We designed and implemented a culturally tailored, language-concordant navigator program to identify and overcome barriers to colorectal cancer screening among an ethnically diverse group of low-income patients attending a community health center. The program more than doubled colorectal cancer screening rates among intervention patients compared to control patients randomly assigned to usual care. The intervention specifically increased colonoscopy screening rates, considered the most sensitive and specific of available CRC screening tests46
, and it was effective in all patient subgroups regardless of gender, language spoken, race/ethnicity, or insurance status.
Prior studies have demonstrated the benefits of navigator programs for cancer prevention in general and for CRC screening in particular.35–40,47–49
Tu et al.’s health educator study among US ethnic Chinese patients focused on FOBT rather than colonoscopy screening and showed a 5.98 increased odds for FOBT screening among intervention patients over the 6-month study.41
A study using centralized telephone case management among low-income women increased rates of CRC screening by 13% (95% CI 7-20%) in intervention compared to usual care patients.37
However, most of the CRC screening was FOBT, and they found no difference in colonoscopy rates.37
Another telephone outreach program among predominately African-Americans in metropolitan New York also showed benefit.50
However, the study population was limited to patients with current employment and health insurance, and is thus less generalizable to low income populations such as the patients in our study. In addition, our study showed that patients with in-person contact with the navigator were more likely to have CRC screening, especially colonoscopy, than patients with only phone contact.
Available evidence does not support choosing one CRC screening test over another, none is ideal but all save lives.51,52
Our study sought to emphasize colonoscopy since it is the most sensitive and specific method46
and is widely recommended as the preferred CRC screening test.44,53,54
Our data demonstrated that colonoscopy was a broadly achievable goal for an underserved population with a high prevalence of procedure-related barriers. Jandorf et al.35
reported on a randomized trial of a patient navigator in an urban health clinic that increased colonoscopy as the CRC screening test. However, their study included only 78 patients of whom 49% received navigation services. After 6 months, nine (23.7%) patients in the intervention group had colonoscopy compared with two patients (5%) in the control group (p
0.019). Our study population included 1,223 patients with 409 patients in the intervention group. Over the 9-month study period, 163 colonoscopies were performed including 85 in the intervention group.
Race and ethnic disparities in colorectal cancer screening, diagnosis, treatment, and survival are well documented in the literature.6–8,10–14,55–58
We designed our intervention to be generalizable across a range of cultural, language, and racial/ethnic differences among patients served by the community health center. We trained a group of outreach workers and interpreters to identify and address each patient’s unique social or culturally based concerns and barriers to screening. Reflecting this tailored and adaptable approach, the intervention improved CRC screening in all intervention subgroups. While the odds ratios in Fig. suggest that the program had somewhat greater relative benefit for English-speaking patients, further analysis (Fig. ) revealed that this was due to the higher screening rates for non-English speaking patients in the usual care group. We believe, after discussion with the navigators, that the higher rate in our controls may have been due to “intervention contamination” among non English-speaking control patients, many of whom had interaction with navigators (study-trained HC outreach workers) or became interested in CRC screening through family or friends who interacted with navigators.
Many barriers previously identified6,15–20,22,23
were also reported by patients in our study, particularly knowledge gaps, lack of motivation, and concerns about the colonoscopy procedure. Many patients needed help with scheduling their procedure. For our intervention, the MGH Gastrointestinal Department assigned a secretary whom our navigators could directly contact to schedule appointments. In addition, department policy waives all charges for a screening colonoscopy for patients with the MGH Free Care plan. This may explain the lack of difference in screening colonoscopies according to insurance status. Although study patients often reported lack of someone to accompany them as a reason they did not have a colonoscopy, only 18 patients had a navigator accompany them. Some patients may have used transportation as an excuse for other underlying reservations. Assistance with transportation was also provided via a free shuttle service directly to the main hospital, and in some cases, taxicab vouchers were provided to get home after the procedure.
Our results must be interpreted in the context of the study design. Although our intervention was relatively inexpensive to implement, results from a single urban community health center may not be generalizable to other clinical settings. Some patients may have had CRC screening outside of our clinical network, thereby underestimating our measured overall screening rate. However, it is unlikely that outside screening occurred more commonly in control patients. In addition, group allocation was not concealed, and the study design precluded blinding of intervention status. The higher rates of CRC screening among Latinos and other non-English speakers among control patients suggest that there may have been some cross-over contamination specifically in these patients. Such contamination would bias our results towards the null, and we nonetheless demonstrated a significant intervention impact even within this sub-group.
Using a large randomized clinical trial design, we definitively demonstrated that a culturally tailored, language-concordant navigator program designed to identify and overcome barriers to colorectal cancer screening can significantly improve colonoscopy rates in a wide spectrum of low income, ethnically and linguistically diverse patients. Future research should focus on integrating navigator programs into routine care, examining their cost effectiveness, and devising additional strategies to motivate the large number of residual patients who do not complete screening despite the navigator program. Given the beneficial impact of navigator programs on cancer screening and reduction of disparities, current payment structures may need to be revised to support these population-level approaches to delivering health care.