Breast Cancer Navigation Research Articles

Bridging gaps with navigator support and its influence on breast cancer clinical trial matching and accessibility.

e13509 Background: Breast cancer patients face challenges navigating clinical trials. Online trial matching platforms like BreastCancerTrials.org (BCT) and MetastaticTrialSearch (MTS) are important resources to assist patients in identifying suitable clinical trials. However, data collected from users shows a concerning underrepresentation of ethnic minorities using this technology. Acknowledging the need to address this inequality through personalized support, we have incorporated a Clinical Trial Navigator. The navigator has engaged in partnerships with diverse community organizations and is committed to offering continuous support to patients throughout their experience. Methods: We analyzed data from our online trial matching sites spanning the period 2009–2023 (BCT) and data from our new platform MTS covering the years 2018-2023. Users visiting these sites provided details about their breast cancer type and medical history to identify appropriate clinical trials. Demographic information including race, gender, and education level was collected. The utilization and effectiveness of these features in facilitating patient access to relevant clinical trials were evaluated. Results: Analysis of the data reveals information about the characteristics of patients actively using the BreastCancerTrials.org matching service. Although BCT and MTS strives to reach a diverse patient population, 87% of BCT users identified as white women, with African American users making up only 5%. Education level of all users was high with 73% stating a college degree or higher. On the MTS site, 80% of users identified as white, while 7% identified as African American.This emphasized the need for specific interventions designed to tackle the underrepresentation of ethnic minorities and underserved populations when utilizing BCT and MTS. Conclusions: For more than 15 years, BCT has offered a patient-centric trial matching service. Within the last six years, with the enhancements to the website, BCT has served over 281,197 users. To improve minority enrollment in trials, we have developed a comprehensive clinical trial breast cancer navigation program. We plan to use this program to expand our outreach to underserved populations. Navigators can enhance patient engagement, help patients make informed decisions, and ultimately improve access to participation in breast cancer research.

The Unmet Needs of Breast Cancer Navigation Services: Reconciling Clinical Care With the Emotional and Logistical Challenges Experienced by Younger Women with Breast Cancer in a Healthcare Delivery System.

This study explores the experience of the breast cancer journey for younger women receiving patient navigation services in a healthcare delivery system and any remaining challenges that navigation services may leave unaddressed. In this qualitative analysis, we used a purposeful sampling approach to conduct a semistructured in-person interview with 19 younger women (under 50 years at the time of diagnosis) at various stages of breast cancer treatment and receiving care that included some form of patient navigation services/within the Sutter Health system. Thematic analysis was performed using an inductive grounded theory approach. The patient experience revealed that women receiving navigation services throughout their cancer journey had little concern related to clinical decision-making and treatment. Rather, emotional, and logistical challenges dominate their experience and perceptions of the cancer journey. Managing day-to-day life and the emotional aspects of a cancer diagnosis cannot be disentangled from clinical care. Navigating the emotional and logistical aspects of the cancer journey is an ongoing unmet need for women under age 50, and navigation services can potentially be enhanced to help address these specific needs. Women with breast cancer may benefit from navigation programs focused not only on clinically related challenges but also on recognizing the daily needs of younger women and guiding them through family and job-related obstacles encountered while navigating cancer care. Health systems could enhance existing nurse navigation programs and redesign other aspects of care to focus on meeting these needs.

Lean Practices for Resource Use, Timeliness, and Coordination of Care in Breast Cancer Navigation.

Cancer care is described as insufficiently patient-centered, requiring improved accessibility and coordination. Breast oncology nurse navigators may help provide timely patient care by improving care coordination. This study evaluated a breast cancer navigation (BCN) program in a large ambulatory healthcare system. It examined measures related to quality and value, including timely service delivery, appropriate use of resources, and care coordination. Using Lean methods, a BCN program focused on women receiving a breast biopsy was developed at a pilot site and later implemented throughout the healthcare system. Study data evaluated timely disclosure of biopsy results, prompt scheduling of initial consultations, outpatient use of cancer specialists, and coordination between primary care and oncology practices. After implementing the BCN program, more timely biopsy results were delivered to patients. Patients were more likely to complete an initial consultation within two weeks of biopsy and made fewer outpatient visits. Referrals to cancer specialists within a month of biopsy increased, and primary care encounters with patients decreased.

