Walking forward: the South Dakota Native American project

Access to Lung Cancer Screening Among American Indian and Alaska Native Adults: A Qualitative Study

BACKGROUND

Lung cancer is the leading cause of cancer mortality among American Indian and Alaska Native populations. American Indian and Alaska Native people use commercial tobacco products at higher rates compared with all other races and ethnicities. Moreover, they show lower adherence to cancer screening guidelines.

RESEARCH QUESTION

How do American Indian and Alaska Native adults perceive and use lung cancer screening?

STUDY DESIGN AND METHODS

We conducted a study in which we recorded and transcribed data from three focus groups consisting of American Indian and Alaska Native adults. Participants were recruited through convenience sampling at a national health conference. Transcripts were analyzed by inductive coding.

RESULTS

Participants (n = 58) of 28 tribes included tribal Elders, tribal leaders, and non-Native volunteers who worked with tribal communities. Limited community awareness of lung cancer screening, barriers to lung cancer screening at health care facilities, and health information-seeking behaviors emerged as key themes in discussions. Screening knowledge was limited except among people with direct experiences of lung cancer. Cancer risk factors such as multigenerational smoking were considered important priorities to address in communities. Limited educational and diagnostic resources are significant barriers to lung cancer screening uptake in addition to limited discussions with health care providers about cancer risk.

INTERPRETATION

Limited access to and awareness of lung cancer screening must be addressed. American Indian and Alaska Native adults use several health information sources unique to tribal communities, and these should be leveraged in designing screening programs. Equitable partnerships between clinicians and tribes are essential in improving knowledge and use of lung cancer screening.

The National Cancer Institute's Cancer Disparities Research Partnership Program: a unique funding model 20 years later

The burden of cancer and access to effective treatment are not experienced equally by all in the United States. For underserved populations that often access the health-care system when their cancers are in advanced disease stages, radiation oncology services are essential. In 2001, the National Cancer Institute's (NCI's) Radiation Research Program created and implemented the Cancer Disparities Research Partnership Program (CDRP). CDRP was a pioneering funding model whose goal was to increase participation of medically underserved populations in NCI clinical trials. CDRP's Cooperative Agreement funding supported for awardees the planning, development, and conduct of radiation oncology clinical research in institutions not traditionally involved in NCI-sponsored research and cared for a disproportionate number of medically underserved, health-disparities populations. The awardee secured and provided support for mentorship from 1 of 2 NCI comprehensive cancer centers named in its application. Six CDRP awards were made over two 5-year funding periods ending in 2013, with the end-of-program accomplishments previously reported. With the current focus on addressing equity, diversity, and inclusion, the 6 principal investigators were surveyed, 5 of whom responded about the impact of CDRP on their institutions, communities, and personal career paths. The survey that was emailed included 10 questions on a 5-point Likert scale. It was not possible to collect patient data this long after completion of the program. This article provides a 20-year retrospective of the experiences and observations from those principal investigators that can inform those now planning, building, and implementing equity, diversity, and inclusion programs.

Health service provider responses to indigenous peoples with cancer: An integrative review

Indigenous populations around the world have a higher burden of cancer incidence, severity and mortality. This integrative review aims to identify and appraise the evidence of health providers' responses to the issue of indigenous peoples with cancer. A surprisingly small number of studies were found (n = 9) that reported on programmes and interventions for indigenous people with cancer, the majority of which were from the USA. Our review shows that a service delivery approach that is focused on the indigenous population and includes culturally appropriate activities, resources and environments resulted in an increase in cancer knowledge, reduction in treatment interruption, improved access to cancer care and enrolment in clinical cancer trials, and increased satisfaction with health care. However, the question of why there are so few published studies needs further consideration.

Effectiveness of a patient navigator on patient satisfaction in adult patients in an ambulatory care setting: a systematic review

BACKGROUND

One approach to overcoming healthcare system barriers and facilitating timely access to quality care and patient satisfaction is with a patient navigator. A patient navigator is a trained person who individually assists patients, families and caregivers navigate the healthcare system barriers efficiently and effectively at any point along the care continuum, improving patient care at all levels of an organization.

OBJECTIVES

To synthesize the best available evidence on the effectiveness of a patient navigator on patient satisfaction in adult patients 18 years and older in ambulatory care settings.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

This review considered studies that involved adults of any ethnicity, race or gender, aged 18 years or older, regardless of diagnoses, stage of illness, whether the illness is acute or chronic or previous treatment, who had been receiving care in an ambulatory care setting.

