Walking Forward: American Indian Cancer Disparity Program 16 Year Update; Lung Cancer Screening in the Frontier Population

Transcription

1 Walking Forward: American Indian Cancer Disparity Program 16 Year Update; Lung Cancer Screening in the Frontier Population Daniel G Petereit, MD, FASTRO Avera Cancer Care Institute, Sioux Falls, SD Regional Cancer Care Institute, Rapid City, SD SD Cancer Coalition Fall Meeting

2 Objectives National Cancer Institute (NCI) Cancer Disparity Research Partnership (CDRP) Program Walking Forward Origins: Phase I and II: Objectives and 10 year results Phase III: Mobile health smoking cessation program Phase IV: Lung Cancer Screening Project (LDCT) Phase V: Palliative care grant ( )

3 Cancer in Native America Guadagnolo, Petereit Sem in Rad Oncol, 2017 McClelland, Leberknight, Petereit Advances in Radiation Oncology 2017 High rates of high risk health behaviors and comorbidities (social stressors) Low screening rates (resources, trust, remoteness, health literacy) AI/ANs more likely to have advanced-stage cancer at diagnosis than other racial groups AI/ANs less likely to get cancer-directed therapies after cancer diagnosis than non-hispanic whites

4 Stage of Cancer at Presentation Site Lung Breast Colorectal Prostate Cervix TOTAL: Total Patients Stage 1&2 Stage 3 Stage 4 Total % 3 & 4 Total Patients Stage 1&2 Stage 3 Stage 4 Total % 3 & % % % % % % % % % % % % Petereit et al JCO 22: , 2004

5 CDRP (Cancer Disparity Research Partnership) Build and stabilize independent and collaborative clinical research capabilities of institutions providing radiation oncology care to populations experiencing the negative consequences of cancerrelated health disparities. Story beings in 2001 e mail from a colleague C. Norman Coleman, MD, FASTRO Frank Govern, PhD Bhadrasain Vikram, MD, FASTRO Rosemary Wong, PhD Radiation Research Program Division of Cancer Treatment and Diagnosis National Cancer Institute

6 CDRP: Cancer Disparities Research Partnership Supporting the Nation s goal of eliminating cancer health disparities: Increase minority access to and participation in clinical trials Increase the number of clinical and translational scientists studying cancer disparities Develop new institutions ability to engage in long-term research efforts Investigate new areas of health disparities research

7 Target Institutions State-of-the-art radiation oncology facilities - Institutions with experience in research Access to a population that suffers negative consequences of health care disparities Radiation oncologist interested in clinical disparities with academic background

8 Addressing Cancer Disparities Behavioral research: assessing barriers to early cancer detection Culturally appropriate community education Comprehensive patient navigation program Recruitment to clinical trials Shorter treatment schedules for prostate and breast cancer: brachytherapy and IMRT (geographic distance) Primary Hypothesis: these interventions would lead to patients presenting with earlier stages of cancer Petereit et al. Addressing Cancer Disparities among American Indians, Frontiers in Radiation Oncology 6/22/11 Founding Partners: UW - Minesh Mehta, Mayo Judith Kaur

9 CDRP Award Recipients

10 Sept 2002: Grant Awarded

11 Western South Dakota Pine Ridge Rosebud Cheyenne River Rapid City

12 Walking Forward Critical Outcomes Accrual rate of 10% of AIs to clinical trials

13 Walking Forward Critical Outcomes Accrual rate of 10% of AIs to clinical trials Nearly 4,000 American Indians enrolled research studies

14 Walking Forward Critical Outcomes Accrual rate of 10% of AIs to clinical trials Nearly 4,000 American Indians enrolled research studies Significant reduction in the number of missed treatment days among navigated AI cancer patients undergoing cancer treatment

15 Walking Forward Critical Outcomes Accrual rate of 10% of AIs to clinical trials Nearly 4,000 American Indians enrolled research studies Significant reduction in the number of missed treatment days among navigated AI cancer patients undergoing cancer treatment Identification of specific barriers to effective cancer screening and cancer care

16 Walking Forward Critical Outcomes Accrual rate of 10% of AIs to clinical trials Nearly 4,000 American Indians enrolled research studies Significant reduction in the number of missed treatment days among navigated AI cancer patients undergoing cancer treatment Identification of specific barriers to effective cancer screening and cancer care Successful completion of a genetic study (ATM)

