Patient navigation to address sociolegal barriers for patients with cancer: A comparative-effectiveness study

Systematic Review of Interventions Addressing Racial and Ethnic Disparities in Cancer Care and Health Outcomes

PURPOSE

Cancer health disparities result from complex interactions among socioeconomic, behavioral, and biological factors, disproportionately affecting marginalized racial and ethnic groups. The objective of this review is to synthesize existing evidence on interventions addressing racial or ethnic disparities in cancer-related health care access and clinical outcomes.

METHODS

A comprehensive search of Cochrane Library, Google Scholar, Ovid MEDLINE, Ovid Embase, PubMed, Scopus, and Web of Science Core Collection was conducted from database inception to February 23, 2023. Controlled vocabulary and keywords helped to identify studies on cancer-related disparities and interventions in adults age 18 years or older. Two reviewers followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis reporting guidelines. Study quality was assessed using the Joanna Briggs Institute Critical Appraisal Tool.

RESULTS

Of 7,526 screened studies, 34 met the inclusion criteria involving 24,134 participants. Most studies focused on breast cancer (n = 17) and Hispanic/Latino populations (n = 10) and enrolled participants primarily from community-based sites (n = 19). Twenty-one studies examined patient-centered outcomes, such as health-related quality of life and psychological well-being, while 15 studies assessed process-of-care outcomes, such as timeliness of care. Most studies followed a community-based participatory research framework. Five patient-centered outcome studies reported a positive intervention effect, often combining cancer education with psychological well-being interventions. Among the 15 process-of-care outcome studies, nine reported positive effects, with the majority (n = 8) being navigation-based interventions.

CONCLUSION

This systematic review emphasizes the vital role of community partnerships in addressing racial and ethnic disparities in oncology care and highlights the need for standardized approaches in intervention research because of the heterogeneity of studied interventions. Furthermore, the prevailing emphasis on breast cancer and Hispanic populations indicates the need for future investigations into other priority demographic groups.

Patient Navigation in Cancer Treatment: A Systematic Review

PURPOSE OF REVIEW

Patient navigation promotes access to timely treatment of chronic diseases by eliminating barriers to care. Patient navigation programs have been well-established in improving screening rates and diagnostic resolution. This systematic review aimed to characterize the multifaceted role of patient navigators within the realm of cancer treatment.

RECENT FINDINGS

A comprehensive electronic literature review of PubMed and Embase databases was conducted to identify relevant studies investigating the role of patient navigators in cancer treatment from August 1, 2009 to March 27, 2023. Fifty-nine articles were included in this review. Amongst studies focused on cancer treatment initiation, 70% found a significant improvement in treatment initiation amongst patients who were enrolled in patient navigation programs, 71% of studies focused on treatment adherence demonstrated significant improvements in treatment adherence, 87% of studies investigating patient satisfaction showed significant benefits, and 81% of studies reported a positive impact of patient navigators on quality care indicators. Three palliative care studies found beneficial effects of patient navigation. Thirty-seven studies investigated disadvantaged populations, with 76% of them concluded that patient navigators made a positive impact during treatment. This systematic review provides compelling evidence supporting the value of patient navigation programs in cancer treatment. The findings suggest that patient navigation plays a crucial role in improving access to care and optimizing treatment outcomes, especially for disadvantaged cancer patients. Incorporating patient navigation into standard oncology practice can reduce disparities and improve the overall quality of cancer care.

Financial-legal navigation reduces financial toxicity of pediatric, adolescent, and young adult cancers

BACKGROUND

Pediatric, adolescent, and young adult patients with cancer and their caregivers are at high risk of financial toxicity, and few evidence-based oncology financial and legal navigation programs exist to address it. We tested the feasibility, acceptability, and preliminary effectiveness of Financial and Insurance Navigation Assistance, a novel interdisciplinary financial and legal navigation intervention for pediatric, adolescent and young adult patients and their caregivers.