TYPES OF INTERVENTION(S)/PHENOMENA OF INTEREST

This review considered studies on the use of a patient navigator as an additional intervention to usual care for promoting patient satisfaction for adult patients in an ambulatory care setting. Usual care without a patient navigator was considered as a comparator.

TYPES OF STUDIES

This review considered experimental and observational studies.

OUTCOMES

The outcome considered was patient satisfaction.

SEARCH STRATEGY

The literature search included published and unpublished studies in the English Language from 1990 through July 2015. A search of PubMed, CINAHL, Excerpta Medica Database (EMBASE), Academic Search Premier, Cochrane Library, PsycINFO and Health Source: Nursing/Academic Edition, Social Work Abstracts and Web of Science was conducted. A search for gray literature and electronic hand searching of relevant journals was also performed.

METHODOLOGICAL QUALITY

Two reviewers independently evaluated the included studies for methodological quality utilizing standardized critical appraisal instruments from the Joanna Briggs Institute.

DATA EXTRACTION

Standardized data extraction tools from Joanna Briggs Institute were used by two independent reviewers for data extraction.

DATA SYNTHESIS

A statistical meta-analysis was not possible due to heterogeneity between the included studies. Results are presented in a narrative form.

RESULTS

Four studies were included in this review, two were randomized controlled trials (RCTs), one was a quasi-experimental pre-post-test design study and one was a cohort study. The four studies showed that a patient navigator had clinical benefit for patient satisfaction, care coordination and patient access to timely healthcare services. One RCT reported a mean satisfaction score of 4.3 for navigated patients and 2.9 for non-navigated patients; P < 0.001. A second RCT showed an odds ratio 1.29; 95% confidence interval 0.92-1.82 for navigated versus non-navigated patients. The quasi-experimental pre-test-post-test study showed navigated patient satisfaction with a mean = 11.45 (standard deviation [SD], 3.69) in comparison with the non-navigated patient (mean, 14.95; SD, 1.69) (F = 11.85; P = 0.000). The cohort study demonstrated a mean satisfaction score of 90.7 for navigated patients and 85.5 for non-navigated patients; P = 0.03. The four studies showed no clinically significant results; however, the patient navigator role may promote relationships among the healthcare team, reducing barriers for patient-centered care and enhanced patient satisfaction.

CONCLUSION

There is a paucity of evidence on the effectiveness of a patient navigator on patient satisfaction. In the four studies selected for inclusion, a patient navigator had a positive effect on patient satisfaction, although none of the studies demonstrated statistical significance with a patient navigator on patient satisfaction. The effect of a patient navigator remains questionable with differences in perceptions on the best individual for the role and the expected role perception and performance. A standardized approach to the role of the patient navigator may maximize health outcomes and positively affect the quality of life for all patients.

The pervasive crisis of diminishing radiation therapy access for vulnerable populations in the United States, part 2: American Indian patients

INTRODUCTION

American Indian/Alaska Native (AI/AN) patients with cancer disproportionally present with more advanced stages of disease and have the worst cancer-specific survival rates of any racial/ethnic group in the United States. The presence of disparities in radiation therapy (RT) access for AI/AN patients has rarely been examined.

METHODS AND MATERIALS

National Cancer Institute (NCI) initiatives toward addressing AI/AN disparities were examined. Additionally, an extensive PubMed literature search for studies investigating RT access disparities in AI/AN patients was performed.

RESULTS

Literature describing RT access disparities for the AI/AN patient population is sparse, revealing only 3 studies, each of which described initiatives from the Walking Forward program, the NCI Cancer Disparity Research Partnership initiative to address barriers to cancer screening among AI populations in the Northern Plains region (eg, geographic remoteness and mistrust of health care providers). This program has used patient navigation, community education, and access to clinical trials for more than 4000 AI/AN patients to combat high cancer mortality rates. Over the course of its 15-year existence, the program has resulted in patients presenting with earlier stages of disease and experiencing higher cure rates. Lung cancer, the most common cause of cancer-related mortality in AI/AN patients, is the most recent and ongoing focus of the program.

