancer Survivors: Informational Needs uses focus group methods to assess survivors' informational needs.

Cancer Awareness and Education Activities

Over the 5 years of the project, the SPN developed a number of community education and health promotion projects.21 As mentioned earlier, the SPN produced a bilingual outreach play, The Cancer Monologues, and also hosted an annual Network ‘Summit,’ in addition to holding 2 annual health fairs, Dia de la Mujer Latina/Day of the Latin Woman, to promote breast cancer screening and education. Latino/a students were also recruited to cancer research through a 6-week NCI training program held yearly at the UCHSC campus and sponsored by the CU Cancer Center. During the 5 years of our Network, 50 students of color were recruited and attended the training program out of a total of 300 students during that time frame. Data by ethnic group is unavailable. Also, no study of the student's career outcome has been conducted because of lack of funding.

The Cancer Monologues

The Cancer Monologues represents a unique approach to cancer awareness and prevention—a play developed by the local Denver Chicano theater group, El Centro Su Teatro (The Center, Your Theater). In collaboration with the Network, Su Teatro members and staff, along with Network members, including Cancer Information Service representatives, conceived and developed the play (Fig. 2).

Figure 2.

El Centro Su Teatro's The Cancer Monologues. Caption: 2 Latino actors Magaly and Laura perform the ‘breast self exam dance’ while Christian looks on.

The play was developed to reach the most underserved Latinos—uninsured, low literacy, and monolingual Spanish-speakers—those not likely to read from a brochure or talk to health care providers about cancer prevention and early detection.

The play used Prochaska's Transtheoretical Stage of Change Behavioral Model as a guide.25 The first version of the play, which included a qualitative outcome evaluation component, incorporated the ‘precontemplation’ stage of change and sought to raise awareness of cancer prevention and early detection. Additional scenes were later added with a focus on the ‘contemplation’ and ‘action’ stages of change, and the first skit was translated into Spanish to reach migrant and immigrant Latino populations. At the conclusion of each performance, Dr. Espinoza facilitated discussion of the play's cancer prevention and education messages with the audience, and provided a ‘resource table’ where bilingual NCI/CIS, ACS, and Susan G. Komen cancer brochures were made available.

The Cancer Monologues play was performed 35 times at 7 Network community organization sites, including a baseball field at a community fair, and reached a total audience of nearly 500 during Year 3. Denver's Channel 9 TV (NBC) also covered the play in a 5:00 p.m., 120-second spot. In addition, the SPN presented a performance of the play at the Office of Minority Health's National Leadership Summit in 2002, and was awarded the Outstanding Innovative Cancer Project by the Colorado Cancer Coalition.

The Cancer Monologues uses a culturally proficient method to educate and raise awareness based on Mexican culture's rich history of using parody in portraying death: Dia de los Muertos (Day of the Dead) is the prime example. Parody and humor also play major roles and are a key feature among the 7 skits constituting The Cancer Monologues. Humor is employed to help defuse the ‘deathly’ topic of cancer. This approach provides an enjoyable milieu for cancer education, in which jokes, dancing, and music were all used in dramatic and comedic style. For example, “Dr. Goldfinger” was used in a skit where a Latino worried about getting a prostate examination. This method of using a play to reach audiences employs another tradition in Latino culture—that of Chicano politics and guerilla or street theater—performed wherever ‘natural’ audiences gather (e.g., at community centers, health fairs, churches, etc.). This approach was first employed successfully by the United Farm Workers Teatro Campesino/Farmworker Theater in the 1960s to organize workers and to diffuse their boycott.26

Because the target audience was hard-to-reach, underserved Latinos who had low literacy levels, initial evaluation of the play was qualitative in nature. All performances and audiences were observed by a research assistant who took field notes indicating among other things, the number in attendance, the gender make-up of the audience, the general age of the audience (i.e., older than 40 years, younger than 20–40 years, children, and youth), the ethnic make-up of the audience (i.e., Latino, Non-Latino, noting undetermined when appropriate), language preference of the audience (i.e. Monolingual Spanish, Bilingual, or English), and the audience's response to the play, including facial expression and body language displayed during the play along with the types of questions asked during postplay discussion.

These qualitative data collected on The Cancer Monologues seemed to indicate that audiences appreciated the play. They laughed and stayed engaged during the performance and asked poignant questions upon its completion. Usually, someone in the audience had a loved one or friend suffering from cancer and they shared a personal cancer experience or asked questions regarding some health aspect of that particular cancer. Other frequently asked questions addressed the incidence and mortality rates among Latinos on various cancers, beliefs about cancer prevention, diagnosis, and treatment, and where to access low-cost screening services. In 1 instance, a young woman was observed practicing proper self-breast examination techniques as is shown during a self-breast exam dance sequence in the play. Spanish and English brochures were always provided at the end of the play for audience members to take home, and follow-up calls were invited. The NCI-funded pilot project on The Cancer Monologues seeks to verify the qualitative evaluation of the early versions of the play's effectiveness using a pre–post-play cancer education assessment.