17 Walking Forward Critical Outcomes Accrual rate of 10% of AIs to clinical trials Nearly 4,000 American Indians enrolled research studies Significant reduction in the number of missed treatment days among navigated AI cancer patients undergoing cancer treatment Identification of specific barriers to effective cancer screening and cancer care Successful completion of a genetic study (ATM) Establishment of trusting partnerships with AI communities

18 Walking Forward Critical Outcomes Accrual rate of 10% of AIs to clinical trials Nearly 4,000 American Indians enrolled research studies Significant reduction in the number of missed treatment days among navigated AI cancer patients undergoing cancer treatment Identification of specific barriers to effective cancer screening and cancer care Successful completion of a genetic study (ATM) Establishment of trusting partnerships with AI communities Creation of research infrastructure to address new research questions

19 Walking Forward Critical Outcomes Accrual rate of 10% of AIs to clinical trials Nearly 4,000 American Indians enrolled research studies Significant reduction in the number of missed treatment days among navigated AI cancer patients undergoing cancer treatment Identification of specific barriers to effective cancer screening and cancer care Successful completion of a genetic study (ATM) Establishment of trusting partnerships with AI communities Creation of research infrastructure to address new research questions Continuation and creation of partnerships for sustainability

20 Sociodemographics Conceptual Model Prior Satisfaction with Health Care Mistrust Screening and Access Behaviors Cancer Stage At Presentation Cancer / Screening Knowledge Health System Factors

21 Patient Navigation Program Two Navigation Programs: 1. Community Navigation Program - Community Research Representatives (CRRs) - Assessment of barriers to early cancer detection - Goal: promote education, outreach networking 2. Cancer Navigation Program - RN navigators - Identify barriers during cancer treatment - Goal: assist cancer patients during cancer treatment

22 Pine Ridge Oglala Lakota Sioux Population: 40,000 Area: 3,468 square miles Pine Ridge Hospital Indian Health Services Romaine Tobacco, AA nursing Walking Forward Community Research Representative Smoking Cessation Research Clinic Education Patient navigation Doris Thibeault, RN Walking Forward Community Research Representative Smoking Cessation Research Colorectal Project (Univ of WA) Clinic Education Patient navigation

23 Rosebud Rosebud Sioux Tribe (Sicangu Oyate Lakota) Population: 10,000 Rosebud Indian Health Services Margaret O Connor, BA Walking Forward Community Research Representative Smoking Cessation Research Community Health Fairs Cancer Support Group Patient navigation Area: 1,970 square miles Simone Bordeaux, LPN Walking Forward Community Research Representative Smoking Cessation Research Community Health Fairs Cancer Support Group Health Board Representative Patient navigation

24 Rapid City Urban Population Rapid City Indian Hospital Kristin Cina Walking Forward Community Research Representative Dave Koop, RN Walking Forward Special Projects

25 Community and Cancer Surveys Cancer Screening in Native Americans from the Northern Plains Study conducted by: Ashleigh Guadagnolo, MD (University of Texas, M.D. Anderson Cancer Center) Shalini Kanekar, PhD (Rapid City Regional Hospital, Cancer Care Institute) Nancy Pandhi, MD (University of Wisconsin School of Medicine and Public Health) Daniel Petereit, MD (Rapid City Regional Hospital, Cancer Care Institute) Maureen Smith, MD (University of Wisconsin School of Medicine and Public Health)

26 Community Survey Implementation Participants: 975 individuals from three reservations and among the urban Native American community in the service region of Rapid City Regional Hospital Survey Purpose: collect data of participants screening and cancer specific knowledge, attitudes, beliefs Screening knowledge based on questions in the National Health Interview Survey Cancer specific attitudes, beliefs included in survey were based on input from community members and Community Research Representatives Survey Evaluation: examine the rates and determinants of cancer screening

27 Community Survey Conclusions Persistent Stage Disparity: o Native Americans (NA) presented with more advanced-stage screen-detectable cancers than non-nas: 45% versus 24% (breast, cervix, colorectal, prostate cancers) p=0.04 o Of patients with screen-detectable cancer, the identifying diagnosis was a screening test for 37% NA versus 68% non-nas p=0.006 Cancer screening was markedly underutilized in this sample - only 44% reported ever receiving cancer screening Strongest determinant of receiving cancer screening overall or for a specific cancer site was a screening recommendation by a doctor or nurse

