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

Discussion

Study Design

Clearly, the review of navigation efficacy indicates a positive trend toward adherence to breast cancer screening, follow-up of diagnostic abnormalities, initiation of breast cancer treatment, and stability or improvement in quality of life with patient navigation in breast cancer. These results are encouraging, yet there is still a great deal to pursue in the research agenda. Research design overall is still not appropriately rigorous. Only 3 of the 12 studies were a randomized, controlled design.[40–42] Regardless of design, power analysis was not included in any reporting.

Navigation influence can be heavily personally influenced through the strength of an engaging personality. All of the interventions required individuals to deliver the intervention. The interpersonal or "indirect" effect on the interpersonal relationship needs to be separated from the navigation intervention to understand the effects of the individual components of the navigation intervention. The individual navigator's personality and warmth may be an important, integral component of the navigation's success, but it is important to discern if the relationship between the navigator and patient is a direct, quantifiable effect (and measurement tools used to quantify) or an indirect effect of the intervention. These delineations are important for analysis and for dissemination into routine clinical practice.

In addition, few reviews detailed or evaluated the role of navigation through breast cancer treatment, including surgery, chemotherapy, and radiation therapy, and/or long-term hormonal therapy. In addition, all studies concentrated on nonmetastatic breast cancer. Concentrating all navigation research in early-stage, predominantly diagnostic settings does not address the potential navigation needs of women with more advanced-stage illness, women receiving chronic breast-cancer therapy, or women reluctant to finish initial treatment.

Study Setting

Although heterogeneous in location, each of the studies had settings that provided accessible and affordable breast cancer screening and follow-up support to women in predominantly minority, urban, and socioeconomically disadvantaged areas. Each particular study and setting had a unique goal with respect to navigational intervention for women undergoing breast cancer screening. Despite different goals and settings, independent results of each study illustrate similar outcomes. The most compelling is the documented or potential value of accessible, affordable, and supportive breast navigation services across breast cancer settings. These studies were conducted in predominantly minority and economically underserved areas, many in urban cancer centers (10/12 studies), and may be an important intervention toward reducing breast cancer outcome disparity for underserved populations. Interventions using navigation for optimal breast cancer outcomes should be extended to rural settings.

Intervention/Navigation Role The role of the patient navigator in these studies (Table 2), although heterogeneous, always involved coordination or encouragement toward further care. The roles varied in the scope and the attention toward an emotional or quality-of-life component. More information is desired. The extent of the protocol of the navigator role was not well described in any study. For example, we do not know of a script or an algorithm of response in the encouragement components of the interventions. These data could be helpful for further analysis or replication of the navigator role. The navigator characteristics were not always addressed.[32,34,36,38] Despite literature supporting the importance of survivors and race-matched interventionists,[2–4] navigators seemed to be effective without meeting all traditional criteria (member of the community they intend to serve and cancer survivor).[2] None of the studies specifically identified the navigators as being race matched. Two studies[35,37] used breast cancer survivors in a navigator role. When described, most navigation roles were nonhealthcare professionals educated for a primarily supportive, co-coordinating role.[39–41] Importantly, the cost of the navigation role/patient benefit was not discussed. The lack of attention to the cost of navigation will limit its clinical usefulness.

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