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Possible Impact of Nurse Navigation Program in Achieving Equitable Care and Outcomes in Minority vs White Patients


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In a single-institution study reported in Cancer, Bei Hu, MD, of the Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute/Atrium Health in Charlotte, and colleagues found that use of a dedicated nurse navigation program contributed to redressing the recognized inequities in care and outcomes between minority patents and White patients with aggressive large B-cell lymphoma (LBCL).1

As stated by the investigators: “Aggressive … LBCLs are curable, but previous studies have shown inferior outcomes in minorities. Nurse navigation programs can improve patient outcomes by providing patient support. This study presents the outcomes of White and minority patients with aggressive LBCL at an institution with an active nurse navigation program.”

Bei Hu, MD

Bei Hu, MD

Study Details

The study involved prospectively collected data on 204 consecutive patients with LBCL, including 47 minority patients (Black/African American, Asian, Native American/Pacific Islander patients and those of Hispanic/Latinx ethnicity) and 157 White patients, receiving initial treatment, treatment for relapse, or both at the Levine Cancer Institute central location between January 2016 and June 2019. Among the 204 patients, 186 had diffuse large B-cell lymphoma, 14 had primary mediastinal B-cell lymphoma, and 4 had high-grade B-cell lymphoma.

Cases were discussed at a weekly multidisciplinary meeting attended by nursing staff, nurse navigator cellular therapy coordinators, oncology pharmacists, lymphoma faculty, and research staff. Nurse navigation encounters were characterized as low or high intensity. Low-intensity encounters were used for basic needs and initial guidance/education with either no further follow-up or follow-up as needed. High-intensity encounters were used for coordination of multimodality treatment to overcome major barriers and comply with treatment, including providing assistance to patients who were uninsured/underinsured, homeless, undocumented, or had poor health literacy.

Patient Characteristics and Nurse Navigation Use

Results are presented as minority vs White. Median age at diagnosis was 56 vs 62 years (P = .03). Males accounted for 45% vs 50% (P = .62). Proportions with Medicaid or no insurance at diagnosis were 26% vs 4% (P < .001), and 62% vs 35% lived less than 20 miles from the Levine Cancer Institute central location. There were no differences between groups in lymphoma types (P = .80), prognostic scores (Revised International Prognostic Index [R-IPI] score of 3–5 in 43% vs 47%, P = .50), or in proportions with relapsed or refractory disease (40% vs 38%, P = .74). Double-hit lymphomas were present in 11% vs 13% of patients (P = .80).

While both groups had equal nurse navigation use, 81% vs 87% (P = .35), minorities had more high-intensity encounters, 42% vs 21% (P = .01). Median duration of encounters was 135 vs 60 minutes (P < .001) for high- vs low-intensity encounters. More minority patients relied on nurse navigation for assistance with compliance concerns (18% vs 7%, P = .04), insurance questions (29% vs 8%, P = .002), financial concerns (37% vs 18%, P = .02), and transportation concerns (16% vs 2%, P = .004).

Care Received and Survival Outcomes

KEY POINTS

  • No differences between minority and White patients with large B-cell lymphoma were found for receipt of first-line therapy, treatments for relapsed or refractory disease, enrollment in clinical trials, or 2-year progression-free and overall survival.
  • A significantly higher proportion of minority patients had high-intensity nurse navigation encounters.

Among minority vs White patients, the vast majority underwent first-line treatment with multiagent rituximab/anthracycline-based chemotherapy:  98% vs 96% of patients (P = .68). Among patients with relapsed or refractory disease, there were no  significant differences in minorities vs White patients who underwent hematopoietic stem cell transplantation [32% vs 29% (P > .99)], or enrolled in clinical trials [17% vs 14% patients (P = .64)].

Median follow-up was 35 months. The estimated 2-year progression-free survival rate was 62% vs 65% (hazard ratio [HR] = 1.07, 95% confidence interval [CI] = 0.66–1.74, P = .78), and estimated 2-year overall survival rate was 81% vs 76% (HR = 0.68, 95% CI = 0.34–1.35, P = .27) for minority vs White patients, respectively.

On univariate analysis among all patients, inferior overall survival was significantly associated with age at diagnosis (HR per 5-year increase = 1.33, P < .001), driving distance at least 20 miles (HR = 2.75, P = .002), R-IPI score at least 3 (HR = 2.63, P = .001), relapsed or refractory disease (HR = 5.13, P < .001), and diagnosis of double-hit lymphoma (HR = 2.30, P = .02), but not with race, sex, or use of nurse navigation. On multivariate analysis, no difference in overall survival was observed between minority and White patients (HR = 1.20, P = .62), whereas age (HR per 5-year increase = 1.41, P < .001), relapsed or refractory disease (HR = 4.30, P < .001), and driving distance at least 20 miles (HR = 2.34, P = .02) remained independent predictors of poorer survival.

The investigators concluded: “[We] report similar outcomes between Whites and minorities with aggressive LBCL [possibly] due to equal access to guideline-conforming care and clinical trials. The availability of an active nurse navigation program may have helped overcome socioeconomic barriers, although a prospective trial for the role of nurse navigation in helping to achieve equitable outcomes is needed for further confirmation. This observation is important because it demonstrates that true equity can be achieved in the management of curable malignancies in underserved populations.” 

DISCLOSURE: The investigators reported that there was no external funding for the study. Dr. Hu has served as a consultant or advisor to Bayer, Cellectar, and Kite Pharma; and has received institutional research funding from BeiGene and Genentech.

REFERENCE

1. Hu B, Boselli D, Pye LM, et al: Equal access to care and nurse navigation leads to equitable outcomes for minorities with aggressive large B-cell lymphoma. Cancer 127:3991-3997, 2021.

 


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