Baseline preferences for digital information engagement in patients with breast cancer by age and status of diagnosis.

e24119 Background: The need for improvement in education and decision-making support for patients with breast cancer is well documented. Digital health applications offer potential to address these needs through widely available smartphone technology. Understanding patients’ baseline preferences for information sources, breast cancer-related topics of interest, and current use of smartphones and how these interests may differ based on demographic and clinical factors can inform the development of a patient-centered digital navigation tool. Methods: As part of a pilot trial of the Outcomes4Me breast cancer navigation app, we conducted a baseline cross-sectional survey of patients presenting for routine breast cancer care at an academic medical center and community-based sites. Eligible patients had invasive breast cancer of any stage and were actively in treatment. Survey-specific questions addressed sources of cancer information and informational needs. Analysis is descriptive with statistical comparisons based on Fisher’s exact test. Results: Ninety out of 107 patients in the pilot trial completed the survey items of interest. The majority of patients were over age 50 (59%) and 35% had stage IV disease. Baseline reported uses for mobile devices included text (67%), email (61%), phone (47%), social media (41%), accessing the internet (18%), and apps (12%). Only 7% of patients noted using mobile apps for navigating disease and treatment options. When asked to rank the importance of cancer information sources, 88% and 42% of patients reported relying heavily on their oncologist and the rest of the care team, respectively. Forty percent of patients relied at least moderately on the internet for health information and 27% on online support groups, with patients < age 50 more likely than those > age 50 to rely on online support groups for health information (41% vs 17%, P = 0.02). The most common educational needs reported were side effects (79%), followed by prognosis (72%), healthy lifestyle (71%), treatment options (70%), general breast cancer news and research (67%), information about their current cancer status (59%), potential clinical trials (44%), and costs of treatment (14%). Patients with metastatic breast expressed greater interest in information about clinical trials compared to those without metastatic disease (64% vs 36%, P = 0.01), and less interest in information about prognosis (54% vs. 81%, P = 0.01). Conclusions: Despite reliance on their oncologist and oncology team for information, patients report multiple unmet educational needs related to their disease and treatment options. While a substantial percentage of patients with breast cancer turn to the internet for information, there is untapped potential to use mobile devices to improve patient education and awareness of treatment options, including clinical trials.

Abstract PO-208: The value of estimating spillover effects in health equity interventions: A case study to promote mammogram uptake among African American women and their social networks

Abstract Introduction: Standard economic evaluation methods may underestimate the value of health equity interventions by focusing exclusively on program costs and direct effects on participants' health. Yet, these interventions have spillover effects – wherein participants transition from being intervention recipients to becoming health advocates for their social networks. Consequently, interventions may improve the health of participants and other community members who are not directly connected with interventions. This study demonstrates the utility of incorporating spillover effects by comparing incremental cost-effectiveness ratios via a patient navigation intervention to promote mammography screening among African American (AA) women. Specifically, we compare the relative costs and cost-effectiveness when including mammography uptake of: (1) AA intervention participants (egos) only versus (2) AA intervention participants (egos) and their screening eligible social network members (alters). Methods: Our study draws from two studies: (1) an individual randomized trial to test the efficacy of patient navigation on mammography uptake (Patient Navigation in Medically Underserved Areas [PNMUA]) and (2) an observational ancillary study to test the effects of PNMUA on breast cancer survivor egos and their alters (Offering AA Survivors Increased Support [OASIS]). Overall, we used a healthcare system perspective. For 2021 cost data, we collected data from study records and expense reports. For effects data, we used: (1) medical record data for egos' mammography uptake, (2) self-report data from egos regarding their alters' mammography uptake, and (3) self-report data from alters about their own mammography uptake. We consequently computed incremental cost-effectiveness ratios (ICERs), using different data sources, to assess the impact of estimating spillover effects on economic evaluation of patient navigation. Results: Total cost of the intervention was $196,601. The greatest expense were breast cancer navigators' salaries and fringe rates ($126,745). In PNMUA, more navigated vs. non-navigated egos obtained biennial mammograms (45% vs. 39%). In terms of spillover effects, more navigation arm alters obtained biennial mammograms compared to alters in the non-navigated arm (ego self-report: n=1296 vs 949; alter self-report: n=1521 vs. 1195). Navigation had lower value when only incorporating participants' mammography uptake ($3,277 per each additional woman screened) versus when incorporating spillover effects ($2,027-$2,114 per each additional woman screened). Conclusion: Our results suggest breast cancer navigation programs may be more valuable when including spillover effects. This case study provides insight with real-world applicability into integrating spillover effects into economic evaluation. Our methods offer a new avenue for improved cost and effect estimates of health equity interventions, which may be useful for assessing future resource allocation in healthcare practice and policy. Citation Format: Nyahne Bergeron, Veronica Fitzpatrick, Carl Asche, Karriem S. Watson, Aditya S. Khanna, Bridgette Hempstead, Elizabeth A. Calhoun, Jean McDougall, Yamilé Molina. The value of estimating spillover effects in health equity interventions: A case study to promote mammogram uptake among African American women and their social networks [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-208.

