Low-income populations experience substantial barriers to cancer care, and in the year 2014, the burden of cancer mortality surpassed that of heart disease in 22 US states, according to Dwana “Dee” Calhoun, MS, Director of SelfMade Health Network, a member of the CDC’s Consortium of National Networks to Impact Populations Experiencing Tobacco-Related and Cancer Health Disparities. “So we have a lot of work to do for these populations,” she told attendees at the Academy of Oncology Nurse & Patient Navigators 7th Annual Navigation & Survivorship Conference.
Low-Income Populations and the Birth of Navigation
In 1989, the American Cancer Society held “National Hearings on Cancer in the Poor” in 7 cities nationwide. The objective of these hearings was to target the magnitude of unmet need among underserved populations diagnosed with cancer, as well as common barriers and strategies to address them. The report to the nation unveiled critical issues in low-income populations: individuals in these populations often do not seek care if they cannot afford to pay for expenses, and low-income patients and their families often make extreme personal sacrifices to obtain and pay for cancer care.
To compound the problem, cancer education programs are often viewed as culturally insensitive and irrelevant to many low-income populations, and these patients typically endure more pain and suffering related to their cancer when compared with other Americans due to late-stage diagnosis. “These findings were so important because at the time of the report, the American Cancer Society estimated that cancer survival rates among poor populations were significantly higher when compared to other populations with cancer,” Ms Calhoun reported.
Conclusions from this report led to the first patient navigation program, pioneered in 1990 by Dr Harold Freeman in Harlem, NY, that resulted in a significant decrease in late-stage breast cancer and a significant increase in early detection among low-income African American women in Harlem. Subsequently, the scope of that navigation program was expanded and applied across the entire healthcare continuum and has now become an integral part of healthcare.
“According to Dr Freeman, the basic goal of navigation is to promote and facilitate timely access to quality standard care for all populations, in a culturally sensitive manner,” said Ms Calhoun. Studies have demonstrated that poverty is associated with low education, inadequate social support, substandard living conditions, unemployment, risky behaviors or exposure to risky behaviors (ie, secondhand cigarette smoke), and diminished access to timely healthcare. But patient navigation aims to reduce these harmful delays in accessing services while increasing the timeliness of diagnosis and treatment and reducing the number of patients lost to follow-up.
Patient-centered care is vital to patient education and empowerment, particularly among impoverished cancer patients, and according to Ms Calhoun, it is important to consider a patient’s health literacy level. They might be reluctant to ask questions, but effective communication and shared decision-making are critical in this population. “Patient centeredness is so important in low-income populations,” said Ms Calhoun. “It means providing equitable care not only respectful of, but responsive to, the patients’ preferences, needs, and value systems.”
The Impact of Navigators in Underserved Populations
Health outcomes are influenced by complex, integrated, ever-evolving and sometimes overlapping structures and systems, including health system factors (health insurance coverage, out-of-pocket costs, access to a usual source of care, lack of care coordination), social factors (socioeconomic status, social support mechanisms), and environmental factors (housing, segregation, food insecurity). “Health disparities are differences in health outcomes closely linked with social, economic, and environmental disadvantage,” Ms Calhoun explained. “And cumulatively, these things can also impact patient navigation–related outcomes.”
According to the National Cancer Institute (NCI), cancer health disparities are adverse differences in cancer incidence, prevalence, morbidity, mortality, and survivorship, and the burden of cancer or related health conditions that exist among specific populations. Mortality-related breast and colorectal cancer disparities exist by race/ethnicity, and lung and bronchus cancer disparities exist by geographic region, for example.
Due to the large increase in the number of cancer survivors, survivorship is now explicitly mentioned in the NCI’s cancer care continuum, and economically disadvantaged people experience significant social and economic challenges during the permanent stage of survivorship, when they might have concerns about employment status and health insurance, fear of recurrence, and secondary effects from previous cancer treatment.
According to Ms Calhoun, patient navigators provide hope for this population. Among underserved patient populations, patient navigation services have been shown to decrease anxiety associated with medical treatment and increase patient satisfaction with services. Additionally, patients in this population receiving navigation services report fewer disruptions in cancer care and are more likely to complete their cancer treatment. But encouraging patients to complete satisfaction surveys is crucial to gathering metrics and showing progress in the field, she added.