CONCLUSION

The amount of information regarding RT access in AI/AN patients is limited, with nearly all peer-reviewed published progress in this area being associated with the Walking Forward program. Further initiatives from this program will hopefully inspire similar initiatives throughout the country to reduce the barriers to optimized cancer care that these patients face. Given the similarities with cancer disparities of populations worldwide, the AI/AN experience should be included within the broad issue of a global shortage of cancer care among underserved populations.

Cancer Care Access and Outcomes for American Indian Populations in the United States: Challenges and Models for Progress

Low socioeconomic and health care access realities of being American Indian/Alaskan Native (AI/AN) in the United States combined with decades of data documenting poor cancer outcomes for this population provide a population nested within the United States that is analogous to the cancer care landscape of low- and middle-income countries internationally. We reviewed the medical literature with respect to cancer prevention, access to cancer treatment, and access to effective supportive and palliative care for AI/AN populations in the United States. Research confirms poorer cancer outcomes, suboptimal cancer screening, and high-risk cancer behaviors among AI/AN communities. AI/AN cancer patients are less likely to undergo recommended cancer surgeries, adjuvant chemotherapy, and radiation therapy than their White counterparts. Studies including both rural and urban survivors with AI cancer revealed barriers to receipt of optimal cancer symptom management and proportionally lower hospice use among AI/AN populations. Culturally tailored programs in targeted communities have been shown to mitigate the observed cancer-related health disparities among AI/AN communities. There is still much work to be done to improve cancer-related health outcomes in AI/AN communities, and the goals of the providers serving them corresponds with those propelling the growing interest in global oncology equity. Policy work and more funding are needed to continue to build upon the work that the Indian Health Service and established cancer-related health programs have begun in AI/AN communities.

Poor Survival for American Indians with Head and Neck Squamous Cell Carcinoma

OBJECTIVE

To examine patient characteristics, treatment modalities, and human papillomavirus (HPV) prevalence to identify potential mediators of disparities that may lead to differences in outcomes for American Indians with head and neck squamous cell carcinoma (HNSCC).

STUDY DESIGN

Historical cohort study.

SETTING

Community cancer centers.

PATIENTS AND METHODS

We reviewed all patients older than 18 years with a new diagnosis of HNSCC in South Dakota from 1999 to 2009. We assessed tissue samples from cases of oropharyngeal cancer for the presence of HPV DNA.

RESULTS

In total, 474 white patients were compared with 32 American Indians. American Indians experienced significantly worse survival compared with whites (hazard ratio [HR], 0.59; P = .05), even after controlling for other factors such as age, sex, distance, Charlson comorbidity index, alcohol abuse, smoking, insurance, and disease stage. American Indians had a greater risk of alcohol abuse (68% vs 42%; P = .008), current smoking (67% vs 49%; P = .03), living more than 1 hour from a cancer center (81% vs 30%; P < .001), lacking private insurance (24% vs 68%; P < .001), and late-stage disease presentation (stages III and IV) (74% vs 55%; P = .04). There were no detected differences in age, sex, medical comorbidities, tumor site, tumor grade, HPV status, time to treatment, or type of treatment received.

CONCLUSION

American Indians in South Dakota with HNSCC have poorer survival compared with white patients. Once presented to a cancer center, American Indians received nearly identical treatment to white patients. Disparities in outcomes arise primarily due to sociodemographic factors and later stage at presentation.

A systematic review of barriers and facilitators to participation in randomized controlled trials by Indigenous people from New Zealand, Australia, Canada and the United States

ISSUE

Many randomized controlled trials (RCTs) are conducted each year but only a small proportion is specifically designed for Indigenous people. In this review we consider the challenges of participation in RCTs for Indigenous peoples from New Zealand, Australia, Canada and the United States and the opportunities for increasing participation.

APPROACH

The literature was systematically searched for published articles including information on the barriers and facilitators for Indigenous people's participation in health-related RCTs. Articles were identified using a key word search of electronic databases (Scopus, Medline and EMBASE). To be included, papers had to include in their published work at least one aspect of their RCT that was either a barrier and/or facilitator for participation identified from, for example, design of intervention, or discussion sections of articles. Articles that were reviews, discussions, opinion pieces or rationale/methodology were excluded. Results were analysed inductively, allowing themes to emerge from the data.

KEY FINDINGS

Facilitators enabling Indigenous people's participation in RCTs included relationship and partnership building, employing Indigenous staff, drawing on Indigenous knowledge models, targeted recruitment techniques and adapting study material. Challenges for participation included both participant-level factors (such as a distrust of research) and RCT-level factors (including inadequately addressing likely participant barriers (phone availability, travel costs), and a lack of recognition or incorporation of Indigenous knowledge systems.

