Edited by: Sarah M. Temkin, National Cancer Institute, USA
Reviewed by: Reuven Reich, Hebrew University of Jerusalem, Israel; Brigitte Mlineritsch, Private Medical University Clinic Salzburg, Austria
Specialty section: This article was submitted to Women's Cancer, a section of the journal Frontiers in Oncology
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
Patient navigation (PN) is a patient-centered health-care service delivery model that assists individuals, particularly the medically underserved, in overcoming barriers (e.g., personal, logistical, and system) to care across the cancer care continuum. In 2012, the American College of Surgeons Commission on Cancer (CoC) announced that health-care facilities seeking CoC-accreditation must have PN processes in place starting January 1, 2015. The CoC mandate, in light of the recent findings from centers within the Patient Navigation Research Program and the influx of PN interventions, warrants the present literature review.
PubMed and Medline were searched for studies published from January 2010 to October 2015, particularly those recent articles within the past 2 years, addressing PN for breast and gynecological cancers, and written in English. Search terms included patient navigation, navigation, navigator, cancer screening, clinical trials, cancer patient, cancer survivor, breast cancer, gynecological cancer, ovarian cancer, uterine cancer, vaginal cancer, and vulvar cancer.
Consistent with prior reviews, PN was shown to be effective in helping women who receive cancer screenings, receive more timely diagnostic resolution after a breast and cervical cancer screening abnormality, initiate treatment sooner, receive proper treatment, and improve quality of life after cancer diagnosis. However, several limitations were observed. The majority of PN interventions focused on cancer screening and diagnostic resolution for breast cancer. As observed in prior reviews, methodological rigor (e.g., randomized controlled trial design) was lacking.
Future research opportunities include testing PN interventions in the post-treatment settings and among gynecological cancer patient populations, age-related barriers to effective PN, and collaborative efforts between community health workers and patient navigators as care goes across segments of the cancer control continuum. As PN programs continue to develop and become a standard of care, further research will be required to determine the effectiveness of cancer PN across the cancer care continuum, and in different patient populations.
Profound advances in cancer screening, reductions in the prevalence of risk factors, and development of more effective treatments have positively contributed to increased longevity and quality of life among cancer survivors. Despite these improvements, disparities by race/ethnicity and socioeconomic status remain in cancer prevention, incidence, treatment, and mortality (
Patient navigation began in 1990 by Harold Freeman who developed a PN program within a public hospital in Harlem, NY, USA to provide assistance to low-income women in need of breast cancer screening and timely follow-up to reduce diagnoses of late-stage breast cancer (
Several recent literature reviews including Robinson-White et al. (
Since the 2011 literature review, many additional PN programs have been implemented especially those within the Patient Navigation Research Program (PNRP), funded by the National Cancer Institute (
Breast and gynecological cancers are an optimal arena to use PN because of the known survival benefit of early detection through mammography and Pap tests with prompt follow-up of detected abnormalities. PN is particularly important in women’s cancers because of documented racial and ethnic disparities in cancer care across disease trajectories. In 2015, cervical cancer incidence rates among Hispanic women were the highest of any racial/ethnic group, 50% higher than those among non-Hispanic whites (
The purpose of this review is to: (a) provide a summary of the recent literature (2010–2015) on PN and breast and gynecologic cancers from screening through treatment along the cancer care continuum; and (b) highlight research challenges and opportunities of PN that impact women’s health.
PubMed and Medline were searched for studies published from January 2010 to October 2015, particularly those recent articles within the past 2 years, addressing PN for breast and gynecological cancers and written in English. Only original studies reporting quantitative, qualitative, or mixed methods results regarding PN that dealt with cancer screening, diagnosis, treatment, clinical trials, or survivorship were included in this review. Editorials, abstracts, anecdotal reports, literature reviews, and articles lacking data from original research were excluded, as were articles that included non-breast/non-gynecological cancers and/or men in the analyses. Search terms included patient navigation, navigation, navigator, cancer screening, clinical trials, cancer patient, cancer survivor, breast cancer, gynecological cancer, ovarian cancer, uterine cancer, vaginal cancer, and vulvar cancer.
