April 2016 VOL 7, NO 3
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Patient Navigation Success Varies Among Different Groups of Women with Breast and Gynecologic Cancers
Patient navigation is a patient-centered healthcare delivery method that assists patients in overcoming barriers to oncology care throughout the cancer care continuum. Patient navigation is especially helpful for patients with breast and gynecologic cancers because of the survival benefit of early detection in this population.1 Documented racial and ethnic inequalities also exist in women’s cancer care across disease trajectories. In 2015, cervical cancer incidence rates among Hispanic women were 50% higher than in white, non-Hispanic women; the death rate for cervical cancer in black women was twice that of white, non-Hispanic women. Although white women had the highest rate of breast cancer incidence, black women had the highest breast cancer mortality rate; therefore, patient navigation may be helpful in reducing these disparities. In addition, because the American College of Surgeons Commission on Cancer (CoC) announced in 2012 that healthcare facilities pursuing CoC accreditation must implement patient navigation processes by the first of January 2015, Jessica L. Krok-Schoen, PhD, Comprehensive Cancer Center, The Ohio State University, Columbus, and colleagues identified the need for a review of the influx of new patient navigation interventions. To explore whether these new patient navigation interventions can help reduce healthcare disparities, the study authors summarized the recent literature on patient navigation in breast and gynecologic cancers from screening through treatment, and highlighted the challenges and opportunities of patient navigation that impact women’s health.
They searched PubMed and Medline for studies published from January 2010 to October 2015—particularly from the past 2 years—addressing patient navigation for patients with breast and gynecologic cancers. A total of 209 articles related to patient navigation in women’s cancers were found, 29 of which met inclusion criteria. These articles were then sorted into categories that spanned the cancer care continuum (ie, screening, diagnostic resolution, and after primary diagnosis).
The literature on patient navigation interventions to increase breast cancer screening included 5 studies, whereas the literature pertaining to gynecologic cancer was limited to 1.
Of note, in a large, clinical trial of 3895 women from inner cities, researchers found no statistical difference in mammography adherence between patients who received standard care, and those who received patient navigation at baseline. After the 9-month intervention, mammogram adherence was significantly higher in the patient navigation group compared with the control group (87% vs 76%, respectively; P <.001). Women who received educational materials and patient navigation services had a significantly higher likelihood of being within guidelines for mammography screening at the end of the follow-up period compared with those who only received educational material.
In the study examining the impact patient navigation has on gynecologic cancer screening rates, it was found that, among Chinese women in need of Papanicolaou tests, screening rates were significantly higher in those who received patient navigation services and education versus women who only received education without patient navigation services (70% vs 11.1%, respectively; P <.001).
In several quasi-experimental studies on patient navigation and diagnostic resolution for abnormal breast and gynecologic cancer screenings, patient navigation significantly shortened the time to diagnostic resolution compared with women who did not receive patient navigation.
One study exploring patient perceptions of clinical care and patient navigation in abnormal mammography follow-up demonstrated no differences in timeliness of care, ease of access, quality of care, unmet needs, and patient satisfaction between groups who did and did not receive patient navigation. However, another study showed an association between patient navigation for abnormal breast cancer screening and shorter time to diagnostic resolution (95% confidence interval, 1.20-2.28; P = .002) from days 31 to 365.
After Primary Diagnosis
Of the 8 studies on patient navigation after cancer diagnosis included in the review—none of which pertained to gynecologic cancers—showed no significant effect of patient navigation on disease-specific quality-of-life scores in patients with breast cancer who were navigated versus those receiving standard care from baseline to 3 months. Another study that sought to examine the effectiveness of patient navigation in reducing time from breast cancer diagnosis to treatment among Hispanic/Latino women showed that there was a significantly higher percentage of women who received patient navigation who initiated treatment within 30 days and 60 days from diagnosis versus those who did not receive navigation. Time from breast cancer diagnosis to initial treatment was significantly lower in the group that received patient navigation (22.22 days) than those who did not receive patient navigation (48.30 days). In another study seeking to improve the receipt of recommended care for patients newly diagnosed with breast cancer, the findings varied based on the type of treatment the patients received; patients who received navigation were more likely to have been given antiestrogen therapy compared with patients receiving standard usual care.
Trends in Patient Navigation
“As evidenced in this literature review, patient navigation has been shown to help women receive cancer screenings, receive more timely diagnostic resolution after a breast and cervical cancer screening abnormality, initiate treatment sooner, receive proper treatment, and improve quality of life among cancer patients,” Dr Krok-Schoen and colleagues reported. “Also, it was shown that patient navigation eliminates barriers to care.” They also noted the trend in patient navigation programs that specifically focus on reducing health disparities among racial and ethnic minorities and/or underserved populations. Another trend was the limited efficacy of patient navigation in certain groups, suggesting that patient navigation may not be equally effective for all groups; for example, there were differences found in patient navigation effectiveness with regard to age, ethnicity, location of care, and type of screening test and treatment. As a result, the study authors noted that although patient navigation is appropriate for all populations, a “one-size-fits-all” approach may not be best. They suggest that targeting patient navigation to specific populations may be a solution if implementation across the entire patient population is too demanding, especially because the CoC’s accreditation mandates are not currently funded. Through identification of women who are most in need of patient navigation, resources can be targeted to those who are more likely to delay or not receive quick and suitable care.
Future Research Opportunities
Because of the increased prevalence of patient navigation, there are growing research opportunities in patient navigation and women’s health. “One area that is ripe for researchers is patient navigation in cancer survivorship, particularly among posttreatment cancer survivors,” the study authors stated. “As evidenced by this review, the few studies that have explored patient navigation in gynecological cancers showed promising results. Thus, researchers should make gynecological cancers a focus for their [patient navigation] interventions to maximize the positive impact on this survivor population.” Dr Krok-Schoen and colleagues also noted that future research opportunities can include testing patient navigation interventions in posttreatment settings and patients with gynecologic cancers, age-related barriers to patient navigation, and collaborative efforts between community health workers and patient navigators. They suggested that further research will be required to determine the effectiveness of patient navigation across the cancer care continuum and in different patient populations as these programs continue to develop.
- Krok-Schoen JL, Oliveri JM, Paskett ED. Cancer care delivery and women’s health: the role of patient navigation. Front Oncol. 2016;6:2.
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