Effect of Patient Navigation on Completion of Lung Cancer Screening in Vulnerable Populations

Authors:
Sheena Bhalla Division of Hematology-Oncology, UT Southwestern Medical Center, Dallas, TX
Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX
Parkland Health, Dallas, TX

Search for other papers by Sheena Bhalla in
Current site
Google Scholar
PubMed
Close
 MD
,
Vijaya Natchimuthu Parkland Health, Dallas, TX

Search for other papers by Vijaya Natchimuthu in
Current site
Google Scholar
PubMed
Close
 MD
,
Jessica L. Lee Peter O’Donnell Jr. School of Public Health, UT Southwestern Medical Center, Dallas, TX

Search for other papers by Jessica L. Lee in
Current site
Google Scholar
PubMed
Close
 MPH
,
Urooj Wahid Peter O’Donnell Jr. School of Public Health, UT Southwestern Medical Center, Dallas, TX

Search for other papers by Urooj Wahid in
Current site
Google Scholar
PubMed
Close
 MS
,
Hong Zhu Department of Public Health Services, University of Virginia School of Medicine, Charlottesville, VA

Search for other papers by Hong Zhu in
Current site
Google Scholar
PubMed
Close
 PhD
,
Noel O. Santini Parkland Health, Dallas, TX
Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX

Search for other papers by Noel O. Santini in
Current site
Google Scholar
PubMed
Close
 MD, MBA
,
Travis Browning Department of Radiology, UT Southwestern Medical Center, Dallas, TX

Search for other papers by Travis Browning in
Current site
Google Scholar
PubMed
Close
 MD
,
Heidi A. Hamann Department of Psychology, University of Arizona, Tucson, AZ

Search for other papers by Heidi A. Hamann in
Current site
Google Scholar
PubMed
Close
 PhD
,
David H. Johnson Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX

Search for other papers by David H. Johnson in
Current site
Google Scholar
PubMed
Close
 MD
,
Hsienchang Chiu Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX

Search for other papers by Hsienchang Chiu in
Current site
Google Scholar
PubMed
Close
 MD
,
Simon J. Craddock Lee Department of Population Health, University of Kansas School of Medicine, Kansas City, KS

Search for other papers by Simon J. Craddock Lee in
Current site
Google Scholar
PubMed
Close
 PhD
, and
David E. Gerber Division of Hematology-Oncology, UT Southwestern Medical Center, Dallas, TX
Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, Dallas, TX
Parkland Health, Dallas, TX
Peter O’Donnell Jr. School of Public Health, UT Southwestern Medical Center, Dallas, TX

Search for other papers by David E. Gerber in
Current site
Google Scholar
PubMed
Close
 MD
Restricted access

Background: Although low-dose, CT–based lung cancer screening (LCS) can decrease lung cancer mortality in high-risk individuals, the process may be complex and pose challenges to patients, particularly those from minority underinsured and uninsured populations. We conducted a randomized controlled trial of telephone-based navigation for LCS within an integrated, urban, safety-net health care system. Patients and Methods: Patients eligible for LCS were randomized (1:1) to usual care with or without navigation at Parkland Health in Dallas, Texas. The primary endpoint was completion of the first 3 consecutive steps in a patient’s LCS process. We explored differences in completion of LCS steps between navigation and usual care groups, controlling for patient characteristics using the chi-square test. Results: Patients (N=447) were randomized to either navigation (n=225) or usual care (n=222). Mean patient age was 62 years, 46% were female, and 69% were racial/ethnic minorities. There was no difference in completion of the first 3 steps of the LCS algorithm between arms (12% vs 9%, respectively; P=.30). For ordered LCS steps, completion rates were higher among patients who received navigation (86% vs 79%; P=.03). The primary reason for step noncompletion was lack of order placement. Conclusions: In this study, lack of order placement was a key reason for incomplete LCS steps. When orders were placed, patients who received navigation had higher rates of completion. Clinical team education and enhanced electronic health record processes to simplify order placement, coupled with patient navigation, may improve LCS in safety-net health care systems.

Submitted May 29, 2023; final revision received August 29, 2023; accepted for publication October 4, 2023. Published online March 15, 2024.

Author contributions: Conceptualization: Hamann, Craddock Lee, Gerber. Data curation: Wahid, Zhu. Formal analysis: Wahid, Zhu. Funding acquisition: Hamann, Craddock Lee, Gerber. Investigation: Bhalla, Craddock Lee, Gerber. Methodology: Craddock Lee, Gerber. Project administration: Lee. Supervision: Gerber. Visualization: Bhalla, Wahid. Writing—original draft: Bhalla. Writing—review and editing: All authors.

