Background
Sociolegal barriers to cancer care are defined as health‐related social needs like affordable healthy housing, stable utility service, and food security that may be remedied by public ...policy, law, regulation, or programming. Legal support has not been studied in cancer care.
Methods
The authors conducted a randomized controlled trial of patients who had newly diagnosed cancer at a safety‐net medical center in Boston from 2014 through 2017, comparing standard patient navigation versus enhanced navigation partnered with legal advocates to identify and address sociolegal barriers. English‐speaking, Spanish‐speaking, or Haitian Creole‐speaking patients with breast and lung cancer were eligible within 30 days of diagnosis. The primary outcome was timely treatment within 90 days of diagnosis. Secondary outcomes included patient‐reported outcomes (distress, cancer‐related needs, and satisfaction with navigation) at baseline and at 6 months.
Results
In total, 201 patients with breast cancer and 19 with lung cancer enrolled (response rate, 78%). The mean patient age was 55 years, 51% of patients were Black and 22% were Hispanic, 20% spoke Spanish and 8% spoke Haitian Creole, 73% had public health insurance, 77% reported 1 or more perceived sociolegal barrier, and the most common were barriers to housing and employment. Ninety‐six percent of participants with breast cancer and 73% of those with lung cancer initiated treatment within 90 days. No significant effect of enhanced navigation was observed on the receipt of timely treatment among participants with breast cancer (odds ratio, 0.88; 95% CI, 0.17‐4.52) or among those with lung cancer (odds ratio, 4.00; 95% CI, 0.35‐45.4). No differences in patient‐reported outcomes were observed between treatment groups.
Conclusions
Navigation enhanced by access to legal consultation and support had no impact on timely treatment, patient distress, or patient needs. Although most patients reported sociolegal barriers, few required intensive legal services that could not be addressed by navigators.
Lay Summary
In patients with cancer, the experience of sociolegal barriers to care, such as unstable housing, utility services, or food insecurity, is discussed. Addressing these barriers through legal information and assistance may improve care.
This study compares standard patient navigation versus enhanced navigation partnered with legal advocates for patients with breast and lung cancers. Almost all patients in both navigation groups received timely care and also reported the same levels of distress, needs, and satisfaction with navigation.
Although 75% of patients in the study had at least 1 sociolegal barrier identified, few required legal advocacy beyond what a navigator who received legal information and coaching could provide.
In this comparative‐effectiveness, randomized controlled trial, the effect of standard patient navigation on clinical and patient‐reported outcomes is compared with the effect of enhanced navigation supported by legal advocacy. Although no impact of enhanced navigation on the receipt of timely treatment or on patients' distress or needs was identified, 75% of patients had at least 1 sociolegal barrier to care.
Background
Minority women in the U.S. continue to experience inferior breast cancer outcomes compared with white women, in part due to delays in care delivery. Emerging cancer care delivery models ...like patient navigation focus on social barriers, but evidence demonstrating how these models increase social capital is lacking. This pilot study describes the social networks of newly diagnosed breast cancer patients and explores the contributing role of patient navigators.
Materials and Methods
Twenty‐five women completed a one hour interview about their social networks related to cancer care support. Network metrics identified important structural attributes and influential individuals. Bivariate associations between network metrics, type of network, and whether the network included a navigator were measured. Secondary analyses explored associations between network structures and clinical outcomes.
Results
We identified three types of networks: kin‐based, role and/or affect‐based, or heterogeneous. Network metrics did not vary significantly by network type. There was a low prevalence of navigators included in the support networks (25%). Network density scores were significantly higher in those networks without a navigator. Network metrics were not predictive of clinical outcomes in multivariate models.
Conclusion
Patient navigators were not frequently included in support networks, but provided distinctive types of support. If navigators can identify patients with poorly integrated (less dense) social networks, or who have unmet tangible support needs, the intensity of navigation services could be tailored. Services and systems that address gaps and variations in patient social networks should be explored for their potential to reduce cancer health disparities.
Implications for Practice
This study used a new method to identify the breadth and strength of social support following a diagnosis of breast cancer, especially examining the role of patient navigators in providing support. While navigators were only included in one quarter of patient support networks, they did provide essential supports to some individuals. Health care providers and systems need to better understand the contributions of social supports both within and outside of health care to design and tailor interventions that seek to reduce health care disparities and improve cancer outcomes.
Disparities in breast cancer care in the U.S. are multifactorial, arising from differences in income, education, cultural beliefs, and social support. This article describes the social networks of newly diagnosed breast cancer patients and explores the contributing role of patient navigators.
