Abstract
Background: Delays in follow-up after breast cancer screening may contribute to disparities in breast cancer outcomes. To eliminate breast cancer disparities in Washington, D.C., The GW Cancer Institute established the D.C. Citywide Patient Navigation Research Program (DC-PNRP), which is one of nine national PNRP sites funded by the National Cancer Institute and the American Cancer Society to evaluate the effectiveness of patient navigation. The primary objective of this study is to determine the impact of patient navigation in reducing breast cancer diagnostic time, defined as the number of days from abnormal screening to definitive diagnosis.
Methods: This is a prospective study of 1922 women (728 navigated and 1194 concurrent race-matched records-based non-navigated) examined for breast cancer between 1998 and 2010 at nine hospitals and clinics located in Washington, D.C. Analysis of variance (ANOVA) was used to test for significant differences in diagnostic time between navigated and non-navigated women, while controlling for race/ethnicity (non-Hispanic white (NHW), non-Hispanic black (NHB), Hispanic), type of health insurance (private, government, none), and age at abnormal screening (<40, 40–49, 50–59, 60+). Two-way interactions between group and each of the demographic variables race/ethnicity, type of health insurance, and age at abnormal screening were considered. To satisfy model assumptions, diagnostic time was normalized through a log transformation. Geometric means were estimated and compared using a Tukey-Kramer p-value adjustment.
Results: Unadjusted average—geometric mean (95% CI)—diagnostic times (in days) were 23.9 (20.5, 27.8) for navigated and 37.2 (33.0, 41.8) for non-navigated women (p<0.0001). A factorial ANOVA model revealed significant interactions between navigation and both race/ethnicity (p=0.02) and age at abnormal screening (p=0.03) after controlling for type of insurance (p=0.0008). Navigated NHW had a significantly shorter adjusted average diagnostic time, 6.1 (3.5, 10.5) days, than non-navigated NHW, 16.0 (11.5, 22.3) days (p=0.03); and navigated Hispanics had a significantly shorter adjusted average diagnostic time, 26.5 (19.5, 36.0) days, than non-navigated Hispanics, 57.2 (44.8, 73.1) days (p=0.0005). While navigated NHB had a shorter adjusted average diagnostic time, 26.2 (21.5, 31.9) days, than non-navigated NHB, 34.3 (28.4, 41.4) days, this decrease was not statistically significant (p=0.32). Navigation reduced the diagnostic time for women of all ages, but this decrease was statistically significant only for women aged 60+ years (p<0.0001). Navigated women younger than 40 or 60+ had significantly shorter adjusted average diagnostic times than those aged 50–59 (p=0.03 for each). Adjusted average diagnostic times (in days) by age group were 11.2 (7.7, 16.3) for navigated and 22.8 (14.9, 35.0) for non-navigated women <40; 21.6 (15.9, 29.2) for navigated and 33.7 (27.4, 41.4) for non-navigated women 40–49; 23.8 (17.0, 33.5) for navigated and 35.5 (28.4, 44.4) for non-navigated women 50–59; 11.9 (8.4, 16.9) for navigated and 36.2 (28.4, 46.2) for non-navigated women 60+.
Conclusions: The time required for navigated women to reach a definitive diagnosis following an abnormal screening was significantly shorter as compared to non-navigated women. While navigation was effective overall, the program proved to be more helpful for Hispanics and NHW than for NHB, especially among women aged 60+ years. Barriers preventing a rapid diagnostic resolution for NHB need to be explored further.
Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):B90.
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