A Perfect Storm: Interventions – Closing the survival gap
The study employed a multivariable regression to identify associations between patient, surgeon, and treatment-setting factors and accurate knowledge of the survival benefit and recurrence risk related to mastectomy and breast-conserving surgery with radiation. The authors found that minority women were significantly less likely to have adequate knowledge and more likely to be uncertain about recurrence risk than were white patients. In the multivariate logistic regression model, neither provider characteristics nor treatment setting attenuated observed racial disparities in knowledge. Quality health care depends on the ability to make an informed treatment decision. As the authors concluded, this study underscores the need for providers to communicate information effectively to all patients, and effective communication relies on the cultural competency of providers.13 Without effective, culturally competent communication, there are treatment delays and omissions that result in poor-quality cancer care. Currently, the research has established that these communication deficits are found across providers and treatment center types.
Patient Navigation
Patient navigation has been championed as a method of improving care in breast cancer by enhancing patient communication and education, and removing barriers to timely care. Patient navigation empowers patients to become knowledgeable about their own health and supports them through the course of care.14 Patient navigation programs have been developed to address the patient communication breakdowns and underuse and misuse of treatment among vulnerable populations, which were detailed earlier in this series and are thought to contribute to the racial mortality gap.15
A benefit of patient navigation has been suggested in studies evaluating the time to diagnosis and follow-up from an abnormal screening. Markossian et al.16 evaluated the efficacy of a Chicago-based cancer patient navigation program developed to reduce the time from abnormal screening to definitive diagnostic testing. The majority of patients in this study were Hispanic (66%) and African American (32%). Compared with controls without navigation, the breast navigation group had a shorter time to diagnostic resolution. Hoffman et al.17 evaluated patient navigation in the District of Columbia to determine its ability to reduce the breast cancer diagnostic time (number of days from abnormal screening to a definitive diagnosis). African American women comprised 48% of the study population. The investigators found that women in the navigation group reached their diagnostic resolution significantly faster than did other women. Among women with breast cancer, there was a nearly fourfold reduction in time to diagnostic resolution for women in the navigation group versus women without a navigator.
In a national multicenter study, Ko et al.14 were the first to evaluate whether patient navigation can improve the quality of breast cancer care. The authors hypothesized that breast cancer patients assigned a navigator would be more likely to receive recommended standard treatment than were those without a navigator. Three separate quality measures of breast cancer care, including initiation of antiestrogen therapy, radiation therapy, and chemotherapy, were evaluated. Study participants were racially and ethnically diverse, with a plurality being African American (37.5%). The study produced mixed results: Patients in the navigation group had a statistically higher likelihood of receiving antiestrogen therapy than were non–navigated controls, but navigation patients eligible for radiation therapy were no more likely to receive it than were controls. The initiation of chemotherapy could not be accurately assessed because of a limited sample size. The study concluded that navigation alone does not remove all of the barriers to quality care for breast cancer patients, and barriers are diverse and potentially specific to the modality of treatment.
A study by Tejeda et al.18 used a systematic framework to characterize barriers faced by minority patients with breast and cervical cancer. The investigators categorized barriers as intrapersonal (defined by characteristics of the individual, such as knowledge, belief, attitudes, and transportation and financial barriers), interpersonal (defined by processes that involve other people, such as social support systems, child care, and employment issues), or institutional (defined by characteristics and policies of organizations). The authors found that although navigators were able to easily resolve intrapersonal barriers, ongoing navigation was needed to address institutional barriers. Thus, patient navigation in a vacuum does not work, and it is only in examining the entire health care system that changes can be implemented to eliminate barriers to quality care and close the racial mortality chasm.
System Change
To this effect, Clarke et al.19 performed a review of the disparities intervention literature to understand which interventions are being evaluated to improve minority health. The authors found that the majority of such interventions are focused on changing the patient rather than the system that serves her, with the most common strategy being education and training (37% of strategies studied). Interventions aimed at health care system improvements were surprisingly few, with the responsibility for change resting with the patient rather than the care delivery system. Interventions incorporating community involvement were also severely lacking and reflected only 6.5% of the reviewed intervention tactics. The majority of interventions failed to involve major stakeholders, including providers, health care institutions, community organizers, and policy makers, and accordingly, were unlikely to succeed in creating meaningful change.