A total of 209 articles referencing PN in women’s cancers were found, of which 180 did not meet the inclusion criteria, resulting in 29 articles that met the criteria for inclusion in this review. Several notable PNRP articles were excluded because they included non-breast/non-gynecological cancer and men in their analyses (
Reference | Cancer | Design | Participants | Results |
---|---|---|---|---|
Burhansstipanov et al. ( |
Breast | Natural experiment then a quasi-control study | 313 African American, Latina, Native American, and poor White women who had not received a mammography in more than 18 months enrolled in a navigation intervention | Navigation improved mammography among women for all racial/ethnic groups who received the navigation intervention compared to those women in the non-navigated group |
Marshall et al. ( |
Breast | Randomized controlled trial | 1,358 African American female Medicare beneficiaries who were ≥65 years of age randomized to receive either patient navigation and educational materials ( |
Women in the intervention group had significantly higher odds of being up to date on mammography screening compared to women in the education only group (OR = 2.26, 95% CI = 1.59–3.22) |
Percac-Lima et al. ( |
Breast | Quasi-experimental intervention | 91 Serbo-Croatian speaking women overdue or never had a mammogram who received individually tailored interventions to encourage breast cancer screenings | At baseline, 44.0% of women had a mammogram within the previous year, with the proportion significantly increasing to 67.0% after 1 year ( |
Percac-Lima et al. ( |
Breast | Quasi-experimental intervention | 188 refugee women eligible for breast cancer screening at an urban community health center. The comparison group was English ( |
Patient navigation increased screening rates in both younger and older refugee women (64.1% before intervention, 81.2% after intervention) and were similar to the English (80.0%) and Spanish-speaking women (87.6%) |
Phillips et al. ( |
Breast | Controlled cluster randomized trial | 3,895 inner city women were randomized to a phone-based navigation intervention ( |
At baseline, there was no difference in mammography adherence between the usual care and intervention groups. After the 9-month intervention, mammogram adherence was significantly higher in the intervention group (87.0%) compared with the usual care group (76.0%) ( |
Wang et al. ( |
Cervical | Two-arm, quasi-experimental pilot study | Chinese women ( |
In the 12 months following the program, Pap screening rates were significantly higher in the intervention group (70.0%) compared to the control group (11.1%) ( |
Basu et al. ( |
Breast | Pre-post design, quasi-experimental intervention | 176 women diagnosed with breast cancer enrolled in a nurse navigation program to increase timeliness to diagnostic resolution and consultation | Navigation was found to significantly shorten time to consultation for women older than 60 years but not for women 31-60 years of age |
Battaglia et al. ( |
Breast, cervical | Quasi-experimental intervention | Women with abnormal breast and cervical cancer screenings who were enrolled in the navigator intervention ( |
There was a significant decrease in time to diagnostic resolution for navigated group compared with usual care group among those with a cervical screening abnormality (aHR = 1.46; 95% CI = 1.1–1.9); and among those with a breast cancer screening abnormality that resolved after 60 days (aHR = 1.40; 95% CI = 1.1–1.9). There was no difference before 60 days |
Charlot et al. ( |
Breast, cervical | Quasi-experimental intervention | Women with a breast ( |
Language concordance was associated with timelier diagnostic resolution for all women of the cervical cancer screening abnormality group during the first 90 days (aHR = 1.46; 95% CI = 1.18–1.80), but not after 90 days. Race concordance was associated with significant decreases in time to diagnostic resolution for minority women with breast and cervical cancer abnormalities |
Donelan et al. ( |
Breast | Group comparison study | 72 women with abnormal mammography enrolled in a navigator program. 181 women with abnormal mammography were in the non-navigated group | There was no difference in timeliness of care, preparation for the visit to the breast center, ease of access, quality of care, provider communication, unmet needs, and patient satisfaction between groups |
Dudley et al. ( |
Breast | Quasi-experimental intervention | 460 low-income Hispanic women (260 navigated, 200 usual care) with an abnormal breast cancer screening result or untreated biopsy in the University of Texas Patient Navigation Research Program | The average days from definitive diagnosis to initiation of therapy was significantly reduced overall with navigation (navigation vs. usual care, 57 vs. 74 days, |
Freund et al. ( |
Breast | Meta analyses | 3,083 women with abnormal breast cancer screening tests and 1,455 women with abnormal cervical cancer screening tests who participated in the Patient Navigation Research Program | One out of seven sites focused on abnormal breast cancer screening and two out of four sites focused on abnormal cervical cancer screening reported a significant benefit of PN on diagnostic resolution after cancer screening abnormality from 0 to 90 days |
Three out of seven sites focused on abnormal breast cancer screening and 2 out of four sites focused on abnormal cervical cancer screening reported a significant benefit of PN during 91–365 days | ||||
Hoffman et al. ( |
