Vol 28, No 5 (2023)
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Published online: 2023-10-05

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RESEARCH LETTER

Reports of Practical Oncology and Radiotherapy

2023, Volume 28, Number 5, pages: 707–709

DOI: 10.5603/rpor.97509

Submitted: 10.06.2023

Accepted: 18.09.2023

© 2023 Greater Poland Cancer Centre.

Published by Via Medica.

All rights reserved.

e-ISSN 2083–4640

ISSN 1507–1367

Navigator utilization among African-American breast cancer patients at a Comprehensive Cancer Center

Shearwood McClelland III12Ursula Burnette1Louisa Onyewadume1Chesley Cheatham1
1Department of Radiation Oncology, University Hospitals Seidman Cancer Center Case Western Reserve University School of Medicine, Cleveland, OH, United States
2Department of Neurological Surgery, University Hospitals Seidman Cancer Center Case Western Reserve University School of Medicine, Cleveland, OH, United States

Address for correspondence: Shearwood McClelland III, MD, Department of Radiation Oncology, University Hospitals Seidman Cancer Center, 11100 Euclid Avenue, Lerner Tower Office Suite B161, Cleveland, OH 44106, tel: 216-286-4149; e-mail: drwood@post.harvard.edu

This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to download articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially

Abstract
Background: Patient navigation has been demonstrated to improve access to standard-of-care oncologic therapy. However, many patients particularly those of African-American race often do not have access to navigation upon receiving a diagnosis of cancer. As the most common cancer among African-American women is breast cancer, we sought to assess the rate of patient navigation among African-American breast cancer patients at our institution, which resides in a regional ZIP code comprised of 46% African-American residents.
Materials and methods: African-American breast cancer patients who had been discussed at our weekly breast cancer multidisciplinary tumor board over a recent three-month period were assessed by a patient navigator representing the Navigator-Assisted Hypofractionation (NAVAH) program to determine their access to navigation in their cancer care. Responses were assessed from a breast cancer support group and culled to determine a baseline proportion of navigation utilization.
Results: A total of 18 women of African-American race having been diagnosed with breast cancer were identified and assessed. Of these a total of 4 noted that they had received navigation, yielding a navigation utilization percentage of 22.2% among African-American breast cancer patients at our institution.
Conclusion: The rate of navigation utilization among African-American breast cancer patients is poor. Despite our center residing in a region comprised of increased African-Americans, such predominance has not translated into optimizing navigation access for African-American breast cancer patients. This 22% rate of navigation utilization serves as a starting benchmark for initiatives such as the NAVAH program to provide tangible improvement in this patient population.
Key words: African-American; breast cancer; patient navigation
Rep Pract Oncol Radiother 2023;28(5):707–709

Introduction

Patient navigation is a community-based intervention designed to optimize access to timely diagnosis and treatment by eliminating barriers to care, thereby serving as a patient-centric healthcare service delivery model [1]. Originally founded by Dr. Harold Freeman, M.D., the importance of navigation and its integration into the healthcare team has increased over time commensurate with the increasing complexity of cancer care requiring coordination between the three primary arms of cancer treatment: surgical, medical, and radiation.

For African-Americans and other underrepresented minority patients diagnosed with cancer, navigation is of particular importance, since underrepresented patients are less likely to receive guideline-concordant oncologic care compared with Caucasian patients. As a result, increased adoption of navigation can potentially reduce oncologic treatment access disparities.

Unfortunately, many patients particularly those of African-American race often do not have access to navigation upon receiving a diagnosis of cancer. Ideally instituted at the time of cancer diagnosis, navigators work with patients to guide them through the maze of visits, laboratory tests and imaging which all comprise optimal care in a timely and cost-efficient manner [2].

As the most common cancer among African-American women is breast cancer (3-4), we sought to assess the rate of patient navigation among African-American breast cancer institutions at our institution, which resides within one of the first 50 National Cancer Institute-designated comprehensive cancer centers.