Breast Cancer Navigation: Using Physician and Patient Surveys to Explore Nurse Navigator Program Experiences.

Patient navigators can improve patient experiences of care and outcomes, but little is known about how navigation programs may affect physician workflows and experience. This study aimed to understand patient and physician experiences with a breast cancer navigation (BCN) program using Lean design principles. Surveys were developed and distributed from 2019 to 2020 to 255 patients diagnosed with breast cancer and 128 physicians in primary care and cancer-related specialties. Descriptive analyses were conducted. Eighty-three physicians and 94 patients completed the survey. A large majority of physicians reported that the BCN program "made their day easier" and improved flow, care coordination, and patient experience. A large majority of patients reported receiving the right level of support during diagnosis communication and high satisfaction in other domains measured.

Abstract C110: Implementation of an integrated framework for a breast cancer screening and navigation program for under-resourced women

Abstract Background As detection and treatment for breast cancer in the United States have improved, racial and ethnic disparities persist. Utilizing an implementation science framework to inform an evidence-based breast cancer screening and navigation program within Federally Qualified Health Centers (FQHCs) with community stakeholders can mitigate multiple barriers to breast cancer screening. Methods Utilizing an integrated theoretical framework of the Practical, Robust Implementation and Sustainability Model (PRISM) and the social ecological model (SEM), the University of Illinois Cancer Center, University of Illinois Hospital & Health Sciences System (UI Health) including Mile Square Health Centers (MSHC) FQHC, and the Chicago Department of Public Health (CDPH) developed a breast cancer screening and navigation program to tackle breast cancer disparities in Chicago among under-resourced women, known as the Mi-MAMO program. To increase access to screening services, patient navigators conducted community outreach and engagement activities. Program partnerships were forged with community-based organizations, healthcare systems and insurers. Program outcomes were monitored using standardized performance measures. Results Between January-December 2017, 103 women received a screening mammogram at MSHC. To increase screening rates, the Mi-MAMO program was started in August 2017. Between January-December 2018, the number of women who received a screening mammogram at MSHC increased to 1051. From August 2017 (start of program) to December 2018, 779 women received navigation to screening and/or diagnostic services through the Mi-MAMO program. The majority of women were uninsured (63.9%) and 95.5% were racial/ethnic minorities. Twenty-four percent (n=185) of women completed diagnostic services and ten women received positive breast cancer diagnoses (mean age 49.7 years). All diagnosed women were successfully navigated to treatment. The Mi-MAMO program is on-going. Conclusion Deploying an integrated framework that merges an implementation science and multi-level behavioral health framework for patient navigation programs has the potential to increase breast cancer screening utilization and awareness among under-resourced populations who may be at higher risk for breast cancer. Citation Format: Vida A Henderson, Katherine Tossas-Milligan, Erica Martinez, Barbara Williams, Paola Torres, Nasima Mannan, Lauren Green, Beti Thompson, Robert Winn, Karriem S Watson. Implementation of an integrated framework for a breast cancer screening and navigation program for under-resourced women [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C110.

Abstract B101: Assessment and resolution of breast and cervical cancer screening barriers for underserved women in Louisiana

Abstract The Louisiana Breast and Cervical Health program (LBCHP) provides breast and cervical cancer screenings and navigation services at no cost to about 5,000 uninsured or underinsured women per year across the state. These low-income, uninsured or underinsured women have barriers that prevent them from receiving screenings and early cancer detection. A core part of the program is to provide navigation services to address these barriers to cancer care. LBCHP navigators provide extra layers of patient-centered education and resources to assist with completion of screening. They intervene on behalf of the patient with clinicians and departments to facilitate ease of navigating large systems. Navigators perform barriers assessments, both initial and ongoing, to anticipate problems and provide resources and support that lead to completion of screening and early cancer detection. This study analyzed the barriers and navigation services provided to 5,316 women at 12 LBCHP provider sites throughout Louisiana. The top five screening barriers identified by the women navigated over the phone were being uninsured (26%), needing information (17%), limited or inflexible appointment times (13%), long wait times (12%) and financial distress unrelated to health insurance (12%). Though cited as an important barrier in the literature, transportation issues ranked a distant 10th, with only 1% of women identifying it as a barrier. The barriers for women who completed screening services paid by LBCHP differed greatly from women who did not receive screening. The women who completed screening services listed their top barriers as uninsured (41%), needed information (20%) and non-English speaking (12%). In contrast, the women who did not receive screening listed their top barriers as financial distress unrelated to health insurance (42%) and screening was a low health priority (34%). The aforementioned two barriers were identified by 8% and 4%, respectively, of women who completed screening. Because cancer screening is a low health priority in Louisiana's unscreened population, it appears that women under financial distress would not prioritize cancer screening. The barriers will be presented by race/ethnicity, geographic location, insurance status and services provided. The results of this study suggest that financial distress is a difficult barrier to overcome and that barriers differ greatly by population. Services provided need to be tailored by the types of barrier encountered. Citation Format: Janet Brown, Nannozi Ssenkoloto, Tyler Bartley, Donna Williams. Assessment and resolution of breast and cervical cancer screening barriers for underserved women in Louisiana [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr B101.