28 Results published: Community Survey Impact Planned interventions (to be discussed): lead to successful funding for another five years (Walking Forward II) - Pandhi, N, Guadagnolo, B A, Kanekar, S, Petereit, DG, Smith, M A., Cancer Screening in Native Americans from the Northern Plains. American Journal of Preventive Medicine, 38(4), 2010; Pandhi N; Guadagnolo, BA; Kanekar, S; Petereit, DG: Karki, C; Smith, MA, Intention to Receive Cancer Screening in Native Americans from the Northern Plains, Cancer Causes and Control. 22(2): , Guadagnolo A, Petereit D, et al. Assessing cancer stage and screening disparities among Native American cancer patients. Public Health Reports Jan-Feb; 124 (1): Guadagnolo A, Petereit D, et al. Medical mistrust and less satisfaction with health care among Native Americans presenting for cancer treatment. Journal of Health Care for the Poor and Underserved. Feb;20(1):210-26, 2009.

29 Patient Navigation for Native Americans Undergoing Cancer Treatment Analysis of 332 NAs navigated February 2004 through September 2009 Historical comparison to 70 NAs not navigated Treatment interruptions during XRT, curative intent: 1.7 days navigated patients vs. 4.9 days non-navigated 22% of navigated patients enrolled in a clinical trial Guadagnolo BN, Petereit DG, et al, Cancer June 15, 2011

30 Patient Navigation Impact Reduction treatment interruptions: Yes Overall experience during treatment enhanced: Yes Change in trust towards healthcare system: No Cultural Competency: Yes Molloy, K, Petereit, D et al. Developing and Implementing a Culturally Competent Patient Navigator Program in American Indian communities in Western, South Dakota. Association of Community Cancer Centers Oncology Issues, 22 (5);38-41, Sept/Oct Guadagnolo BA, Cina K, Koop D, Brunette D, Petereit DG. A pre-post survey analysis of satisfaction with health care and medical mistrust after patient navigation for American Indian cancer patients in the Northern Plains. Journal of Health care for the Poor and Underserved. 22(4), 2011;

31 Yearly Mileage for Walking Forward Team September 2006 August 2007 OST RST CRST RC Kevin Total by Month Sept Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug TOTALS

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34 Clinical Trials Rationale o Emerging technologies often only available and early in implementation are best administered through clinical trials: o Nationally, minority participation rates in clinical trials are low (approximately 3%) o Racial discrepancies in clinical trial participation rates may contribute to cancer-related disparities

35 Clinical Trials Breast Brachytherapy o Mastectomy rates Northern Plains Medicare survey reported that only 1.4% Medicare patients underwent breast conservation in Rapid City Duration of treatment and distance from cancer center barrier to breast conservation? o Phase II trial developed to address community needs

36 Breast Cancer: Treatment Options Linear Accelerator

37 : Clinical Trials Breast Brachytherapy

38 Change in Breast Conservation Rates Impact Breast PN and Brachytherapy? Petereit DG, Guadagnolo A (2016). "A Multi-faceted Approach to Improving Breast Cancer Outcomes in a Rural Population, and the Potential Impact of Patient Navigation " South Dakota Medicine 69(6):

39 Breast Brachytherapy Utilization Brachytherapy (%) Presley C J et al, Journal of Clinical Oncology 2012;30:

40 Clinical Trials Intensity Modulated Radiotherapy (IMRT) Rapid City was the first community site and the fourth unit worldwide installed 2001

41 Phase I/II Prostate Hypofractionation Trial Low-Risk Disease (Early Stage Disease) Mark Ritter, MD, PhD, PI Predicted late toxicities equivalent to 76 Gy in 2 Gy fractions -320 patients accrued -50 enrolled from Rapid City

42 Phase I/II Prostate Hypofractionation Biochemical PFS versus Hypofractionation Level Ritter, MA, et al, IJRBP 2009

43 Prostate Hypofractionation Trial: Rectal Bleeding Fig. 5

44 ATM Mutations in American Indians Possible Association with Cancer and Radiotherapy Toxicities Determine the association between ATM heterozygosity and sensitivity to radiation Amy Moser, PhD, UW Gene sequencing Enrollment: 100 Native Americans 100 non-native Americans

