Authors

1. Tho, Poh Chi RN, AdvDipNsg(Ortho)
2. Ang, Emily RN, CCNC, ONC, BN, MN, DNurs

Abstract

Review question/objective: The objective of this review is to synthesize the best available evidence on the effectiveness of a patient navigation program in adult cancer patients undergoing treatment.

The question to be answered in this review is:

1. What is the clinical impact, including patient satisfaction (with cancer-related care), quality of life, distress level and symptom improvement of a patient navigation program in adult cancer patients who are undergoing treatment?

Background: Cancer is a leading health burden worldwide, the prevalence of which is growing at a disturbing rate. Research suggests that by 2030, there will be about 21.4 million new cancer cases and 13.2 million cancer-related deaths. This trend is associated with increasing longevity and an increase in the aging population across many countries of the world.1 There were 51,657 notifications of new cancer cases diagnosed per year in Singapore from 2006-2010, which represented an increase compared to previous reports.2

In spite of advancement in technologies and medical care related to treating cancer, the treatment and follow-up of cancer patients remains a challenge. Patients who are newly diagnosed with cancer and undergoing treatment commonly experience significant negative impact on their quality of life.3 They feel stressed, emotional and commonly find it difficult to make life-altering decisions. Cancer and it's treatment often generate various symptoms, such as sleep disturbance, fatigue, nausea and vomiting which can affect the patients both physically and psychologically.4 These symptoms often cause delay or premature termination of treatment.4 They also commonly lead to psychological distress and functional impairment,4 which can compromise quality of life and satisfaction with cancer care.5

Most cancer patients seek treatment in a health care institution. The health care system consists of organizations, people and actions whose primary intent is to promote, restore or maintain health.6 Within the health care system, there are many inter-related and independent sub-systems of care provision which create a sophisticated multi-system network.7 Common issues raised by cancer patients and their carers, which may include family members, are a lack of communication and lack of information.8 The cancer care treatment route is complex and fragmented as sub-specialization is the current trend in health care. Cancer patients commonly receive care from multiple specialists, for example medical oncologists, surgical oncologists and radiation oncologists and other health care professionals including dieticians and medical social workers.7 This implies a need for patients and their carers to digest and integrate the information received from different health care providers and for coordination of service to ensure high quality care.

Research suggests that navigating through the maze of the health care system is often challenging for cancer patients. Moreover, this challenge has been increasing because of growth in the range and number of physicians involved in treatment and a wider range of treatment options becoming available.9 There is therefore an increasing need to implement strategies that help coordinate care among the healthcare providers involved in cancer care and improve the efficiency of the process (i.e. to find ways to coordinate that economize on resource use). Research suggests that the implementation of strategies to enhance coordination of cancer care delivered by different providers in the health system may improve clinical outcomes for cancer patients undergoing treatment. It has been suggested that these strategies may help to equip the patients and their carers with knowledge/information, reduce their number of incorrect assumptions and thereby make cancer care more efficient.10 If these strategies are successfully implemented, they can lead to a more complete process of care being delivered that is more focused on individual patient outcomes and satisfaction.10 For tertiary cancer care, these strategies could influence patients' distress level, the cancer and its treatment-related problems/symptoms, patients' satisfaction and quality of life. In addition, systems for coordinating cancer care and helping patients to navigate through the health care system need to be such that patient outcomes are maintained or improved. Failure to narrow the gap in the interface of cancer care may contribute to ongoing anxiety for patients and suboptimal clinical outcomes such as avoidable delays in treatment progression and the development of comorbid conditions.10

In the recent years, there has been a growing interest among patients and health care professionals in a program called the Patient Navigation Program (PNP).11 Navigation in this context is defined by the Canadian Partnership Against Cancer as a proactive, intentional process of collaborating with a person and his or her family to provide guidance as they negotiate the maze of treatments, services and potential barriers throughout the cancer journey.11 The PNP was first developed in 1990 in Harlem to address disparities in cancer care among the underserved population12 and to reduce disparities in access to healthcare.13 The initiative was designed to promote efficient and effective care of breast cancer patients who were treated at the Harlem Hospital Center. A research study on the effectiveness of the program found that it was associated with an increase in the survival rate of breast cancer patients from 39% at baseline to 70% at follow-up.14 The PNP focuses on the patients' health condition15 and facilitating better care through providing a liaison between patients and health care teams.16 The PNP is aimed at overcoming barriers to care through a variety of means.17,18 The essence of the PNP is to provide a holistic approach to the care of patients with cancer and their family members so that they are able to navigate through the healthcare system more efficiently.19

The navigator in the PNP assists patients and their family members to navigate the fragmented system of doctors' offices, clinics, hospitals, out-patient centers, payment systems, support organizations and other components of the health care system.20 The fundamental role of the navigator is to help the patient and their family members stride through the system as smoothly as possible and also to ensure that any unmet needs are addressed.21 He/she also helps to identify and communicate valuable information on behalf of patients to the nurses and physicians who provide their care, thus enhancing the quality of care.22 It is essential for the success of the program for the navigator to have effective communication and problem-solving skills, clinical expertise and wide knowledge of the health care system. In view of these qualities, some literature has identified nurses as those who are most suited to assume the role of a navigator.19,23,24 Studies have suggested that having a nurse navigator in cancer care may assist in alleviating patients' anxiety,25 and help them to cope and complete their treatment more successfully.26 There are several studies that have been conducted to evaluate the impact of the PNP. These studies have shown positive results. More specifically that the program may increase patient satisfaction, decrease barriers to care, increase treatment adherence and improve the quality of life of cancer patients.27-30 At present, the idea of a PNP is viewed as a promising approach to cancer care at many cancer centers.21 There is therefore a need to enhance understanding about the contribution that the PNP can make to improving outcomes in cancer patients.

A cursory search (Cochrane Library, JBI Library, Medline and CINAHL) of the evaluation literature on PNPs in the cancer care setting revealed no systematic review exists on this topic. It is in this context that the importance of this review needs to be seen.