METHODS

We used a single-arm feasibility and acceptability trial design in a pediatric hematology and oncology clinic and collected preintervention and postintervention surveys to assess changes in financial toxicity (3 domains: psychological response/Comprehensive Score for Financial Toxicity [COST], material conditions, and coping behaviors); health-related quality of life (Patient-Reported Outcomes Measurement Information System Physical and Mental Health, Anxiety, Depression, and Parent Proxy scales); and perceived feasibility, acceptability, and appropriateness.

RESULTS

In total, 45 participants received financial navigation, 6 received legal navigation, and 10 received both. Among 15 adult patients, significant improvements in FACIT-COST (P = .041) and physical health (P = .036) were noted. Among 46 caregivers, significant improvements were noted for FACIT-COST (P < .001), the total financial toxicity score (P = .001), and the parent proxy global health score (P = .0037). We were able to secure roughly $335 323 in financial benefits for 48 participants. The intervention was rated highly for feasibility, acceptability, and appropriateness.

CONCLUSIONS

Integrating financial and legal navigation through Financial and Insurance Navigation Assistance was feasible and acceptable and underscores the benefit of a multidisciplinary approach to addressing financial toxicity.

CLINICALTRIALS.GOV REGISTRATION

NCT05876325.

Evaluating implementation of a community-focused patient navigation intervention at an NCI-designated cancer center using RE-AIM

BACKGROUND

Patient navigation is an evidence-based intervention that reduces cancer health disparities by directly addressing the barriers to care for underserved patients with cancer. Variability in design and integration of patient navigation programs within cancer care settings has limited this intervention's utility. The implementation science evaluation framework, RE-AIM, allows quantitative and qualitative examination of effective implementation of patient navigation programs into cancer care settings.

METHODS

The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework was used to evaluate implementation of a community-focused patient navigation intervention at an NCI-designated cancer center between June 2018 and October 2021. Using a 3-month longitudinal, non-comparative measurement period, univariate and bivariate analyses were conducted to examine associations between participant-level demographics and primary (i.e., barrier reduction) and secondary (i.e., patient-reported outcomes) effectiveness outcomes. Mixed methods analyses were used to examine adoption and delivery of the intervention into the cancer center setting. Process-level analyses were used to evaluate maintenance of the intervention.

RESULTS

Participants (n = 311) represented a largely underserved population, as defined by the National Cancer Institute, with the majority identifying as Hispanic/Latino, having a household income of $35,000 or less, and being enrolled in Medicaid. Participants were diagnosed with a variety of cancer types and most had advanced staged cancers. Pre-post-intervention analyses indicated significant reduction from pre-intervention assessments in the average number of reported barriers, F(1, 207) = 117.62, p < .001, as well as significant increases in patient-reported physical health, t(205) = - 6.004, p < .001, mental health, t(205) = - 3.810, p < .001, self-efficacy, t(205) = - 5.321, p < .001, and satisfaction with medical team communication, t(206) = - 2.03, p = .029. Referral patterns and qualitative data supported increased adoption and integration of the intervention into the target setting, and consistent intervention delivery metrics suggested high fidelity to intervention delivery over time. Process-level data outlined a successful transition from a grant-funded community-focused patient navigation intervention to an institution-funded program.

CONCLUSIONS

This study utilized the implementation science evaluation framework, RE-AIM, to evaluate implementation of a community-focused patient navigation program. Our analyses indicate successful implementation within a cancer care setting and provide a potential guide for other oncology settings who may be interested in implementing community-focused patient navigation programs.

Increasing access to palliative care for patients with advanced cancer of African and Latin American descent: a patient-oriented community-based study protocol

BACKGROUND

Cancer disparities are a major public health concern in Canada, affecting racialized communities of Latin American and African descent, among others. This is evident in lower screening rates, lower access to curative, and palliative-intent treatments, higher rates of late cancer diagnoses and lower survival rates than the general Canadian population. We will develop an Access to Palliative Care Strategy informed by health equity and patient-oriented research principles to accelerate care improvements for patients with advanced cancer of African and Latin American descent.