Disclosures: Dr. Bhalla has disclosed serving on a data safety monitoring board for Mirati Therapeutics; and serving on an advisory board for AstraZeneca, Merus, Novocure, and Takeda. Dr. Browning has disclosed serving as a consultant for Change Healthcare. Dr. Gerber has disclosed receiving grant/research support from AstraZeneca, BerGenBio, Karyopharm, and Novocure; serving as a consultant for BeiGene, Catalyst, Daiichi-Sankyo, Elevation Oncology, Janssen, Mirati Therapeutics, Regeneron, and Sanofi; owning stock/having ownership interest in Gilead Sciences, Medtronic, and Walgreens; and holding an executive position at OncoSeer Diagnostics. The remaining authors have disclosed that they have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.

Funding: Research reported in this publication was supported by Cancer Prevention and Research Institute of Texas (RP160030, PP190052, PP230041; H.A. Hamann, S.J. Craddock Lee, D.E. Gerber), Biostatistics Shared Resource in the Harold C. Simmons Comprehensive Cancer Center (5P30 CA142543), and UT Southwestern Center for Patient-Centered Outcomes Research (R24 HS022418).

Supplementary material: Supplementary material associated with this article is available online at https://doi.org/10.6004/jnccn.2023.7094. The supplementary material has been supplied by the author(s) and appears in its originally submitted form. It has not been edited or vetted by JNCCN. All contents and opinions are solely those of the author. Any comments or questions related to the supplementary materials should be directed to the corresponding author.

Correspondence: David E. Gerber, MD, Division of Hematology-Oncology, Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Mail Code 8852, Dallas, TX 75390-8852. Email: David.Gerber@UTSouthwestern.edu

Supplementary Materials

    • Supplemental Materials (PDF 752 KB)
  • Collapse
  • Expand
  • 1.

    Siegel RL, Giaquinto AN, Jemal A. Cancer statistics, 2024. CA Cancer J Clin 2024;4:1249.

  • 2.

    National Cancer Institute. Cancer stat facts: lung and bronchus cancer. Accessed February 20, 2023. Available at: https://seer.cancer.gov/statfacts/html/lungb.html

    • PubMed
    • Export Citation
  • 3.

    Aberle DR, Adams AM, Berg CD, et al.Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 2011;365:395409.

  • 4.

    de Koning HJ, van der Aalst CM, de Jong PA, et al. Reduced lung-cancer mortality with volume CT screening in a randomized trial. N Engl J Med 2020;382:503513.

  • 5.

    American Lung Association. State of lung cancer. Accessed February 20, 2023. Available at: https://www.lung.org/research/state-of-lung-cancer

    • PubMed
    • Export Citation
  • 6.

    Fedewa SA, Kazerooni EA, Studts JL, et al. State variation in low-dose computed tomography scanning for lung cancer screening in the United States. J Natl Cancer Inst 2021;113:10441052.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Jemal A, Fedewa SA. Lung cancer screening with low-dose computed tomography in the United States—2010 to 2015. JAMA Oncol 2017;3:12781281.

  • 8.

    Aberle DR, Adams AM, Berg CD, et al. Baseline characteristics of participants in the randomized national lung screening trial. J Natl Cancer Inst 2010;102:17711779.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    Warren Andersen S, Blot WJ, Lipworth L, et al. Association of race and socioeconomic status with colorectal cancer screening, colorectal cancer risk, and mortality in southern US adults. JAMA Netw Open 2019;2:e1917995.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Rakowski W, Breen N, Meissner H, et al. Prevalence and correlates of repeat mammography among women aged 55-79 in the year 2000 National Health Interview Survey. Prev Med 2004;39:110.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11.

    Eng VA, David SP, Li S, et al. The association between cigarette smoking, cancer screening, and cancer stage: a prospective study of the women’s health initiative observational cohort. BMJ Open 2020;10:e037945.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12.

    Damiani G, Basso D, Acampora A, et al. The impact of level of education on adherence to breast and cervical cancer screening: evidence from a systematic review and meta-analysis. Prev Med 2015;81:281289.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Rahman SM, Dignan MB, Shelton BJ. Factors influencing adherence to guidelines for screening mammography among women aged 40 years and older. Ethn Dis 2003;13:477484.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14.

    Percac-Lima S, Ashburner JM, Zai AH, et al. Patient navigation for comprehensive cancer screening in high-risk patients using a population-based health information technology system: a randomized clinical trial. JAMA Intern Med 2016;176:930937.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15.

    Nelson HD, Cantor A, Wagner J, et al. Effectiveness of patient navigation to increase cancer screening in populations adversely affected by health disparities: a meta-analysis. J Gen Intern Med 2020;35:30263035.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16.

