# Presentation: 011861

## American Society for Therapeutic Radiology and Oncology Cancer Disparity Symposium

- Patient Navigation:
- Facing the Challenge of Involving Underserved Populations
- in Clinical Trials
- October 16, 2005

- Harold P Freeman, M.D.
- Senior Advisor to the Director, The National Cancer Institute
- Founder and CEO of Ralph Lauren Cancer Center
- New York

## Key Questions:What are cancer disparities?What is patient navigation?What is the major challenge of the Program?How has Patient Navigation improved cancer survival in Harlem?  What are some observations from the Cancer Disparities Research Program (CDRP) Navigation Pilots?

## The Discovery-Delivery Disconnect

**Discovery**

**Development**

**Delivery**

**Critical Disconnect**

**The Discovery-Delivery Disconnect**

*Voices of a Broken System: Real People, Real Problems*
- President’s Cancer Panel, Freeman, March 2002

## Profound advances in biomedical science have contributed to:

	increased longevity 
	improved quality of life  for 	many Americans.  

- 	increased longevity
- 	improved quality of life  for 	many Americans.

## Despite these advances, some Americans have not fully benefited from this progress - particularly the poor and underserved - 
 as evidenced by their high cancer incidence, mortality, and lower survival.

-  as evidenced by their high cancer incidence, mortality, and lower survival.

- Disease always occurs within a context of human circumstances including economic status social position, culture, and environment.
- These human circumstances are determinants of:
- survival, and quality of life.

## Causes of Health Disparities

**Causes of Health Disparities**

- Freeman, Adapted from *Cancer Epidemiology Biomarkers & Prevention*, April 2003

**Prevention**

**Treatment**

**Post Treatment/****Quality of Life**

**Survival and Mortality**

**Social Injustice**

**Early Detection**

**Diagnosis/****Incidence**

**Culture**

**Poverty/****Low Economic****Status**

## POVERTY

**POVERTY**

**CULTURE**

**DECREASED  SURVIVAL**

**Inadequate physical and social environment**

**Inadequate**** information ****and ****knowledge**

**Risk-promoting lifestyle, ****attitude, behavior**

**Diminished access to ****health care**

- Freeman, H.P., 1989.

## Poverty acts through the prism of culture. Culture may augment or diminish poverty’s expected negative effects.  

## Race Perhaps the single most defining issue in the history of American society

## Popular conceptualizations of race date back several centuries and in, particular, are rooted in 19th and 20th century scientific thought. 

The presumption was that visible traits produced the measure of all other traits in an individual or population. 

- The presumption was that visible traits produced the measure of all other traits in an individual or population.

## Race

- While health disparities have been framed historically as racial and ethnic differences, race and ethnic classifications have been socially and politically determined
- There is no genetic basis for racial classification.
- 95% variation _within_ “race”
- 5% variation _between_ “races”

- Marcus Feldman, 2003

## “Racial and ethnic categories used in the census have been socially and politically determined and were never intended to be scientific or anthropological in nature.”

- Office of Management and Budget
- Directive Number 15

## Patient Navigation Model

**Outreach**

**Patient Navigation**

**Rehabilitation**

**Abnormal**** ****Results**

**Diagnosis**

**Treatment**

**Abnormal Finding**

**Resolution**

**Conclude****Navigation**

- Freeman, et.al., *Cancer Practice*, 1995.

## The Challenge:

- Navigating a Patient from _suspicious finding to resolution_
- through the complex Health Care Delivery System

## Cancer Disparities Research Partnership (CDRP)

**Abnormal**** ****results**

**Diagnosis**

**Treatment**

**Conclude****Navigation**

- Patient Navigation Model

**Outreach**

**Patient Navigation**

**Rehabilitation**

**Abnormal**** ****Results**

**Diagnosis**

**Treatment**

**Abnormal Finding**

**Resolution**

**Conclude****Navigation**

- Freeman, et.al., *Cancer Practice*, 1995.

**Cancer Diagnosis**

## The Challenge:

- Navigating a Patient from  _diagnosis to resolution_

## Resolution:Universal access to Cancer Treatment Enrolling and Navigating patients through clinical trials to access state-of-the-art cancer treatment or Navigating patients through the complex Health Care Delivery System to access standard cancer treatment

## A cancer diagnosis at later stages of disease is common among poor, and underserved patients, making them ineligible to participate in clinical trials.

## The Harlem ExperienceA Personal Journey

## Harlem: Geographic Area of Extreme Excess Mortality

## Central Harlem Community Characteristics

- Central Harlem Community Characteristics

- Ethnicity is predominantly African-American.
- Median household income in Central Harlem is $22,367/year.
- Median years of school completed is 12.
- 11% less than high school
- 47% high school, no diploma
- 17% high school graduate
- 18% some college
- 8% 4+ yrs. of college

## East Harlem Community Characteristics

**Ethnicity**
-  Puerto Rican, 51.8%		 – Central American, 3%
-  Mexican, 9%			 – Ecuadorian, 1%
-  Dominican, 5%
**Median household income in East Harlem is $23,309/year.**
**Median years of school completed is 11. **
-  30% less than high school	 	– 13% some college
-  31% high school, no diploma		 –  5% 4+ yrs. of college
-  22% high school graduate

**Source:** National Cancer Institute INFORUM database

## The Harlem Patient Navigator Program

## Impact of Harlem Hospital Center Breast Cancer Screening and Patient Navigator Program 

**	****	**	_1964-1986_		_1995-2000_
- Stage 0		   0%		   12%
- Stage I		   6%		   29%
- Stage II		 45%		   38%
- Stage III		 39%		   14%
- Stage IV		 10%		     7%

- Oluwole, et.al., Journal of American College of Surgeons, 2003

- Freeman HP, Wasfie TJ (1989). Cancer of the breast in poor black women. *Cancer, *63(12), 2562-2569.

## Impact of Screening and Patient Navigation on Breast Cancer 5-year Survival Rates Harlem Hospital Center 

- *Freeman HP, Wasfie TJ (1989). Cancer of the breast in poor black women. *Cancer, *63(12), 2562-2569.
- Oluwole, et.al., Journal of American College of Surgeons, 2003

## Some Observations:CDRP Pilot Patient Navigation Programs

- Patient-centered navigation programs tend to yield better compliance to treatment schedules.
- Financial issues, transportation, and skepticism over being a “guinea pig” in clinical trials are primary concerns for patients

## How we approach patients about navigation and clinical trials can greatly affect participation.

Building trust is an essential component of the Patient Navigation Program.

- Building trust is an essential component of the Patient Navigation Program.

- Some Observations:CDRP Pilot Patient Navigation Programs

## Causes of Health Disparities

**Causes of Health Disparities**

- Freeman, Adapted from *Cancer Epidemiology Biomarkers & Prevention*, April 2003

**Prevention**

**Treatment**

**Post Treatment/****Quality of Life**

**Survival and Mortality**

**Social Injustice**

**Early Detection**

**Diagnosis/****Incidence**

**Culture**

**Poverty/****Low Economic****Status**

##  Of all of the forms of inequality, Injustice in health is the most shocking and inhumane. 

    Dr. Martin Luther King Jr. 

-     Dr. Martin Luther King Jr.