Lay Patient Navigators a Boon to Latinos With Advanced Cancer

Fran Lowry

September 24, 2018

Lay patient navigators can improve advanced care planning in populations that are very reticent to engage in such planning, according to new research.

In a study published online in JAMA Oncology, the research team found that Latinos with advanced cancer who were assigned their own patient navigator to help them with issues such as end-of-life care planning, pain management, and hospice were more likely to complete an advanced directive than their counterparts who were not assigned a patient navigator.

"Helping patients do advanced care planning, which was one of our objectives, is a tremendous outcome, and I feel very proud of the work that our navigators were able to do. They were very helpful in completing advanced directives and ensuring they got placed in the electronic records," lead author Tracy M. Fischer, MD, University of Colorado School of Medicine, Aurora, told Medscape Medical News.

Having a patient navigator was also associated with improved physical symptoms.

However, the intervention had no effect on pain management, hospice use, or overall quality of life.

In an interview, Fischer commented that her interest in improving access to care for Latino adults with advanced cancer stems from her travels to Central and South America during a gap year between her residency and fellowship training.

"I became very interested in issues surrounding social justice, Latino culture, and the use of laypersons from the community to improve health outcomes. Having community health workers engage with patients is a way to establish trust and help ensure that the values of the culture are being integrated into the care of the patient," Fischer said.

Many hospitals have patient navigators who help patients get to clinic appointments and undergo laboratory tests. But in this study, the patient navigators were lay people who had received training on working with patients and families to reduce barriers to care.

"Our patient navigators meet with patients and families in their homes to talk about pain control, quality of life, advance care planning, and medical decision making. They also let patients know what hospice is in a way that is concordant with Latino cultural values," Fischer said.

One issue that emerged was that, in Latino culture, the word "hospicio" translates poorly.

"When we worked with Spanish speaking patients in our focus group, we found out that the way we were translating the word 'hospicio' meant that it was an orphanage, or a place where one could drop off a loved one when they could not take care of them anymore. This had a very negative translational meaning to patients," she explained.

"But when we had the navigators explain that hospice afforded a place where the family could get the support and help they needed to be able to care for their loved one, that made the idea of hospice much more acceptable, since family is such an important aspect of Latino culture," she said.

Study Details

In the Apoyo con Cariño (Support With Caring) Trial, Fischer and her team sought to determine whether a patient navigator intervention that was culturally tailored and carried out by laypersons in the community could improve palliative care outcomes for Latino adults with advanced cancer.

The trial, which was conducted from July 2012 to March 2016, included 223 Latino adult (mean age, 58.1 years; SD, 13.6 years; 55.6% women).

The patients were randomly assigned to receive patient-navigated intervention (n = 112) or treatment as usual (controls, n = 111).

Primary outcome measures were advance care planning in the medical record, the Brief Pain Inventory, and hospice use.

Secondary outcome measures included the McGill Quality of Life Questionnaire (MQOL), hospice length of stay, and aggressiveness of care at the end of life.

Patients in the intervention group were more likely to have a documented advance directive compared with control patients (73 of 112; 65.2%), as compared with 40 of 111 patients (36.0%; P <.001).

Pain intensity was mild in both groups; the mean pain rating was 3 on a scale of 0 to 10.

For patients in the intervention group, the mean reported change from baseline in the Brief Pain Inventory (BPI) pain severity subscale was 0.1, compared with 0.2 for patients in control group (P = .88). For the interference subscale, the mean reported change from baseline was 0.1 for the intervention group, compared with -0.2 for the control group (P = .66).

"The lack of effect of the intervention on pain may be related to the skill set of the patient navigators, but overall pain was well controlled to begin with, so that might be a reason why we did not see a greater effect," Fischer said.

For both groups, the rates of hospice use were similar, with 81.7% of patients enrolled in hospice.

"This is above previously reported national averages for Hispanic enrollment, which is about 40%. Our study rates of hospice use did not significantly vary across urban and rural sites, suggesting that this high rate of hospice use is a Colorado phenomenon," Fischer said.

Secondary outcomes of overall MQOL score and aggressiveness of care at the end of life were similar between the two groups, but the MQOL physical subscale showed a mean significant change from baseline of 1.4 in the intervention group, compared with 0.1 in the control group (P = .004).

Fischer said her group plans more research on the use of culturally sensitive lay patient navigators for Latino cancer patients.

"These complex psychosocial interventions show very incremental effects. I can say very clearly that navigators are tremendously helpful in helping patients do advanced care planning, and that alone is a tremendous outcome. We are currently working with patients and their caregivers to offer caregiver support, and we are also integrating a therapist to help with some of the psychosocial and well-being aspects of palliative care. For this research, we are selecting a population that is more distressed, because it is very hard to improve quality of life or distress if the patient population was not really distressed at baseline."

Fischer added that patients "really liked working with their patient navigators."

The study was sponsored by the American Cancer Society. Dr Fischer has disclosed no relevant financial relationships.

JAMA Oncol. Published online September 20, 2018, Abstract

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