Posted by A recent article in the Washington Post was headlined “‘Navigators’ for cancer patients: A nice perk or something more?”
A “nice perk”? It certainly seems like anything that would help to lessen the confusion for patients and help them obtain and adhere to treatment would improve outcomes and help keep costs down too. I took a closer look at the article and especially at the main research study it was reporting on.
The Post article notes that patient navigation programs have been proliferating at hospitals and cancer treatment centers across the country and now number in the thousands. But it claims research shows that navigation has only a modest effect on how well patients do and that there is little evidence it saves money.
But here’s the thing–the article goes to say that the debate over effectiveness and costs centers mostly on one nine-site study of patient navigation that was conducted by the National Cancer Institute. And about that study–it was extremely limited in scope, focusing on only one piece of the cancer care continuum: following up on an abnormal result on a screening test.
Now, following up on abnormal screening results is a critical piece of the cancer care continuum, especially for patients in underserved populations, where this part of the process often breaks down. That, in fact, is how patient navigation got started in the first place.
But patient navigation in recent years has come to mean much more.
Seeking Better Outcomes for Underserved Patients
Last fall, I wrote a post about the challenges often faced by underserved patients in obtaining treatment that meets current standard of care, and the role of patient navigation in helping some of these patients. The concept of patient navigation started in the early 1990’s when it was recognized that poor, uninsured patients often experienced significant delays to obtaining treatment after a screening test showed an abnormal result, and that these delays were resulting in higher mortality rates for breast cancer and other cancers.
After twenty-odd years’ experience with patient navigation, the National Cancer Institute (NCI) conducted a major study to assess the effectiveness of patient navigation.
The NCI study, published in 2014, compared patient navigation with usual care for about 12,000 patients treated in nine different cancer centers between 2007 and 2010. The purpose was to find out what the impact of patient navigation was on time to diagnosis or time to treatment for participants–mostly minority–with breast, cervical, colorectal or prostate screening abnormalities and/or cancer.
And the results? The study found that patient navigation was beneficial in improving timeliness of follow-up or care, especially in centers that had the greatest delays under usual care.
What About Cost Effectiveness?
So does patient navigation saves money?
The recent Post article refers to an analysis coming out of that same NCI study that tried to assess the cost effectiveness of patient navigation, as it related to this one piece of the process, i.e. initial follow-up for an abnormal screening result.
But the study really wasn’t really able to draw any conclusions about cost effectiveness, at least not any very meaningful conclusions. The study compared the time to resolution of the screening findings for patients with and without navigation (that is, for those who did get resolution), whether or not there was a difference in stage at diagnosis for those diagnosed with cancer, and then factored in costs.
These were the main findings:
- There was no difference in average number of days to resolution of the screening results for those who did follow up.
- The probability of ever getting resolution of the abnormal findings was higher with navigation.
- The added cost of navigation was $275 per patient.
- There was no significant difference in stage at diagnosis for those with navigation compared to those without (again, for those who did follow up).
- In sum, navigation adds cost and modestly increases the probability of diagnostic resolution among patients with abnormal screening tests.
The additional cost was just $275 per patient! And from what I could determine, the study did not factor in the economic impact of some patients never obtaining resolution of their abnormal results, i.e. patients who enter the medical system again later with more advanced cancer and who are then likely to need more costly treatment and care.
Patient Navigation Has Evolved
Although patient navigation started with the intent of helping underserved patients obtain follow-up care after an abnormal screening result, the concept has expanded to encompass the entire range of cancer patient care. The Oncology Nursing Society, in “Oncology Nurse Navigator Core Competencies,” provides this explanation of how the role of the oncology nurse navigator has evolved:
Over the past 20 years, the role of the navigator has expanded to encompass cancer care across the continuum, from prevention to survivorship to end-of-life care. In many cancer programs, oncology nurses are functioning in the role of professional navigator secondary to their cancer-specific knowledge and clinical expertise. Benefits of a nurse performing the role of navigator include the skill to clinically assess patients, provide support and education, manage the complexity of the cancer diagnosis, and communicate and collaborate with other clinicians (Gilbert et al., 2011).
In fact, the concept of patient navigation has become so broad that some are asking what this says about our cancer treatment system in the first place. The Post article includes this comment from Scott Ramsey, a professor of public health sciences at Fred Hutchinson Cancer Research Center in Seattle, who worked on the NCI project:
One question worth asking is why do [patient navigators] exist. And the reason is the cancer community has done a very poor job of helping patients through the system. The fact that navigation exists is kind of an indictment of the cancer-care system.
In the short term, it seems that ensuring the availability of qualified navigators when they are needed could potentially make a big difference for patients. And perhaps it’s worth studying the impact of navigation over the entire course of care in helping patients to do better along with its cost effectiveness.
Navigating the cancer care system is complicated and presents many different kinds of challenges. Not only could many of us benefit from help in navigating these challenges, we need our health care system to be capable of addressing patient needs in a coordinated manner for everyone.
For More Information
“Patient Navigation: An Update on the State of the Science”, published in 2011 in the American Cancer Society’s CA: A Cancer Journal for Clinicians, provides an excellent overview of the history of patient navigation, what it is and who it serves.
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