Assessment of patient navigation programs for breast cancer patients across the city of Boston

PURPOSE

Healthcare systems contribute to disparities in breast cancer outcomes. Patient navigation is a widely cited system-based approach to improve outcomes among populations at risk for delays in care. Patient navigation programs exist in all major Boston hospitals, yet disparities in outcomes persist. The objective of this study was to conduct a baseline assessment of navigation processes at six Boston hospitals that provide breast cancer care in preparation for an implementation trial of standardized navigation across the city.

METHODS

We conducted a mixed methods study in six hospitals that provide treatment to breast cancer patients in Boston. We administered a web-based survey to clinical champions (n = 7) across six sites to collect information about the structure of navigation programs. We then conducted in-person workflow assessments at each site using a semi-structured interview guide to understand site-specific implementation processes for patient navigation programs. The target population included administrators, supervisors, and patient navigators who provided breast cancer treatment-focused care.

RESULTS

All sites offered patient navigation services to their patients undergoing treatment for breast cancer. We identified wide heterogeneity in terms of how programs were funded/resourced, which patients were targeted for navigation, the type of services provided, and the continuity of those services relative to the patient's cancer treatment.

CONCLUSIONS

The operationalization of patient navigation varies widely across hospitals especially in relation to three core principles in patient navigation: providing patient support across the care continuum, targeting services to those patients most likely to experience delays in care, and systematically screening for and addressing patients' health-related social needs. Gaps in navigation across the care continuum present opportunities for intervention.

TRIAL REGISTRATION

Clinical Trial Registration Number NCT03514433, 5/2/2018.

Culture of prevention and early disease detection of cancer in Russia

This study analyzed the early cancer detection in Russia. Using data from the Russian Ministry of Health from 2005 to 2016, this study aims to evaluate relationships between the number of patients diagnosed with I-II stage of cancer with the number of preventive visits, screening tests, and expedited access to specialists. The results of de-trending time-series model indicate that the number of specialists in outpatient facilities and the number of patients' preventive visits positively affect the number of patients diagnosed with cancer for the first time and the number of patients diagnosed with I-II degree cancer. The Russian Federation's experience suggests that early detection of cancer can be achieved by increasing the number of early cancer screening facilities, providing free screening, and moderating geographical and time constraints that prevent people of different geographic and socio-economic backgrounds from being screened. Another strategy includes dispelling myths associated with cancer screening, fostering outreach and patient education, and assuring availability and timely referrals to specialists and laboratory work.

The efficacy and cost-effectiveness of patient navigation programs across the cancer continuum: A systematic review

Published studies regarding patient navigation (PN) and cancer were reviewed to assess quality, determine gaps, and identify avenues for future research. The PubMed and EMBASE databases were searched for studies investigating the efficacy and cost-effectiveness of PN across the cancer continuum. Each included article was scored independently by 2 separate reviewers with the Quality Assessment Tool for Quantitative Studies. The current review identified 113 published articles that assessed PN and cancer care, between August 1, 2010, and February 1, 2018, 14 of which reported on the cost-effectiveness of PN programs. Most publications focused on the effectiveness of PN in screening (50%) and diagnosis (27%) along the continuum of cancer care. Many described the effectiveness of PN for breast cancer (52%) or colorectal cancer outcomes (51%). Most studies reported favorable outcomes for PN programs, including increased uptake of and adherence to cancer screenings, timely diagnostic resolution and follow-up, higher completion rates for cancer therapy, and higher rates of attending medical appointments. Cost-effectiveness studies showed that PN programs yielded financial benefits. Quality assessment showed that 75 of the 113 included articles (65%) had 2 or more weak components. In conclusion, this review indicates numerous gaps within the PN and cancer literature where improvement is needed. For example, more research is needed at other points along the continuum of cancer care outside of screening and diagnosis. In addition, future research into the effectiveness of PN for understudied cancers outside of breast and colorectal cancer is necessary along with an assessment of cost-effectiveness and more rigorous reporting of study designs and results in published articles.

