Patient navigation job roles by levels of experience: Workforce Development Task Group, National Navigation Roundtable

PLAIN LANGUAGE SUMMARY

Cancer patient navigators work in diverse settings ranging from community-based programs to comprehensive cancer centers to improve outcomes in underserved populations by eliminating barriers to timely cancer prevention, early detection, diagnosis, treatment, and survivorship in a culturally appropriate and competent manner. This article clarifies the roles and responsibilities of Entry, Intermediate, and Advanced level cancer patient navigators. The competencies described in this article apply to patient navigators, nurse navigators, and social work navigators. This article provides a resource for administrators to create job descriptions for navigators with specific levels of expertise and for patient navigators to advance their oncology careers and attain a higher level of expertise.

Increasing Lung Cancer Screening for High-Risk Smokers in a Frontier Population

Northern Plains American Indians (AIs) have some of the highest smoking and lung cancer mortality rates in the USA. They are a high-risk population in which many are eligible for low-dose computed tomography (LDCT) screening, but such screening is rarely used. This study investigated methods to increase LDCT utilization through both a provider and community intervention to lower lung cancer mortality rates. This study used the Precaution Adoption Model for provider and community interventions implemented in four study regions in western South Dakota. The goal was to increase LDCT screening for eligible participants. Intake surveys and LDCT screenings were compared at baseline and 6 months following the education programs for both interventions. A total of 131 providers participated in the provider intervention. At the 6-month follow-up survey, 31 (63%) referred at least one patient for LDCT (p < 0.05). Forty (32.3%) community participants reported their provider recommended an LDCT and of those, 30(75%) reported getting an LDCT (p < 0.05). A total of 2829 patient surveys were completed at the imaging sites and most (88%, n = 962) cited provider recommendation as their reason for obtaining an LDCT. Almost half (46%; n = 131) of the referring providers attended a provider education workshop, and 73% of the providers worked at a clinic that hosted at least one community education session. Over the study period, LDCT utilization increased from 640 to 1706, a 90.9% increase. The provider intervention had the strongest impact on LDCT utilization. This study demonstrated increased LDCT utilization through the provider intervention but increases also were documented for the other intervention combinations. The community-based education program increased both community and provider awareness on the value of LDCTs to lower lung cancer mortality rates.

Factors Associated with Cancer Screening Among Hopi Men

Cancer screening rates remain low among American Indian men, and cancer screening behaviors and barriers to cancer screening among American Indian men are not well understood. This study evaluated cancer screening behaviors in 102 Hopi men who were 50 years of age or older from the Hopi Survey of Cancer and Chronic Disease. Reported cancer screening frequencies were 15.7%, 45.1%, and 35.3% for fecal occult blood test (FOBT), colonoscopy, and prostate-specific antigen (PSA) test, respectively. Among men who reported having had a FOBT, 81.2% had the test more than 1 year ago. Among men who reported a colonoscopy, 60.8% had colonoscopy within the past 3 years. Similarly, among men who reported having had PSA, 72.3% had PSA within the past 3 years. "No one told me" was the most common answer for not undergoing FOBT (33.7%), colonoscopy (48.2%), and PSA (39.4%). Men who reported having had a PSA or digital rectal exam were three times as likely to also report having a FOBT or colonoscopy (odds ratio [OR] 3.19, 95% confidence interval [CI]: 1.21-8.46). Younger age (< 65) was associated with reduced odds of ever having prostate cancer screening (OR 0.28, 95% CI: 0.10-0.77). Ever having colorectal cancer screening and previous diagnosis of cancer increased odds of ever having prostate cancer screening (OR 3.15, 95% CI: 1.13-8.81 and OR 5.28, 95% CI: 1.15-24.18 respectively). This study illustrates the importance of community cancer education for men to improve cancer screening participation.

Collective pursuit for equity in cancer care: The National Navigation Roundtable

BACKGROUND

The evidence continues to build in support of implementing patient navigation to reduce barriers and increase access to care. However, health disparities remain in cancer outcomes. The goal of the National Navigation Roundtable (NNRT) is to serve as a convener to help support the field of navigation to address equity.

METHODS

To examine the progress and opportunities for navigation, the NNRT submitted a collection of articles based on the results from 2 dedicated surveys and contributions from member organizations. The intent was to help inform what we know about patient navigation since the last dedicated examination in this journal 10 years ago.

RESULTS

The online survey of >700 people described navigators and examined sustainability and policy issues and the longevity, specific role and function, and impact of clinical and nonclinical navigators in addition to the role of training and supervision. In addition, a full examination of coronavirus disease 2019 and contributions from member organizations helped further define progress and future opportunities to meet the needs of patients through patient navigation.

CONCLUSIONS

To achieve equity in cancer care will demand the sustained action of virtually every component of the cancer care system. It is the hope and intent of the NNRT that the information presented in this supplement will be a catalyst for action in this collective action approach.

A Systematic Review of Fear of Cancer Recurrence Among Indigenous and Minority Peoples

While cancer survivors commonly experience fear and anxiety, a substantial minority experience an enduring and debilitating fear that their cancer will return; a condition commonly referred to as fear of cancer recurrence (FCR). Despite recent advances in this area, little is known about FCR among people from Indigenous or other ethnic and racial minority populations. Given the high prevalence and poor outcomes of cancer among people from these populations, a robust understanding of FCR among people from these groups is critical. The current review identified and aggregated existing literature on FCR amongst adult cancer survivors from Indigenous and minority populations. The protocol of this review was registered with PROSPERO in July 2020 (Registration number: CRD42020161655). A systematic search of bibliographic databases was conducted for relevant articles published from 1997 to November 2019. Data from eligible articles were extracted and appraised for quality by two independent reviewers. Nineteen articles from four countries (United States of America, Canada, Australia and the United Kingdom) met the inclusion criteria, including 14 quantitative, 4 qualitative and 1 mixed-methods study. Only one article reported on an Indigenous population. Few studies reported on FCR prevalence (n = 3) or severity (n = 9). While the variation in tools used to measure FCR hindered a robust estimate of severity, results suggested some differences in FCR severity between minority and dominant populations, although these may have been due to study metholodological differences. Few factors were reported as being associated with FCR in minorities across multiple studies. The qualitative synthesis found five themes associated with the lived experience of FCR: (i) variations in the lived experience of FCR; (ii) spirituality and worldview impacting on FCR; (iii) the importance of staying positive; (iv) complexities around support; and (v) increasing cancer knowledge. The findings of this review highlight differences in FCR across cultures and contexts, which reinforces the need for culturally-specific approaches to this condition. The dearth of research in this area is of concern given the significant burden of cancer in these populations. A deeper understanding of this condition among Indigenous and minority populations is critical to developing and delivering appropriate and effective psychosocial care for cancer survivors from these groups. Systematic Review Registration: identifier [CRD42020161655].

