Lay navigator model for impacting cancer health disparities.

This paper recounts experiences, challenges, and lessons learned when implementing a lay patient navigator program to improve cancer care among medically underserved patients who presented in a primary care clinic with a breast or colorectal cancer abnormality. The program employed five lay navigators to navigate 588 patients. Central programmatic elements were the following: (1) use of bilingual lay navigators with familiarity of communities they served; (2) provision of training, education, and supportive activities; (3) multidisciplinary clinical oversight that factored in caseload intensity; and (4) well-developed partnerships with community clinics and social service entities. Deconstruction of healthcare system information was fundamental to navigation processes. We conclude that a lay model of navigation is well suited to assist patients through complex healthcare systems; however, a stepped care model that includes both lay and professional navigation may be optimal to help patients across the entire continuum.

Patient navigation for breast and colorectal cancer in 3 community hospital settings: an economic evaluation.

BACKGROUND: The Ralph Lauren Cancer Center implemented patient navigation programs in sites across the United States building on the model pioneered by Harold P. Freeman, MD. Patient navigation targets medically underserved with the objective of reducing the time interval between an abnormal cancer finding, diagnostic resolution, and treatment initiation. In this study, the authors assessed the incremental cost effectiveness of adding patient navigation to standard cancer care in 3 community hospitals in the United States. METHODS: A decision-analytic model was used to assess the cost effectiveness of a colorectal and breast cancer patient navigation program over the period of 1 year compared with standard care. Data sources included published estimates in the literature and primary costs, aggregate patient demographics, and outcome data from 3 patient navigation programs. RESULTS: After 1 year, compared with standard care alone, it was estimated that offering patient navigation with standard care would allow an additional 78 of 959 individuals with an abnormal breast cancer screening and an additional 21 of 411 individuals with abnormal colonoscopies to reach timely diagnostic resolution. Without including medical treatment costs saved, the cost-effectiveness ratio ranged from $511 to $2080 per breast cancer diagnostic resolution achieved and from $1192 to $9708 per colorectal cancer diagnostic resolution achieved. CONCLUSIONS: The current results indicated that implementing breast or colorectal cancer patient navigation in community hospital settings in which low-income populations are served may be a cost-effective addition to standard cancer care in the United States.

Determinants of cancer disparities: barriers to cancer screening, diagnosis, and treatment.

There is a critical disconnect between what we discover and what we deliver to all Americans in the form of prevention, screening, detection, diagnosis, and treatment of cancer. We must identify and eliminate all barriers that prevent the benefits of research from reaching all people. Such barriers may be experienced at any point along the continuum of prevention, screening, diagnosis and treatment, and palliative care. In communities of low socioeconomic status, patient navigation has proved to be an effective intervention in promoting such timely diagnosis and treatment when applied at the point of abnormal finding. Geographic areas with excess cancer mortality should be delineated and targeted with an intense approach to providing culturally relevant education, appropriate access to screening diagnosis and treatment, and improved support systems, including navigation.

Impact of a cancer screening program on breast cancer stage at diagnosis in a medically underserved urban community.

BACKGROUND: Our previous report showed that the disparity in breast carcinoma survival between black and white women because of advanced stage of disease at presentation in poor black women is related to their low socioeconomic status and lack of health insurance. This observation led to establishment of a community-oriented free cancer screening service. STUDY DESIGN: To evaluate the impact of screening on breast cancer stage at diagnosis, analysis of data from the Harlem Hospital Tumor Registry between 1995 and 2000 was performed and compared with our 1964-1986 report. RESULTS: Twenty-three percent of cancers (324 of 1,405) diagnosed between 1995 and 2000 were breast carcinoma. Data confirm that lack of insurance remains a major problem among poor black women. We observed a marked fall, from 49% in our earlier report to 21% in this study, in late-stage (III and IV) disease at presentation. This fall is associated with significant (p < 0.001) improvement in early detection of breast cancer, with 41% of cancers in stages 0 and I in this data compared with 6% in the previous study. Of note, 53% of women with breast carcinoma had breast-conserving surgery and 45% had modified radical mastectomy in this study; 71% had radical or modified radical mastectomy in the earlier report. CONCLUSIONS: This study confirms the importance of a free cancer screening program in the improvement of early-stage breast cancer detection, treatment, and survival in a poor urban community.

Characteristics of the original patient navigation programs to reduce disparities in the diagnosis and treatment of breast cancer.