Analysis of Tumor Biology to Advance Cancer Health Disparity Research

Cancer mortality rates in the United States continue to decline. Reductions in tobacco use, uptake of preventive measures, adoption of early detection methods, and better treatments have resulted in improved cancer outcomes for men and women. Despite this progress, some population groups continue to experience an excessive cancer burden when compared with other population groups. One of the most prominent cancer health disparities exists in prostate cancer. Prostate cancer mortality rates are highest among men of African ancestry when compared with other men, both in the United States and globally. This disparity and other cancer health disparities are largely explained by differences in access to health care, diet, lifestyle, cultural barriers, and disparate exposures to carcinogens and pathogens. Dietary and lifestyle factors, pathogens, and ancestry-related factors can modify tumor biology and induce a more aggressive disease. There are numerous examples of how environmental exposures, like tobacco, chronic stress, or dietary factors, induce an adverse tumor biology, leading to a more aggressive disease and decreased patient survival. Because of population differences in the exposure to these risk factors, they can be the cause of cancer disparities. In this review, we will summarize recent advances in our understanding of prostate and breast cancer disparities in the United States and discuss how the analysis of tumor biology can advance health disparity research.

Patient navigation for traumatic brain injury promotes community re-integration and reduces re-hospitalizations

OBJECTIVE

To determine the effectiveness of a Navigation programme for patients with traumatic brain injury.

DESIGN

Prospective programme evaluation.

SETTING

Inpatient rehabilitation facility and community settings.

PARTICIPANTS

Eighteen individuals who suffered a traumatic brain injury (TBI), were between the ages of 16-70 years, and had a Rancho Score greater than IV.

INTERVENTION

Patient navigation programme focused on identifying and addressing barriers to positive outcomes, including coordination of care and facilitating communication among the family and healthcare providers, psychosocial support, caregiver support, adherence to treatment, education, community resources and financial issues.

MAIN OUTCOME MEASURES

Functional status, re-hospitalizations, falls, neurobehavioral symptom inventory, neuroendocrine status, activities of daily living, community integration and caregiver burden.

RESULTS

There was a significant reduction in re-hospitalization and fall rate when comparing individuals who received navigation services and those who did not. We also observed improved adherence treatment plans and a significant increase in community integration, independence level and functional abilities.

CONCLUSIONS

This study begins to highlight the effectiveness of a patient navigation programme for individuals with TBI. Future research with a larger sample will continue to help us refine patient navigation for chronic disabling conditions and determine its sustainability.

Characterizing Time to Diagnostic Resolution After an Abnormal Cancer Screening Exam in Older Adult Participants in the Ohio Patient Navigation Research Program

OBJECTIVE

This study aims to test the effectiveness of a patient navigation (PN) intervention to reduce time to diagnostic resolution among older adults age ≥65 years versus those <65 years with abnormal breast, cervical, or colorectal cancer screening exams participating in the Ohio Patient Navigation Research Program (OPNRP).

METHOD

The OPNRP utilized a nested cohort group-randomized trial design to randomize 862 participants ( n = 67 for ≥65 years; n = 795 for <65 years) to PN or usual care conditions. A shared frailty Cox model tested the effect of PN on time to resolution.

RESULTS

Older adult participants randomized to PN achieved a 6-month resolution rate that was 127% higher than those randomized to usual care ( p = .001). This effect was not significantly different from participants <65 years.

DISCUSSION

PN significantly reduced time to diagnostic resolution among older adults beginning 6 months after an abnormal cancer screening exam. Health care systems should include this population in PN programs to reduce cancer disparities.

Patient-Perceived Access to Care When Actively Seeking Treatment

PURPOSE/OBJECTIVES

To examine predictors of perceived access to care and reported barriers to care of patients with cancer actively seeking treatment.
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DESIGN

Retrospective secondary data analysis.
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SETTING

U.S. Medical Expenditure Panel Survey, a national survey with questions about healthcare coverage and access.
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SAMPLE

1,170 adults with cancer actively seeking treatment.
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METHODS

A retrospective analysis of data. Bivariate tests for significant association between individual characteristics and low perceived access to care were conducted using a chi-square test. 
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MAIN RESEARCH VARIABLES

The dependent variable was perceived access to care. The independent variables included sex, age, race, poverty status, education level, marital status, cancer site, comorbidities, and insurance status.
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FINDINGS

Those with Medicaid insurance or no health insurance had significantly lower perceived access to care compared to those with Medicare. Institutional barriers to treatment, such as financial or insurance, were the most common reported barriers.
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CONCLUSIONS

Most adults with cancer reported adequate access to medical care and medications, but a small yet vulnerable population expressed difficulties in accessing treatment.
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IMPLICATIONS FOR NURSING

To effectively advocate for vulnerable populations with Medicaid or no insurance, nurses may require specialized knowledge beyond the scope of general oncology nursing.

