Although patient navigation is increasingly recognized as an important component in the delivery of patient-centered cancer care, the service is not universally available across all cancer programs in the United States, often because of the concerns of extra cost without tangible financial benefits.
Defined by various professional organizations as “individualized assistance offered to patients, families, and caregivers to help overcome health-care system barriers and facilitate timely access to quality health and psychosocial care from prediagnosis through all phases of the cancer experience,”1 patient navigation programs were originally designed to reduce barriers to care for those patients with advanced disease. They have now been shown to close a variety of gaps in care at every stage of the cancer experience, from active treatment through survivorship, by improving patient care coordination and symptom management as well as reducing costs.1
Patient navigators providing care in these programs can be either nonclinical members of the community or health-care professionals (usually nurses), social workers, and financial counselors. And each one provides benefit to patients and their families, according to Arif Kamal, MD, MBA, MHS, FACP, FAAHPM, FASCO, Chief Patient Officer at the American Cancer Society.
Arif Kamal, MD, MBA, MHS, FACP, FAAHPM, FASCO
“Although they are two different paths to patient navigation, they offer complementary roles, because some navigation issues may be more clinical in nature requiring direct communication with the medical team to provide structured feedback to the patient or inquire about an issue a patient is having,” said Dr. Kamal. “Community or lay navigators can meet patients where they live and lend an understood voice because they share a similar geographic or demographic profile with the patient, or perhaps they have a similar cancer experience, so there is alignment there. What we can confidently say is that both clinical and lay navigators have a positive impact on patients, and the reason is that patients and their caregivers need extra layers of support to journey through a very complex health system, from prevention and early screening and detection to treatment and survivorship.”
In 2012, the American College of Surgeons’ Commission on Cancer (CoC) established a standard requiring every CoC-accredited cancer program to have a patient navigation service to support patient care. And although this standard has increased the adoption of patient navigation programs across the United States, many programs face challenges with the financial cost of launching and staffing the service, as well as how best to define the scope of the practice.1
Enhancing Oncology Patient Navigation Programs
To aid the launch of new navigation services and help sustain existing ones, this past July, the American Cancer Society awarded $4.2 million in multiyear grants to bolster patient navigation programs in 20 health systems across the country.2 The health systems included both academic cancer centers and community centers. Each facility received $300,000.
To learn more about how the health-care systems were chosen for the American Cancer Society grants as well as how patient navigation programs can eliminate health disparities, enhance health equity in cancer care, and improve patient outcomes, The ASCO Post talked with Dr. Kamal and Tawana Thomas-Johnson, Senior Vice President and Chief Diversity Officer at the American Cancer Society.
Addressing Access to Equitable Care
Please talk about the criteria used to choose the 20 health-care systems for the American Cancer Society grants for patient navigation programs.
Dr. Kamal: We first asked various health systems for a letter of intent and received nearly 200 letters of intent, which demonstrated the amount of interest and the need for investment in patient navigation programs. Of these letters, we solicitated about 50 applications, which I reviewed. We are funding 20 health systems because it is all the funding we have, but all the applications were very strong.
Part of what we looked for in the applications were any new areas of service that have not classically been part of a navigation program. One example is navigation to an early-stage clinical trial, in which the navigator was being deployed to educate the patient about the benefits of clinical trials and help the patient stay on the trial. The idea here is to build trust and demystify clinical trial enrollment and ensure that all patients have equal access to clinical studies, especially Black women, who are less likely to be offered an early-stage clinical trial, with the purpose of building equity across the research enterprise.
Ms. Thomas-Johnson: One of the critical roles of the patient navigator, whether it is a clinical or lay navigator, is facilitating health-care access, particularly access to quality health care for underserved populations. We know that patient navigation programs help address some of the deep-rooted issues related to the distrust many communities and patients experience. And that distrust often leads to avoidance of dealing with health problems, which can result in treatment noncompliance and worse outcomes. So, navigators are critical in addressing some of the disparities that are often associated with race, ethnicity, and sexual orientation, as well as language and cultural barriers, and reaching underserved populations.
Measuring the Long-Term Impact of Navigation Services
Were the grants awarded to health systems to start a navigation program or to provide funding for existing programs?
Dr. Kamal: We largely focused on the health systems that had existing patient navigation infrastructure in place and were looking to increase their footprint in some way, either by increasing the service or focusing on a different component of care. Our overall approach was about investment. The funding was labeled as a grant, but really the money is for a long-term investment not only in a specific program, but in the nation’s overall capacity to increase patient navigation programs and to push policymakers to reimburse health systems for these services.
We were interested in funding not just diverse cancer centers in terms of their size, geographic location, and population served, but diversity in terms of their experience running a program, as well as diversity in their areas of impact (such as population, type of cancer, and issues that need addressing). Our goal is to create a diverse set of data that show which populations in this cohort had improved outcomes with navigation and which types of navigation services, clinical or lay, had the greatest impact.
Finding Solutions to Quality Care
Some of the health systems that received a grant, including Fred Hutchinson Cancer Center in Seattle, are major cancer centers. Did these centers already have a patient navigation program in place prior to the award?
Dr. Kamal: Yes, they did. In the Fred Hutchinson Cancer Center example, Seattle is a city with two very distinct populations. Although there is plenty of wealth in that city, there is also a working-class population that is often marginalized, and patients usually must travel large distances to get to a cancer center. Navigation services address issues such as lodging and transportation, so there are some problem-solving components of navigation that are important to lower-income patients or those with no insurance or high-deductible insurance.
However, the high financial cost of cancer affects even those patients with good insurance, because there is usually a 20% co-insurance that patients must pay. If a patient is prescribed an oral drug that costs $10,000 a month, and the patient’s co-insurance is $2,000, I do not know many patients who could afford that monthly expense over the long term.
Ms. Thomas-Johnson: The American Cancer Society has made a commitment to funding patient navigation, which we see through the lens of health disparities and advancing health equities, by reaching out and engaging patient populations that bear a disproportionate burden of cancer within the health-care systems.
For us, health equity and issues around diversity and inclusion are embedded into the fabric of our organization. We know that by 2030, the majority population in this country will be people of color, so it is extremely important that we ensure the work we are doing and the research we are funding are looking for solutions to guarantee health equity and health equality for all patients with cancer.
DISCLOSURE: Dr. Kamal and Ms. Thomas-Johnson reported no conflicts of interest.
1. Kline RM, Rocque GB, Rohan EA, et al: Patient navigation in cancer: The business case to support clinical needs. J Oncol Pract 15:585-590, 2019.
2. American Cancer Society: Navigation Capacity-Building Initiative Grant Program Request for Applications. Available at www.cancer.org/content/dam/cancer-org/online-documents/en/pdf/policies/navigation_capacity_rfa.pdf. Accessed February 17, 2023.