A large study of the impact of patient navigation (PN) on breast cancer management has found that women who receive PN are diagnosed faster than non-navigated women, and the difference is most striking among biopsied women. The findings are important given that shortened time to diagnosis can potentially translate into earlier treatment and improved patient outcomes.
Heather J. Hoffman, PhD, from the department of epidemiology and biostatistics at the George Washington University School of Public Health and Health Services, Washington, DC, is lead author of the study, which was published in the October issue of the journal Cancer Epidemiology, Biomarkers & Prevention.
Patient navigators are trained nurses, social workers, or laypeople who assist patients in moving through the sometimes confusing maze of the healthcare system, addressing barriers that can cause them to miss medical appointments and delay treatment. PN services include helping patients to complete insurance paperwork, find transportation to medical appointments, identify local resources (for care of very young or elderly family members, etc), optimize their communication with healthcare professionals, and feel supported emotionally.
The first PN program was launched in 1990 at Harlem Hospital Center in New York City, by Harold J. Freeman, MD, to address a disparity in access to timely diagnosis and treatment of breast cancer among poor women. That pilot program showed improved 5-year survival rates for breast cancer among the navigated women, and subsequent studies of PN by investigators in a variety of settings indicate that it can benefit cancer patients. But Dr. Hoffman and coauthors emphasize in their article that, while PN has been implemented in cancer centers across the US, “empirical evidence [of] its effectiveness is lacking.”
The current investigation by Hoffman et al is part of a multicenter program initiated by the National Cancer Institute in 2005, to assess the impact of PN on a variety of cancers. The George Washington Cancer Institute is a participant in the project, and established a District of Columbia research initiative to determine the ability of PN to reduce breast cancer diagnostic time (ie, number of days from abnormal screening to definitive diagnosis). Washington, DC, has one of the highest death rates from breast cancer in the United States.
The study included 2,601 women 18 to 98 years old who were examined for breast cancer due to what the authors described as “a suspicious breast abnormality,” from 2006 to 2010 at nine hospitals or clinics in Washington, DC. All of the women had a breast lump. Of this group, 1,047 received PN and 1,554 did not participate in PN but received advice from a healthcare professional to follow up on the lump. (Non-navigated women were selected randomly and retrospectively.) Dr. Hoffman and coauthors wrote that “analyses included only women who reached complete diagnostic resolution.” ANOVA models were used to assess relationships between diagnostic time and a number of independent variables (including navigation group, race/ethnicity, type of health insurance, age, and biopsy as the definitive test).
The diagnostic time was significantly shorter for navigated vs non-navigated women, at an average of 25.1 days vs 42.1 days, respectively. Patient subgroup analyses showed that among biopsied women, average diagnostic time was cut in half with PN, at an average of 26.6 days, compared with an average diagnostic time of 57.5 days in non-navigated women (P < .0001). Among women who were not biopsied, the authors wrote, average diagnostic time was shorter for navigated vs non-navigated women, but the difference was not statistically significant, at 27.2 days vs 34.9 days (P = .15), respectively.
The authors commented on several study limitations, including a patient sample selected from a single metropolitan area and the fact that all patients had reached diagnostic resolution, so it was not possible to assess differences in diagnostic resolution rates between navigated vs non-navigated women. However, they concluded that their study “clearly shows navigation is effective in decreasing time to diagnostic resolution, particularly among women who have a biopsy and have a diagnostic resolution of cancer,” and emphasized that “patient navigation should be implemented as a means to reduce diagnostic times.”
Importantly, Dr. Hoffman and coauthors also noted that, “analyses of the national PRNP data are currently being conducted, including further analysis of navigation’s cost-effectiveness. These results will determine whether patient navigation will be viewed positively by national health policy makers and will become a usual part of the cancer care process with insurance reimbursement for patient navigation.”