David Raubach: I want to welcome you guys to the Cancer Project podcast. We're really excited today to be joined by Jennifer Watkins. She is the chronic disease coordinator for the Oklahoma Department of Health, and she and her team are leading a broad spectrum of initiatives dealing with things like arthritis, tobacco use, and cancer — and that's what we're going to talk about today here on the Cancer Project podcast. So, Jennifer, thank you so much for joining us.

Jennifer Watkins: Thank you for having me.

David Raubach: So, first I think we should get to know you as a person. Tell us a little bit about your background and how you ended up working for the Department of Health here in Oklahoma.

Jennifer Watkins: Yeah. So cancer kind of came into my life when I was 11 years old, sitting there waiting for the school bus, and I found out my mom was diagnosed with breast cancer. About two years later, on July 4th, she passed away from cancer. It definitely changed the image of freedom to me. But it gave me a purpose for the rest of my life. I started out working for the American Cancer Society right out of college and then worked for the National Cancer Institute, MD Anderson, and different organizations. My goal was just to make sure no one else went through what my family did. That really drove the cancer piece for me — 25 years of professional career. And then about 10 years ago I lost my dad to colorectal cancer too. So just knowing how these families feel when they don't always know where to get the answers really is what drives my work.

David Raubach: Cancer is one of those things that impacts everybody. Just about everybody has a friend or a family member — or maybe it's them personally — that have gone through cancer. What was it like for you as a child of two parents who had gone through cancer?

Jennifer Watkins: Back then, this was the late '80s, and we didn't know what cancer really was. Oddly, I was from a very small town and a couple of other girls whose moms had gone through cancer at the same time. We had a cheerleading coach who was able to connect us — she would have lunch with us about once a month and we would just talk. That was kind of the first connection I had to the support of what families go through. It really helped me understand what some families are going to need. And as much as you hate to have gone through it, knowing a little bit about what a family is going to need definitely helped.

David Raubach: What was maybe similar or different going through being a caretaker a second time with your dad?

Jennifer Watkins: It brought up a lot of those old feelings that you didn't really expect, but also knowing a little bit about, okay, this is the connection we need to make and this is who I need to talk to. I think that really helped the second time around — knowing what questions to ask and having the resources to be able to ask them. My dad actually went through treatment at the Proton Center, and I knew about it from my work with the coalition, but getting to see that firsthand and the patient care and the resources was an incredible opportunity as well.

David Raubach: One of the things we talk about at the Proton Center is that we have great technology, but there's also a human element — a psychosocial and mental health aspect to going through treatment. We want patients to have the best health care experience possible even as they navigate something as difficult as cancer. Talk about the importance of care that exists outside of just the treatment itself.

Jennifer Watkins: Absolutely. It has to be that holistic approach because your 10 or 15 minutes with your physician — you can't get all your questions answered. It's not possible. Having the big picture approach, a patient navigator or a social worker or somebody who can help you understand your insurance options and your rights, is incredible. We have kicked off a cancer survivorship series called Beyond the Diagnosis and yesterday was financial toxicity — we brought in an attorney who specializes in cancer legal matters. She walked our participants through what your rights are and the questions you're allowed to ask. When you're so worried about the financial aspect — can I put food on the table, do I pay the medication bill or the electric bill — you need to know that you have absolute rights and it shouldn't be a terrifying experience from every angle.

David Raubach: Let me make sure I get these right — I have the titles of some of the sessions written down. Financial toxicity: the other side effect. Food, fitness, and fighting cancer. Caring for the mind: suicide prevention and emotional well-being in cancer. More than survival: the lasting journey of childhood and young adult cancer survivors. And unspoken questions: intimacy and connection after cancer. These are every Wednesday?

Jennifer Watkins: Yes, every Wednesday at noon via Zoom. And like I said, these will all be recorded. So people that aren't able to participate will have them linked to our website. I'm happy to share those with you as well.

David Raubach: Over 50% of patients that go through cancer treatment end treatment in some type of debt — from the treatment itself, being out of work, caretakers being out of work, travel expenses. What are some resources that people should think about as they wonder how to pay for everything during a cancer diagnosis?

Jennifer Watkins: The organization we partnered with yesterday is a national organization called Triage Cancer. It was founded by two attorneys who saw the need for cancer patients, survivors, and family members to have access to legal support. With every session we do, we have a survivor tell their story. The man we had yesterday — his name is Curtis — actually worked in insurance before being diagnosed with prostate cancer. When he didn't have the strength or stamina to keep up with his job, he lost his job and his insurance just as he was diagnosed. He had a little bit of savings, but that doesn't go very far with treatment. Triage Cancer has attorneys you can actually connect with, a simple form on their website to start the conversation, and resources and worksheets to help you walk through the financial side.