Healthy Pregnancies Project: Cluster Randomized Controlled Trial of a Community Intervention to Reduce Tobacco Use among Alaska Native Women

Substantial gaps remain in the evidence base for prenatal tobacco use interventions among Indigenous women. Using a cluster randomized controlled trial (RCT), the Healthy Pregnancies Project evaluated a community-level intervention for Alaska Native (AN) women in rural western Alaska. Sixteen villages were randomly assigned to usual care (control, n = 8 villages) or usual care plus a community-level intervention delivered by local AN "Native Sisters" (n = 8 villages). Outcomes were tobacco use rate at delivery and at 2 and 6 months postpartum, with biochemical confirmation obtained at 6 months. The program had high reach, enrolling 73% of all eligible women screened. Of the 352 participants, 67% used tobacco at baseline. No significant differences emerged between study groups on follow-up in tobacco use rates. More intervention than control participants made a quit attempt at 2 months postpartum (70% vs. 51%, respectively, p = 0.012). Participants in both study groups reported the program helped to raise awareness of healthy pregnancies in the study villages. This trial supports the reach of a community-level intervention, but not its efficacy for reducing tobacco use during pregnancy or postpartum. Efforts to sustain early quit attempts appear warranted. The community involvement, and reported impact on raising awareness of the importance of healthy pregnancies, supports the value of the research program in this community.

Association of Tobacco Use During Pregnancy, Perceived Stress, and Depression Among Alaska Native Women Participants in the Healthy Pregnancies Project

INTRODUCTION

In general population samples, higher levels of stress and depression have been associated with increased prevalence of smoking in pregnancy. Little is known about the association of prenatal tobacco use, stress, and depression among American Indian or Alaska Native (AI/AN) women.

METHODS

The Healthy Pregnancies Project is a cluster-randomized controlled trial, evaluating a community-level intervention compared with usual care, for reducing tobacco use during pregnancy and postpartum among AN women in 16 villages in western Alaska. This cross-sectional study analyzed baseline data from enrolled pregnant women. Baseline measures included the self-reported, 7-day, point-prevalence current use of any tobacco, Perceived Stress Scale (PSS), and the Center for Epidemiological Studies-Depression (CES-D). Generalized estimating equations (GEE) analyses adjusted for village, participant age, and gestational age.

RESULTS

Participants (N = 352) were on average (SD) 25.8 (5.0) years of age and at 26.8 (9.8) weeks gestation. 66.5% were current tobacco users, of which 77% used Iqmik, a homemade form of smokeless tobacco. Compared with nonusers, tobacco users reported lower PSS score (p = .020) and less clinical levels of depression (CES-D ≥ 16) (18.1% vs. 9.3%, p = .21). Findings were not accounted for by nicotine dependence severity or self-reported tobacco use before pregnancy.

CONCLUSIONS

In this sample of pregnant AN women, tobacco users report less stress and clinical levels of depression than nonusers. A potential challenge with tobacco treatment for pregnant AN women is to provide alternative ways of deescalating stress and affect management instead of using tobacco.

IMPLICATIONS

This study contributes novel information on the association of tobacco use, perceived stress, and depression among Alaska Native women enrolled in a clinical trial to promote healthy pregnancies. Most prior studies addressing this topic were conducted among general population samples of pregnant women who smoked cigarettes. Little is known about these associations with prenatal smokeless tobacco, or among American Indian or Alaska Native women. The results are contrary to findings reported previously, because current tobacco use was associated with less stress and depression than nonuse. The study findings have implications for cessation treatment for this tobacco-use disparity group.

Sharing Wisdom, Sharing Hope: Strategies Used by Native American Cancer Survivors to Restore Quality of Life

PURPOSE

The purpose of this study was to gain insight into the experiences of Native American cancer survivors in navigating life after cancer and what resources and strategies survivors found useful for coping and achieving optimal quality of life (QoL) after diagnosis (the terms "Native Americans" and "Natives" are used interchangeably in this article to describe American Indians and Alaska Natives). The research questions were What advice and words of wisdom do Native cancer survivors prioritize in messages to other Native cancer survivors? and What do those messages reveal about how Native cancer survivors interpret, experience, and restore QoL after diagnosis?

METHODS

This study used a qualitative phenomenologic descriptive study design. Researchers used thematic analysis to identify themes related to peer advice and QoL from transcripts of semi-structured interviews with 52 geographically and clinically diverse Native cancer survivors in the United States.

RESULTS

Survivors' lived experiences directly informed their advice to other survivors, which was characterized by four themes: listen to your body, advocate for yourself, embrace your culture and spirituality, and share your story. A deeper look into the origins of those messages revealed challenges survivors face balancing their responsibility to care for themselves while simultaneously embracing cultural values of selflessness.

CONCLUSION

Providers and researchers should work with Native cancer survivors to identify and leverage existing community strengths in ways that support all aspects of a survivors' QoL rather than limiting support to a single QoL domain (eg, physical, spiritual, mental/emotional, or social issues). Interventions should ensure that supports and services align with survivors' cultural values and attend to competing responsibilities to optimize QoL.

A randomized trial to reduce smoking among American Indians in South Dakota: The walking forward study

BACKGROUND

Lung cancer is an important public health issue, particularly among American Indians (AIs). The reported decline in tobacco use for most racial/ethnic groups is not observed among AIs. This project was designed to address the research question, "Why don't more Northern Plains American Indians alter tobacco use behaviors known to increase the risk of cancer?"

METHODS

Guided by the Theory of Planned Behavior, a multi-component intervention study was implemented. Adult AIs, age 18 years or older and currently smoking, were enrolled. Eligible subjects were randomized to one of 15 groups and exposed to either a MINIMAL or an INTENSE level of 4 intervention components. The intervention was delivered face-to-face or via telephone by Patient Navigators (PN). The primary outcome was self-reported abstinence from smoking verified by carbon monoxide measurement.

RESULTS

At 18 months post-quit date, 88% of those who were still in the study were abstinent. This included 6% of all participants who enrolled in the study (14/254) and 13% of those who made it to the quit date (14/108). No intervention groups were found to have significant proportions of participants who were abstinent from smoking at the quit date (visit 5) or primary outcome visit (18 months post-quit date, visit 11), but use of pharmacologic support for abstinence was found to be an effective strategy for individuals who continued participation throughout the study. Those who remained in the study received more visits and were more likely to be abstinent.

CONCLUSIONS

Use of NRT increased the odds of not smoking, as assessed at the 18-month follow-up visit, but no other interventions were found to significantly contribute to abstinence from smoking. Although the intervention protocol included numerous points of contact between CRRs and participants (11 visits) loss to follow-up was extensive with only 16/254 remaining enrolled. Additional research is needed to improve understanding of factors that influence enrollment and retention in smoking cessation interventions for AI and other populations.

