The NCI Center to Reduce Cancer Health Disparities: Moving Forward to Eliminate Cancer Health Disparities and Diversify the Cancer Biomedical Workforce.

The National Cancer Institute's (NCI) Center to Reduce Cancer Health Disparities (CRCHD) was established in 2001 with the purpose of confronting and eliminating cancer health disparities, while increasing workforce diversity in cancer research. Over the last two decades, CRCHD has generated a broad range of research, training, and community outreach activities to address these overarching goals through a variety of programs including the Continuing Umbrella of Research Experiences (CURE), Partnerships to Advance Cancer Health Equity (PACHE), Special Populations Networks (SPN), Community Networks Program (CNP), CNP Centers (CNPC), and Patient Navigation Research Program (PNRP). CRCHD, through its CURE and now its Intramural CURE (iCURE) programs, has been fully dedicated to training the next generation of competitive researchers from backgrounds typically underrepresented in the cancer and cancer health disparities research fields. Today, CRCHD leads NCI's efforts in supporting research training and career development experiences beginning as early as middle school and continuing through to tenured track appointments. CRCHD has also developed a robust basic research focus in cancer disparities, which has recently expanded into translational disparities research and the generation of novel, authenticated animal models appropriate for advancing disparities research investigations. Additionally, CRCHD has fostered an integrated networks infrastructure to complement and support its disparities research and diversity training efforts, as well as provide cancer education and outreach among racially and ethnically diverse and medically underserved communities. Moving forward, the CRCHD will continue its steadfast efforts to move us closer to the day when diversity is a given and disparities no longer exist.

Screen to Save: Results from NCI's Colorectal Cancer Outreach and Screening Initiative to Promote Awareness and Knowledge of Colorectal Cancer in Racial/Ethnic and Rural Populations.

BACKGROUND: The Center to Reduce Cancer Health Disparities (CRCHD), NCI, implemented Screen to Save, NCI's Colorectal Cancer Outreach and Screening Initiative to promote awareness and knowledge of colorectal cancer in racial/ethnic and rural populations. METHODS: The initiative was implemented through CRCHD's National Outreach Network (NON). NON is a national network of Community Health Educators (CHE), aligned with NCI-designated Cancer Centers across the nation. In phases I and II, the CHEs focused on the dissemination of cancer-related information and implementation of evidence-based educational outreach. RESULTS: In total, 3,183 pre/post surveys were obtained from male and female participants, ages 50 to 74 years, during the 347 educational events held in phase I. Results demonstrated all racial/ethnic groups had an increase in colorectal cancer-related knowledge, and each group strongly agreed that the educational event increased the likelihood that they would engage in colorectal cancer-related healthful behaviors (e.g., obtain colorectal cancer screening and increase physical activity). For phase II, Connections to Care, event participants were linked to screening. Eighty-two percent of the participants who obtained colorectal cancer screening during the 3-month follow-up period obtained their screening results. CONCLUSIONS: These results suggest that culturally tailored, standardized educational messaging and data collection tools are key change agents that can serve to inform the effectiveness of educational outreach to advance awareness and knowledge of colorectal cancer. IMPACT: Future initiatives should focus on large-scale national efforts to elucidate effective models of connections to care, related to colorectal cancer screening, follow-up, and treatments that are modifiable to meet community needs.

What Makes Patient Navigation Most Effective: Defining Useful Tasks and Networks.

Given the momentum in adopting patient navigation into cancer care, there is a need to understand the contribution of specific navigator activities to improved clinical outcomes. A mixed-methods study combined direct observations of patient navigators within the Patient Navigation Research Program and outcome data from the trial. We correlated the frequency of navigator tasks with the outcome of rate of diagnostic resolution within 365 days among patients who received the intervention relative to controls. A focused content analysis examined those tasks with the strongest correlations between navigator tasks and patient outcomes. Navigating directly with specific patients (r = 0.679), working with clinical providers to facilitate patient care (r = 0.643), and performing tasks not directly related to their diagnostic evaluation for patients were positively associated with more timely diagnosis (r = 0.714). Using medical records for non-navigation tasks had a negative association (r = -0.643). Content analysis revealed service provision directed at specific patients improved care while systems-focused activities did not.

Relation of comorbidities and patient navigation with the time to diagnostic resolution after abnormal cancer screening.

