Patient Navigation in Breast Cancer: A Systematic Review

Stephanie Robinson-White, MD; Brenna Conroy, BS; Kathleen H. Slavish, BA; Margaret Rosenzweig, PhD, APN-BC, AOCNP

Disclosures

Cancer Nurs. 2010;33(2):127-140. 

In This Article

Abstract and Introduction

Abstract

Background: The role of the patient navigator in cancer care and specifically in breast cancer care has grown to incorporate many titles and functions.
Objective: To better evaluate the outcomes of patient navigation in breast cancer care, a comprehensive review of empiric literature detailing the efficacy of breast cancer navigation on breast cancer outcomes (screening, diagnosis, treatment, and participation in clinical research) was performed.
Methods: Published articles were reviewed if published in the scientific literature between January 1990 and April 2009. Searches were conducted using PubMed and Ovid databases. Search terms included MeSH (Medical Subject Headings) terms, "patient navigator," "navigation," "breast cancer," and "adherence."
Results: Data-based literature indicates that the role of patient navigation is diverse with multiple roles and targeted populations. Navigation across many aspects of the breast cancer disease trajectory improves adherence to breast cancer care. The empiric review found that navigation interventions have been more commonly applied in breast cancer screening and early diagnosis than for adherence to treatment.
Conclusion: There is evidence supporting the role of patient navigation in breast cancer to improve many aspects of breast cancer care.
Implications for Practice: Data describing the role of patient navigation in breast cancer will assist in better defining future direction for the breast navigation role. Ongoing research will better inform issues related to role definition, integration into clinical breast cancer care, impact on quality of life, cost-effectiveness, and sustainability.

Introduction

Patient navigators have become highly prevalent within cancer care. Cancer care navigation was originally conceived by Harold P. Freeman, MD, in response to disproportionate late-stage cancer presentation among African Americans attributed, in part, to an inability to access complex and often confusing existing cancer care services. In an effort to address those disparities and improve cancer care access, Freeman[1] started the first patient navigator program in 1990 at Harlem Hospital and later expanded to the Breast Examination Center of Harlem and the Ralph Lauren Center for Cancer Care and Prevention. The goal of the navigation intervention was to "assist patients with abnormal findings or cancer in navigating and, at times, circumnavigating to the hospital and human services bureaucracies to accomplish the follow-up and diagnosis of an abnormal finding on cancer screening tests and the treatment of cancer."[1] Freeman et al[2,3] differentiated patient navigator programs from other services designed to reduce healthcare disparities by emphasizing the need for navigators to be members of the community they intend to serve and that they be familiar with healthcare to allow navigators to personally relate to their patient.

Since 1990, the role of the patient navigator in healthcare and specifically in cancer care has grown to incorporate many titles and functions.[4,5] Initially, patient navigation was not meant to address psychological, social, and physical support systems that are mainly directed at improving the quality of life of patients with cancer. However, with the recognition of the interconnection of psychosocial issues with adherence to screening and cancer treatment,[6–13] cancer care navigation has evolved to include outcomes encompassing not only screening and diagnostic and treatment adherence but quality-of-life outcomes as well.

Growth of Navigation Role

The promising results of Freeman's[1,2] initial navigation program initiated the development of additional patient navigator programs nationally. Many of these programs, although somewhat heterogeneous in their design and implementation, reported success assisting patients through a complex cancer care system.[14–19] Program outcomes of navigation in cancer care needed to be defined and rigorously tested.[20] Increased interest and requests for financial support of navigation programs created the need for a comprehensive and more rigorous review of navigation methods and outcomes.

In 2002, the National Cancer Institute established funding for the implementation and evaluation of patient navigator programs in cancer care. The primary project is the Patient Navigator Research Program: Eliminating Barriers to Timely Delivery of Cancer Diagnosis and Treatment Services. This program provided funding to 8 institutions nationwide for 5 years "to develop and assess the efficacy and cost-effectiveness of various innovative navigator interventions in communities experiencing cancer health disparities."[21] Table 1 outlines the location, patient population, navigator characteristics, and specific aims of the National Cancer Institute grantees.

Navigation in Breast Cancer

Cancer navigators are evolving as the cancer care navigation role becomes more defined and delineated in cancer care. Breast cancer is an optimal arena for patient navigation because of known survival benefit of early detection through clinical breast examination, mammography, and early intervention. Navigation is particularly important in breast cancer care because of the documented racial disparity in breast cancer care across the disease trajectory. The 5-year mortality rate after a first diagnosis of breast cancer is 90% for white women, but only 77% for black women.[22]

The historic explanation for the survival disparity among African American women is late-stage presentation of breast cancer[23,24] due to poor adherence to recommended screening tests or nonreporting of clinical symptoms. However, reviews of US cancer studies have also found strong evidence that white patients receive more aggressive initial treatment for breast cancers than do black patients, resulting in higher mortality among the nonwhite populations.[25–27] In addition, in the only identified analysis of specifically appointment adherence during systemic breast-cancer therapy, black women were overly represented among women who missed appointments,[28] and a greater number of missed appointments correlated with shorter survival.[28] Consequently, despite other potential etiologies, there is an increasing need to consider navigation, not only in early detection, but also throughout the breast cancer treatment trajectory.

Navigation is also necessary in breast cancer care to coordinate the multidisciplinary providers and complexity of care across the disease trajectory inherent in breast cancer treatment, including advanced breast cancer.[29] Bickell and Young[30] described 67 interviews of care providers for early-stage breast cancer patients who described many efforts toward coordination of care for women with early-stage breast cancer, but no consistent methods to track care, receipt of care, or missed appointments. Ongoing research will better inform issues related to role definition, integration into clinical breast cancer care, impact on quality of life, cost-effectiveness, and navigation sustainability.

To evaluate the outcomes of patient navigation in breast cancer care, a comprehensive review of empiric literature detailing the efficacy of breast cancer navigation on outcomes related specifically to breast cancer care (screening, diagnosis, treatment, quality-of-life survivorship, and participation in clinical research) was performed.

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