IMPLICATION

The findings from our review add to the body of knowledge on elimination of health disparities, by identifying effective and practical strategies for conducting and engaging Indigenous peoples with RCTs. Future trials that seek to benefit Indigenous peoples should actively involve Indigenous research partners, and respect and draw on pertinent Indigenous knowledge and values. This review has the potential to assist in the design of such studies.

Prevalence of ATM Sequence Variants in Northern Plains American Indian Cancer Patients

Purpose: To identify sequence variants of the ataxia telangiectasia mutated (ATM) gene and establish their prevalence rate among American Indian (AI) as compared with non-AI cancer patients.

Materials and Methods: DNA was isolated from blood samples collected from 100 AI and 100 non-AI cancer patients undergoing radiation therapy, and a blinded assessment of the ATM sequence was conducted. Quantitative PCR assessment of copy number for each exon was also performed. The main outcome measure was the prevalence of ATM variants in the two patient populations.

Results: No statistically significant differences for total prevalence of ATM variants among AI and non-AI patients were found. Of the 25 variants identified, 5 variants had a prevalence of >2%, of which 4 occurred at a rate of >5% in one or both groups. The prevalence of these four variants could meaningfully be compared between the two groups. The only statistically significant difference among the groups was the c.4138C > T variant which is predicted not to affect protein function, seen in 8% of AI versus 0% of non-AI patients (P = 0.007). No exonic copy number changes were found in these patients.

Conclusion: This study is the first to determine the prevalence of ATM variants in AIs.

Native cancer navigation: the state of the science

The purpose of this literature review is to determine the current state of the science for the effectiveness of patient navigation on improving outcomes of cancer care across the continuum among Native Americans. The research will help healthcare professionals ascertain potential evidence-based practice guidelines and gaps in knowledge, which may provide direction for future research. Data synthesis included the use of Native navigation for cancer care, which has been demonstrated in limited, nonrandomized studies to improve cancer knowledge, access to care, and quality of life for Native Americans. Those studies had limitations, including small sample size, self-report of outcome measures, and lack of randomization. Evidence is insufficient to conclude that the use of Native navigation is superior to usual cancer care for Native American patients. Oncology nurses have a role in training personnel to serve as cancer navigators. Nurses need to be supportive of culturally appropriate navigation programs and know about services provided by navigators. In addition, nurse educators need to encourage Native Americans in their communities to consider choosing nursing as a profession. If an oncology nurse has an interest in research, opportunities exist to assist with or conduct research projects regarding Native cancer navigation. A particular need exists for addressing the gaps in research identified in this article.

Navigating the cancer journey: a review of patient navigator programs for Indigenous cancer patients

Patient navigator programs have evolved to facilitate access to care and improve outcomes for Indigenous cancer patients. We reviewed the scientific literature on patient navigator programs in Indigenous people with cancer. We conducted a review of the published literature up to 13 April 2011. PubMed, MEDLINE and CINAHL databases were searched for original articles on Indigenous patient navigation programs. The review produced eight relevant articles covering two specific programs, the Native Sisters Program and the Walking Forward Program. Program descriptions, patient navigator's roles, cultural aspects and the impact of the programs were described. Patient navigators' roles in the programs varied, as did their qualifications, but importantly, all were Indigenous. Both programs aimed to increase participation in screening, remove barriers to treatment and decrease mortality. The Native Sisters Program documented an increase in adherence to breast screening among navigated American Indian participants, although there were substantial differences in the baseline screening adherence between navigated and non-navigated participants. The Walking Forward Program yielded on average 3 fewer days of treatment delays for navigated American Indians than for non-navigated American Indians. However, adjustments for socioeconomic characteristics and disease characteristics were not described. Although preliminary outcomes are seemingly positive, further rigorous evaluation of quantitative impacts are needed.

A pre-post survey analysis of satisfaction with health care and medical mistrust after patient navigation for American Indian cancer patients

PURPOSE

To assess the impact of patient navigation (PN) on satisfaction with health care and medical mistrust among American Indians (AI) undergoing cancer treatment.

METHODS

This was a pre-post cohort survey study of 52 AI cancer patients who participated in a culturally-tailored PN program during their cancer treatment. Surveys were administered prior to and after cancer treatment assessing medical mistrust and satisfaction with health care using two Likert-type scales.