45 ATM Mutations in American Indians Conclusions: No higher prevalence in AIs versus non-ais Of variants identified, many are predicted to effect protein function; proving this is extremely difficult without in vitro assays of each SNP currently did not exist Success of recruiting AIs to genetic study (low refusal rate) Identified commons variants and possibly some new ones Petereit, D G; Hahn, L J; Kanekar, S; Boylan, A; Bentzen, S M; Ritter, M; Moser, A R. Prevalence of ATM Sequence Variants in Northern Plains American Indian Cancer Patients. Frontiers in Oncology. 3(319):1-5. Dec 30, 2013.

46 Clinical Trial Development Enrollment

47 Successful Recruitment Clinical Trials 225 AIs with patient navigation during radiation enrolled on a clinical trial Reasons for non-participation in clinical treatment trials for AIs: o 29% Advanced stage and/or poor performance status o 16% No trial available for cancer site o 15% Ineligible for other reasons after evaluation Guadagnolo B, Petereit D, Helbig P, et al, Involving American Indians and Medically Underserved populations in Cancer Clinical Trials. Clinical Trials: Journal of the Society for Clinical Trial, 6(6), Dec 2009;

48 Walking Forward II Objectives Increased efforts cancer screening and education Placement of cancer screening navigators within the Indian Health Services (IHS) Hospitals Continuation of Patient Navigation Enrollment clinical trials Partnerships with other national disparity programs

49 Model for Expanding Patient Navigation Walking Forward II ( )

50 Cancer Screening Coordinators

51 Walking Forward: Screening Initiatives Totals for Rapid City, Pine Ridge, Rosebud, and Cheyenne River Breast, cervix, colorectal, and prostate: 1,781 Cancer Screening Among American Indians by Walking Forward Program Site # of Screens Abnormal Test Results Cancer Diagnosis Pending Results Breast Cervix Colorectal Prostate Total

52 American Indian Stage at Cancer Presentation Potential Impact of Walking Forward Interventions P < Cancer Stage at Presentation (WF era) In situ 13 (8%) 18 (4%) Localized 48 (29%) 187 (45%) Regionalized 41 (25%) 126 (30%) Distant 63 (38%) 89 (21%) Total

53 mhealth Smoking Cessation Study (WF Phase III) Study Timeframe: October 2012 to July 2017 Principal Investigator: DG Petereit Co-Investigators / Research Team - L. Burhansstipanov, MSPH, DrPH - Linda U. Krebs, PhD, RN, AOCN, FAAN - Sheikh Iqbal Ahamed, PhD - Mark Dignan, PhD - Stevens Smith, PhD

54 Research Question / Hypotheses Primary H o : Why don t more Northern Plains American Indians alter tobacco use behaviors known to increase the risk of cancer? AI mhealth Smoking Dependence - Findings; Petereit R01CA170336; Burhansstipanov, Native American Cancer 54

55 Mobile Health Smoking Cessation Study Target Population 254 adult AIs living on one of the three study sites: Rosebud, Pine Ridge, Rapid City Users of commercial tobacco (50% smoking rate AI population) Desire to quite smoking 10 interactions with CCRs o Ten surveys (5 long, 5 abridged) o Eight carbon monoxide tests o Multiple Pre-cessation and cessation counseling sessions RCT with 15 interventions: minimal vs intense The primary outcome was self-reported abstinence from smoking which was verified by carbon monoxide (CO) measurements, and was assessed during visits 1, 5, 6, 7, 9, 10 and 11

56 Mobile Health Smoking Cessation Study Four Interventions: minimal versus intense (RCT) 1. Nicotine replacement therapy (NRT): patch and/or oral 2. Pre-cessation counseling 3. Post-cessation counseling 4. Smart phones (mhealth): text messaging

57 Recruitment and Implementation 57

58 Eligibility American Indian 18 years or older Living in 1 of the 3 study sites Current daily smoker (not concerned about ceremonial use of tobacco) Willing to Willing to take part in: Counseling sessions Use NRT Take CO tests Stop smoking (3 mos) Daily text messaging 11 visits with CRR 58

59 256 AI daily smokers enrolled in study 108 made it to visit 5 (QUIT date) Why didn t the others (148 participants)? Some more interested in receiving phones/service than smoking cessation Level of readiness to quit Excessive family stress (change) IHS pharmacies in 1 study site did not want to provide NRT E-Cigarettes (removed from study) 59