Breast | Prospective, pre-post study | 2,601 women (1,047 navigated, 1,554 usual care) with abnormal breast cancer screening result/clinical abnormality enrolled in the DC City-wide Patient Navigation Research Program | The average number of days to diagnostic resolution was significantly shorter for navigated women than non-navigated women (25.1 vs. 42.1 days, respectively, |
Lee et al. ( |
Breast | Controlled cluster randomized trial design | 1,039 (494 navigated, 545 usual care) women with abnormal breast cancer screening result/clinical abnormality enrolled in the Moffitt Patient Navigation Research Program | Patient navigation did not increase the timeliness of diagnostic resolution during the initial 3 months of follow-up but started to reduce time to diagnostic resolution after 3 months (aHR = 2.8, 95% CI = 1.30–6.13) and had a significant effect after 4.7 months ( |
Luckett et al. ( |
Cervical, vulvar | Descriptive study | 4,199 women at a tertiary care referral colposcopy center implementing a patient navigator program to reduce non-show rates | No-show rates declined from 49.7 to 29.5% after implementation of the patient navigator program |
Markossian et al. ( |
Breast, cervical | Quasi-experimental intervention | Underserved women with abnormal breast or cervical screening test results were assigned to either patient navigation intervention ( |
Compared with the usual care group, the breast navigation group had shorter time to diagnostic resolution (aHR = 1.65, 95% CI = 1.20–2.28) and the cervical navigation group had shorter time to diagnostic resolution for those who resolved after 30 days (aHR = 2.31, 95% CI = 1.75–3.06), with no difference before 30 days |
Paskett et al. ( |
Cervical | Meta-analysis | 2,317 women with low and high-risk cervical abnormalities from four Patient Navigation Program centers who received patient navigation ( |
Low-risk women in the navigated group showed improvement in timely diagnostic follow-up in all racial groups, but significant effects were only observed in non-English speaking Hispanic women (OR = 5.88, 95% CI = 2.81–12.29). No effect was observed in high-risk women |
Percac-Lima et al. ( |
Cervical | Quasi-experimental intervention | 533 Latina women with an abnormal Pap smear requiring colposcopy received patient navigation. The comparison group was 253 non-navigated Latinas with an abnormal Pap smear requiring colposcopy | Navigated women had significantly fewer missed colposcopy appointments over time, with the average falling from 19.8 to 15.7% ( |
Raich et al. ( |
Breast | Randomized clinical trial | 628 patients with abnormal breast screenings tests randomized to either intervention ( |
For the abnormal breast screening group, 92% of the navigated patients reached diagnostic resolution of the initial abnormal test, as compared with 77% for the usual care patients ( |
Ramirez et al. ( |
Breast | Prospective, pre-post study | 425 Latina women with abnormal breast cancer screening results enrolled in either a patient navigator program (Six Cities Patient Navigation Study) ( |
The time to diagnosis was shorter in the navigated group (mean, 32.5 vs. 44.6 days in the usual care group; HR = 1.32). Navigation significantly shortened the time to diagnosis among women who had BI-RADS-3 radiologic abnormalities (mean, 21.3 vs. 63.0 days; HR = 2.42); but not among those who had BI-RADS-4 or 5 (mean, 37.6 vs. 36.9 days; HR = 0.98) |
Chen et al. ( |
Breast | Pre-post design, quasi-experimental intervention | 100 newly diagnosed women with breast cancer who were enrolled in a navigator program ( |
Overall adherence to the quality indicators significantly improved from 69 to 86% ( |
Haideri and Moormeier ( |
Breast | Retrospective case series analysis | 157 women who received navigation services and 103 women who received usual care after being diagnosed with breast cancer | There was no difference in the stage of presentation or the overall survival between the intervention and usual care groups. For the navigated women, there was a modest decrease (9 days) in the time between initial presentation and definitive therapy |
Hendren et al. ( |
Breast | Randomized controlled trial | 319 newly diagnosed breast cancer patients were randomized to receive a patient navigation intervention for improved quality of life ( |
There was no significant effect of patient navigation on disease-specific quality of life scores between navigated and usual care breast cancer patients undergoing primary cancer treatment |
Ko et al. ( |
Breast | Multisite, quasi-experimental intervention | 1,004 (navigated = 498, usual care = 506) women newly diagnosed with breast cancer enrolled in the Patient Navigation Research Program to improve receipt of recommended care | Among women eligible for antiestrogen therapy, navigated women had a significant higher likelihood of receiving antiestrogen therapy compared with non-navigated controls (OR = 1.73, |
Madore et al. ( |
Breast | Quasi-experimental pilot study | 20 medically underserved women recently diagnosed with breast cancer who were enrolled in the Breast CARES intervention to overcome treatment barriers | There was a decrease in depression and cancer-related distress and an increase in social support. Participation in the intervention helped the women overcome financial barriers (73.0%), transportation problems (60.0%), and communication barriers with medical staff (73.0%) |
Raj et al. ( |
Breast | Retrospective, pre-post study | 186 women with breast cancer from a disadvantaged minority community who participated in a patient navigator program to improve quality measures | Women who received navigation services received high-quality cancer care, as defined by concordance with ASCO/NCCN quality measures. These navigated women also had a favorable breast cancer stage distribution with >50% having |