ABSTRACT
BACKGROUND
Inequity in cancer outcomes for minorities and vulnerable populations has been linked to delays in cancer care that arise from barriers to accessing care. Social service barriers ...represent those obstacles related to meeting life’s most basic needs, like housing and income, which are often supported by public policy, regulation and services.
OBJECTIVE
To examine the association between social service barriers and timely diagnostic resolution after a cancer screening abnormality.
DESIGN
Secondary analysis of the intervention arm of Boston Patient Navigation Research Program (2007–2008) conducted across six urban community health centers. Subjects with no barriers, other barriers, and social service barriers were compared on their time to diagnostic resolution.
SUBJECTS
Women ≥ 18 years of age with a breast or cervical cancer screening abnormality.
MAIN MEASURES
Social service barriers included: income supports, housing and utilities, education and employment, and personal/family stability and safety. Time to event analyses compared across five groups: those with no barriers, one barrier (other), one barrier (social service), two or more barriers (all other), and two or more barriers (at least one social service).
KEY RESULTS
1,481 navigated women; 31 % Hispanic, 27 % Black, 32 % White; 37 % non-English speakers and 28 % had private health insurance. Eighty-eight women (6 %) had social service barriers. Compared to those without social service barriers, those with were more likely to be Hispanic, younger, have public/no health insurance, and have multiple barriers. Those with two or more barriers (at least one social service barrier), had the longest time to resolution compared to the other four groups (aHR resolution < 60 days = 0.27, ≥ 60 days = 0.37).
CONCLUSION
Vulnerable women with multiple barriers, when at least one is a social service barrier, have delays in care despite navigation. The impact of patient navigation may never be fully realized if social service barriers persist without being identified or addressed.
While there is widespread dissemination of patient navigation programs in an effort to reduce delays in cancer care, little is known about the impact of barriers to care on timely outcomes.
We ...conducted a secondary analysis of the Boston Patient Navigation Research Program (PNRP) to examine the effect that the presence of barriers had on time to diagnostic resolution of abnormal breast or cervical cancer screening tests. We used multivariable Cox proportional hazards regression with time to diagnostic resolution as the outcome to examine the effect of the number of barriers, controlling for demographic covariates and clustered by patients' primary navigator.
There were 1481 women who received navigation; mean age was 39 years; 32% were White, 27% Black, and 31% Hispanic; 28% had private health insurance; and 38% did not speak English. Overall, half (n=745, 50%) had documentation of one or more barriers to care. Women with barriers were more likely to be older, non-White, non-English language speakers, and on public or no health insurance compared with women without barriers. In multivariable analyses, we found less timely diagnostic resolution as the number of barriers increased (one barrier, adjusted hazard ratio aHR 0.81 95% CI 0.56-1.17, p=0.26; two barriers, aHR 0.55 95% CI 0.37-0.81, p=0.0025; three or more barriers, aHR 0.31 95% CI 0.21-0.46, p<0.0001).
Within a patient navigation program proven to reduce delays in care, we found that navigated patients with documented barriers to care experience less timely resolution of abnormal cancer screening tests.
To investigate whether the 2006 American Society for Colposcopy and Cervical Pathology guidelines for conservative management of minimally abnormal Pap test results (atypical squamous cells of ...undetermined significance, human papillomavirus-positive, and low-grade squamous intraepithelial lesions) and moderate dysplasia (cervical intraepithelial neoplasia 2) in adolescents 1) resulted in fewer colposcopies and loop electrosurgical excision procedures (LEEPs) in adolescents or 2) resulted in unintended treatment changes in older age groups.
We analyzed data from 1,806 women aged 18 years and older attending one of six community health centers who were diagnosed with abnormal Pap test results between January 1, 2004, and December 31, 2008. We used multivariable logistic regression to examine treatment differences in women with minimally abnormal Pap test results before and after guideline changes. Variables included date of abnormality, site of care, race or ethnicity, language, and insurance type. We used Fisher exact tests to examine rates of LEEP in patients with moderate dysplasia before and after guideline publication.
Among 206 women aged 18-20 years, rates of colposcopy after a minimally abnormal Pap test result decreased from 78% (n=102) to 45% (n=34) after guideline changes (P<.001). Colposcopy among women over age 21 (n=1,542) remained unchanged (greater than 90%). Multivariable logistic regression indicated that both date of abnormality and site of care were associated with colposcopy referral. After guideline changes, management of moderate dysplasia with LEEP in women aged 18-23 decreased from 55% to 18% (P=.04); rates remained stable in women ages 24 and older (70% compared with 74%; P=.72).
Health care providers quickly adopted new conservative management guidelines for low-income, minority adolescents, which may reduce preterm deliveries in these high-risk populations.