BACKGROUND: Patient navigation is an intervention developed to reduce disparities in cancer care that is being widely replicated and receiving considerable support for demonstration projects and research to test its effectiveness. In the current study, the authors present an in-depth descriptive analysis of the original patient navigation programs to inform current and future program development. METHODS: A qualitative multistakeholder case study using interviews and site visits of the first patient navigation site and 2 sites subsequently developed by the leadership of the original site were evaluated. RESULTS: At these sites, patient navigation is a system, as opposed to a person, comprised primarily of navigators and directors that work together to remove barriers and facilitate access in a well-defined course of care; navigators were from the community or were culturally similar to the patient population served but were also paid employees of the clinical care site with detailed knowledge of the clinical course patients must traverse to complete care plans. Directors had administrative authority over the clinical facility and social capital across institutions, and communicated regularly and openly with navigators to implement system level changes to remove barriers to care. Contextual factors such as policies supporting breast cancer care also influenced the implementation of these programs. CONCLUSIONS: The first patient navigation programs combined community and culturally sensitive care-coordination with aspects of disease management programs to reduce racial, ethnic, and poverty-driven disparities in care. Future efforts to replicate and evaluate patient navigation should take into account these unique aspects of the original patient navigation programs.

Patient navigation: a community centered approach to reducing cancer mortality.

BACKGROUND: Profound advances in biomedical science have contributed to increased longevity and improved quality of life for many Americans. Despite this progress, a heavier burden of disease is borne by some population groups in the United States, particularly the poor and underserved. Landmark reports published since 1973 have highlighted these health disparities, explored their causal factors, and outlined strategies to reduce them. More recent research studies underscore the results of these early reports that identify social position, economic status, culture, and environment as critical determinants of who develops and survives cancer and of the quality of life of cancer survivors. METHODS: The Patient Navigation Program was established in Harlem, New York, in 1990 to address the dramatic disparities in breast cancer mortality among minority women in the community. RESULTS AND CONCLUSIONS: The success of the Harlem Patient Navigation Program has provided the impetus for the development of many similar patient navigation programs across the country and for federal support for Patient Navigation research to address the critical need for effective interventions to eliminate cancer health disparities, particularly among minorities and the underserved.

Acculturation and its relationship to smoking and breast self-examination frequency in African American women.

The concept of acculturation has been used to understand differences in health behaviors between and within a variety of racial and ethnic immigrant groups. Few studies, however, have examined the potential impact of acculturation on health behaviors among African Americans. The present study has two goals: 1) to reconfirm relations between acculturation and cigarette smoking; 2) to investigate the impact of acculturation on another type of health behavior, cancer screening and specifically breast self-examination (BSE). African American women (N = 66) attending an inner-city cancer-screening clinic completed study questionnaires. Results reconfirmed psychometric properties of the African American Acculturation Scale (AAAS); replicated the negative association between acculturation and lifetime smoking status; and found relations between acculturation and women's adherence to BSE frequency guidelines. Findings from this study raise the possibility that specific aspects of acculturation may better explain specific health behaviors.

Colorectal carcinoma in poor blacks.

BACKGROUND: Death rates for most cancers continue to be higher for African Americans, particularly those in inner cities. Harlem Hospital serves a poor, predominantly African-American community in New York City. METHODS: Tumor registry records for 615 patients treated for colorectal carcinoma at Harlem Hospital between 1973 and 1992 were reviewed. RESULTS: Of the patients, 45.2% were male and 54.8% female, 97.2% were black, and 82% resided in Harlem. All patients were symptomatic at the time of diagnosis;15.3% were first diagnosed intraoperatively; 8.4% were in American Joint Committee on Cancer Stage I, 20.8% Stage II, 22.8% Stage III, 39.0% Stage IV, and 8.0% could not be staged. Colon resection with intention of cure was performed on 50.6%, 21.5% had palliative resection, and 11.6% had colostomy or other palliative surgery. Adjuvant chemotherapy or radiotherapy was given to 6.2%; 16.9% had no surgical treatment because of advanced stage, poor condition, or refusal of surgery; 12.7% presented with perforation or intestinal obstruction. Operative mortality was 15.3% overall and 10.6% for 311 patients who had surgery with intention of cure. Twenty-five patients had local recurrence, 86 had subsequent distant metastases, and 33 patients had both local and distant recurrence. Forty-nine patients (8%) were lost to follow-up. The 5-year crude survival rate for 615 patients was 18.7%. The relative survival rate was 19.7%, substantially lower than the national average for the same years. CONCLUSIONS: Although colorectal carcinoma mortality continues to decline nationally, in this population of poor blacks the mortality rate remained high and unchanged. The most important cause of this is late presentation at an incurable stage, resulting from the combined effects of poverty, lack of education, and lack of access to primary care. Culturally sensitive educational programs and accessible health care systems for the poor are needed.

Trends in prostate cancer mortality among black men and white men in the United States.