Analysis of nurse navigators' activities for hospital discharge coordination: a mixed method study for the case of cancer patients

Background

Modern cancer care requires the development of clinical pathways to enhance coordination, but there are few descriptive studies about the content of coordination activities. More specifically, little is known about hospital discharge coordination, although this is seen as a sensitive phase of clinical pathway.

Purpose

The purpose of this study was to identify and quantify the categories of activities performed by nurse navigators for hospital discharge coordination.

Methods

Patients supported within the Coordinating Outpatient Care department (COC) at Gustave Roussy (Villejuif, France). Study conducted over two consecutive phases (Feb-September 2014): (1) a qualitative phase to identify the categories of coordination activities (interviews with patients plus, focus groups with nurse navigators—NNs); (2) a quantitative phase to quantify the relative share of each category. The calls received through the telephone platform of COC (made by both patients and primary care providers) were systematically reported (caller; reason for the call; procedure performed) and then analyzed.

Results

Qualitative phase: 17 interviews with patients, plus 2 focus groups with NNs. Quantitative phase: 543 calls analyzed. The callers were patients or their relatives (38 %), private nurses (35 %), medical device providers (20 %), and other primary care providers (e.g., pharmacists, family physicians) (7 %). Five categories of coordination activities identified: (F1) Patient monitoring (29 %); (F2) Helping to navigate (24 %); (F3) Managing technical problems (17 %); (F4) Explaining care protocols (16 %); (F5) Collecting and transmitting the patient medical record information (14 %).

Conclusions

The majority of requirements are related to organizational issues (e.g., navigation, lack of information, appointments). Nurse navigators’ training and qualification must therefore combine both clinical and managerial skills.

Patient Navigation in Breast Cancer Treatment and Survivorship: A Systematic Review

PURPOSE

Patient navigation is an intervention approach that improves cancer outcomes by reducing barriers and facilitating timely access to cancer care. Little is known about the benefits of patient navigation during breast cancer treatment and survivorship. This systematic review evaluates the efficacy of patient navigation in improving treatment and survivorship outcomes in women with breast cancer.

METHODS

The review included experimental and quasi-experimental studies of patient navigation programs that target breast cancer treatment and breast cancer survivorship. Articles were systematically obtained through electronic database searches of PubMed/MEDLINE, PsycINFO, Web of Science, CINAHL, and Cochrane Library. The Effective Public Health Practice Project Quality Assessment Tool was used to evaluate the methodologic quality of individual studies.

RESULTS

Thirteen studies met the inclusion criteria. Most were of moderate to high quality. Outcomes targeted included timeliness of treatment initiation, adherence to cancer treatment, and adherence to post-treatment surveillance mammography. Heterogeneity of outcome assessments precluded a meta-analysis. Overall, results demonstrated that patient navigation increases surveillance mammography rates, but only minimal evidence was found with regard to its effectiveness in improving breast cancer treatment outcomes.

CONCLUSION

This study is the most comprehensive systematic review of patient navigation research focused on improving breast cancer treatment and survivorship. Minimal research has indicated that patient navigation may be effective for post-treatment surveillance; however, more studies are needed to draw definitive conclusions about the efficacy of patient navigation during and after cancer treatment.

Racial and Gender Disparities in Incidence of Lung and Bronchus Cancer in the United States: A Longitudinal Analysis

Background

Certain population groups in the United States carry a disproportionate burden of cancer. This work models and analyzes the dynamics of lung and bronchus cancer age-adjusted incidence rates by race (White and Black), gender (male and female), and prevalence of daily smoking in 38 U.S. states, the District of Columbia, and across eight U.S. geographic regions from 1999 to 2012.