How can an Education Workshop Serve as an Intervention for American Indian Screening Participation

American Indians (AIs) continue to have elevated cancer incidence and mortality, and most have issues accessing cancer screening services. During 2013-2014, Mayo and its partners created Native Cancer 101 Module 10 "Prevention and Early Cancer Detection" education workshop. A community-based AI organization implemented nine of these workshops during 2014-2015 via diverse venues. Nearly all participants eligible for at least one type of cancer screening participated in a workshop and consented to follow-up within 3 to 6 months to determine if screenings had been completed or scheduled. Native Cancer 101 Module 10 workshops were conducted with 150 community members of whom 6 had recently completed cancer screening (n = 144). The workshops had a 25.20% increase in knowledge, and 97.1% of subjects responded that they would recommend the workshop to their friends and family. Most (136 of 144) submitted a consent form to be contacted 3 to 6 months following the workshop. Patient navigators reached 86 (63.2%) of the consented participants in the follow-up calls after the workshop, and 63 (46.3%) self-reported that they had completed at least one cancer screening test for which they were eligible. The single implementation of the workshop influenced community participants' completion of cancer screening.

The Healthy Pregnancies Project: Study protocol and baseline characteristics for a cluster-randomized controlled trial of a community intervention to reduce tobacco use among Alaska Native pregnant women

BACKGROUND

Tobacco use prevalence is high among pregnant Alaska Native (AN) women but few interventions have been evaluated for this group. The Healthy Pregnancies Project aims to evaluate a multicomponent intervention for reducing tobacco use during pregnancy and the postpartum period among AN women. This report describes the study protocol and participant baseline characteristics.

DESIGN

Cluster-randomized controlled trial with village as the unit of assignment. Sixteen villages in rural southwest Alaska were stratified on village size and randomized to a multicomponent intervention (n = 8 villages) or usual care (n = 8 villages).

METHODS

Pregnant AN women from the study villages were enrolled. All participants receive the usual care provided to pregnant women in this region. Participants from intervention villages additionally receive individual phone counseling on healthy pregnancies plus a social marketing campaign targeting the entire community delivered by local AN "Native Sisters." Baseline measurements for all enrolled pregnant women have been completed. Follow-up assessments are ongoing at delivery, and at 2 and 6 months postpartum. The primary outcome is biochemically verified tobacco use status at 6 months postpartum.

RESULTS

Recruitment was feasible with 73% of eligible women screened enrolled. The program reached more than half (56%) of AN pregnant women from the study villages during the recruitment period. Participants are N = 352 pregnant AN women, 188 enrolled from intervention villages and 164 from control villages. At baseline, participants' mean (SD) age was 25.8 (5.0) years, they were at 26.8 (9.8) weeks gestation, and 66.5% were current tobacco users.

DISCUSSION

Processes and products from this project may have relevance to other Native American populations aiming to focus on healthy pregnancies in their communities.

Developing health communication messaging for a social marketing campaign to reduce tobacco use in pregnancy among Alaska Native women

Background

Despite the high prevalence of tobacco use during pregnancy among Alaska Native and American Indian (AI/AN) women, few efforts have focused on developing tobacco cessation interventions for this group. This paper describes development of messaging for a social media campaign targeting the entire community to reduce tobacco use in pregnancy (cigarette smoking and smokeless tobacco use including a homemade product known as Iqmik) among AN women, as part of a multi-component intervention.

Method

The study (clinical trial registration #NCT02083081) used mixed methods with two rounds of assessments to develop and refine culturally relevant message appeals. Round 1 used qualitative focus groups and individual interviews (N=60), and Round 2 used quantitative survey interviews (N=52). Each round purposively sampled adult AN pregnant women, family/friends, and Elders in Western Alaska, and included tobacco users and non-users. Round 1 also assessed reasons for tobacco use in pregnancy.

Results

Qualitative findings generally converged with quantitative results to indicate that many participants preferred factual, loss-framed, visual concepts on how maternal tobacco use harms the fetus, newborn, and child; in contrast to spiritual or emotional appeals, or gain-framed messaging. Stress was indicated as a major reason for tobacco use in pregnancy and strategies to manage stress along with other health pregnancy targets (e.g., prenatal care) were suggested.

Conclusions

This preliminary study suggests campaign messages targeting the entire community to reduce tobacco use in pregnancy among rural AN women should include factual messaging for being tobacco-free as well as focus on reducing stress and other healthy pregnancy targets.

Abstract C76: Developing an online resource for lung cancer screening in a frontier population

Objective: To develop an online resource for lung cancer screening, to be used by both primary care providers and high-risk individuals in western South Dakota. Western South Dakota is considered a frontier population with lower-than-average access to medical care and American Indians comprising 20% of the population. This population experiences cancer health disparities for many reasons including geographic isolation, poverty, fragmented health care, and cultural barriers.

Methods: The online resource was pilot tested among six focus groups (25 primary care providers and 21 individuals) and was developed to target the specific needs of the high-risk frontier population in western South Dakota. Focus group participants were asked to comment on content, understandability, visual appeal, geographic and cultural relevance, and usability. The focus group input was gathered using both notes and audio recordings, and their recommendations informed the resource development.

Results: The project developed a comprehensive lung cancer screening online resource with both regionally and culturally appropriate content, including information about the ceremonial use of tobacco. The online resource includes information on lung cancer screening guidelines, screening referrals, billing codes, and smoking cessation. In addition, the focus groups recommended adding more basic information, such as: what is a low-dose computed axial tomography scan (LDCT), why is it recommended over chest x-rays, and how does one determine a pack-year smoking history? Both providers and individual members of the focus groups expressed the desire to have this online resource along with lung cancer screening education available to them.

Conclusions: This project developed an online resource for all-inclusive, comprehensive information about lung health and lung cancer screening for use by both primary care providers and individuals. The project was completed in March 2017, with community stakeholders strongly endorsing the online resource. The Walking Forward team has since proposed a multilevel intervention study using the online resource developed by this project, as well as lung cancer screening education to investigate whether provider and/or individual level interventions will increase lung cancer screening among high-risk smokers living in this understudied, underserved frontier population (R01 submission).

Citation Format: Jennifer Leberknight, Michele Sargent, Kristin Cina, Margaret O'Connor, Romaine Tobacco, Sheikh Iqbal Ahamed, Daniel Petereit, Linda Burhansstipanov. Developing an online resource for lung cancer screening in a frontier population [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr C76.

Findings from American Indian Needs Assessments

Because of decreased access and dismal survival rates, strategies need to be developed to increase cancer awareness and facilitate cancer prevention, early detection, and screening activities within American Indian (AI) populations. The purpose of this study was to develop a locally tailored needs assessment to collect cancer prevention, control, and risk factor information and knowledge, attitude, and perceived behavior (hereafter referred to as "needs assessment") data from 500 community members living in 3 geographically diverse settings: the Southeastern USA, the Rocky Mountain region, and the Northern Plains. Needs assessment data helped identify local health priorities and create a pilot cancer prevention and early detection education intervention. There were two versions of common items of the instrument: short (~35 items) and long (55 items), and each partner added items that were recommended by their local AI Advisory Committee. Each partner collaborated with local AI organizations to identify and recruit participants at community venues. During the sessions, facilitators used Power Point® slides and ARS equipment and software to anonymously collect participants' responses. The partners collected needs assessment data from 677 community members over a 4-year period. Cancer education knowledge was low, barriers to accessing timely cancer screening and care services were excessive, tobacco use was excessive, and daily physical activity was insufficient for most participants. ARS was an effective way to collect needs assessment information. During discussions following the data collection, community members requested more cancer education opportunities, access to patient navigation services, and cultural competency training for healthcare providers.

