Patient Navigation Boosts Colorectal Cancer Screening Rate in Ethnically Diverse Patients

Karen E. Lasser, MD

A recent study showed that a patient-navigation-based intervention may help increase the rate of colorectal cancer (CRC) screening in typically underserved groups, including low-income, ethnically diverse patients. Karen E. Lasser, MD, MPH, with the Boston University School of Public Health, and colleagues randomized patients to receive patient navigation-based intervention or usual care and tracked them for 1 year after enrollment.

While CRC is the second leading cause of cancer death in the United States and can be prevented through screening, the investigators pointed out that nearly half of eligible adults are overdue for CRC screening. Studies have identified racial minorities, patients on Medicaid or who lack health insurance, immigrants, and the socioeconomically disadvantaged as being at greatest risk for not being screened.

Prior research has also documented improved CRC screening rates in city-dwelling racial minorities with patient navigation, which involves the use of laypeople to guide patients through the healthcare system so that they receive appropriate care.

Lasser and her team wanted to expand on the earlier studies, which were mostly nonrandomized. One study that was randomized was conducted at a single health center that largely served patients who speak English or Spanish as their primary language.

Within the intervention group, the screening rate was significantly higher among those whom the navigators were able to contact than those whom the navigators could not reach.

The present analysis included 465 immigrants from the Azores, Brazil, Haiti, and Portugal who were receiving care at 4 different health centers and 2 public hospital-based clinics that were part of the Cambridge Health Alliance, which is a network of primary care practices in the Boston area.

Study participants ranged in age from 52 to 74 years and had not completed CRC screening per federal guidelines, defined as a colonoscopy in the past 10 years, sigmoidoscopy or double-contrast barium enema in the past 5 years, or fecal occult blood testing (FOBT) in the past year. Patients spoke English, Haitian Creole, Portugese, or Spanish as their primary language.

Patients assigned to the intervention group underwent a maximum of 6 hours of patient navigation over a 6-month period. Intervention patients received an introductory letter from their primary care provider along with educational material and follow-up telephone calls from a navigator who spoke the same language. The intervention encouraged FOBT or colonoscopy, which were the most commonly used screening tests at the study sites. The primary outcome was the completion of any CRC screening within 1 year.

At 1 year, 33.6% of patients in the intervention group had been screened for CRC versus 20.0% of patients in the control group (P <.001). Intervention patients were also more likely to be screened by colonoscopy (26.4% vs 13.3%; P <.001) and to have adenomas detected (8.1% vs 3.9%; P =.06).

Within the intervention group, the screening rate was significantly higher among those whom the navigators were able to contact than those whom the navigators could not reach (39.8% and 18.6%; P <.001). In prespecified subgroup analyses, the intervention was found to be especially beneficial for black patients and for patients whose primary language was not English.

Lasser and associates noted that, at the time of the study, Cambridge Health Alliance was having financial problems that prompted health center closures and the departure of primary care practitioners. They maintain that their intervention might have had a more dramatic effect in a more stable healthcare environment.

The researchers cited the study’s inclusion of a racially heterogeneous patient population from multiple health centers and public hospital-based clinics in the real-world setting as important study strengths. On the other hand, patients were drawn from a single geographic area and thus may have undergone CRC screening at a healthcare clinic or hospital that was not 1 of the study sites. They also cautioned against extrapolating the results to patients with active substance abuse and mental illness because these groups were excluded from the study.

Lasser KE, Murillo J, Lisboa S, et al. Colorectal cancer screening among ethnically diverse, low-income patients: a randomized, controlled trial. Arch Intern Med. 2011;171(10);906-912.