Methods

Data, obtained from the U.S. Cancer Statistics Section of the Centers for Disease Control and Prevention, reflect approximately 77% of the U.S. population and constitute a representative sample for making inferences about incidence rates in lung and bronchus cancer (henceforth lung cancer). A longitudinal linear mixed-effects model was used to study lung cancer incidence rates and to estimate incidence rate as a function of time, race, gender, and prevalence of daily smoking.

Results

Between 1999 and 2012, age-adjusted incidence rates in lung cancer have decreased in all states and regions. However, racial and gender disparities remain. Whites continue to have lower age-adjusted incidence rates for this cancer than Blacks in all states and in five of the eight U.S. geographic regions. Disparities in incidence rates between Black and White men are significantly larger than those between Black and White women, with Black men having the highest incidence rate of all subgroups. Assuming that lung cancer incidence rates remain within reasonable range, the model predicts that the gender gap in the incidence rate for Whites would disappear by mid-2018, and for Blacks by 2026. However, the racial gap in lung cancer incidence rates among Black and White males will remain. Among all geographic regions, the Mid-South has the highest overall lung cancer incidence rate and the highest incidence rate for Whites, while the Midwest has the highest incidence rate for Blacks. Between 1999 and 2012, there was a downward trend in the prevalence of daily smokers in both genders. However, males have significantly higher rates of cigarette smoking than females at all time points. The highest and lowest prevalence of daily smoking are found in the Mid-South and New England, respectively. There was a significant correlation between lung cancer incidence rates and smoking prevalence in all geographic regions, indicating a strong influence of cigarette smoking on regional lung cancer incidence rates.

Conclusion

Although age-adjusted incidence rates in lung cancer have decreased throughout the U.S., racial and gender disparities remain. This longitudinal model can help health professionals and policy makers make predictions of age-adjusted incidence rates for lung cancer in the U.S. in the next five to ten years.

Age at cancer diagnosis, amenability to medical interventions, and racial/ethnic disparities in cancer mortality

PURPOSE

Racial disparities in cancer mortality may be greater for cancers that are amenable to available early detection and treatment (amenability level). We investigated whether these patterns vary by age at cancer diagnosis.

METHODS

Using 5-year relative survival rates (5Y-RSR), we classified 51 cancer sites into least amenable, partly amenable, and mostly amenable cancers (<40%, 40-69%, ≥70% 5-YRS, respectively). We examined whether racial disparities in mortality rates (African-Americans, Asian/Pacific Islanders, Hispanics, whites), as estimated through Cox regression models, were modified by age at diagnosis and amenability level in 516,939 cancer cases diagnosed in 1995-1999.

RESULTS

As compared with whites, all racial minority groups experienced higher cancer mortality rates in the youngest age group of 20-34 years. African-Americans and Hispanics diagnosed with partly and mostly amenable cancers had higher mortality rates relative to whites with cancers of the same amenability levels; further, these differences decreased in magnitude or reversed in direction with increasing age. In contrast, the racial differences in mortality were smaller and remained fairly constant across age groups for least amenable cancers. For example, in the youngest (20-34) and oldest (80-99) age groups, the adjusted hazard ratios (HRs) for African-Americans versus whites with least amenable cancers were, respectively, 1.26 (95% CI 1.02, 1.55) and 0.90 (95% CI 0.85, 0.96), while the HRs for African-Americans versus whites with mostly amenable cancers were 2.77 (95% CI 2.38, 3.22) and 1.07 (95% CI 0.98, 1.17).

CONCLUSIONS

Cancer survival disadvantage for racial minorities is larger in younger age groups for cancers that are more amenable to medical interventions.