II.
Patient navigation (PN) has been used to improve breast cancer outcomes but has not been evaluated in resident practices. The objective of this study was to evaluate the feasibility of PN in resident ...clinics to improve biennial screening mammography. All participants whose last screening mammogram was at 18 months or after received PN. Feasibility outcomes included practicality (ability to carry out intervention), effectiveness (ability of intervention to increase biennial screening mammography rates), and acceptability (resident satisfaction with PN). Despite difficulty contacting patients, we found PN improved screening mammography adherence in resident practices serving vulnerable populations. Adherence rates increased significantly postintervention. Residents reported interest in using PN in practice.
This study assessed current levels of sunbathing and sunscreen use in the United States.
From a general-population telephone survey of aquatic activities among adults in 3042 US households, we ...examined responses by the 2459 Whites.
Most adults (59%) reported sunbathing during the past year, and 25% reported frequent sunbathing. Of the subsample who reported sunbathing during the month before the interview, 47% routinely used sunscreen. Of these individuals, almost half did not use sunscreens with a solar protection factor of 15 or higher.
About a quarter of US White adults report frequent sunbathing, and only about a quarter of sunbathers use sunscreens at recommended levels. These results should help focus future sun protection educational efforts.
To improve detection of domestic violence as a problem for women seeking primary care, we compared the addition of a single question about domestic violence on an existing self-administered health ...history form, to discretionary inquiry alone. We studied 689 consecutive new women patients in an internal medicine practice. Domestic violence identification rose from 0% in the control group with discretionary inquiry alone to 11.6% (95% confidence interval 8.8-14.4%) when the health history form included the following question: "At any time has a partner ever hit you, kicked you, or otherwise physically hurt you?" The addition of a single question can increase identification of domestic violence as a problem in patients' lives.
Breast cancer treatment disparities in racial/ethnic minority and low-income populations are well documented; however, underlying reasons remain poorly understood. This study sought to identify ...barriers to the delivery of quality breast cancer treatment, addressing compliance with the National Quality Forum (NQF) quality metric for adjuvant hormone therapy (HT; administration of HT within 365 days of diagnosis in eligible patients) at an urban safety net hospital.
This retrospective, observational study included women diagnosed with nonmetastatic, T1c or greater, estrogen and/or progesterone receptor-positive breast cancer from 2006 to 2008. Data sources included the hospital cancer registry and electronic medical record. Compliance with the NQF quality metric was defined as HT prescription within 365 days of diagnosis. Bivariate analysis compared compliant with noncompliant patients. Qualitative analysis assessed reasons for delayed compliance (HT at > 365 days) and never compliance (no HT at 4 years).
Of 113 eligible patients, the majority were racial/ethnic minority (56%), stage II (54%), unmarried (60%), and had public or no insurance (72%). Sixty-four percent were compliant, and 36% were noncompliant. Of the noncompliant, 78% had delayed compliance, and 22% were never compliant. Noncompliant patients were significantly more likely to be Black, Hispanic, foreign-born, and stage III at diagnosis. Ten reasons for delayed compliance were identified, including patient- and system-level barriers. Most patients (56%) had more than one reason contributing to delay.
Urgently needed interventions to reduce disparities in breast cancer treatment should take into account obstacles inherent among immigrant and indigent populations and complexities of multidisciplinary cancer care.
Approximately 35% of patients with amyotrophic lateral sclerosis (ALS) exhibit mild cognitive deficits in executive functions, language and fluency, without dementia. The precise pathology of these ...extramotor symptoms has remained unknown. This study aimed to determine the pathological correlate of cognitive impairment in patients with non-demented ALS.
In-depth neuropathological analysis of 27 patients with non-demented ALS who had undergone cognitive testing (Edinburgh Cognitive and Behaviour ALS Screen (ECAS)) during life. Analysis involved assessing 43 kDa Tar-DNA binding protein (TDP-43) accumulation in brain regions specifically involved in executive functions, language functions and verbal fluency to ascertain whether functional deficits would relate to a specific regional distribution of pathology.
All patients with cognitive impairment had TDP-43 pathology in extramotor brain regions (positive predictive value of 100%). The ECAS also predicted TDP-43 pathology with 100% specificity in brain regions associated with executive, language and fluency domains. We also detected a subgroup with no cognitive dysfunction, despite having substantial TDP-43 pathology, so called mismatch cases.
Cognitive impairment as detected by the ECAS is a valid predictor of TDP-43 pathology in non-demented ALS. The profile of mild cognitive deficits specifically predicts regional cerebral involvement. These findings highlight the utility of the ECAS in accurately assessing the pathological burden of disease.
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