Lessons Learned While Developing “Clinical Trials Education for Native Americans” Curriculum

This paper highlights lessons learned while developing the Clinical Trials Education for Native Americans (CTENA) curriculum. The CTENA is a culturally specific clinical trials education curriculum that evolved from another ongoing NCI-supported project, Clinical Trials Education for Colorado Providers. The multicultural team learned many lessons while developing, pretesting, and revising this curriculum. These include allocating sufficient time and resources to tailor presentations for diverse tribal settings and workshop participants, addressing barriers to participation in clinical trials through culturally appropriate strategies, providing information to foster informed decision making related to participation, and writing as a team to increase cultural breadth of examples and interactive experiences. There are multiple challenges to developing and implementing a culturally acceptable curriculum on clinical trials within medically underserved communities. Both the multicultural team and the curriculum benefited from the collaborative process, resulting in a culturally relevant clinical trials curriculum that will assist Native Americans to make informed choices about clinical trials participation. The lessons shared here, which may need to be modified to be culturally relevant to other underrepresented communities, may be beneficial to others developing similar curricula for other medically underserved populations.

Reality Versus Grant Application Research "Plans"

This article describes the implementation of the American Indian mHealth Smoking Dependence Study focusing on the differences between what was written in the grant application compared to what happened in reality. The study was designed to evaluate a multicomponent intervention involving 256 participants randomly assigned to one of 15 groups. Participants received either a minimal or an intense level of four intervention components: (1) nicotine replacement therapy, (2) precessation counseling, (3) cessation counseling, and (4) mHealth text messaging. The project team met via biweekly webinars as well as one to two in-person meetings per year throughout the study. The project team openly shared progress and challenges and collaborated to find proactive solutions to address challenges as compared to what was planned in the original grant application. The project team used multiple strategies to overcome unanticipated intervention issues: (1) cell phone challenges, (2) making difficult staffing decisions, (3) survey lessons, (4) nicotine replacement therapy, (5) mHealth text messages, (6) motivational interviewing counseling sessions, and (7) use of e-cigarettes. Smoking cessation studies should be designed based on the grant plans. However, on the ground reality issues needed to be addressed to assure the scientific rigor and innovativeness of this study.

The experience of treatment barriers and their influence on quality of life in American Indian/Alaska Native breast cancer survivors

BACKGROUND

American Indian and Alaska Native (AI/AN) breast cancer survivors experience disparities in breast cancer incidence and age-adjusted mortality compared with non-Hispanic white (NHW) breast cancer survivors. In addition, mortality-to-incidence rates indicate that AI/ANs continue to have the poorest survival from breast cancer compared with other racial groups. "Native American Cancer Education for Survivors" (NACES) is a cultural education and support intervention for AI/AN patients with cancer that collects data from voluntary participants through the NACES quality-of-life (QOL) survey regarding their cancer experience and survivor journey.

METHODS

Data from the NACES QOL survey were analyzed to determine whether barriers accessing and during initial cancer treatment impacted QOL domains for AI/AN cancer survivors. Exploratory analyses of selected variables were conducted and were followed by Kruskal-Wallis tests to determine whether these barriers influenced survivorship QOL for AI/AN breast cancer survivors.

RESULTS

AI/AN breast cancer survivors' social QOL was significantly affected by barriers to accessing cancer treatment. Many respondents experienced barriers, including a lack of cancer care at local clinics and the distance traveled to receive cancer care. During treatment, too much paperwork and having to wait too long in the clinic for cancer care were the most frequently reported barriers.

CONCLUSIONS

Treatment barriers influence AI/AN breast cancer survivors' social QOL. Mediating these barriers is crucial to ameliorating AI/AN survivors' disparities when accessing and completing cancer treatment and improving survivorship QOL. Cancer 2017;123:861-68. © 2016 American Cancer Society.

Recommendations for Cancer Epidemiologic Research in Understudied Populations and Implications for Future Needs

Medically underserved populations in the United States continue to experience higher cancer burdens of incidence, mortality, and other cancer-related outcomes. It is imperative to understand how health inequities experienced by diverse population groups may contribute to our increasing unequal cancer burdens and disparate outcomes. The National Cancer Institute convened a diverse group of scientists to discuss research challenges and opportunities for cancer epidemiology in medically underserved and understudied populations. This report summarizes salient issues and discusses five recommendations from the group, including the next steps required to better examine and address cancer burden in the United States among our rapidly increasing diverse and understudied populations. Cancer Epidemiol Biomarkers Prev; 25(4); 573-80. ©2016 AACR SEE ALL ARTICLES IN THIS CEBP FOCUS SECTION, "MULTILEVEL APPROACHES TO ADDRESSING CANCER HEALTH DISPARITIES".

Abstract IA10: Challenges in addressing cancer health disparities in Native American communities

Brief Overview of Demographics and Risk Factors: There are more than 760 federally and state-recognized American Indians/Alaska Natives (AI/ANs) tribes in the US.1 Of those AI/ANs responding to the 2010 Census, 41% lived in the West and the majority (78%) lived in urban and rural areas or in states that do not have a federal Reservation.2 AI/ANs have daily behaviors and co-morbidities that increase their risks for cancer. They are more likely to be obese, use commercial tobacco, and have diabetes or high blood pressure. They also have long experienced lower health status in comparison with other US populations. AI/ANs born in 2011 have a lower life expectancy than all US populations (72.6 years vs. 77.8 years).2 Their poverty level is nearly twice that of the overall US population; only half as many having health insurance. When compared to other populations, AI/ANs are more likely to have a lower socioeconomic status and live in poverty, leading to less access to cancer prevention and screening services. Additionally, 20% of AI/ANs have not completed high school as opposed to only 8% of non-Hispanic Whites. Not completing high school has been associated with unhealthy and risk taking behaviors.3 The Indian Health Service (IHS) reported that cancer screening rates for AI/ANs were significantly lower in comparison to the overall US population with only 59% receiving cervical screening, 45% breast screening and 33% receiving colorectal screening, leading to increased risk of late diagnosis and decreased survival from cancer.2