Dia de la Mujer Latina

This annual event, begun in Year 3, was a culturally proficient health festival to promote health education, prevention, resources, and screening services to Latina women and their families, especially breast and cervical cancer screening. Día de la Mujer Latina-Denver was modeled after the original Día de la MujerLatina event held in Atlanta.27 Two Dias were held during the Network's term, one on June 7, 2003 and another on June 5, 2004. Both were held at a Network partner site, Denver Health's La Casa Quigg Newton Family Health Center. Over $80,000 were raised to support both Dias, including support from the Komen Foundation; Eli Lilly, Inc.; and American Family Insurance.

Cosponsored with the Mexican and Peruvian Consulates, the CU Cancer Center, the American Cancer Society, Denver Health, the 2 six-hour Dia events drew some 6000 persons over both years (4000 the first year and 2000 the second year). The event averaged 40 educational booths and raised funds for free health screenings, clinical breast examinations, mammograms, blood draws, pap tests, blood pressure tests, depression screenings, hepatitis C screening, human immunodeficiency virus (HIV) tests, etc.

Through Dia, the SPN overcame barriers often faced by Latina women in accessing health education and preventive screening services. Typical barriers include language, limited financial resources, a lack of transportation, a system with limited consideration for the impact of cultural differences on service delivery, and lack of culturally appropriate educational literature and curricula.28–33 Over 2 years, the LRPC provided more than 1000 free health screenings. We provided 214 free pap tests and mammograms at the 2 fairs (Table 2).

Table 2. Dia de la Mujer Latina Health Fairs: Free Breast and Cervical Cancer Screenings
 20032004
Pap Test7282
Mammogram3232
Total104114

Dia featured culturally appropriate community health resources and health education,31 with education booths providing information on a variety of health topics for the entire Latino family, including breast, cervical, and prostate cancer screenings. We offered novel health education opportunities such as ‘health education bingo’ and performances of The Cancer Monologues and Cigarettes: A Love Story.

Día de la MujerLatina-Denver included cultural competency training so that volunteers were more effective in their provision of services to participants. The health fair spanned 2 blocks in a neighborhood with a large Latino population all around La Casa-Quigg Newton Family Health Center. Dia provided family centered activities with ethnic music, food, entertainment, and giveaways. The SPN marketed, solicited, and secured media coverage for Dia before, during, and after the event via the Spanish-language media (radio, television, and newspapers).

Other SPN awareness and education activities

In Years 3 and 4, Network cancer awareness and education presentations reached ∼7400 persons in the community. Network staff also appeared in 2 ‘Latin View’ 30-minute taped programs on Denver's Channel 12 (local PBS), one on Health and Cancer and the other on Latinos and Tobacco.

To help sustain the Network, the SPN leveraged an additional $550,000 in supplemental funds for cancer-related work. This included a 2-year Avon Comadre project to train promotoras/lay health outreach workers, in outreach to Latinas for breast and cervical cancer prevention. The project educated 2800 women and secured 800 mammograms for Latinas. The Network also collaborated with the CU Cancer Center on a 3-year, P-20 NCI Project, Partnership to Increase Hispanic Cancer Research in Colorado. The Center also completed a statewide Tobacco Needs Assessment on Latinos, which in 2006, has resulted in the creation of the Latino Statewide Tobacco Prevention Education Network. Another state contract, the Second-Hand Smoke project, built a mutually beneficial partnership with the Colorado Tobacco Education Prevention Alliance to conduct prevention work among Denver's Latino population.34 Finally, the Denver Latino Cancer Health Disparity Study (CDPHE) addressed the cancer prevention needs of a high-risk community on Denver's north side. All this work allowed the Network to build on the NCI parent grant with new endeavors to fight cancer with new partners in novel ways.35, 36

DISCUSSION

Building the Network was not without problems. Some of the most difficult Network discussions occurred during the first meetings of Year 1. Network members had anticipated, as had NCI, that various social and political issues between community and scientific Network partners might surface early on, and they did. There were issues in the Latino community over the perceived lack of health services that erupted early on.37

The ethnic composition of the newly developed SPN was a salient factor. Almost all of the Network community partners were Latino: most were Mexican American or Chicano. The representatives for the scientific partners were mostly Anglos or non-Hispanic whites who represented institutions such as Denver Health, the public hospital system for the indigent. In meetings, the 30–35 Network members sat in a large rectangle on the outside of tables to facilitate face-to-face discussions. Almost all of the community members working at ethnic-specific, nonprofit organizations were Latino, while almost all of the scientific members working at large, established health institutions were white.