Ramirez et al. ( |
Breast | Quasi-experimental intervention | 480 Latinas with breast cancer enrolled in either a patient navigation program for timely diagnostic resolution ( |
A significantly higher percentage of navigated women initiated treatment within 30 days (69.0 vs. 46.3%, |
Ulloa et al. ( |
Breast | Prospective, pre-post study | 130 low-income women from California enrolled in a patient navigation intervention to improve communication about survivorship care | The intervention significantly improved short-term recall of patient-specific breast cancer knowledge ( |
The literature on PN interventions to increase breast cancer screening included five studies (
The other three studies (
One study in our review examined the impact of PN on screening rates for gynecological cancers. Wang et al. (
Six studies (
Three studies, a meta-analysis (
Three studies (
The PNRP studies included other cancers (colorectal and prostate), but the majority of the cancers were breast and cervical. A meta-analysis by Freund et al. (
One study (
The results of the literature review for PN after cancer diagnosis resulted in eight studies (
A study by Ramirez et al. (
In a large, multisite study, Ko et al. (
Several studies have conducted secondary analyses to understand the association between barriers to care and clinical outcomes, particularly within the PNRP. A 2015 study by Ramachandran et al. (
Specific types of barriers patients report were described by several studies (
Some studies have attempted to determine which variables are associated with having a barrier to cancer care to identify women most in need of PN. Several studies (
As evidenced in this literature review, PN has been shown to help women receive cancer screenings, receive more timely diagnostic resolution after a breast and cervical cancer screening abnormality, initiate treatment sooner, receive proper treatment, and improve quality of life among cancer patients. Also, it was shown that PN eliminates barriers to care. PNRP demonstrated: (1) who has barriers; (2) that barriers delay the receipt of care; and (3) types of numbers of barriers that impact time to treatment (
Several trends emerged from this review. PN programs have been implemented among diverse populations specifically focused on reducing health disparities in racial and ethnic minorities and/or underserved populations. It is important to note that each study population and setting was unique, thus generalizability of these findings may be limited. Another trend noted was the limited effectiveness for certain groups receiving PN, alluding to the possibility that PN is not equally effective for all groups. Results found significant differences in PN effectiveness with regard to age (
Finally, although there is evidence of the potential of PN to improve outcomes related to cancer screening and diagnostic resolution, many studies have utilized less robust designs (i.e., quasi-experimental and descriptive studies), as mentioned by previous reviews (
Due to the increased prevalence of PN in health-care systems, there are growing research opportunities in PN and women’s health. One area that is ripe for researchers is PN in cancer survivorship, particularly among post-treatment cancer survivors. Increases in the number of individuals diagnosed with cancer each year, as well as improving survival rates, have led to an ever-increasing number of cancer survivors (
The PN literature on women’s cancers is growing; however, it is limited in that researchers have primarily focused on breast cancer (as seen in the literature on PN after diagnosis). Although cervical cancer incidence and mortality rates have steadily decreased, it is estimated that in 2015, 12,900 new cases of invasive cervical cancer occurred and 4,100 died from this disease (
Women may also benefit from PN during cancer care that is tailored to specific family-related barriers, such as child care and transportation. Women often assume the role of caregivers and income-earners and may need more assistance in caregiving for others while receiving cancer care for themselves. PN can link them to resources that offer emotional (i.e., support groups) and tangible support (i.e., house cleaning, child care) and has the potential to improve quality of life and psychosocial outcomes for both women with cancer and women who are caregivers.
Navigators should consider the age of the female patient and their stage in life during PN interventions. For example, younger women often face very different challenges and complications than older women, including concerns about becoming a mother; caring for children when faced with a life-threatening illness; premature menopause leading to loss of fertility; sudden onset of vasomotor symptoms; long-term consequences of early ovarian decline; body image and sexuality; and career and work concerns related to productivity and job security (
The similarity of patient navigators to the participants is important for the success of PN interventions. For example, patient navigator race and language concordance improved the timeliness of care in a minority population (
JK-S was responsible for the planning, literature review, writing, editing, and submitting the manuscript. JO was responsible for the planning, literature review, writing, and editing the manuscript. EP was responsible for the planning, writing, and editing the manuscript.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.