Excerpts from “Native American Cancer Education for Survivors” (NACES): Native American Cancer Education for Survivors” (NACES) is the largest AI cancer survivorship database, education and support program in the US, with almost 900 survivors. NACES is a cancer education intervention designed to improve the Quality of Life (QOL) of cancer survivors by increasing knowledge and informed choice using innovative, tailored, web-based technology. The website includes a QOL survey, culturally appropriate and scientifically accurate content based on the Medicine Wheel (physical, mental-emotional, social and spiritual health), video excerpts from almost 90 AI survivors, sample questions to ask providers, and other interactive information. It is organized as a QOL Tree with information written at reading grade levels 5-7, and is based on AI survivors sharing their cancer-related stories throughout the education materials. Native Patient Navigators (NPNs) assist cancer survivors to effectively use the website and complete a QOL survey. This survey was adapted and culturally tailored from Ferrell's QOL survey initiated at the City of Hope. In 2013, 75 items, mostly NIH PROMIS® items, were added. As of September 2014, 890 AI cancer survivors completed the survey. Findings include: Most (n=710; 79.8%) are female, 46% have high school or less education, more than half (54.6%) are full-bloods, and almost half (47.6%) were diagnosed with cancer prior to age 50. About 1/3 (35.7%) travel 200 or more miles one way to access cancer care and because of rural road conditions and other geographic issues, almost half (48.1%) travel more than 2 hours one way to access such care. More than 1/3 (37.4%) had difficulties getting into cancer treatment. These data differ greatly from NCI published findings of older age at diagnosis, living within a reasonable distance from cancer care services and access to treatment.4 5

Affordable Care Act (ACA): IHS offers basic clinic services until there is a cancer diagnosis. Then patients are referred through Contract Health Services (CHS) out of the IHS system to private health providers. When there are not enough CHS funds available in a contract year, patients cannot be referred until the next year begins. The current system typically results in people returning to their home reservation for 3-6 months to re-establish “residency”, then they are placed on the CHS priority / waiting list to be referred elsewhere for cancer care. This means that AIs must return to the reservation to seek care. However, the ACA, should eliminate such obstacles to accessing timely cancer services.

Those AIs who have health insurance receive care in sites determined by their healthcare plans. Those without health insurance and not living near an IHS clinic access health care the same as others in poverty, often not receiving healthcare until an emergency. For many reasons, few receive health care at public institutions. Contrary to popular belief, AIs living in urban areas do not have easier access to healthcare services in comparison to Reservation-based AIs. While almost 2/3 of AIs live in urban areas, only 2% of the total IHS budget is allocated to urban AI clinics, affecting access to cancer screening and early detection programs. Those who seek public screening services often experience fragmented care due to lack of a primary care provider, delayed or lost results reporting or insufficient or delayed follow-up care of suspicious findings.

Because the ACA allows AIs the option for exemption from obtaining health insurance, many will rely solely on care through IHS. However, due to major reductions in the IHS budget, tribes and Indian organizations are referring AIs for private insurance through the ACA to assure that they receive healthcare. Because private health insurance is not the norm for AIs, many are unfamiliar with how to use it and are unclear how to access health services such as routine cancer screenings.

Access to Technology: In 2012, NACR and its collaborators (Muscogee (Creek) Nation, Rapid City Regional Hospital's Walking Forward Program, Intertribal Council of Michigan) had their Native Patient Navigators (NPNs) administer a short survey on access to and use of technology to AIs (n= 306). Two thirds of respondents were female, 64% were between 31 and 64 years of age and 68.9% had less than a college education. About 2/3 had positive responses to the use of cell phones, with 76% having a cell phone, 66.6% currently using text messaging and 74.8% willing to receive and respond to about 4-6 health-related texts per day. Many of the elders used Facebook to stay in contact with their grandchildren. Cell phone towers on Reservations are increasing; in 2014, 85% of Reservations have cell phone coverage. Although the majority of AIs now have cell phones, many do not know how to use common features.

The need for “cultural” Native Patient Navigators: AIs experience barriers to accessing health care due to socioeconomic and cultural issues as well as historical trauma, even when it is second and third generation.6 7 NPNs help patients understand healthcare information by translating it into terms that are more comfortable and easily understood. They know how to address historical issues unique to tribal members, varying communication patterns and spirituality practices that may impact contemporary medical practices. They provide support and referrals to education programs, resources and cancer screenings and improve and enhance AI patient outcomes through recognizing and integrating culture in overall healthcare.

References:

1 US Census Bureau, (2012). The American Indian and Alaska Native Population: 2010 (based on the 2010 Census Redistricting Data (Public Law 94-171) Summary File). In: Commerce USDo, editor. Washington, DC.

2 Indian Health Service DHHS. (2012). Indian Health Service. IHS Fact Sheets. In: http://www.ihs.gov/publicaffairs/ihsbrochure/disparities.asp.

3 DHHS, Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, CDC Health Disparities and Inequalities Report—United States, 2013, Supplement, volume 62, number 3, November 22, 2013, page 9

4 Howlader N, Noone A, Krapcho M, Neyman N, Aminou R, Waldron W, et al. (eds). SEER Cancer Statistics Review, 1975–2009 (Vintage 2009 Populations), National Cancer Institute; Bethesda, MD, http://seer.cancer.gov/csr/1975_2009_pops09/, based on November 2011 SEER data submission, posted to the SEER web site, April 2012.

5 de Moor JS, Mariotto AB, Parry C, Alfano CM, Padgett L, Kent EE, Forsythe L, Scoppa S, Hachey M, and Rowland JH. Cancer Survivors in the United States: Prevalence across the Survivorship Trajectory and Implications for Care. Cancer Epidemiol Biomarkers Prev. 2013 Apr;22(4):561-70.

6 Harjo, Lisa, Burhansstipanov, Linda, Lindstrom, Denise, Rationale for “Cultural” Native Patient Navigators in Indian Country. Journal of Cancer Education. (online June 2014, in print summer 2014) Doi 10.1007/s13187-014-0684-0

7 Cutler M (n.d.) Multigenerational trauma: behavior patterns in cultures. Retrieved from http://edweb.boisestate.edu/instituteforthestudyofaddiction/pp/Historical_Trauma_and_Grief.ppt on July 2014

Citation Format: Linda Burhansstipanov, Linda U. Krebs, Lisa D. Harjo. Challenges in addressing cancer health disparities in Native American communities. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr IA10.

Attitudes Toward Breast Cancer Genetic Testing in Five Special Population Groups

PURPOSE

This study examined interest in and attitudes toward genetic testing in 5 different population groups.

METHODS

The survey included African American, Asian American, Latina, Native American, and Appalachian women with varying familial histories of breast cancer. A total of 49 women were interviewed in person. Descriptive and nonparametric statistical techniques were used to assess ethnic group differences.

RESULTS

Overall, interest in testing was high. All groups endorsed more benefits than risks. There were group differences regarding endorsement of specific benefits and risks: testing to "follow doctor recommendations" (p=0.017), "concern for effects on family" (p=0.044), "distrust of modern medicine" (p=0.036), "cost" (p=0.025), and "concerns about communication of results to others" (p=0.032). There was a significant inverse relationship between interest and genetic testing cost (p<0.050), with the exception of Latinas, who showed the highest level of interest regardless of increasing cost.

CONCLUSION

Cost may be an important barrier to obtaining genetic testing services, and participants would benefit by genetic counseling that incorporates the unique cultural values and beliefs of each group to create an individualized, culturally competent program. Further research about attitudes toward genetic testing is needed among Asian Americans, Native Americans, and Appalachians for whom data are severely lacking. Future study of the different Latina perceptions toward genetic testing are encouraged.