Effects of Patient Navigation on Patient Satisfaction Outcomes

Patient navigation (PN) may reduce cancer health disparities. Few studies have investigated the effects of PN on patient-reported satisfaction with care or assessed patients' satisfaction with navigators. The objectives of this study are to test the effects of PN on patient satisfaction with cancer care, assess patients' satisfaction with navigators, and examine the impact of barriers to care on satisfaction for persons with abnormal cancer-related screening tests or symptoms. Study participants included women and men with abnormal breast, cervical, or colorectal cancer screening tests and/or symptoms receiving care at 18 clinics. Navigated (n=416) and non-navigated (n=292) patients completed baseline and end-of-study measures. There was no significant difference between navigated and non-navigated patients in change in patient satisfaction with cancer care from baseline to exit. African-American (p<0.001), single (p=0.03), low income (p<0.01), and uninsured patients (p<0.001) were significantly less likely to report high patient satisfaction at baseline. A significant effect was found for change in satisfaction over time by employment status (p=0.04), with full-time employment showing the most improvement. The interaction between satisfaction with navigators and satisfaction with care over time was marginally significant (p=0.08). Baseline satisfaction was lower for patients who reported a barrier to care (p=0.02). Patients reporting other-focused barriers (p=0.03), including transportation (p=0.02), had significantly lower increases in satisfaction over time. Overall, results suggested that assessing barriers to cancer care and tailoring navigation to barrier type could enhance patients' experiences with health care. PN may have positive effects for healthcare organizations struggling to enhance quality of care.

Health disparities and cancer: racial disparities in cancer mortality in the United States, 2000-2010

Declining cancer incidence and mortality rates in the United States (U.S.) have continued through the first decade of the twenty-first century. Reductions in tobacco use, greater uptake of prevention measures, adoption of early detection methods, and improved treatments have resulted in improved outcomes for both men and women. However, Black Americans continue to have the higher cancer mortality rates and shorter survival times. This review discusses and compares the cancer mortality rates and mortality trends for Blacks and Whites. The complex relationship between socioeconomic status and race and its contribution to racial cancer disparities is discussed. Based on current trends and the potential and limitations of the patient protection and affordable care act with its mandate to reduce health care inequities, future trends, and challenges in cancer mortality disparities in the U.S. are explored.

Physical Triggers of Anxiety in African Americans

Understanding the primary triggers of anxiety for African Americans, and the cultural factors associated with these triggers, can enhance our knowledge of emotional responding in African Americans and can ultimately influence how we assess and treat anxiety disorders in this population. In the current study, we investigated the experience of anxiety for African Americans following physical stressors, with an emphasis on cardiovascular arousal. Specifically, anxious responding, following cardiovascular arousal, other physical stressors, and a control task, was evaluated among African American ( n = 23) and European American ( n = 23) groups on affective, cognitive, and physiological measures of anxiety. Findings suggest physical stressors in general (as opposed to cardiovascular arousal specifically) may be a prominent trigger of anxiety for African Americans. Discussion centers on the idea that the observed relationship between anxiety and physical stressors for African Americans may stem from a cultural sense of vulnerability regarding physical disease.

Adherence to repeat fecal occult blood testing in an urban community health center network

Annual fecal occult blood testing (FOBT) has the potential to reduce colorectal cancer mortality, but in practice it is challenging to complete FOBT every year. Repeat FOBT adherence may be especially low in community health center (CHC) settings, where many patients face barriers to annual FOBT completion. We conducted a retrospective cohort analysis to investigate adherence to annual FOBT in an urban CHC network that serves a predominantly Spanish-speaking, uninsured adult patient population. This study used data from the two-year period between January 2010 and December 2011, and included adults aged 50-74 who completed a screening FOBT with a negative result during the first 6 months of 2010. We examined whether each patient completed a second FOBT between 9 and 18 months after the initial negative FOBT, and tested whether repeat FOBT adherence was associated with patient characteristics or the number of clinic visits after the initial negative FOBT. Only 69 of 281 included patients completed repeat FOBT (24.6 % adherence), and none of 62 patients (0 %) with 0 clinic visits completed repeat FOBT. We detected no significant differences in adherence by age, sex, preferred language, insurance status, or number of chronic conditions. In multivariable regression, the adjusted relative risk of repeat FOBT was 1.66 (95 % CI 1.09-2.54; p = 0.02) among patients with 3 or more clinic visits (referent: patients with 1-2 visits). The observed low rate of adherence greatly diminishes the effectiveness of FOBT in reducing CRC mortality. Findings demonstrate the need for systems-based interventions that increase adherence without requiring face-to-face encounters.