BACKGROUND: Prostate cancer mortality rates in the United States declined sharply after 1991 in white men and declined after 1992 in black men. The current study was conducted to investigate possible mechanisms for the declining prostate cancer mortality rates in the United States. METHODS: The authors examined and compared patterns of prostate cancer incidence, survival rates, and mortality rates among black men and white men in the United States using the 1969-1999 U.S. prostate cancer mortality rates and the 1975-1999 prostate cancer incidence, survival, and incidence-based mortality rates from the Surveillance, Epidemiology, and End Results (SEER) Program for the U.S. population. The SEER data represent approximately 10% of the U.S. population. RESULTS: Prostate cancer incidence and mortality rates showed transient increases after 1986, when the U.S. Food and Drug Administration approved the use of prostate specific antigen (PSA) testing. The age-adjusted prostate cancer mortality rates for men age 50-84 years, however, have dropped below the rate in 1986 since 1995 for white men and since 1997 for black men. In fact, for white men ages 50-79 years, the 1998 and 1999 rates were the lowest observed since 1950. Incidence-based mortality rates by disease stage revealed that the recent declines were due to declines in distant disease mortality. Moreover, the decrease in distant disease mortality was due to a decline in distant disease incidence, and not to improved survival of patients with distant disease. CONCLUSIONS: Similar incidence, survival, and mortality rate patterns are seen in black men and white men in the United States, although with differences in the timing and magnitude of recent rate decreases. Increased detection of prostate cancer before it becomes metastatic, possibly reflecting increased use of PSA testing after 1986, may explain much of the recent mortality decrease in both white men and black men.

Racial disparities in breast carcinoma survival rates: seperating factors that affect diagnosis from factors that affect treatment.

BACKGROUND: Black females have lower breast carcinoma survival rates compared with white females. One possible reason is that black females have more advanced-stage breast disease. Another factor may be racial differences in the utilization of cancer treatments. METHODS: The authors determined racial differences in 6-year stage specific survival rates, adjusting for age and treatments (using estrogen receptor [ER] status), to determine whether there were racial differences in treatment. Racial differences in the stage distributions of breast disease were used to examine the impact of racial factors on breast carcinoma diagnosis. RESULTS: For all breast carcinoma cases, the stage specific 6-year survival rates, in general, were significantly lower for black females for all stages combined and for Stages I-III in every age group. However, examination by different treatments, as measured by ER status, revealed some different results. Only black women younger than age 50 years with ER-positive tumors and women younger than age 65 years with ER-negative tumors had significantly lower stage-specific survival rates. In addition, the stage distribution analyses showed that black females of every age group had less Stage I breast disease. CONCLUSIONS: For younger black women (younger than age 50 years), there was evidence of racial differences in treatment for both women with ER-positive tumors and women with ER-negative tumors, as indicated by their lower stage-specific survival rates. In contrast, for black females age 65 years or older with ER-positive or ER-negative tumors, the lack of a significant difference in the stage-specific survival rate suggests that Medicare may help to alleviate racial disparities in cancer treatment. Furthermore, racial differences in the stage distributions indicated the need for earlier diagnosis for black females of every age.

Carcinoma detection at the breast examination center of Harlem.

BACKGROUND: Breast carcinoma is one of the leading causes of excess mortality rates in Harlem, an inner-city neighborhood with the highest mortality rates and worst life expectancy in New York City. This study reports the results of a breast carcinoma screening and diagnostic program in Harlem. METHODS: Retrospective review was performed of a database of 49,750 visits to the Breast Examination Center of Harlem from 1995 to 2000. During this period, 181 breast carcinomas were diagnosed in 178 women. The medical records of these 178 women were reviewed to determine the method of detection, stage, and treatment. RESULTS: Among these women, 89% were black or Hispanic, 45% had no medical insurance, and 38% had incomes below federal poverty guidelines. Breast carcinoma stage, known for 167 carcinomas, was Stage 0 in 38 (23%), Stage I in 38 (23%), Stage II in 63 (38%), Stage III in 24 (14%), and Stage IV in 4 (2%). Fifty-six cases (34%) were minimal breast carcinomas. Of 181 breast carcinomas, 122 (67%) were palpable and 59 (33%) were nonpalpable, detected only by mammography in asymptomatic women. Nonpalpable, as opposed to palpable, breast carcinomas were significantly more likely to be ductal carcinoma in situ (30 of 55 [54%] vs. 8 of 112 [7%], P < 0.0000001) or minimal breast carcinoma (39 of 55 [71%] vs. 17 of 112 [15%], P = 0.0000001) and were more likely to be treated with breast-conserving surgery (47 of 56 [84%] vs. 76 of 110 [69%], P < 0.04). CONCLUSIONS: A breast carcinoma screening and diagnostic program has been established in Harlem, a traditionally underserved area in New York City. Early, curable breast carcinomas were detected but outreach remains a challenge, particularly for the uninsured.