60 Smoking Status by Visit Longer participants remained in the study, the higher likelihood of smoking cessation

61 Table X: Smoking Status of participants at each visit; percent calculated based on all those who made it to visit 5 Non Smoker Smoker Total Frequency Percent Frequency Percent Frequency Visit 5 (quit date) Visit 6 (1 week after quit date) Visit 7 (2 weeks after quit date) Visit 9 (6 months) Visit 10 (12 months)

62 Summary/Conclusions 25% 6 months from QUIT date (108 participants) Cold Turkey baseline is 3-5% Chantix 14% success rate 21.3% 1 year from QUIT date People quit without sufficient perceived social support All 4 intervention components (NRT, Pre- and Post- cessation MI counseling, mhealth) had impact in every combination 62

63 Summary/Conclusions The results identified use of pharmacologic support for quitting smoking and participation in counseling were most effective in individuals who continued participation through the study NRT was a primary factor supporting successful smoking cessation mhealth text messages did not appear to contribute to cessation 63

64 Why Did 148 Keep Smoking? Many participants were more interested in receiving phones and phone service than smoking cessation Some participants attempted to confuse the CRRs about their smoking status by going to the local casinos to inhale tobacco contaminated air and then visiting the CRR to take the CO test Family stress, gaining weight, anxiety, anger irritability: NOT ready to quit Some had private insurance and went to Chantix, were successful in smoking cessation, but had to be removed from the study 64

65 Lung Cancer Screening Rationale Northern Plains AIs: highest lung cancer mortality rate US Plescia American Journal of Public Health, (S3) Smoking rates western, SD: 13-41% National Lung Cancer Screening Trial (NLST) Reduction lung cancer mortality with LDCT for high risk patients LDCTs markedly underutilized 2-4% Jemal et al Lung cancer screening with low-dose computed tomography in the united states 2010 to JAMA Oncology, Limited understanding LDCTs primary care providers (PCP) High risk individuals: many unaware Higher cure rates and good treatment options: surgery or SRS 65

66 AI Lung Cancer Disparity Rapid City ( ) p=.008

67 Early detection through low-dose CT screening may reduce mortality

68 Lung Cancer Screening Pilot Study in the Frontier Population Conducted CME workshops to increase LDCTs and development of an online tool: 6 communities PCPs needed more information lung screening guidelines, screening referrals, billing codes Evaluated the effectiveness of the online tool 68

69 Increasing Lung Cancer Screening for High Risk Smokers in a Frontier Population Research Question: will provider and/or individual level interventions increase low dose computerized axial tomography (LDCT) lung cancer screening among high risk smokers living in western South Dakota? Project Goal: To increase lung cancer screening rates by educating primary care providers and their clinic staff as well as community members in western South Dakota.

70 Increasing Lung Cancer Screening for High Risk Smokers in a Frontier Population Bristol-Myers Squibb Foundation - Funded February x 2 study design to evaluate provider (n=135) and individual level (n=1000) interventions Both interventions include education and introduction to the online resource Metric will be increase in screening LDCTs 14,000 patients at risk in Western, SD **First WF Project to include all of western SD 70

71 Study Schematic 71

72 Challenge: Limited access to screening LDCT 2 X 2 Design Intervention: Study Groups: A B C D Provider No* Yes No* Yes Individuals No* No* Yes Yes *delayed intervention based on study findings 72

73 Lessons Learned / Critical Outcomes Community buy-in (CBPR)

74 Lessons Learned / Critical Outcomes Community buy-in (CBPR) Patience / time - Inherent conflict: NCI versus community goals

75 Lessons Learned / Critical Outcomes Community buy-in (CBPR) Patience / time - Inherent conflict: NCI versus community goals Essential that PI is part of the community/region

76 Lessons Learned / Critical Outcomes Community buy-in (CBPR) Patience / time - Inherent conflict: NCI versus community goals Essential that PI is part of the community/region Personnel issues

77 Lessons Learned / Critical Outcomes Community buy-in (CBPR) Patience / time - Inherent conflict: NCI versus community goals Essential that PI is part of the community/region Personnel issues Dedicated research time (funding)