Implementation of a triage system in the Alerta Rosa breast cancer navigation program.

e19064 Background: Alerta Rosa is a navigation program in Nuevo Leon, Mexico that aims to reduce delays in breast cancer (BC) diagnosis and treatment initiation irrespective of healthcare coverage. Via a call center, a navigator registers each patient’s initial concern and schedules a medical evaluation. This study aimed to assess the implementation of a triage system to guide appointment prioritization for undiagnosed BC patients with abnormal breast findings or imaging studies. Methods: Women that contacted Alerta Rosa were stratified according to their clinical characteristics into three priority groups. Asymptomatic women seeking check-up information were classified as low-priority (“Green”), those with nonspecific symptoms (e.g. mastalgia) or indeterminate image studies (BIRADS 0) as intermediate-priority (“Yellow”), and patients with suspicious symptoms (i.e. palpable mass, nipple retraction or bloody discharge), abnormal image studies (BIRADS 3-5) or an established BC diagnosis as high-priority (“Red”) for an appointment. The triage system’s ability to detect undiagnosed BC was evaluated against the number of patients per category in whom BC was later confirmed. Differences in time from initial contact to first medical evaluation were explored with an independent t-test. Results: From December 2017 to 2019, 561 women with a median age of 44 years (range: 8-89) contacted Alerta Rosa. 369 (66%) reported breast symptoms, 92 (16%) sought check-up information, 68 (12%) had an indeterminate/abnormal image study and 32 (6%) had received a BC diagnosis and wanted a second opinion. Accordingly, 16% of patients were classified as “Green”, 25% “Yellow” and 59% “Red”. The median time from stratification to medical evaluation was 4 days for the “Red” group and 7 days for those in other categories ( p= 0.003). A total of 558 appointments were scheduled, of which 441 (79%) were attended. Excluding those who had received a prior BC diagnosis, 20/299 patients from the “Red” group had BC confirmed (6.7%) compared to 1/138 patient from the “Yellow” (0.7%) and none from the “Green” categories. Therefore, the “Red” category achieved a sensitivity of 95.2% (CI95%: 76.2-99.9%) and specificity of 53.8% (CI95%: 49.3-58.3%) for BC. Conclusions: The triage system adequately identified women with different probabilities of having BC. Thus, the implementation of a stratification system could help identify high risk patients in limited-resource settings where screening programs are ineffective and efforts to prioritize access to medical attention is crucial to achieve early-stage diagnoses.

Hereditary Breast Cancer Risk Analysis in Uninsured Mexican-Origin Women Living in the U.S.-Mexico Border Region.

This article describes the risk of hereditary breast cancer (HBC) in low-income Hispanic women living on the U.S.-Mexico border using the Pedigree Assessment Tool (PAT). The PAT was administered as part of the El Paso and Hudspeth County Breast Cancer Education, Screening and NavigaTion program (BEST). Baseline data (n = 1,966) from this program was used to analyze risk factors for HBC. Analysis was conducted to determine significant covariates associated with the presence of any PAT risk factors. The PAT identified 17% (95% CI [15%, 19%]) of the women in the study as having some risk of HBC. Having had a mammogram within 3 years was significantly associated with having any PAT risk factors (odds ratio [OR] = 1.79, p = .006). Women who immigrated to the United States during childbearing age (OR = 0.610, p = .009) or during peri/menopause (OR = 0.637, p = .024) were significantly less likely to have any PAT risk factors. The PAT instrument detected a substantial pool of women who may be at risk for HBC. A significant proportion of these women were not up to date mammogram. The PAT is an effective tool to identify women at risk for HBC and encourage regular screening.