Using organizational network analysis to plan cancer screening programs for vulnerable populations

OBJECTIVES

We examined relationships among organizations in a cancer screening network to inform the development of interventions to improve cancer screening for South Asians living in the Peel region of Ontario.

METHODS

From April to July 2012, we surveyed decision-makers, program managers, and program staff in 22 organizations in the South Asian cancer screening network in the Peel region. We used a network analytic approach to evaluate density (range = 0%-100%, number of ties among organizations in the network expressed as a percentage of all possible ties), centralization (range = 0-1, the extent of variability in centrality), and node characteristics for the communication, collaboration, and referral networks.

RESULTS

Density was similar across communication (15%), collaboration (17%), and referral (19%) networks. Centralization was greater in the collaboration network (0.30) than the communication network (0.24), and degree centralization was greater in the inbound (0.42) than the outbound (0.37) referral network. Diverse organizations were central to the networks.

CONCLUSIONS

Certain organizations were unexpectedly important to the South Asian cancer screening network. Program planning was informed by identifying opportunities to strengthen linkages between key organizations and to leverage existing ties.

Socioeconomic deprivation as a determinant of cancer mortality and the Hispanic paradox in Texas, USA

Introduction

We have recently reported that delayed cancer detection is associated with the Wellbeing Index (WI) for socioeconomic deprivation, lack of health insurance, physician shortage, and Hispanic ethnicity. The current study investigates whether these factors are determinants of cancer mortality in Texas, the United States of America (USA).

Methods

Data for breast, colorectal, female genital system, lung, prostate, and all-type cancers are obtained from the Texas Cancer Registry. A weighted regression model for non-Hispanic whites, Hispanics, and African Americans is used with age-adjusted mortality (2004–2008 data combined) for each county as the dependent variable while independent variables include WI, percentage of the uninsured, and physician supply.

Results

Higher mortality for breast, female genital system, lung, and all-type cancers is associated with higher WI among non-Hispanic whites and/or African Americans but with lower WI in Hispanics after adjusting for physician supply and percentage of the uninsured. Mortality for all the cancers studied is in the following order from high to low: African Americans, non-Hispanic whites, and Hispanics. Lung cancer mortality is particularly low in Hispanics, which is only 35% of African Americans’ mortality and 40% of non-Hispanic whites’ mortality.

Conclusions

Higher degree of socioeconomic deprivation is associated with higher mortality of several cancers among non-Hispanic whites and African Americans, but with lower mortality among Hispanics in Texas. Also, mortality rates of all these cancers studied are the lowest in Hispanics. Further investigations are needed to better understand the mechanisms of the Hispanic Paradox.

Implementation science and its application to population health

Implementation science studies the use of strategies to adapt and use evidence-based interventions in targeted settings (e.g., schools, workplaces, health care facilities, public health departments) to sustain improvements to population health. This nascent field of research is in the early stages of developing theories of implementation and evaluating the properties of measures. Stakeholder engagement, effectiveness studies, research synthesis, and mathematical modeling are some of the methods used by implementation scientists to identify strategies to embed evidence-based interventions in clinical and public health programs. However, for implementation science to reach its full potential to improve population health the existing paradigm for how scientists create evidence, prioritize publications, and synthesize research needs to shift toward greater stakeholder input and improved reporting on external validity. This shift will improve the relevance of the research that is produced and provide information that will help guide decision makers in their selection of research-tested interventions.

Fundamental causes of colorectal cancer mortality: the implications of informational diffusion

CONTEXT

Colorectal cancer is a major cause of mortality in the United States, with 52,857 deaths estimated in 2012. To explore further the social inequalities in colorectal cancer mortality, we used fundamental cause theory to consider the role of societal diffusion of information and socioeconomic status.

METHODS

We used the number of deaths from colorectal cancer in U.S. counties between 1968 and 2008. Through geographical mapping, we examined disparities in colorectal cancer mortality as a function of socioeconomic status and the rate of diffusion of information. In addition to providing year-specific trends in colorectal cancer mortality rates, we analyzed these data using negative binomial regression.