Abstract PL02-02: Lessons learned from the Walking Forward Program in recruiting American Indians on clinical trials

Purpose/Objective(s): American Indians (AIs) present with more advanced stages of cancer and, therefore, suffer from higher cancer mortality rates compared to non-AIs. Under the National Cancer Institute Cancer Disparities Research Partnership Program (CDRP), we have been researching methods of improving cancer treatment and outcomes since 2002, for AIs in Western South Dakota, through the Walking Forward (WF) Program.

Materials/Methods: This program consists of a) a culturally-tailored patient navigation program that facilitated access to innovative clinical trials in conjunction with a comprehensive educational program encouraging screening and early detection, b) surveys to evaluate barriers to access, c) clinical trials focusing on reducing treatment length as AIs live a median of 140 miles from the cancer center, d) a molecular study (ATM - Ataxia telangectasia mutation) to address whether there is a molecular profile that increases toxicity risks, and e) a recently funded project using mHealth (mobile) technology to address the high smoking rates in this population.

Results: To date, over 3,700 AIs have participated in various WF research studies. Critical outcomes include the establishment of trust within tribal communities, identification of barriers to cancer screening, creation of research infrastructure, higher completion rates and patient satisfaction for patients undergoing cancer treatment, enrollment of patients on phase II trials with excellent clinical outcomes, and the establishment of new research partners. Recent analysis suggests that AI cancer patients with screen detectable cancers are now presenting with earlier stages of disease and higher cure rates. Lessons learned will also be presented.

Conclusions: This NCI funded pilot program has achieved some initial measures of success. A research infrastructure has been created in a community setting to address new research questions and interventions. One critical objective of the CDRP program was to create sustainable, community research programs that has been achieved at our site.

Citation Format: Daniel G. Petereit, Shalini Kanekar, Ashleigh Guadagnolo, Amy Boylan, Kristin Cina, Linda Burhansstipanov. Lessons learned from the Walking Forward Program in recruiting American Indians on clinical trials. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr PL02-02. doi:10.1158/1538-7755.DISP13-PL02-02

Findings from the native navigators and the Cancer Continuum (NNACC) study

Native Navigators and the Cancer Continuum (NNACC) was a community based participatory research study among Native American Cancer Research Corporation, CO; Inter-Tribal Council of Michigan, MI; Rapid City Regional Hospital's Walking Forward, SD; Great Plains Tribal Chairman's' Health Board, SD; and Muscogee (Creek) Nation, OK. The project goal was to collaborate, refine, expand, and adapt navigator/community education programs to address American Indian communities' and patients' needs across the continuum of cancer care (prevention through end-of-life). The intervention consisted of four to six site-specific education workshop series at all five sites. Each series encompassed 24 h of community education. The Social Ecology Theory guided intervention development; community members from each site helped refine education materials. Following extensive education, Native Patient Navigators (NPNs) implemented the workshops, referred participants to cancer screenings, helped participants access local programs and resources, and assisted those with cancer to access quality cancer care in a timely manner. The intervention was highly successful; 1,964 community participants took part. Participants were primarily American Indians (83 %), female (70 %) and between 18 and 95 years of age. The education programs increased community knowledge by 28 %, facilitated referral to local services, and, through site-specific navigation services, improved access to care for 77 participants diagnosed with cancer during the intervention. Approximately, 90 % of participants evaluated workshop content as useful and 92.3 % said they would recommend the workshop to others. The intervention successfully increased community members' knowledge and raised the visibility of the NPNs in all five sites.

Providing community education: lessons learned from Native Patient Navigators

Native Navigators and the Cancer Continuum (NNACC) was a community-based participatory research study among five American Indian organizations. The intervention required lay Native Patient Navigators (NPNs) to implement and evaluate community education workshops in their local settings. Community education was a new role for the NPNs and resulted in many lessons learned. NPNs met quarterly from 2008 through 2013 and shared lessons learned with one another and with the administrative team. In July 2012, the NPNs prioritized lessons learned throughout the study that were specific to implementing the education intervention. These were shared to help other navigators who may be including community education within their scope of work. The NPNs identified eight lessons learned that can be divided into three categories: NPN education and training, workshop content and presentation, and workshop logistics and problem-solving. A ninth overarching lesson for the entire NNACC study identified meeting community needs as an avenue for success. This project was successful due to the diligence of the NPNs in understanding their communities' needs and striving to meet them through education workshops. Nine lessons were identified by the NPNs who provided community education through the NNACC project. Most are relevant to all patient navigators, regardless of patient population, who are incorporating public education into navigation services. Due to their intervention and budget implications, many of these lessons also are relevant to those who are developing navigation research.

Developing cancer-related educational content and goals tailored to the Comanche Nation

Cancer-related educational content and goals should be modified to the needs of Native Americans to ensure adherence to healthy lifestyles. The current article describes the development of cancer-related educational modules that include creating behavioral goals specific to the people of the Comanche Nation. A community-based participatory research approach was used to conduct focus groups in the Comanche Nation and obtain feedback related to cancer-related educational modules and behavioral goals. Content analysis, verbatim transcriptions, field notes, and observations were used to analyze data and create five major themes. Comanche people need cancer educational modules and goals tailored to their culture to become engaged and maintain interest, thereby improving the likelihood of increasing cancer-related knowledge. Oncology nurses should respect guidance provided by Comanche community members to adapt cancer-related education materials and processes, as well as goal development, to address cultural concepts. When Comanche community members become knowledgeable and work toward healthy behavioral change, cancer health disparities may decrease.

Navigation as an intervention to eliminate disparities in American Indian communities

OBJECTIVES

To identify the role of patient navigation in decreasing health care disparities through an exemplar of a successful patient navigation program for American Indian populations living in the Northern and Southern Plains of the United States.

DATA SOURCES

Published literature and data from the Native Navigators and the Cancer Continuum study.

CONCLUSION

Native Patient Navigators successfully collaborated with local American Indian organizations to provide cancer education through a series of 24-hour workshops. These workshops increased community knowledge about cancer, influenced cancer screening behaviors, and increased the visibility and availability of the navigators to provide navigation services.

IMPLICATIONS FOR NURSING PRACTICE

Reaching those with health care disparities requires multiple strategies. Collaborating with patient navigators who are embedded within and trusted by their communities helps to bridge the gap between patients and providers, increases adherence to care recommendations, and improves quality of life and survival.

Toward an mHealth Intervention for Smoking Cessation

The prevalence of tobacco dependence in the United States (US) remains alarming. Invariably, smoke-related health problems are the leading preventable causes of death in the US. Research has shown that a culturally tailored cessation counseling program can help reduce smoking and other tobacco usage. In this paper, we present a mobile health (mHealth) solution that leverages the Short Message Service (SMS) or text messaging feature of mobile devices to motivate behavior change among tobacco users. Our approach implements the Theory of Planned Behavior (TPB) and a phase-based framework. We make contributions to improving previous mHealth intervention approaches by delivering personalized and evidence-based motivational SMS messages to participants. Our proposed solution implements machine learning algorithms that take the participant's demographic profile and previous smoking behavior into account. We discuss our preliminary evaluation of the system against a couple of pseudo-scenarios and our observation of the system's performance.