Patient Navigation: Breaking the Barriers of Care While Empowering Patients to Fight Cancer

Purpose Through the Union for International Cancer Control and Pfizer Oncology SPARC MBC grant, Project PINK BLUE–Health & Psychological Trust Centre implemented the Breast Cancer Navigation and Palliative Program with strategic activities focused on metastatic breast cancer with the goal of “empower[ing] women at risk of, or living with advanced breast cancer and to reduce [the] incidence of stage III or IV breast cancer.” The project established Nigeria's first patient navigation program, which trained 138 health workers and social workers across the six area councils of Abuja and connected 116 breast health facilities, 58 in Abuja and another 58 across Nigeria—diagnostic centers and hospitals—in a Web-based navigation map application. The program was designed to train only 18 patient navigators for Abuja only; however, we trained 44 patient navigators from National Hospital Abuja, Enugu, and Kebbi states who are currently working on establishing Breast Cancer Navigation and Palliative Programs in their respective states. Trained oncology nurse navigators are providing optimum palliative care and navigation to patients across the mapped health facilities in Abuja. Whereas 72 institutions have been engaged through diverse partnerships, 27 resources were produced, including videos, documents, and a palliative/navigation book for health care workers. Ten ECHO palliative care trainings were organized for nurses and pain doctors, with an additional eight in-person workshops on palliative care and patient navigation and five patient support group meetings. Seventy-two news articles were published, including for TV, radio, and in interviews. Methods The program used training of nurses, cancer survivors and nurses to become patient navigators at National Hospital Abuja and across the six area councils of Abuja. Currently, navigators in Niger State and Enugu state have also received training on patient navigation, and more patients with cancer have been tracked and observed during their cancer journeys in Nigeria. Results The program has transited to lead national advocacy at Nigeria’s parliament for the establishment of the National Institute on Cancer Research and Treatment and has also establish such initiatives as Abuja’s first cancer support group and patient-led advocacy and campaign. Several patients with metastatic breast cancer were navigated through their journey with cancer. Conclusion Patients with metastatic breast cancer need more support to live a quality life; more than just pain medication. They need someone to listen to them and caregivers who show their care and love. Patient navigation is an emerging area of oncology and there is a need to support the patient navigators so that they may devote more time to its effects. AUTHOR’S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/site/ifc . Runcie C.W. Chidebe Travel, Accommodations, Expenses: Jansen and Jansen Consulting or Advisory Role: Novartis Pharmaceuticals

Patient Navigation: Breaking the Barriers of Care While Empowering Patients to Fight Cancer in Nigeria

Background and context: Through the UICC and Pfizer Oncology SPARC MBC grant, Project PINK BLUE - Health and Psychological Trust Centre implemented Breast Cancer Navigation and Palliative Program (BCNPP) with strategic activities focused on metastatic breast cancer with the goal “to empower women at risk of, or living with advanced breast cancer and to reduce incidence of stage III or IV breast cancer”. The project established Nigeria´s first patient navigation program which trained 138 health workers and social workers across the 6 area councils of Abuja and connected 116 breast health facilities, 58 in Abuja and another 58 across Nigeria (diagnostic centers and hospitals) in a Web-based navigation map application. The program was designed to train only 18 patient navigators for Abuja only, however, we trained 44 patient navigators from National Hospital Abuja, Enugu and Kebbi states whom are currently working on establishing BCNPP programs in their respective states. The trained oncology nurse navigators are providing optimum palliative care and navigation to patients across the mapped health facilities in Abuja. While 72 institutions have been engaged through diverse partnerships, 27 resources were produced including videos, documents, and palliative/navigation book for healthcare workers; 10 ECHO palliative care training were organized for nurses and pain doctors, with additional 8 face-to-face workshops on palliative care and patient navigation and 5 patient support group meetings. Seventy-two news articles were published including TV, radio, and interviews. Aim: To empower women at risk for, or living with advanced breast cancer and to reduce incidence of stage III or IV breast cancer. Strategy/Tactics: The program used training of nurses, cancer survivors and nurses to become patient navigators at National Hospital Abuja and across the 6 area councils of Abuja. Currently, Niger state and Enugu state have also been trained on patient navigation and more cancer patients have been tracked and followed up through their journey with cancer in Nigeria. Outcomes: The program has transited to lead national advocacy at Nigeria's Parliament for the establishment of National Institute on Cancer Research and Treatment and has also establish some initiatives, such as Abuja's first cancer support group and patient-led advocacy and campaign. Several metastatic breast cancer patients were navigated through their journey with cancer. What was learned: Metastatic breast cancer patient needed more support to live a quality life, they needed more than just pain drugs. They need listening ear and caregiver who would show their care and love. Patient navigation is an emerging area of oncology, hence, there is a need to support the patient navigators to devote more time for the impact.