Longstanding issues of mistrust and criticism of the health delivery system were broached at the first few meetings. Network organizers anticipated this dynamic and were prepared for conflicts. Some Latino community representatives were suspicious of the ‘real’ motives of NCI and scientific partners. Others were extremely upset over decades of neglect of the Latino community's health. One community representative stated angrily, “Why should we trust you since for decades you were not interested in our community's health?” The Principal Investigators (PIs) facilitated these heated sessions to resolve the thorny problems that surfaced and threatened the successful establishment of the Network. In frank discussions, scientific members explained that they were participating in ‘good faith’ to work on improving the health of the Latino community, especially related to cancer. The PIs emphasized that as organizers of the Network, their goal was to forge new and positive relationships among partners so that all might improve the health of the Latino community together.35 All partners, through these difficult discussions, accepted this goal and the Network was able to move forward.

Since the NCI had built into the Network RFA expectations on possible conflict, Network organizers were prepared and their expertise and experience in cultural competency facilitated this work. It was reemphasized throughout Year 1 that expected norms for participation included mutual respect, honesty, and a commitment to achieve the project's aims. These issues were explicitly and openly addressed, and little damage to developing partner relationships was perceived. The relative lack of dropouts from the Network speaks for its success.

In addition, the value of the incentive payments to the community-based partner organizations cannot be overstated. These organizations are frequently asked to participate on worthy causes, with no remuneration for their expertise, time, and knowledge, and they welcomed being paid for their participation. In sum, the Network objective was to inform the medical community of cultural competency in working with Latino communities, as much as it was to inform the Latino community of the importance of cancer awareness and participation in medical community cancer control activities.15

Recruitment of Latino junior investigators to the NCI pilot project submission program was found to be a daunting task. The paucity of Latino PhDs or MDs doing academic NCI-type research in Colorado was one barrier. Developing an NCI-worthy proposal from new investigators was another barrier, as the SPN had to convince some potential new investigators about the magnitude of work required for a proposal to be forwarded to NCI. Some junior investigators were simply not able to submit a revised proposal in a timely fashion to the Steering Committee.

The pilot project research served to enhance both the science base and the community. Tobacco research funded by state health department that the SPN began at the Latino Research & Policy Center was a needs assessment on Latinos and tobacco prevention.38, 39 It is a testament to, first, how an SPN can successfully develop new meaningful research and, second, how this project has impacted the community's need for knowledge and prevention strategies on a local level.17, 37

Conclusions

Awareness-raising activities described in the paper include the play, the annual health fair, and others. Prior to the implementation of specific pilot projects, evaluation of the Network's activities were limited to ‘counts’—the number and nature of activities accomplished, the number of participants who engaged in or were exposed to these activities, etc. This is the most basic measure of raising awareness since prior to the Network's existence, these activities targeting Latinos in the metro Denver area were few or met with very limited success in reaching Latinos (e.g. 9 Health Fair). The authors recognize that this level of evaluation for ‘awareness raising’ is limited in its ability to conclude ‘success.’ There is much work yet to be done in reaching the underserved Latinos with measurable cancer education prevention and early detection messages. Given the scope of the grant, the pilot project mechanism of this grant was used to provide scientific measurement for testing hypotheses regarding cancer awareness interventions.

Over the grant's 5 years, the SPN has served as a catalyst for numerous projects (some of which were learned about after the fact) that occurred between the Network's community and scientific partners. The Network methodology of bringing together the Latino community with the scientific community increased the number of cancer awareness activities provided to the Denver Metro Latino population and increased the level of engagement of the scientific partners with the Latino community. The Network model for cancer control and prevention is a promising one that could be diffused throughout the National Institutes of Health and the Department of Health and Human Services. This method, with accompanying programmatic funds, could be applied to cardiovascular disease, diabetes, and obesity.

Acknowledgements

We especially thank the grant staff who over the years helped build a successful Greater Denver Latino Cancer Prevention/Control Network, including: Chris Armijo, MSPH, research associate; Azita Jacobson, Kelly Middlebrook, and Maria Gavier, project coordinators; Juana Cavero, education coordinator; Adela Samper Imaz, grant manager; Neilsun Valenski, MS, Web master; Mary Helen Duran, comadre/outreach worker; David Montez and Christina Garcia, event coordinators; and Cecilia Hernandez, student assistant. Of course, the success of the work would not have been possible without our 23 community-based organization partners, 14 scientific partners, the steering committee, and pilot project junior investigators. To all of these individuals and organizations, who are discussed in this article, we offer you all of our thanks; we and our community are indebted to you.

Ancillary