METHODS

This is a community-based participatory research study that will take place in two Canadian provinces. Patients and community members representatives have been engaged as partners in the planning and design of the study. We have formed a patient advisory council (PAC) with patient partners to guide the development of the Access to Palliative Care Strategy for people of African and Latin American descent. We will engage100 participants consisting of advanced cancer patients, families, and community members of African and Latin American descent, and health care providers. We will conduct in-depth interviews to delineate participants' experiences of access to palliative care. We will explore the intersections of race, gender, socioeconomic status, language barriers, and other social categorizations to elucidate their role in diverse access experiences. These findings will inform the development of an action plan to increase access to palliative care that is tailored to our study population. We will then organize conversation series to examine together with community partners and healthcare providers the appropriateness, effectiveness, risks, requirements, and convenience of the strategy. At the end of the study, we will hold knowledge exchange gatherings to share findings with the community.

DISCUSSION

This study will improve our understanding of how patients with advanced cancer from racialized communities in Canada access palliative care. Elements to address gaps in access to palliative care and reduce inequities in these communities will be identified. Based on the study findings a strategy to increase access to palliative care for this population will be developed. This study will inform ways to improve access to palliative care for racialized communities in other parts of Canada and globally.

Lung Cancer Patients' Conceptualization of Care Coordination in Selected Public Health Facilities of KwaZulu-Natal, South Africa

BACKGROUND

Cancer patients commonly receive care, including comprehensive treatment options, from multiple specialists within and across facilities offering varying levels of care. Given this multi-layered approach to cancer care, there is a need for coordinated care enhanced through integrated information flow for optimal patient care and improved health outcomes.

OBJECTIVE

This study aimed to explore how patients conceptualized cancer care coordination in an integrated health care system in KwaZulu-Natal.

METHODS

The study employed a grounded theory design to qualitatively explore the patients' experiences and views on cancer care coordination using in-depth interviews. Guided by the grounded theory principles, data generation and analysis were conducted iteratively, followed by systematic thematic analysis to organize data, and review and interpret comprehensive findings. This process culminated in the development of themes relating to barriers to cancer care coordination and the interface between the primary and tertiary settings. Theoretical saturation was achieved at 21 in-depth interviews with consenting respondents.

RESULTS

This study revealed that care coordination was affected by multilevel challenges, including pertinent health system-level factors, such as difficulty accessing specialty care timeously, weak communication between patients and healthcare providers, and unmet needs concerning supportive care. We found that negative experiences with cancer care erode patient trust and receptiveness to cancer care, and patients advocated for better and proactive coordination amongst different care facilities, services, and providers.

CONCLUSIONS

An integrated care coordination setup is essential to create and sustain a high-performance health care system. These findings make a case for developing, implementing, and evaluating interventions to enhance the quality of cancer care for patients and ultimately improve health outcomes for patients in KwaZulu-Natal. This study will provide comprehensive data to inform professionals, policymakers, and related decisionmakers to manage and improve cancer care coordination.

Solidifying roles, responsibilities, and the process of navigation across the continuum of cancer care: The Professional Oncology Navigation Task Force

Since its founding in 1990, the profession of oncology navigation has grown and evolved. Although core concepts serve as a unifying thread throughout the profession, there has not been formal agreement on standardization of definitions, scopes, and roles for the various types of navigators. This has created challenges for sustainability, including reimbursement for navigation services. Emerging from the Biden Cancer Initiative's patient navigation working group, the Professional Oncology Navigation Task Force was created to serve as the voice of professional oncology organizations with an ultimate goal of solidifying definitions, scopes, and roles of navigators across the care continuum. Task group members are committed to cross-disciplinary partnership (including nursing, social work, and nonclinically licensed navigation). As the Task Force worked to define, refine, and disseminate professional standards (with input from the navigation community), the work done by the National Navigation Roundtable was vital to our evolving understanding of the profession. This article outlines the importance of that partnership and highlights the relevant findings of each article in this supplement of Cancer to the standardization work. LAY SUMMARY: Within the profession of oncology navigation, definitions, scopes, and roles of navigators have not been solidified. Standardization of the profession is critical to allow for continued growth and evolution as well as policy direction. This article introduces the work of the Professional Oncology Navigation Task Force, which created the Oncology Navigation Standards of Professional Practice with input from professional leaders and community stakeholders. The article also links the work of the National Navigation Roundtable and the critical need to coordinate and amplify efforts across groups.