BACKGROUND: Whether patient navigation improves outcomes for patients with comorbidities is unknown. The aims of this study were to determine the effect of comorbidities on the time to diagnostic resolution after an abnormal cancer screening test and to examine whether patient navigation improves the timeliness and likelihood of diagnostic resolution for patients with comorbidities in comparison with no navigation. METHODS: A secondary analysis of comorbidity data collected by Patient Navigation Research Program sites using the Charlson Comorbidity Index (CCI) was conducted. The participants were 6,349 patients with abnormal breast, cervical, colon, or prostate cancer screening tests between 2007 and 2011. The intervention was patient navigation or usual care. The CCI data were highly skewed across projects and cancer sites, and the CCI scores were categorized as 0 (CCI score of 0 or no comorbidities identified; 76% of cases); 1 (CCI score of 1; 16% of cases), or 2 (CCI score ≥ 2; 8% of cases). Separate adjusted hazard ratios for each site and cancer type were obtained, and then they were pooled with a meta-analysis random effects methodology. RESULTS: Patients with a CCI score ≥ 2 had delayed diagnostic resolution after an abnormal cancer screening test in comparison with those with no comorbidities. Patient navigation reduced delays in diagnostic resolution, with the greatest benefits seen for those with a CCI score ≥ 2. CONCLUSIONS: Persons with a CCI score ≥ 2 experienced significant delays in timely diagnostic care in comparison with patients without comorbidities. Patient navigation was effective in reducing delays in diagnostic resolution among those with CCI scores > 1. Cancer 2017;123:312-318. © 2016 American Cancer Society.

Racial and ethnic differences in patient navigation: Results from the Patient Navigation Research Program.

BACKGROUND: Patient navigation was developed to address barriers to timely care and reduce cancer disparities. The current study explored navigation and racial and ethnic differences in time to the diagnostic resolution of a cancer screening abnormality. METHODS: The authors conducted an analysis of the multisite Patient Navigation Research Program. Participants with an abnormal cancer screening test were allocated to either navigation or control. The unadjusted median time to resolution was calculated for each racial and ethnic group by navigation and control. Multivariable Cox proportional hazards models were fit, adjusting for sex, age, cancer abnormality type, and health insurance and stratifying by center of care. RESULTS: Among a sample of 7514 participants, 29% were non-Hispanic white, 43% were Hispanic, and 28% were black. In the control group, black individuals were found to have a longer median time to diagnostic resolution (108 days) compared with non-Hispanic white individuals (65 days) or Hispanic individuals (68 days) (P<.0001). In the navigated groups, black individuals had a reduction in the median time to diagnostic resolution (97 days) (P<.0001). In the multivariable models, among controls, black race was found to be associated with an increased delay to diagnostic resolution (hazard ratio, 0.77; 95% confidence interval, 0.69-0.84) compared with non-Hispanic white individuals, which was reduced in the navigated arm (hazard ratio, 0.85; 95% confidence interval, 0.77-0.94). CONCLUSIONS: Patient navigation appears to have the greatest impact among black patients, who had the greatest delays in care. Cancer 2016. © 2016 American Cancer Society. Cancer 2016;122:2715-2722. © 2016 American Cancer Society.

Satisfaction with cancer care among underserved racial-ethnic minorities and lower-income patients receiving patient navigation.

BACKGROUND: Patient navigation is a barrier-focused program of care coordination designed to achieve timely and high-quality cancer-related care for medically underserved racial-ethnic minorities and the poor. However, to the authors' knowledge, few studies to date have examined the relationship between satisfaction with navigators and cancer-related care. METHODS: The authors included data from 1345 patients with abnormal cancer screening tests or a definitive cancer diagnosis who participated in the Patient Navigation Research Program to test the efficacy of patient navigation. Participants completed demographic questionnaires and measures of patient satisfaction with cancer-related care (PSCC) and patient satisfaction with interpersonal relationship with navigator (PSN-I). The authors obtained descriptive statistics to characterize the sample and conducted regression analyses to assess the degree of association between PSN-I and PSCC, controlling for demographic and clinical factors. Analyses of variance were conducted to examine group differences controlling for statistically significant covariates. RESULTS: Statistically significant relationships were found between the PSCC and PSN-I for patients with abnormal cancer screening tests (1040 patients; correlation coefficient (r), 0.4 [P<.001]) and those with a definitive cancer diagnosis (305 patients; correlation coefficient, 0.4 [P<.001]). The regression analysis indicated that having an abnormal colorectal cancer screening test in the abnormal screening test group and increased age and minority race-ethnicity status in the cancer diagnosis group were associated with a higher satisfaction with cancer care (P<.01). CONCLUSIONS: Satisfaction with navigators appears to be significantly associated with satisfaction with cancer-related care. Information regarding the patient-navigator relationship should be integrated into patient navigation programs to maximize the likelihood of reducing caner disparities and mortality for medically underserved racial-ethnic minorities and the poor.

Barriers to health care contribute to delays in follow-up among women with abnormal cancer screening: Data from the Patient Navigation Research Program.