78 Lessons Learned / Critical Outcomes Community buy-in (CBPR) Patience / time - Inherent conflict: NCI versus community goals Essential that PI is part of the community/region Personnel issues Dedicated research time (funding) Communication with staff and community

79 Lessons Learned / Critical Outcomes Community buy-in (CBPR) Patience / time - Inherent conflict: NCI versus community goals Essential that PI is part of the community/region Personnel issues Dedicated research time (funding) Communication with staff and community NCI Funding: funding of patient navigation is no longer a priority

80 Lessons Learned / Critical Outcomes Community buy-in (CBPR) Patience / time - Inherent conflict: NCI versus community goals Essential that PI is part of the community/region Personnel issues Dedicated research time (funding) Communication with staff and community NCI Funding: funding of patient navigation is no longer a priority 5-year program turned into a 20-year program

81 Lessons Learned / Critical Outcomes Community buy-in (CBPR) Patience / time - Inherent conflict: NCI versus community goals Essential that PI is part of the community/region Personnel issues Dedicated research time (funding) Communication with staff and community NCI Funding: funding of patient navigation is no longer a priority 5-year program turned into a 20-year program Hospital administration: education Avera Health integrated Walking Forward into their system

82 Lessons Learned / Critical Outcomes Community buy-in (CBPR) Patience / time - Inherent conflict: NCI versus community goals Essential that PI is part of the community/region Personnel issues Dedicated research time (funding) Communication with staff and community NCI Funding: funding of patient navigation is no longer a priority 5-year program turned into a 20-year program Hospital administration: education Avera Health integrated Walking Forward into their system Absolute persistence

83 Advancing Palliative Care in Northern Plains American Indians PIs: Katrina Armstrong, MD (HMS/MGH), Daniel Petereit, MD (WF) Investigator Team: Mary Isaacson, JR LaPlante, Tinka Duran, Francine Arneson, Harvard Staff (Janet Ho) Partners: MGH, Walking Forward Avera, SDSU, Great Plains Tribal Chairmen s Health Board Phase 1: Development and Refinement of Outcome Measures Development of Educational Program Development of Palliative Care Community Health Worker Program Refinement of Patient Reported Outcome Measures Phase 2: Intervention Implementation and Evaluation

84 Research Team Co-Investigators / Research Team - Linda U. Krebs, PhD, RN, AOCN, FAAN (NACI) - Sheikh Iqbal Ahamed, PhD (Marquette Univ) - Lisa D. Harjo, B.S., M.A. - Daniel Petereit, MD, FASTRO - L. Burhansstipanov, MSPH, DrPH - Mark Dignan, PhD Not Shown: - S. Kanekar, MS, PhD (RCRH) - Stevens Smith, PhD (Univ of Wisc) - Simone Bordeaux, LPN (Avera) - Kristin Cina (Avera) - Kim Crawford (Avera) - Michele Sargent (Avera) - Doris Thibeault (Avera) 84

85 Walking Forward Team

86 Walking Forward Collaborations MD Anderson Cancer Center since 2004 B. Ashleigh Guadagnolo, MD, MPH Enrolled member of the Choctaw Nation of Oklahoma Associate Professor, Radiation Oncology, M.D. Anderson Cancer Care Center

87 Mobile Health Smoking Cessation Study Walking Forward Collaborator Linda Burhansstipanov, MSPH, DrPH Cherokee Nation of Oklahoma Founder, Native American Cancer Research Corporation Founder, Native American Cancer Initiatives, Inc.

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89 Avera Walking Forward Management Team Avera McKennan Hospital & University Health Center Sioux Falls, SD Avera acquired the Walking Forward Research Program from Rapid City Regional Health in September Primary goal: sustainability Daniel G. Petereit, MD, FASTRO Avera Medical Director Disparity Research Brian Leyland-Jones, MD, PhD VP, Molecular and Experimental Medicine Casey Williams, PharmD, BCOP Director, Molecular and Experimental Medicine

90 Walking Forward s Vision To improve the quality of life for AI cancer patients from early detection, successful treatment and survivorship - including end of life care Walking Forward s Mission This has been and will continue to be accomplished through access to screening, state of the art cancer treatments and clinical trials, and comprehensive patient navigation Expansion into the entire Frontier population

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92 Life was lived in the first 20 years and the remainder is just a reflection Graham Greene

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