FINDINGS

The impact of socioeconomic status (SES) on colorectal cancer mortality is substantial, and its protective impact increases over time. Equally important is the impact of informational diffusion on colorectal cancer mortality over time. However, while the impact of SES remains significant when concurrently considering the role of diffusion of information, the propensity for faster diffusion moderates its effect on colorectal cancer mortality.

CONCLUSIONS

The faster diffusion of information reduces both colorectal cancer mortality and inequalities in colorectal cancer mortality, although it was not sufficient to eliminate SES inequalities. These findings have important long-term implications for policymakers looking to reduce social inequalities in colorectal cancer mortality and other, related, preventable diseases.

The Ohio Patient Navigation Research Program: does the American Cancer Society patient navigation model improve time to resolution in patients with abnormal screening tests?

BACKGROUND

Patient navigation (PN) has been suggested as a way to reduce cancer health disparities; however, many models of PN exist and most have not been carefully evaluated. The goal of this study was to test the Ohio American Cancer Society model of PN as it relates to reducing time to diagnostic resolution among persons with abnormal breast, cervical, or colorectal cancer screening tests or symptoms.

METHODS

A total of 862 patients from 18 clinics participated in this group-randomized trial. Chart review documented the date of the abnormality and the date of resolution. The primary analysis used shared frailty models to test for the effect of PN on time to resolution. Crude HR were reported as there was no evidence of confounding.

RESULTS

HRs became significant at 6 months; conditional on the random clinic effect, the resolution rate at 15 months was 65% higher in the PN arm (P = 0.012 for difference in resolution rate across arms; P = 0.009 for an increase in the HR over time).

CONCLUSIONS

Participants with abnormal cancer screening tests or symptoms resolved faster if assigned to PN compared with those not assigned to PN. The effect of PN became apparent beginning six months after detection of the abnormality.

IMPACT

PN may help address health disparities by reducing time to resolution after an abnormal cancer screening test.

Determinants of delayed detection of cancers in Texas counties in the United States of America

INTRODUCTION

Previous studies have shown that delayed detection of several cancers is related to socioeconomic deprivation as measured by the Wellbeing Index (WI) in Texas, the United States of America (USA). The current study investigates whether delayed cancer detection is related to lack of health insurance, physician shortage and higher percentages of Hispanics rather than WI per se since these factors are directly related to delayed cancer detection and may confound WI.

METHODS

Cancer data and potential determinants of delayed cancer detection are derived from Texas Cancer Registry, Texas State Data Center, and Texas Department of State Health Services and U.S. Census Bureau. Texas cancer data from 1997 to 2003 are aggregated to calculate age-adjusted late- and early-stage cancer detection rates. The WI for each county is computed using data from the USA Census 2000. A weighted Tobit regression model is used to account for population size and censoring. The percentage of late-stage cancer cases is the dependent variable while independent variables include WI and the aforementioned potential confounders.

RESULTS

Delayed detection of breast, lung, colorectal and female genital cancers is associated with higher percentage of uninsured residents (p < 0.05). Delayed detection is also associated with physician shortage and lower percentages of Hispanics for certain cancers ceteris paribus ( p < 0.05). The percentage of late-stage cases is positively correlated with WI for lung, and prostate cancers after adjusting for confounders ( p < 0.05).

CONCLUSIONS

The percentages of uninsured and Hispanic residents as well as physician supply are determinants of delayed detection for several cancers independently of WI, and vice versa. Identification of these determinants provides the evidence-base critical for decision makers to address specific issues for promoting early detection in effective cancer control.

Patient navigation: an update on the state of the science

Although patient navigation was introduced 2 decades ago, there remains a lack of consensus regarding its definition, the necessary qualifications of patient navigators, and its impact on the continuum of cancer care. This review provides an update to the 2008 review by Wells et al on patient navigation. Since then, there has been a significant increase in the number of published studies dealing with cancer patient navigation. The authors of the current review conducted a search by using the keywords "navigation" or "navigator" and "cancer." Thirty-three articles published from November 2007 through July 2010 met the search criteria. Consistent with the prior review, there is building evidence of some degree of efficacy of patient navigation in terms of increasing cancer screening rates. However, there is less recent evidence concerning the benefit of patient navigation with regard to diagnostic follow-up and in the treatment setting, and a paucity of research focusing on patient navigation in cancer survivorship remains. Methodological limitations were noted in many studies, including small sample sizes and a lack of control groups. As patient navigation programs continue to develop across North America and beyond, further research will be required to determine the efficacy of cancer patient navigation across all aspects of the cancer care continuum.