The primary zip code for our institution’s primary clinic (44106) is comprised of more than 46% African-American residents, which is far above the 12.6% African-American representation nationally [5], and the paultry 7% of African-American women on the CALGB9343 practice-changing breast cancer radiation therapy randomized controlled trial [6–7]. The Navigator-Assisted Hypofractionation (NAVAH) program has been recently implemented at our institution to address radiation therapy access disparities facing African-American breast cancer patients [8]; consequently, an investigation into the baseline pre-NAVAH navigation rate at our institution represents an important initial step in fostering cancer care equity for African-Americans with breast cancer.

Materials and methods

The University Hospitals Seidman Cancer Center conducts multidisciplinary breast cancer tumor boards comprised of breast surgeons, medical oncologists, radiation oncologists, pathologists, radiologists, nurses, patient navigators, and research coordinators on a weekly basis. All breast cancer patients are eligible for presentation and discussion of optimal management.

For this investigation, African-American breast cancer patients having completed initial surgical management and subsequently discussed for adjuvant radiation therapy at weekly tumor board were assessed by a patient navigator (UB) representing the NAVAH program for consideration of potential inclusion into NAVAH prior to discussion of their adjuvant radiation therapy options with a breast cancer radiation oncologist. This analysis occurred during a recent three-month time interval.

Patient navigation history was ascertained from medical records and during responses from an established breast cancer support group. Patients were considered to have received navigation if they documented having received navigation at any point from the time of their breast cancer diagnosis through the time of NAVAH navigator contact, including the times periods before or after initial surgery and before post-surgical discussion in breast cancer tumor board.

Results

An average of six African-American women per month diagnosed with breast cancer at our institution were identified and assessed, yielding a total of 18 patients evaluated in this analysis.

Of these 18 patients (age range: 28-62), a total of four women noted that they had received navigation between the time of cancer diagnosis and discussion of adjuvant therapy. This yielded a navigation rate among African-American breast cancer patients of 4/18 = 22.2% at our institution. The majority of patients navigated received navigation after their initial cancer surgery.

Discussion

Patient navigation has been demonstrated to improve access to standard-of-care oncologic therapy. In an ongoing oncologic navigation program known as Walking Forward (designed to provide culturally appropriate community education on cancer, screening and treatment for Native American patients), navigation has been demonstrated to: a) facilitate increased participation in clinical trials, b) assist cancer patients in using the healthcare system, c) reduce cancer treatment disparities facing Native American patients residing a median distance of 140 miles from any cancer center [9].

For cancer patients requiring radiation therapy (RT), navigation has also been shown to decrease RT treatment interruption compared with historical non-navigated RT patients [9]. These successes inspired the creation of the NAVAH program to utilize navigation to tangibly combat RT access disparities facing underrepresented minorities [8, 10]. Such a tangible goal requires an initial assessment of navigation prior to NAVAH implementation.

This study indicates that the navigation rate among African-American breast cancer patients at our institution is 22%, a number even more concerning given the high African-American representation in the community geographically located in this institution’s primary clinic location. However, this rate serves as a starting benchmark for subsequent initiatives to provide tangible improvement in this patient population.

Although this study is not without limitations, one of which is the limited time period of sampling, it provides tangible evidence of the need for active intervention to improve navigation exposure in this patient population. The evaluation of the efficacy of future initiatives, such as NAVAH, in comparison with this benchmark will provide evidence as to the utility of such initiatives in improving the care of these patients.

Acknowledgment/Conflicts of interest

Dr. McClelland serves as a consultant for Gilmartin Capital (a company that evaluates surgically targeted radiation therapies), receives travel funding from GT Medical Technologies Inc., and receives research funding from the University Hospitals Minority Faculty Career Development Award, the ASTRO Emerging Investigator Award, the Robert Winn Diversity in Clinical Trials Career Development Award, and the National Cancer Institute Paul Calabresi K12 Clinical Oncology Research Career Development Program. Chesley Cheatham receives research funding from Nature Stone Flooring and the American Cancer Society.

Funding

None declared.

References

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