RESULTS

Participation refusal rate was 7%. Mean scale scores for satisfaction with health care were significantly improved after PN compared with pre-navigation (p<.0001; Wilcoxon signed-rank test). There was no significant difference in the mean scale scores for medical mistrust after PN compared with those observed prior to treatment (p=.13).

CONCLUSIONS

American Indian cancer patients who received PN services during their cancer treatment showed improvement in levels of satisfaction with health. However, no improvements were observed in levels of medical mistrust.

Community-based participatory development, implementation, and evaluation of a cancer screening educational intervention among American Indians in the Northern Plains

The study describes the creation and implementation of a culturally appropriate cancer education intervention, and assesses its efficacy among American Indians in a community with documented cancer-related disparities. Education workshops were developed and conducted on three western South Dakota reservations and in Rapid City by trained community representatives. Over 400 individuals participated in the 2-h workshops. Participants answered demographic questions, questions about previous cancer screening (to establish baseline screening rates), and completed a pre- and post-workshop quiz to assess learning. Participants demonstrated significant increases in cancer screening-related knowledge levels. Surveys reveal that participants found the information of high quality, great value and would recommend the program to friends. Pre-workshop data reveals cancer screening rates well below the national average. Workshop participants increased their knowledge about cancer etiology and screening. This intervention may represent an effective tool for increasing cancer screening utilization among American Indians.

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.

Patient navigation for American Indians undergoing cancer treatment: utilization and impact on care delivery in a regional healthcare center

BACKGROUND

A study was undertaken to assess patient navigation utilization and its impact on treatment interruptions and clinical trial enrollment among American Indian cancer patients.

METHODS

Between February 2004 and September 2009, 332 American Indian cancer patients received patient navigation services throughout cancer treatment. The patient navigation program provided culturally competent navigators to assist patients with navigating cancer therapy, obtaining medications, insurance issues, communicating with medical providers, and travel and lodging logistics. Data on utilization and trial enrollment were prospectively collected. Data for a historical control group of 70 American Indian patients who did not receive patient navigation services were used to compare treatment interruptions among those undergoing patient navigation during curative radiation therapy (subgroup of 123 patients).

RESULTS

The median number of contacts with a navigator was 12 (range, 1-119). The median time spent with the navigator at first contact was 40 minutes (range, 10-250 minutes), and it was 15 minutes for subsequent contacts. Patients treated with radiation therapy with curative intent who underwent patient navigation had fewer days of treatment interruption (mean, 1.7 days; 95% confidence interval [CI], 1.1-2.2 days) than historical controls who did not receive patient navigation services (mean, 4.9 days; 95% CI, 2.9-6.9 days). Of the 332 patients, 72 (22%; 95% CI, 17%-26%) were enrolled on a clinical treatment trial or cancer control protocol.

CONCLUSIONS

Patient navigation was associated with fewer treatment interruptions and relatively high rates of clinical trial enrollment among American Indian cancer patients compared with national reports.

Involving American Indians and medically underserved rural populations in cancer clinical trials

PURPOSE

To assess cancer clinical trial recruitment and reasons for nonaccrual among a rural, medically underserved population served by a community-based cancer care center.

METHODS

We prospectively tracked clinical trial enrollment incidence among all new patients presenting at the Rapid City Regional Cancer Care Institute. Evaluating physicians completed questionnaires for each patient regarding clinical trial enrollment status and primary reasons for nonenrollment. Patients who identified as American Indian were referred to a program where patients were assisted in navigating the medical system by trained, culturally competent staff.

RESULTS

Between September 2006 and January 2008, 891 new cancer patients were evaluated. Seventy-eight patients (9%; 95% confidence intervals, 7-11%) were enrolled on a clinical treatment trial. For 73% (95% confidence intervals, 69-75%) of patients (646 of 891) lack of relevant protocol availability or protocol inclusion criteria restrictiveness was the reason for nonenrollment. Only 45 (5%; 95% confidence intervals, 4-7%) patients refused enrollment on a trial. Of the 78 enrolled on a trial, 6 (8%; 95% confidence intervals, 3-16%) were American Indian. Three additional American Indian patients were enrolled under a nontreatment cancer control trial, bringing the total percentage enrolled of the 94 American Indians who presented to the clinic to 10% (95% confidence intervals, 5-17%).

