Testing Telephone-Based Patient Navigation for Lung Cancer Screening in an Integrated Safety Net System

Background: While adherence to annual screening exceeded 90% in the National Lung Screening Trial, the trial population was disproportionately white, educated, and received care in the tightly controlled environment of a clinical trial. Rates of adherence in real-world settings are likely to be far lower. Low-dose computed tomography (LDCT)-based lung cancer screening represents a complex clinical undertaking that, for some patients, could require multiple referrals, appointments, and time-intensive procedures.¹

We are conducting a pragmatic randomized controlled trial (N = 340) to determine the impact of telephone-based patient navigation on completion of the lung cancer screening process in a county-integrated health system.² Algorithm-driven navigation involves instrumental (task-oriented or logistic) support to assist study participants with appointment scheduling, reminders, expenses, transportation, and other access to care and adherence issues.³ Patient navigators also provide emotional support, address patient-provider communication, manage cancer-related distress, and focus on quality of life.

Protocol approved by the UT Southwestern Medical Center Institutional Review Board (STU#122015-046), and by the Parkland Office of Research.

Objectives: To characterize navigation encounters by type and navigator-identified barriers and facilitators among those patients randomized to intervention (study accrual June 2017-June 2018) on standard-of-care referral to LDCT screening.

Methods: Research navigators, bilingual in English and Spanish, worked individually with study participants by telephone to educate, motivate, and empower participants to traverse the county health system. Navigators were trained using an abbreviated curriculum (~20 hours) adapted from GWU Cancer Institute.⁴ Navigators received supplemental training on motivational techniques and behavioral aspects of lung cancer screening, especially smoking cessation and modalities, as well as on patient resources specific to the county health system. Navigators make systematic contact with patients: initial intake; reminder (2-3 days prior to appointment); follow-up (3-7 days after scheduled appointment); and outreach (triggered by subsequent screening or diagnostic orders). We used both quantitative (EHR-derived trial database) and qualitative (navigator case tracking drawn from the database) methods.

Results: Of 318 patients enrolled at 12 months, 152 had been randomized to navigation. Intake calls averaged 4.9 minutes, with shorter reminder and follow-up calls (3.9; 2.3 minutes). Calls for subsequent procedures averaged 7.4 minutes. For all call types, Spanish language calls were ~30% longer. We found patient-reported barriers varied by screening process step. For example, reported lack of or failure to recall physician discussion of screening was common at intake. Patient motivation to complete screening appointment varied highly; many patients emphasized competing demands, including prevalent diagnoses, and limited transportation options. Although most current smokers were initially unresponsive or resistant to discussion of smoking cessation, uptake of referral to services and resources appeared to increase with navigation contact.

Conclusions: In an era of significant cost constraints, this randomized controlled trial of telephone-based patient navigation will provide key information on whether these services will strengthen lung cancer screening adherence and patient-reported outcomes. Indeed, sustainability of population adoption of CT screening for early detection of lung cancer may well hinge on the capacity of health systems to enable patients to complete all steps of this complex process.

References

1. Gerber DE, Gillam AO, Hamann HA. Lung cancer screening in the “real world” and the role of nurse navigators. Journal of Oncology Navigation & Survivorship. 2013;4(2):21-23.
2. Gerber DE, Hamann HA, Santini NO, et al. Patient navigation for lung cancer screening in an urban safety-net system: protocol for a pragmatic randomized clinical trial. Contemp Clin Trials. 2017;60:78-85.
3. Lin CJ, Schwaderer KA, Morgenlander KH, et al. Factors associated with patient navigators’ time spent on reducing barriers to cancer treatment. J Natl Med Assoc. 2008;100:1290-1297.
4. The GW Cancer Institute. Guide for Patient Navigators. A supplement to the Oncology Patient Navigator Training: The Fundamentals. https://smhs.gwu.edu/gwci/sites/gwci/files/Guide%20for%20Patient%20Naviga tors%20Final%20Jan%202016.pdf.