In 1990, Harold P. Freeman, MD, established the nation’s first patient navigation program at Harlem Hospital Center in New York (see accompanying article here). Since then, Dr. Freeman’s vision has gained national attention and is currently being looked at in a demonstration project across multiple health-care settings. At ASCO’s Quality Care Symposium, Naomi Ko, MD, MPH, discussed a study that looked at the impact of patient navigation on the delivery of breast cancer treatment.
Cancer Care Disparity
“The background that drove this research is the knowledge that low-income, racial and ethnic minorities have significantly higher mortality from breast cancer. Naturally, the goal of our research is to try to eliminate health-care disparities, which is an important component for lessening the cancer burden on vulnerable patient populations,” said Dr. Ko.
“One approach to attack this issue in the cancer disparity setting is to look at this as a paradigm in which there is a critical disconnect between cancer discoveries and the delivery of cutting-edge cancer care to patients of all economic backgrounds,” said Dr. Ko.
Dr. Ko explained that the patient navigation model was originally devised to create a system in which a navigator assists and coordinates all aspects of cancer care, trying ultimately to have things done in an orderly and timely way. “Navigators were first engaged to deal with the challenging issues that poor people from minority communities face, which are exacerbated by low literacy rates and language barriers. However, up until now there is little data on the actual effect on the quality of care that patient navigation has on its intended patient populations,” said Dr. Ko.
Study Objective
“Our study asked the basic question: Are navigated patients with breast cancer more likely to meet quality measures of care? To answer this we did a secondary analysis of pooled data from the Patient Navigation Research Program (PNRP), which is a National Cancer Institute–funded study with nine sites across the country,” said Dr. Ko.
Using data from 2006 to 2011, Dr. Ko and the PNRP co-investigator team a logistic regression model to determine the proportion of navigated and control patients with breast cancer whose care met National Comprehensive Cancer Network (NCCN) quality metrics, which were adjusted for age, race, language, marital status, insurance status, tumor size, and number of nodes. The investigators looked at NCCN category 1 breast cancer quality measures in three settings: (1) hormonal therapy among women with hormone receptor–positive disease, (2) radiation therapy postlumpectomy, and (3) chemotherapy in triple-negative disease for women less than 70 years of age whose tumors were greater than 1 cm in size.
“We looked at 1,004 breast cancer cases and we broke that down into three cohorts: those eligible for hormone therapy (n = 668), radiation therapy (n = 572), or chemotherapy (n = 211). Some of these patients could overlap, so the treatment cohorts were not mutually exclusive; therefore, we had varying sample sizes for each of the three eligibility categories,” said Dr. Ko, adding that the study had several limitations in that it was a hypothesis-generating, secondary analysis that ultimately left certain variables unaccounted for.
“Our preliminary results showed that the odds of receiving these quality metrics—comparing navigated and nonnavigated groups differed in each category. Women eligible for hormone therapy who had a patient navigator were more likely to receive recommended treatment. Similarly, women with a patient navigator were also more likely to receive radiation after lumpectomy. However, among the chemotherapy group, we saw an opposite trend. Patients in the control group who weren’t navigated were actually more likely to receive guideline-driven adjuvant chemotherapy,” noted Dr. Ko.
Overall Conclusions
The researchers found that while navigation did have a positive effect in hormonal therapy, the effect in radiation was statistically insignificant and, surprisingly, more nonnavigated patients received chemotherapy.
“So although we feel that patient navigation programs can have a positive effect on the quality of care in challenged populations, we need more research to determine which navigation models work and on what aspects of care,” said Dr. Ko. ■
Disclosure:Dr. Ko reported no potential conflicts of interest.