LIMITATIONS

Eligibility rates were unable to be calculated and cross validation of the number in the cohort via registries or ICD-9 codes was not performed.

CONCLUSION

Clinical trial participation in this medically underserved population was low overall, but approximately 3-fold higher than reported national accrual rates. Lack of availability of protocols for common cancer sites as well as stringent protocol inclusion criteria were the primary obstacles to clinical trial enrollment. Targeted interventions using a Patient Navigation program were used to engage AI patients and may have resulted in higher clinical trial enrollment among this racial/ethnic group.

Assessing cancer stage and screening disparities among Native American cancer patients

OBJECTIVE

Disparities in cancer-related health outcomes exist among Native Americans. This article assesses barriers to timely and effective cancer care among Native American cancer patients.

METHODS

We conducted a community-based participatory survey of newly diagnosed cancer patients to assess their basic knowledge of cancer screening and their beliefs about cancer management. Sociodemographic and cancer-related information was obtained from medical records. Mean scores for correct answers to the screening knowledge battery were tabulated and analyzed by race/ethnicity and sociodemographic characteristics. Multivariable regression models were used to adjust for sociodemographic characteristics in evaluating the association between screening knowledge and race/ethnicity.

RESULTS

The survey response rate was 62%. Of 165 patients, 52 were Native American and 113 were white. Native Americans with cancers for which a screening test is available presented with significantly higher rates of advanced-stage cancer (p=0.04). Native Americans scored lower on the cancer screening knowledge battery (p=0.0001). In multivariable analyses adjusting for age, gender, income, education level, employment status, and geographic distance from the cancer center, Native American race/ethnicity was the only factor significantly predictive of lower screening knowledge. Native Americans expressed more negative attitudes toward cancer treatment in some of the items regarding impacts and burden of cancer treatment.

CONCLUSIONS

Native American cancer patients presented with higher rates of advanced-stage disease for screening-detectable cancers, lower levels of basic cancer screening knowledge, and more negative attitudes about cancer treatment than white patients. Public health interventions regarding screening and cancer education are needed.

Medical mistrust and less satisfaction with health care among Native Americans presenting for cancer treatment

PURPOSE

To assess barriers to cancer care among Native Americans, whose health outcomes compare unfavorably with those of the general U.S. population.

METHODS AND PATIENTS

We undertook a comparative community-based participatory research project in which newly-diagnosed cancer patients were prospectively surveyed using novel scales for medical mistrust and satisfaction with health care. Socio-demographic information was obtained. Mean scale scores for mistrust and satisfaction were analyzed by race. Multivariable models were used to adjust for income, education level, and distance lived from cancer care institute.

RESULTS

Participation refusal rate was 38%. Of 165 eligible patients, 52 were Native American and 113 where non-Hispanic White. Native Americans expressed significantly higher levels of mistrust (p=0001) and lower levels of satisfaction (p=.0001) with health care than Whites. In multivariable analyses, race was the only factor found to be significantly predictive of higher mistrust and lower satisfaction scores.

CONCLUSION

Native Americans exhibit higher medical mistrust and lower satisfaction with health care.

Patient navigation: state of the art or is it science?

First implemented in 1990, patient navigation interventions are emerging today as an approach to reduce cancer disparities. However, there is lack of consensus about how patient navigation is defined, what patient navigators do, and what their qualifications should be. Little is known about the efficacy and cost-effectiveness of patient navigation. For this review, the authors conducted a qualitative synthesis of published literature on cancer patient navigation. By using the keywords 'navigator' or 'navigation' and 'cancer,' 45 articles were identified in the PubMed database and from reference searches that were published or in press through October 2007. Sixteen studies provided data on the efficacy of navigation in improving timeliness and receipt of cancer screening, diagnostic follow-up care, and treatment. Patient navigation services were defined and differentiated from other outreach services. Overall, there was evidence of some degree of efficacy for patient navigation in increasing participation in cancer screening and adherence to diagnostic follow-up care after the detection of an abnormality. The reported increases in screening ranged from 10.8% to 17.1%, and increases in adherence to diagnostic follow-up care ranged from 21% to 29.2% compared with control patients. There was less evidence regarding the efficacy of patient navigation in reducing either late-stage cancer diagnosis or delays in the initiation of cancer treatment or improving outcomes during cancer survivorship. There were methodological limitations in most studies, such as a lack of control groups, small sample sizes, and contamination with other interventions. Although cancer-related patient navigation interventions are being adopted increasingly across the United States and Canada, further research will be necessary to evaluate their efficacy and cost-effectiveness in improving cancer care.