“Alerta Rosa” Breast Cancer Navigation Program in Mexico: Initial Results and Plan of Action

Background and context: In Mexico, median time between breast cancer (BC) symptom detection and treatment initiation has been reported to be 7 months. We designed the “Alerta Rosa” navigation program with the intent to break down medical care barriers and reduce delays, as well as improve quality of care, by identifying and prioritizing patients with breast symptoms or abnormal breast imaging studies in Nuevo Leon, Mexico. In the first year, we achieved a median time from alert activation to treatment initiation of 33 days, thus shortening health system intervals and supporting the replication/adaptation for other limited resource settings. This project is supported by Susan G. Komen Foundation. Aim: We seek to increase efficiency and outreach of our navigation process in our region, as well as scale up and replicate the program in other parts of Mexico. Strategy/Tactics: Based on the results obtained and limitations observed during the initial year, we have designed changes that will improve our navigation model and patient outcomes. Patients with a palpable breast mass, bloody nipple discharge, nipple/skin retraction or BI-RADS 4 or 5 results will now be given maximum priority. Additionally, we will develop/adapt a computer software that will help refine logistics and care coordination activities, which will lead to increased operational efficiency and reduced costs. Finally, additional breast referral facilities will be incorporated to the current navigation program. These rearrangements will be implemented and evaluated in 2018. Program/Policy process: The following year, we will expand “Alerta Rosa” to a second city, evaluate sustainability and scalability, and make modifications to the program navigation and logistics as needed. After proving success, we intent to further increase the program reach to other regions across Mexico, to ultimately achieve an efficient referral system that will ease earlier BC care. Outcomes: We aim to keep our current standard of healthcare interval duration, while reaching a larger number of women and eventually expanding the project to other regions of the country. The indicators to measure success include time intervals from alert activation to diagnosis, referral, and treatment initiation. Other variables that are being collected are number of activated alerts, medical assessments, follow-ups, biopsies, and BC diagnoses. What was learned: In low-middle income countries, where BC screening programs do not effectively reach the target population, it is crucial to focus efforts in identifying and prioritizing symptomatic patients or those with abnormal imaging studies, to ultimately downstage BC. “Alerta Rosa” proved to be successful in reducing health system intervals and should be replicated and adapted for other limited resource settings. Therefore, we will work toward promoting the integration of this program to improve the current standard of BC healthcare in Mexico.

Abstract B05: An evaluation of a community-based breast education and navigation program: Highlights and lessons learned from the Pitt County Breast Wellness Initiative

Abstract Background: Pitt County is located in a rural disadvantaged part of Eastern North Carolina (ENC) and maintains persistent breast cancer disparities among minority women as compared to their white counterparts. Pitt County has the highest breast cancer mortality rate among minority women in ENC, with breast cancer mortality rates for minority women being twice as high compared to their white counterparts (42.4 vs. 21.9, respectively). Furthermore, minority women are diagnosed at later stages of the disease, with the rate of diagnosis at stage 4 being almost three times higher than white women in Pitt County. The Pitt County Breast Wellness Initiative provides culturally tailored breast cancer education and navigation to age-appropriate screening services for uninsured/underinsured Black and Latina women ages 25 and older. Methods: We conducted a qualitative evaluation to assess the effectiveness of our education and navigation components. We contacted program participants via telephone and administered a structured interview guide. Out of the 85 participants that were both educated by our program and received a free mammogram and clinical breast exam, we reached 60% (n=51) of these women. Results: This funded program has created a network of 20 community-based lay breast health educators, which includes faith leaders, breast cancer survivors, community advocates, and ECU BS in Public Health students. In a span of 2 years, we have educated over 600 women in eastern North Carolina (ENC) on breast health and breast cancer screening guidelines, and navigation services have been provided to 275 women, of whom 230 were given breast health assessments and 85 received a mammogram. We have identified five lessons learned to share in the successful implementation of a community-based cancer screening intervention: (1) community partnerships are critical for successful community-based cancer screening interventions; (2) assuring access to screening and appropriate follow-up should precede interventions to promote increased use of cancer screening; (3) the reduction of access barriers is effective in increasing cancer screening; (4) culturally tailored interventions can overcome barriers to screening for diverse racial/ethnic and socioeconomic groups; and (5) multicomponent interventions that include multiple community-health strategies are effective in increasing screening. Up-to-date results from program participants will be reported during the presentation. Conclusion: Although PCBWI can improve, we have been successful at increasing knowledge and screening for our population. Future community-based interventions must go beyond the overall assessment of effectiveness and expand current understanding of why given strategies are effective and analyze the cost-effectiveness of these strategies, to ensure replicability and sustainability. Citation Format: Essie Torres, Alice Richman. An evaluation of a community-based breast education and navigation program: Highlights and lessons learned from the Pitt County Breast Wellness Initiative [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr B05.

Abstract A72: [Advocate Abstract:] Community initiatives for all women's health

Abstract My poster will describe four community programs I have established at The Resurrection Project. The first focuses on breast cancer education workshops to address the lack of knowledge, cultural misconceptions, fear, and shame in my community and other underserved communities. The second focuses on breast cancer navigation to address the lack of insurance and cost issues in my community and in other underserved communities. The third focuses on breast cancer survivorship and empowerment to address the need for peer role models in my community and for other underserved communities. The fourth focuses on policy advocacy to address the need for resources for other underserved women. Citation Format: Araceli Lucio. [Advocate Abstract:] Community initiatives for all women's health [abstract]. In: Proceedings of the Tenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2017 Sep 25-28; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2018;27(7 Suppl):Abstract nr A72.