David Raubach: One of the things we talk to our patients about is: don't be afraid to bring up the fact that you have a financial burden. All of the big cancer centers here in Oklahoma City — SSM Health, Mercy, OU, Oklahoma Proton Center, Integris — all want to help patients get through treatment and have teams designed to help. Even something as simple as asking for a payment plan or a needs-based charitable discount. Those things exist, but sometimes it is imperative for the patient to take the first step and ask.

Jennifer Watkins: And when you've just kind of been told one of the biggest life changes, you're still trying to process your diagnosis — not all of the other things. So taking a minute to ask, is there an option, what can I do — we've got some amazing centers here in Oklahoma. Feeling like you don't have to travel to put that extra burden on is so important too.

David Raubach: The Hope Lodge is a great example — patients traveling into Oklahoma City for treatment can stay there at a significantly discounted or free rate. Not every city has a Hope Lodge like that.

David Raubach: In two weeks you have a topic on caring for the mind, suicide prevention, and emotional well-being in cancer. Why is that an important topic to cover?

Jennifer Watkins: It's one of those topics that is hard to talk about — so why don't we start the conversation? There's such a need, and sometimes there's a stigma around mental health and hopelessness. The risk of suicide because of depression and hopelessness can be so high in cancer patients, survivors, and caregivers. They feel alone and don't know who to talk to or how to talk about it. The medication may make their brain feel very foggy so they're not in the best headspace. Having an outlet, providing resources — that is going to be so critical to really support them. And I'm glad you mentioned caregivers. For the caregiver, there's no active treatment — they're just trying to support. Well, who is supporting them?

David Raubach: It's not just for the patients — it's for anybody involved in the care. We've seen too many times where a marriage falls apart or there's conflict within the family because of this catastrophic disruption that cancer can cause.

Jennifer Watkins: Absolutely. I would love to see this series break out into a track for survivors and a track for caregivers so they can talk openly to people who have been through it with them.

David Raubach: Let's talk about the Oklahoma Comprehensive Cancer Network more broadly. The purpose of the OCCN is to continually develop, implement, evaluate, and update the cancer prevention and control plan for the Oklahoma State Cancer Plan. When did that first get published?

Jennifer Watkins: The idea came about around 2000 and then around 2004 efforts really started growing. So it has been around 21 or 22 years now. It's got some amazing partners — about 40 organizations participate. The ones you typically think of: health centers, cancer centers, American Cancer Society. But we also have local programs, survivorship groups, and just individuals who are interested. Our primary focuses are primary prevention — how do we prevent or at least reduce the risk of cancer — screening and early detection, and then survivorship.

David Raubach: Despite having high-quality cancer care in Oklahoma, our cancer mortality rates are not great. We tend to be towards the bottom of state rankings nationally. If you get diagnosed with cancer in Oklahoma, what percentage of people will succumb to it? Why do you think that is and what is the coalition doing to address it?

Jennifer Watkins: I came from a small town. I grew up understanding that country bootstraps, tough mentality — you only go to the doctor when your finger's cut off kind of thing. But understanding that yes, going to the doctor is scary and you may not get the news you want, but the sooner you go, your treatment outcomes are so much better. We can tremendously reduce mortality rates by early screenings, by following the guidelines. No one wants a colonoscopy — it's not the funnest thing in the world. But if that could stop your cancer right there, take a nap. We definitely want to encourage the early screenings. Finding it early to reduce the long-term effects is so important. And that's really what will change our mortality rates.

David Raubach: Is there also an access issue on top of the cultural component?

Jennifer Watkins: There definitely is. One of the great things we're seeing are mobile units starting to appear. Some federally qualified health centers and OU have mobile units — we can partner and make sure a community has access to mammography screening and lung cancer screenings by taking the screening to them. Oklahoma in the last year and a half created the Oklahoma Lung Cancer Roundtable and they actually have a website where you can find lung cancer screening locations all over the state. There are also programs like Take Charge at the health department or Oklahoma Project Woman that will help with screening and treatment. Never feel like you have to drive to the city from Idabel or Woodward.

David Raubach: Which cancers do you primarily focus on in terms of screening?

Jennifer Watkins: The ones we primarily focus on based on data are breast cancer, cervical cancer, colorectal cancer, lung, and prostate. Those are the highest incidence that we're seeing and the ones where we can have the biggest effect. There's some great research going on right now in prostate cancer with at-home tests. Men no longer necessarily have to go and have the uncomfortable doctor's appointment. And for average-risk individuals, you can do an at-home colorectal test. If you are high risk — like I am because of my dad — you still need to go get your colonoscopy. We're also seeing research on an at-home cervical cancer test that is about to roll out. Very exciting things that could really change the dynamics across Oklahoma.