Establishing a patient navigator program to reduce cancer disparities in the American Indian communities of Western South Dakota: initial observations and results

BACKGROUND

American Indians (AIs) in the Northern Plains region suffer disproportionately high cancer mortality rates compared with the general US population and with AIs from other regions in the United States.

METHODS

The National Cancer Institute developed the Cancer Disparity Research Partnership to address these inequities. This initiative in Rapid City, South Dakota, attempts to lower cancer mortality rates for AIs by access to innovative clinical trials, behavioral research, and a genetic study. Patient navigation is a critical part of the program. Two navigation strategies are described: navigators at the cancer center and navigators on each reservation. A retrospective analysis was performed to determine if navigated patients (n = 42) undergoing potentially curative radiotherapy had fewer treatment interruptions compared with nonnavigated patients (n = 74).

RESULTS

A total of 213 AIs with cancer have undergone patient navigation. For those undergoing cancer treatment, the median number of patient navigation interactions was 15 (range 1 to 95), whereas for those seen in follow-up after their cancer treatment, the median number of contacts was 4 (range 1 to 26). AIs who received navigation services during curative radiation treatment had on average 3 fewer days of treatment interruptions compared to AIs who did not receive navigation services during curative radiation treatment (P = .002, N = 116).

CONCLUSIONS

Early findings suggest that patient navigation is a critical component in addressing cancer disparities in this population. The program has established trust with individual cancer patients, with the tribal councils, and with the general population on each of the three reservations of western South Dakota.

Establishing trusting partnerships for successful recruitment of American Indians to clinical trials

BACKGROUND

Cancer mortality rates among American Indians (AIs) in the Northern Plains are among the highest in the nation. Reasons for this disparity are unclear but are probably due to multiple barriers. AIs appear to experience more intense side effects from therapeutic radiation compared with other populations. This differential response to treatment, a disparity in itself, might be overcome if the molecular reasons were better understood.

METHODS

The National Cancer Institute developed the Cancer Disparity Research Partnership to address these inequities. This initiative, known as the Walking Forward program, attempts to lower cancer mortality rates for AIs by increasing access to innovative clinical trials, behavioral research, patient navigation, and the ataxia telangiectasia mutated (ATM) gene study. The ATM component of the project was initiated to determine if there is a molecular basis for this apparent differential response to therapeutic radiation. Successful implementation of the genetic study relied on achieving a trusting partnership with AIs since a lack of trust has historically been a barrier to performing research in this population. The authors detail the nature of building partnerships and trust by utilizing lessons learned.

RESULTS

Establishing a trusting partnership between a community hospital and AIs in South Dakota resulted in successful recruitment to this ATM clinical trial. To date, 26 AIs and 40 non-AIs have consented to participate in this ATM analysis. Their shared human desire to assist others, especially family and community members, and their demonstrated responsiveness to community priorities by academic researchers are the primary reasons for participant eagerness to enroll on this study.

CONCLUSIONS

The relatively rapid approval of the ATM genetic study by multiple tribal organizations and the successful accrual of AIs on this study reflect the trusting partnerships achieved at the patient and community levels.

Ancestral links of Chesapeake Bay region African Americans to specific Bight of Bonny (West Africa) microethnic groups and increased frequency of aggressive breast cancer in both regions

The high frequency of aggressive, early onset, and highly fatal breast cancer among Chesapeake Bay region African Americans suggests that there may be a contributing ancestral component. This study identifies the region's founding African, European, and Native American Indian populations using ethnogenetic layering and identifies the microethnic substructure of each founding continental aggregate. The largest component (38%) of the enslaved Africans brought to the Chesapeake Bay originally came from the coastal and hinterlands of the Bight of Bonny, a region with very high rates of aggressive, early onset breast cancer. Ethnogenetic layering is applied a second time to reveal the microethnic groups of the Bight of Bonny hinterlands with historical links to the Chesapeake Bay region. These analyses identify the specific microethnic groups within this region of Africa that may be the sources of relevant polymorphisms contributing to the etiology of aggressive breast cancer in the Chesapeake Bay. This report suggests a historical link between specific African microethnic groups and a US health disparity.