    Molina Y, Kim SJ, Berrios N, et al. Patient navigation improves subsequent breast cancer screening after a noncancerous result: evidence from the Patient Navigation in Medically Underserved Areas study. J Womens Health (Larchmt) 2018;27:317323.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17.

    Percac-Lima S, Grant RW, Green AR, et al. A culturally tailored navigator program for colorectal cancer screening in a community health center: a randomized, controlled trial. J Gen Intern Med 2009;24:211217.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18.

    Phillips CE, Rothstein JD, Beaver K, et al. Patient navigation to increase mammography screening among inner city women. J Gen Intern Med 2011;26:123129.

  • 19.

    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;171:906912.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20.

    Gerber DE, Hamann HA, Santini NO, et al. Patient navigation for lung cancer screening in an urban safety-net system: protocol for a pragmatic randomized clinical trial. Contemp Clin Trials 2017;60:7885.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21.

    American College of Radiology. Lung CT screening reporting and data system (Lung-RADS). Accessed March 20, 2023. Available at: https://www.acr.org/Quality-Safety/Resources/LungRADS

    • PubMed
    • Export Citation
  • 22.

    George Washington University Cancer Institute. Guide for patient navigators: a supplement to the oncology patient navigator training: the fundamentals. Accessed March 20, 2023. Available at: https://cancercontroltap.smhs.gwu.edu/sites/g/files/zaskib661/files/2022-04/PN%20guide_Final.pdf

    • PubMed
    • Export Citation
  • 23.

    Radovanovic D, Seifert B, Urban P, et al. Validity of Charlson comorbidity index in patients hospitalised with acute coronary syndrome. Insights from the nationwide AMIS Plus registry 2002–2012. Heart 2014;100:288294.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24.

    Yousaf-Khan U, Horeweg N, van der Aalst C, et al. Baseline characteristics and mortality outcomes of control group participants and eligible non-responders in the NELSON Lung Cancer Screening study. J Thorac Oncol 2015;10:747753.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25.

    Silvestri GA, Goldman L, Burleson J, et al. Characteristics of persons screened for lung cancer in the United States: a cohort study. Ann Intern Med 2022;175:15011505.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26.

    Lopez-Olivo MA, Maki KG, Choi NJ, et al. Patient adherence to screening for lung cancer in the US: a systematic review and meta-analysis. JAMA Netw Open 2020;3:e2025102.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.

    Kota KJ, Ji S, Bover-Manderski MT, et al. Lung cancer screening knowledge and perceived barriers among physicians in the United States. JTO Clin Res Rep 2022;3:100331.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.

    Henderson LM, Benefield TS, Bearden SC, et al. Changes in physician knowledge, attitudes, beliefs, and practices regarding lung cancer screening. Ann Am Thorac Soc 2019;16:10651069.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29.

    Mukthinuthalapati VVPK, Putta A, Farooq MZ, et al. Knowledge, attitudes, and practices pertaining to lung cancer screening among primary care physicians in a public urban health network. Clin Lung Cancer 2020;21:450454.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30.

    Spalluto LB, Lewis JA, LaBaze S, et al. Association of a lung screening program coordinator with adherence to annual CT lung screening at a large academic institution. J Am Coll Radiol 2020;17:208215.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31.

    Tanner NT, Brasher PB, Wojciechowski B, et al. Screening adherence in the Veterans Administration Lung Cancer Screening Demonstration Project. Chest 2020;158:17421752.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32.

    Hirsch EA, New ML, Brown SL, et al. Impact of a hybrid lung cancer screening model on patient outcomes and provider behavior. Clin Lung Cancer 2020;21:e640646.

  • 33.

    Krist AH, Davidson KW, Mangione CM, et al. Screening for lung cancer: US Preventive Services Task Force recommendation statement. JAMA 2021;325:962970.

  • 34.

    Meza R, Jeon J, Toumazis I, et al. Evaluation of the benefits and harms of lung cancer screening with low-dose computed tomography: modeling study for the US Preventive Services Task Force. JAMA 2021;325:988997.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35.

    Reese TJ, Schlechter CR, Potter LN, et al. Evaluation of revised US Preventive Services Task Force lung cancer screening guideline among women and racial/ethnic minority populations. JAMA Netw Open 2021;4:e2033769.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36.

    Shusted CS, Evans NR, Kane GC, et al. Analysis of lung cancer screening by race after USPSTF expansion of screening eligibility in 2021. JAMA Netw Open 2022;5:e2217578.

    • PubMed
    • Search Google Scholar
    • Export Citation
All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 3140 3140 168
PDF Downloads 2093 2093 180
EPUB Downloads 0 0 0