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.