David Raubach: What about lung cancer specifically, and the tobacco piece? You were part of the Tobacco Settlement Trust for a period of time.

Jennifer Watkins: Oklahoma was one of the only states that did such an amazing job with their tobacco settlement money by creating the Tobacco Settlement Endowment Trust. They've really set aside the money to help Oklahomans change the outcome on health. They established the Oklahoma Tobacco Helpline — anyone in Oklahoma can access that for counseling, help quitting, and even nicotine replacement therapy, all free. As far as lung cancer screening, the guidelines are basically 50 to 80 years old with a 20 pack-year history. If you've smoked a pack a day for more than 20 years and you're 50 or older, talk to your doctor about screening. The sooner we can catch it, the treatment outcomes are so much higher.

David Raubach: We do low-dose CT lung screening at the Proton Center because we have a CT sim there. One thing we discovered when we opened this program is that people would come in with 19 pack years instead of 20, or be 49 instead of 50, and their insurance wouldn't cover it. So we established what we think is a very affordable cash pay rate of $250 to get the low-dose CT lung screen. A pack-year, for our listeners, is an average of one pack a day for a year. If you smoke two packs a day for 10 years, that's 20 pack-years. If you're concerned, don't just say, "Well, I shouldn't get the scan" — there are options out there.

David Raubach: Talk a little bit about the work you're doing with the tribes as well. I think that's an important aspect of cancer mortality and cancer screening here in Oklahoma.

Jennifer Watkins: I absolutely love working with Cherokee Nation — they're the ones we work with most because they have a similar CDC cooperative agreement and a cancer plan. So we partner on so many things. Their program is called OTAA — Oklahoma Strategic Tribal Alliance for Health — and any tribe is welcome to participate. Cherokee Nation leads it because of the funding. They are focusing on how to improve rates for tribal members and anyone within their jurisdiction, using the same primary prevention, screening and early detection, and survivorship model that we do. Chickasaw Nation and Choctaw Nation are also members of the Oklahoma Coalition as well.

David Raubach: Talk about the importance of survivorship and what some of the initiatives are that the cancer coalition is offering.

Jennifer Watkins: We have survivorship divided into two areas: adult survivorship and childhood and young adult survivorship. With childhood and young adult cancers it's so much bigger. Understanding how whatever treatment a child had is going to impact their entire life — whether it's radiation to the chest and how that could impact them later on. We're also working with a national organization called Worth the Wait, which is actually looking at how to provide education on reproductive rights. An 8-year-old diagnosed with cancer — you're starting treatment that day or the next. You're not thinking about the reproductive rights of the child later on, but that's going to be important to them. We're hoping in September to kick off an event for childhood cancer awareness month addressing how parents, children, and young adults post-treatment can navigate building a family and the long-term effects.

David Raubach: Tell me about a patient you've worked with that has really impacted you personally.

Jennifer Watkins: One of them didn't actually become a patient, which makes me so excited. She was a young mother in her late 20s who lived in rural Oklahoma. She had lost her father to colon cancer at a very young age himself. She had had a positive FIT test and she was terrified. She didn't have insurance and had just gotten her green card, so the typical routes for financial assistance weren't available to her. She reached out — just terrified — asking, what am I going to do? I can't pay out of pocket. I can't leave my kid behind. We were able to make some connections and she was able to access a clinic and get an actual colonoscopy. And she just messaged me and said it was clean. Everything was clean and I'm so excited and I wouldn't have found it without you. I'm just lucky to be in a position where I know who to ask. For her to know she has the confidence that she's going to get to stay with her kid — that was amazing to me.

David Raubach: Sometimes those clean scans are the best thing in the world — just having that peace of mind. If somebody is looking for that type of help, how do they get a hold of you or the OCCN?

Jennifer Watkins: The easiest way to reach us is through our email at occn.gov. And if you type "Oklahoma Comprehensive Cancer Network" in a search, we're going to be the first option. And if you can't find the resource, you email me through that OCCN website and I will absolutely do everything I can to help.

David Raubach: Well, thank you so much for your time, Jennifer. This was great and I'm really excited to get all of this information out published online so people can appreciate it. You guys are doing great work, and we really appreciate everything you're doing personally and the team you've assembled there at the OCCN. It's fantastic and great for the state. Thank you.

Jennifer Watkins: Thank you.