Healthcare utilization, Medicare spending, and sources of patient distress identified during implementation of a lay navigation program for older patients with breast cancer.

Despite benefits for patients, sustainability of breast cancer navigation programs is challenging due to the lack of reimbursement for navigators. This analysis describes distress reported by breast cancer patients to navigators and the impact of navigation on healthcare utilization for older adults with breast cancer. We conducted a retrospective cohort study of Medicare administrative claims data and patient-reported distress assessments. The primary outcome was Medicare spending per beneficiary per quarter. Secondary outcomes included (1) the number of hospitalizations or ER visits in each quarter; (2) distress levels; and (3) causes of distress reported by patients to their navigators. A subset analysis was conducted for stage I/II/III versus stage IV patients. 776 navigated and 776 control patients were included in the analysis. The average age at diagnosis was 74years; 13% of the subjects were African American; 95% of patients had stage I-III. Medicare spending declined faster for the navigated group than the matched comparison group by $528 per quarter per patient (95% CL -$667, -$388). Stage I/II/III navigated patients showed a statistically significant decline in Medicare spending, ER visits, and hospitalizations over time compared to the matched comparison group. No differences were observed for stage IV patients. Eighteen percent of patients reported moderate distress. Informational and physical distress were more common in late stage than in early-stage breast cancer. Lay navigation reduced healthcare utilization in older adults with breast cancer, with the greatest impact observed in early-stage breast cancer patients.

Abstract P3-10-05: Successful implementation of a novel breast cancer navigation program in Nuevo León, México

Abstract Introduction: Although the overall incidence of breast cancer (BC) is lower in Latin America than in high-income countries, the mortality burden is greater, mainly due to presentation at more advanced stages. Advanced BC presentation has been directly associated to delays by the patient and provider. In Mexico, it has been previously shown that the longest delay occurs within the health system interval, with a median of 5 months. Navigation programs have been proved to be a valuable strategy to assist individuals in overcoming barriers for care across the cancer care continuum. However, its implementation has been limited to date in low-income settings. Objectives: The aim of this project was to propose a novel BC navigation program to overcome different common barriers for access to accurate diagnosis and early treatment in a limited setting in Nuevo Leon, Mexico. The secondary objectives were to educate and involve medical students by being part of the navigation process and raising women awareness about BC. Methodology: Through an alliance with the local Ministry of Health, during 18 months, we invited women who had their mammogram done in a referral mammographic center to participate in this Navigation Program. Two weeks after recruitment women were taken by a designated transportation to a specialized BC diagnostic unit, participated in a BC self-awareness educational session (increment in knowledge was measured by pre and post tests), received a clinical breast exam and were provided with their mammography report (interpreted by a breast radiologist). When appropriate, core biopsies were performed and onward referrals to a BC Treatment Center were provided. Along with this process, a Navigator Training Program took place as part of the medical students' 5th year curricula in the ITESM Medical School, within their academic clinical practice (knowledge increment was measured by pre and post tests). This project was supported by Susan G. Komen Foundation. Results: 1632 low-income uninsured women were navigated and 37 BC were diagnosed. All BC patients started treatment within 3 months from their initial mammogram. 55% were diagnosed at early stages (0-IIA) and 45% at II-B to IV stages (vs. 26% and 74%, respectively, from the overall report from the Ministry of Health in 2014). Patient BC awareness knowledge increased by 22%. 170 students participated in the navigation process, and their knowledge rose by 18% from baseline. The BC Navigation Training Program is now part of the official academic curricula of the ITESM Medical School. Conclusions: Our Navigation Program was intended to break down medical care barriers to reduce delays and improve quality of care, by guiding Mexican women through the whole continuum of BC diagnosis and early treatment. This successful implementation resulted in shorter health system intervals and BC down staging. Well-designed patient navigation projects should be implemented in low- and middle-income countries to establish their value and feasibility. Due to a lack of educated patient navigators in these regions, health care professionals should be trained to provide navigation guidance through the complex health care systems frequently encountered in underserved settings. Citation Format: Mireles-Aguilar T, Tamez-Salazar JJ, Villarreal-Garza CM, Rodriguez y Silva M, Romero C, Pérez-Reyes P. Successful implementation of a novel breast cancer navigation program in Nuevo León, México [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-10-05.