Communicating evidence-based information on cancer prevention to state-level policy makers

BACKGROUND

Opportunities exist to disseminate evidence-based cancer control strategies to state-level policy makers in both the legislative and executive branches. We explored factors that influence the likelihood that state-level policy makers will find a policy brief understandable, credible, and useful.

METHODS

A systematic approach was used to develop four types of policy briefs on the topic of mammography screening to reduce breast cancer mortality: data-focused brief with state-level data, data-focused brief with local-level data, story-focused brief with state-level data, and story-focused brief with local-level data. Participants were recruited from three groups of state-level policy makers-legislative staff, legislators, and executive branch administrators- in six states that were randomly chosen after stratifying all 50 states by population size and dominant political party in state legislature. Participants from each of the three policy groups were randomly assigned to receive one of the four types of policy briefs and completed a questionnaire that included a series of Likert scale items. Primary outcomes-whether the brief was understandable, credible, likely to be used, and likely to be shared-were measured by a 5-point Likert scale according to the degree of agreement (1 = strongly disagree, 5 = strongly agree). Data were analyzed with analysis of variance and with classification trees. All statistical tests were two-sided.

RESULTS

Data on response to the policy briefs (n = 291) were collected from February through December 2009 (overall response rate = 35%). All three policy groups found the briefs to be understandable and credible, with mean ratings that ranged from 4.3 to 4.5. The likelihood of using the brief (the dependent variable) differed statistically significantly by study condition for staffers (P = .041) and for legislators (P = .018). Staffers found the story-focused brief containing state-level data most useful, whereas legislators found the data-focused brief containing state-level data most useful. Exploratory classification trees showed distinctive patterns for brief usefulness across the three policy groups.

CONCLUSION

Our results suggest that taking a "one-size-fits-all" approach when delivering information to policy makers may be less effective than communicating information based on the type of policy maker.

National patterns and correlates of mentholated cigarette use in the United States

AIM

To examine the patterns and correlates of mentholated cigarette smoking among adult smokers in the United States.

DESIGN

Cross-sectional data on adult current smokers (n = 63,193) were pooled from the 2003 and 2006/07 Tobacco Use Supplements to the Current Population Survey.

MEASUREMENTS

The associations between socio-demographic and smoking variables were examined with gender- and race/ethnicity-stratified multivariate logistic regression models predicting current use of mentholated cigarettes.

FINDINGS

Multivariate logistic regression analyses demonstrated that black smokers were 10-11 times more likely to smoke mentholated cigarettes than white smokers men: odds ratio (OR): 11.59, 99% confidence interval (CI): 9.79-13.72; women: OR: 10.12, 99% CI: 8.45-12.11). With the exception of American Indian/Aleut/Eskimo smokers, non-white smokers were significantly more likely to smoke mentholated cigarettes than were white smokers. Additional significant factors associated with mentholated cigarette smoking included being unmarried (never married: OR: 1.21, 99% CI: 1.09-1.34; divorced/separated: OR: 1.13, 99% CI: 1.03-1.23), being born in a US territory (OR: 2.01, 99% CI: 1.35-3.01), living in a non-metropolitan area (OR: 0.87, 99% CI: 0.80-0.96), being unemployed (OR: 1.24, 99% CI: 1.06-1.44) and lower levels of education. Race/ethnicity-stratified analyses showed that women were more likely than men to smoke mentholated cigarettes. Among black smokers, young adults (aged 18-24 years) were four times more likely to smoke mentholated cigarettes compared with individuals aged 65+.

CONCLUSIONS

Race/ethnicity, gender and age are significant correlates of mentholated cigarette smoking among current smokers. Given the importance of menthol in the cigarette market and the potential untoward health effects of this additive, continued surveillance of the prevalence and correlates of mentholated cigarette use among diverse socio-demographic groups is warranted to inform appropriate interventions.