BACKGROUND: There is limited understanding of the association between barriers to care and clinical outcomes within patient navigation programs. METHODS: Secondary analyses of data from the intervention arms of the Patient Navigation Research Program were performed, which included navigated participants with abnormal breast and cervical cancer screening tests from 2007 to 2010. Independent variables were: 1) the number of unique barriers to care (0, 1, 2, or ≥3) documented during patient navigation encounters; and 2) the presence of socio-legal barriers originating from social policy (yes/no). The median time to diagnostic resolution of index screening abnormalities was estimated using Kaplan-Meier cumulative incidence curves. Multivariable Cox proportional hazards regression examined the impact of barriers on time to resolution, controlling for sociodemographics and stratifying by study center. RESULTS: Among 2600 breast screening participants, approximately 75% had barriers to care documented (25% had 1 barrier, 16% had 2 barriers, and 34% had ≥3 barriers). Among 1387 cervical screening participants, greater than one-half had barriers documented (31% had 1 barrier, 11% had 2 barriers, and 13% had ≥3 barriers). Among breast screening participants, the presence of barriers was associated with less timely resolution for any number of barriers compared with no barriers. Among cervical screening participants, only the presence of ≥2 barriers was found to be associated with less timely resolution. Both types of barriers, socio-legal and other barriers, were found to be associated with delay among breast and cervical screening participants. CONCLUSIONS: Navigated women with barriers resolved cancer screening abnormalities at a slower rate compared with navigated women with no barriers. Further innovations in navigation care are necessary to maximize the impact of patient navigation programs nationwide.

Impact of patient navigation on timely cancer care: the Patient Navigation Research Program.

BACKGROUND: Patient navigation is a promising intervention to address cancer disparities but requires a multisite controlled trial to assess its effectiveness. METHODS: The Patient Navigation Research Program compared patient navigation with usual care on time to diagnosis or treatment for participants with breast, cervical, colorectal, or prostate screening abnormalities and/or cancers between 2007 and 2010. Patient navigators developed individualized strategies to address barriers to care, with the focus on preventing delays in care. To assess timeliness of diagnostic resolution, we conducted a meta-analysis of center- and cancer-specific adjusted hazard ratios (aHRs) comparing patient navigation vs usual care. To assess initiation of cancer therapy, we calculated a single aHR, pooling data across all centers and cancer types. We conducted a metaregression to evaluate variability across centers. All statistical tests were two-sided. RESULTS: The 10521 participants with abnormal screening tests and 2105 with a cancer or precancer diagnosis were predominantly from racial/ethnic minority groups (73%) and publically insured (40%) or uninsured (31%). There was no benefit during the first 90 days of care, but a benefit of navigation was seen from 91 to 365 days for both diagnostic resolution (aHR = 1.51; 95% confidence interval [CI] = 1.23 to 1.84; P < .001)) and treatment initiation (aHR = 1.43; 95% CI = 1.10 to 1.86; P < .007). Metaregression revealed that navigation had its greatest benefits within centers with the greatest delays in follow-up under usual care. CONCLUSIONS: Patient navigation demonstrated a moderate benefit in improving timely cancer care. These results support adoption of patient navigation in settings that serve populations at risk of being lost to follow-up.

Analysis of combined data from heterogeneous study designs: an applied example from the patient navigation research program.

BACKGROUND: The Patient Navigation Research Program (PNRP) is a cooperative effort of nine research projects, with similar clinical criteria but with different study designs. To evaluate projects such as PNRP, it is desirable to perform a pooled analysis to increase power relative to the individual projects. There is no agreed-upon prospective methodology, however, for analyzing combined data arising from different study designs. Expert opinions were thus solicited from the members of the PNRP Design and Analysis Committee. PURPOSE: To review possible methodologies for analyzing combined data arising from heterogeneous study designs. METHODS: The Design and Analysis Committee critically reviewed the pros and cons of five potential methods for analyzing combined PNRP project data. The conclusions were based on simple consensus. The five approaches reviewed included the following: (1) analyzing and reporting each project separately, (2) combining data from all projects and performing an individual-level analysis, (3) pooling data from projects having similar study designs, (4) analyzing pooled data using a prospective meta-analytic technique, and (5) analyzing pooled data utilizing a novel simulated group-randomized design. RESULTS: Methodologies varied in their ability to incorporate data from all PNRP projects, to appropriately account for differing study designs, and to accommodate differing project sample sizes. LIMITATIONS: The conclusions reached were based on expert opinion and not derived from actual analyses performed. CONCLUSIONS: The ability to analyze pooled data arising from differing study designs may provide pertinent information to inform programmatic, budgetary, and policy perspectives. Multisite community-based research may not lend itself well to the more stringent explanatory and pragmatic standards of a randomized controlled trial design. Given our growing interest in community-based population research, the challenges inherent in the analysis of heterogeneous study design are likely to become more salient. Discussion of the analytic issues faced by the PNRP and the methodological approaches we considered may be of value to other prospective community-based research programs.