Cancer patient navigator tasks across the cancer care continuum

Cancer patient navigation (PN) programs have been shown to increase access to and utilization of cancer care for poor and underserved individuals. Despite mounting evidence of its value, cancer patient navigation is not universally understood or provided. We describe five PN programs and the range of tasks their navigators provide across the cancer care continuum (education and outreach, screening, diagnosis and staging, treatment, survivorship, and end-of-life). Tasks are organized by their potential to make cancer services understandable, available, accessible, affordable, appropriate, and accountable. Although navigators perform similar tasks across the five programs, their specific approaches reflect differences in community culture, context, program setting, and funding. Task lists can inform the development of programs, job descriptions, training, and evaluation. They also may be useful in the move to certify navigators and establish mechanisms for reimbursement for navigation services.

Native cancer navigation: the state of the science

The purpose of this literature review is to determine the current state of the science for the effectiveness of patient navigation on improving outcomes of cancer care across the continuum among Native Americans. The research will help healthcare professionals ascertain potential evidence-based practice guidelines and gaps in knowledge, which may provide direction for future research. Data synthesis included the use of Native navigation for cancer care, which has been demonstrated in limited, nonrandomized studies to improve cancer knowledge, access to care, and quality of life for Native Americans. Those studies had limitations, including small sample size, self-report of outcome measures, and lack of randomization. Evidence is insufficient to conclude that the use of Native navigation is superior to usual cancer care for Native American patients. Oncology nurses have a role in training personnel to serve as cancer navigators. Nurses need to be supportive of culturally appropriate navigation programs and know about services provided by navigators. In addition, nurse educators need to encourage Native Americans in their communities to consider choosing nursing as a profession. If an oncology nurse has an interest in research, opportunities exist to assist with or conduct research projects regarding Native cancer navigation. A particular need exists for addressing the gaps in research identified in this article.

Comparison of quality of life between Native and non-Native cancer survivors: Native and non-Native cancer survivors' QOL

This paper compares quality of life (QOL) outcomes between Native American and non-Native cancer survivors. Native Patient Navigators helped Native cancer patients complete a 114-item QOL survey and access survivorship information available on the NACES website. The survey was modified from Ferrell et. al’s QOL measure and assessed the four domains of cancer survivorship: physical, psychological, social, and spiritual. Findings from Native survivors were compared to Ferrell’s findings. This is the first time that QOL outcomes have been compared between Native and Non-Native cancer survivors. Natives scored lower for physical and social QOL, the same for psychological QOL, and higher for spiritual QOL in comparison to non-Natives. Overall QOL scores were the same. Although this is the largest sample of Native cancer survivors reported in peer-reviewed manuscripts, these Native survivorship data are based on a self-selected group and it is unknown if the findings are generalizable to others.

Online evaluation programs: benefits and limitations

Patient navigation programs are increasing throughout the USA, yet some evaluation measures are too vague to determine what and how navigation functions. Through collaborative efforts an online evaluation program was developed. The goal of this evaluation program is to make data entry accurate, simple, and efficient. This comprehensive program includes major components on staff, mentoring, committees, partnerships, grants/studies, products, dissemination, patient navigation, and reports. Pull down menus, radio buttons, and check boxes are incorporated whenever possible. Although the program has limitations, the benefits of having access to current, up-to-date program data 24/7 are worth overcoming the challenges. Of major benefit is the ability of the staff to tailor summary reports to provide anonymous feedback in a timely manner to community partners and participants. The tailored data are useful for the partners to generate summaries for inclusion in new grant applications.

Preliminary lessons learned from the "Native Navigators and the Cancer Continuum" (NNACC)

This community-based participatory research (CBPR) study was based on patient navigation (Navigator) among three original sites: Colorado, Michigan, and South Dakota. During 2010, the study added two sites: the Comanche Nation and the Muscogee (Creek) Nation (Oklahoma). The intervention includes 24-h of a Navigator-implemented cancer education program that addresses the full continuum of cancer care. The partners include agreements with up to two local Native American organizations each year, called Memorandum Native Organizations, who have strong relationships with local American Indians. Family fun events are used to initiate the series of workshops and to collect baseline data and also to wrap up and evaluate the series 3 months following the completion of the workshop series. Evaluation data are collected using an audience response system (ARS) and stored using an online evaluation program. Among the lessons learned to date are: the Institutional Review Board processes required both regional and national approvals and took more than 9 months. All of the workshop slides were missing some components and needed refinements. The specifics for the Memorandum Native Organization deliverables needed more details. The ARS required additional training sessions, but once learned the Navigator use the ARS well. Use of the NACR website for a password-protected page to store all NNACC workshop and training materials was easier to manage than use of other online storage programs. The community interest in taking part in the workshops was greater than what was anticipated. All of the Navigators' skills are improving and all are enjoying working with the community.

Enhancing life after cancer in diverse communities

BACKGROUND

Although large numbers of cancer survivors exist in every community, including minority communities, there is a significant gap in knowledge about best practices for these patients.

METHODS

The Community Networks Program, funded by the National Cancer Institute Center to Reduce Cancer Health Disparities, has developed and tested unique services for these communities. These programs have used community-based participatory research techniques under a framework of diffusion of innovation and communications theory.

RESULTS

This article describes some specifically tailored interventions that may be useful to a wide range of providers working with the underserved.

CONCLUSIONS

Enhancing life after cancer can be achieved in underserved communities by supplementing local resources.

Assessing the impact of patient navigation: prevention and early detection metrics

BACKGROUND

The lack of comparable metrics to evaluate prevention and early detection patient navigation programs impeded the ability to identify best practices.

METHODS

The Prevention and Early Detection Workgroup of the Patient Navigation Leadership Summit was charged with making recommendations for common clinical metrics specific to the prevention and early detection phase of the cancer care continuum. The workgroup began with a review of existing literature to characterize variability in published navigation metrics; then developed a list of priority recommendations that would be applicable to the range of navigation settings (clinical, academic, or community-based).

RESULTS

Recommendations for researchers and program evaluators included the following: 1) Clearly document key program characteristics; 2) Use a set of core data elements to form the basis of your reported metrics; and 3) Prioritize data collection using methods with the least amount of bias.

CONCLUSIONS

If navigation programs explicitly state the context of their evaluation and choose from among the common set of data elements, meaningful comparisons among existing programs should be feasible.