Abstract C19: [Advocate Abstract:] The Buffalo/Niagara Witness Project: Saving Lives

Abstract The Buffalo/Niagara Witness Project educates participants on early cancer detection through stories told by breast and cervical cancer survivors in churches and community settings. My poster will show progress made with the project in the Western New York-region over the past five years regarding breast cancer awareness, screening, navigation, and treatment. Citation Format: Averl Anderson. [Advocate Abstract:] The Buffalo/Niagara Witness Project: Saving Lives. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr C19.

Abstract A34: Using a community-based breast health intervention to reduce structural barriers in accessing breast cancer screening services among underserved rural Latina and black women in Eastern North Carolina

Abstract Background: Although breast cancer mortality rates have been steadily decreasing over time, Black and Latina women continue to have the highest death rate and shortest survival of any racial and ethnic groups in the United States for breast cancers. Most scholars agree, however, that the major cause of this disparity is more likely to be diagnosed with late (vs. early) stage breast cancers that are less responsive to treatment. This disparity in cancer-stage-at-diagnosis reflects Black and Latina women's lower prevalence of breast cancer screening that could detect cancers at earlier, curable stages. Pitt and Edgecombe Counties, located in a rural disadvantaged part of Eastern North Carolina (ENC), maintain breast cancer disparities among its minority women as compared to their white counterparts. Breast cancer incidence among minority women is lower compared to white women for both counties, however the mortality rate for minority women is twice as high compared to their white counterparts (42.4 vs. 21.9 respectively) in Pitt county and slightly higher in Edgecombe county (37.3 vs. 36.7 respectively). Pitt County also has the highest breast cancer mortality rate among minority women and Edgecombe has the fifth highest in Eastern NC. Furthermore, minority women are diagnosed at later stages of the disease, with the rate of diagnosis at stage 4 being almost three times higher than white women in Pitt County and significantly higher in Edgecombe County. This community-based breast health intervention (The Pitt County Breast Wellness Initiative-Education) works to reduce these health disparities in breast cancer mortality through provision of education and navigation to early detection and access to screening for uninsured and underinsured Black and Latina women in Edgecombe and Pitt Counties in NC. Methods: The Pitt County Breast Wellness Initiative-Education provides culturally tailored breast cancer education and navigation to age-appropriate screening services for uninsured/underinsured Black and Latina women age 25 and older in Pitt and Edgecombe Counties, North Carolina. Using a lay health model (adapted from North Carolina Breast Cancer Screening Program Training Curriculum), we trained eight community members on breast health, breast cancer, and being an effective breast health educator. The education component includes a brief 10-minute presentation on breast health, breast cancer, and guidelines for age-appropriate breast cancer screening services. The navigation component includes assistance with the following: (1) Breast Health Assessment Tool and BCCCP applications, (2) scheduling appointments/accessing age-appropriate breast screening services, (3) interpretation, and (4) transportation. Since our program initiation in April 2015, we have educated 85 women and navigated 47 to age-appropriate breast cancer screening services in Pitt and Edgecombe counties. Results: Among the 47 navigated women to age-appropriate screening, 78% (n=37) were 40 years of age or older, 82% (n=39) reported being uninsured, 32% (n=15) reported no previous clinical breast exam, and 38% (n=18) reported no previous mammogram. Among those who reported a having a previous mammogram, many were 2 years or more over due for their yearly mammogram. We use pre-/post-surveys to determine an increase in knowledge and awareness regarding breast health, breast cancer, and guidelines for age-appropriate breast cancer screening services. Up-to-date results from program participants will be reported during the presentation. Conclusion: Specifically, using a LHA community-based model allows this program to serve as a cultural mediation between underserved communities in Pitt and Edgecombe counties and health care service systems and reduces structural barriers in accessing screening services and diagnostic follow-up. Strong collaborative community partnerships will streamline the process of accessing care in an effort to ensure seamless transition within the continuum of breast cancer care. Citation Format: Essie T. Torres, Alice R. Richman. Using a community-based breast health intervention to reduce structural barriers in accessing breast cancer screening services among underserved rural Latina and black women in Eastern North Carolina. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr A34.

Keys to the Successful Implementation of Community-Based Outreach and Navigation: Lessons from a Breast Health Navigation Program.

The well-documented racial disparities in breast cancer mortality have prompted an aggressive response from the public health community, including the development and implementation of breast health education and breast cancer navigation programs. Many programs are successfully reaching women and providing education and motivation to get screened, and separately, many programs are successfully navigating women who have received abnormal results from a screening mammogram and need follow-up. However, a crucial gap in services remains, where women in the community are not receiving systematic navigation to their initial screening mammogram. This paper describes a community-based, community health worker-led breast health education and screening navigation program, details the metrics used to measure navigation outcomes, and discusses unique features of this project which could be adapted within other settings to initiate similar programming.