Community-based participatory development, implementation, and evaluation of a cancer screening educational intervention among American Indians in the Northern Plains

The study describes the creation and implementation of a culturally appropriate cancer education intervention, and assesses its efficacy among American Indians in a community with documented cancer-related disparities. Education workshops were developed and conducted on three western South Dakota reservations and in Rapid City by trained community representatives. Over 400 individuals participated in the 2-h workshops. Participants answered demographic questions, questions about previous cancer screening (to establish baseline screening rates), and completed a pre- and post-workshop quiz to assess learning. Participants demonstrated significant increases in cancer screening-related knowledge levels. Surveys reveal that participants found the information of high quality, great value and would recommend the program to friends. Pre-workshop data reveals cancer screening rates well below the national average. Workshop participants increased their knowledge about cancer etiology and screening. This intervention may represent an effective tool for increasing cancer screening utilization among American Indians.

Breast screening navigator programs within three settings that assist underserved women

Medically underserved women in the Greater Denver Metropolitan Area had low rates of routine repeat mammograms in the latter 1990s. "Increasing Mammography Adherence among Medically Underserved Women" was designed to increase annual rescreening among medically underserved populations living in this area. Four community-based organizations collaborated to implement this 5-year study. A culturally modified navigator model including both face-to-face and telephone formats was used to facilitate mammography for African Americans, Latinas, Native Americans, and poor White women who had not been rescreened in more than 18 months. The navigator-implemented intervention was statistically significant at the 0.05 level for increasing rescreening.

Native American breast cancer survivors' physical conditions and quality of life

BACKGROUND

Based on Survivors' Guidance, an interactive, Web-based, culturally relevant Native American cancer survivorship program, Native American Cancer Education for Survivors (NACES), was developed. The focus of the program is to improve quality of life (QOL) for Native American breast cancer survivors.

METHODS

NACES is a community-driven research and education project, based on the Social Cognitive Theoretical Model. Participants complete a QOL survey that includes physical, psychosocial, spiritual, and social components. This publication focuses on the physical component of the survey collected by trained Native American patient advocates, and compares physical conditions among Native American breast cancer survivors who were diagnosed within 1 year, those diagnosed between 1 and 4 years, and those who are long-term survivors (diagnosed > or = 5 years ago).

RESULTS

For the first time, survivorship issues are reported specifically for Native American breast cancer patients (n = 266). Selected access issues document situations that contribute to disparities. Comorbidities such as high blood pressure and arthritis are common in the survivors, with more than a third having diabetes, in addition to breast cancer. Numerous side effects from cancer treatments are experienced by these survivors.

CONCLUSIONS

These data describe what Native American breast cancer patients are experiencing based on self-reported information. Clearly there is need for much more work and long-term tracking of Native American patients to begin to document if or how the severity of physical symptoms lessens over time and if their experiences are significantly different from non-Native Americans.

"Below their notice": exploring women's subjective experiences of cancer system exclusion

BACKGROUND

The experiences that marginalized breast cancer populations have in common are rarely considered.

METHODS

The authors look across 3 qualitative studies to explore the experiences of older, lower-income, and Aboriginal women diagnosed with cancer and treated by the cancer care system in Ontario, Canada.

RESULTS

The research examines critical moments in participants' narratives that parallel one another and are categorized within 2 themes: Not Getting Cancer Care and Not Getting Supportive Care.

CONCLUSIONS

Although exploratory, the findings merit attention both for what they tell us about women's experiences, and because they suggest disparities in access to treatment and psychosocial support.

Establishing trusting partnerships for successful recruitment of American Indians to clinical trials

BACKGROUND

Cancer mortality rates among American Indians (AIs) in the Northern Plains are among the highest in the nation. Reasons for this disparity are unclear but are probably due to multiple barriers. AIs appear to experience more intense side effects from therapeutic radiation compared with other populations. This differential response to treatment, a disparity in itself, might be overcome if the molecular reasons were better understood.

METHODS

The National Cancer Institute developed the Cancer Disparity Research Partnership to address these inequities. This initiative, known as the Walking Forward program, attempts to lower cancer mortality rates for AIs by increasing access to innovative clinical trials, behavioral research, patient navigation, and the ataxia telangiectasia mutated (ATM) gene study. The ATM component of the project was initiated to determine if there is a molecular basis for this apparent differential response to therapeutic radiation. Successful implementation of the genetic study relied on achieving a trusting partnership with AIs since a lack of trust has historically been a barrier to performing research in this population. The authors detail the nature of building partnerships and trust by utilizing lessons learned.

RESULTS

Establishing a trusting partnership between a community hospital and AIs in South Dakota resulted in successful recruitment to this ATM clinical trial. To date, 26 AIs and 40 non-AIs have consented to participate in this ATM analysis. Their shared human desire to assist others, especially family and community members, and their demonstrated responsiveness to community priorities by academic researchers are the primary reasons for participant eagerness to enroll on this study.

CONCLUSIONS

The relatively rapid approval of the ATM genetic study by multiple tribal organizations and the successful accrual of AIs on this study reflect the trusting partnerships achieved at the patient and community levels.

Disparities in breast cancer treatment among American Indian, Hispanic and non-Hispanic White Women Enrolled in Medicare

Because racial/ethnic disparities in breast cancer survival have persisted, we investigated differences in breast cancer treatment among American Indian, Hispanic, and non-Hispanic White (NHW) women. Surveillance, Epidemiology and End Results data linked to Medicare claims in New Mexico and Arizona (1987-1997) among enrollees aged 65 and older were used to identify treatment, treatment interval, and mortality risk associated with delays in care. We identified 2,031 women (67 American Indian, 333 Hispanic and 1,631 NHW women with time to treatment information. Treatment intervals from diagnosis to surgery (all stages, 18 versus 4 days, p.

Effective Educational Strategies Combining Emerging Genetic Science and Native American Cultural Issues

The purpose of this paper is to describe how new topics in genetic science are implemented and evaluated within Genetic Education for Native Americans (GENA®) workshops. These workshops are typically implemented during professional conferences, training programs, Native American meetings and at tribal colleges. As genetic science evolves, public health educators are more and more likely to need to understand increasingly complex components within genetic research. These research discoveries are likely to impact cardiovascular health, cancer treatments, prevention and control of diabetes. The public and patients want to understand health information that affects them personally, as well as their communities. The focus of this paper is on GENA® objective 14 (emerging genetic science: microRNA), but the three 2006 3-hour workshops also addressed excerpts of GENA® objectives 5 and 29. at three meetings: the 2006 summer and fall Disparities Training Programs held in Houston, Texas and the 2006 Society for the Advancement of Chicanos and Native Americans in the Sciences (SACNAS) conference (October, Tampa, Florida). The emphasis on objective 14 is because it was updated during spring 2006 (initial focus was on stem cell research) and selected components of objectives 5 and 20 have been published elsewhere. The paper briefly describes the content, interactive learning opportunity and the evaluation from the three 2006 workshops. The overall findings verify the effectiveness (p value of less than .01) of GENA® to significantly increase knowledge level of workshop participants about emerging genetic science breakthroughs.

Interactive Lesson on the Cell

The purpose of this article is to explain how a basic hands-on lesson about the human cell was developed, implemented and evaluated through Genetic Education for Native Americans (GENA®) workshops.