Patient Navigation for Breast and Colorectal Cancer in 3
Community Hospital Settings
An Economic Evaluation
Elisabeth A. Donaldson, MHS1; David R. Holtgrave, PhD1; Renea A. Duffin, MPA2;
Frances Feltner, MSN, RN3; William Funderburk, MD4; and Harold P. Freeman, MD5
BACKGROUND: The Ralph Lauren Cancer Center implemented patient navigation programs in sites across the United States building
on the model pioneered by Harold P. Freeman, MD. Patient navigation targets medically underserved with the objective of reducing
the time interval between an abnormal cancer finding, diagnostic resolution, and treatment initiation. In this study, the authors
assessed the incremental cost effectiveness of adding patient navigation to standard cancer care in 3 community hospitals in the
United States. METHODS: A decision-analytic model was used to assess the cost effectiveness of a colorectal and breast cancer
patient navigation program over the period of 1 year compared with standard care. Data sources included published estimates in the
literature and primary costs, aggregate patient demographics, and outcome data from 3 patient navigation programs. RESULTS: After
1 year, compared with standard care alone, it was estimated that offering patient navigation with standard care would allow an addi-
tional 78 of 959 individuals with an abnormal breast cancer screening and an additional 21 of 411 individuals with abnormal colonos-
copies to reach timely diagnostic resolution. Without including medical treatment costs saved, the cost-effectiveness ratio ranged
from $511 to $2080 per breast cancer diagnostic resolution achieved and from $1192 to $9708 per colorectal cancer diagnostic resolu-
tion achieved. CONCLUSIONS: The current results indicated that implementing breast or colorectal cancer patient navigation in com-
munity hospital settings in which low-income populations are served may be a cost-effective addition to standard cancer care in the
United States. Cancer 2012;118:4851-9. V
C 2012 American Cancer Society.
KEYWORDS: patient navigation, breast cancer, colorectal cancer, cost-effectiveness disparities.
Breast cancer is the second leading cause of cancer death among women and colorectal cancer is the third leading cause of
cancer death for both men and women in the United States.1,2Despite a decline in the overall cancer mortality in the
nificant challenge.3African Americans experience higher mortality rates in all cancer sites, including breast and colorectal
cancer, compared with non-Hispanic whites.1,3Disparities in mortality for breast and colorectal cancer often are more
pronounced with respect to socioeconomic status than race.4Individuals between ages 25 and 64 years with less than a
high schooleducationhavenot experienceda significantdeclinein deathfrom colorectalcancer.5
A complexinterplay of individual and community level factorscontribute to excess cancer mortality among the soci-
oeconomically disadvantaged.1,6-8Individuals of low socioeconomic status and the uninsured often experience financial
and nonfinancial barriers when seeking cancer diagnosis and treatment.1,6,8Consequently, these individuals often do not
seek or receive timely and appropriate care, and they present for diagnosis and treatment at with advanced-stage cancer.8-
13Therefore, early detection and timely treatment are important objectives for improving survival rates among medically
underservedpopulations and reducingongoing disparities.1,14
In 1990, in response to the American Cancer Society’s (ACS) Report to the Nation: Cancer in the Poor,8Harold P.
Freeman, MD, with funding from ACS, created the nation’s first patient navigation (PN) program in Harlem, New York
City.15The original patient navigation program provided assistance to a breast cancer patient population of low-income,
African American patients at Harlem Hospital Center.16Approximately 50% of the patients did not have medical insur-
ance.16After providing free and low-cost breast cancer screening and patient navigation to ensure timely follow-up and
treatment, a similar population at Harlem Hospital Center had an increase in the diagnoses of early stage breast cancer
and a survival rate >5 years.17It is estimated that, since Dr. Freeman’s first PN program in 1990, hundreds of programs
DOI: 10.1002/cncr.27487, Received: September 12, 2011; Revised: January 18, 2012; Accepted: January 25, 2012, Published online March 5, 2012 in Wiley
Online Library (wileyonlinelibrary.com)
Corresponding author: Elisabeth A. Donaldson, MHS, 2213 McElderry St., 4th Floor; Baltimore, MD 21205; Fax: (410) 614-1003; email@example.com
1Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland;2Mary Bird Perkins Cancer Center, Baton Rouge, Louisiana;3University of Kentucky Cen-
ter for Excellence in Rural Health-Hazard, Lexington, Kentucky;4General Surgery, Providence Hospital, Washington, DC;5Harold P. Freeman Patient Navigation
Institute, New York, New York
October 1, 2012
have incorporated some aspect of the patient navigator
concept into cancer care.17,18Dr. Freeman’s model aims
to save lives by improving access to screening, ensuring
timely delivery of services, and eliminating barriers to
care. PN programs focus on the movement of the patient
into and through the continuum of care by ensuring that
patients attain resolution in a timely manner after a suspi-
cious finding.15,18,19The navigator increases awareness of
services, works through financial barriers, and facilitates
access to care from outreach through detection and treat-
ment resolution.15,18The navigator works to overcome
patient barriers, including clinical barriers, such as sched-
uling conflicts, social support barriers, and financial con-
The Ralph Lauren Center for Cancer Care and Pre-
vention was founded in June 2003 and later included the
Harold P. Freeman Patient Navigation Institute (PNI) to
train and certify individuals in Dr. Freeman’s model of
port from Pfizer Inc. and the Pfizer Foundation, funded 5
PN programs in 2007 focused throughout the continuum
of cancer care and on various cancer sites in medically
underserved populations. The 5 programs targeted geo-
graphic areas with excess cancer mortality,including com-
munity hospitals in regions with some of the highest age-
adjusted breast and colorectal cancer death rates in the
United States.2Although the literature suggests that PN
programs improve patient satisfaction as well as the time-
liness of screening, follow-up, and early detection,17,21-24
few haveevaluatedthe cost-effectivenessof PN.25
In this study we determined the incremental cost-
effectiveness of breast and colorectal cancer navigation
compared with standard care in 3 community hospitals in
the United States. Given the paucity of information on
the cost of PN, this analysis is 1 of the first to explore
whether the total cost of breast and colorectal cancer PN
can be offset by the improved timeliness to diagnosis for
patient populations at greater risk for delayed diagnosis
and poor adherence. The 3 PN programs included in this
MATERIALS AND METHODS
We used a decision-analytic model from the health care
payer perspective to compare the cost-effectiveness of a
colorectal and breast cancer PN program over the period
of 1 year in a community hospital setting compared with
standard cancer care. In the analysis, we considered the
Table 1. Patient Navigation Program Sites
Patient Population Demographic Characteristics (%)
No. of Patients
African American (76)
Patient navigator (lay person)
Public insurance: Medicaid (50), Medicare (21)
Private insurance (25)
African American (0.9)
Public insurance: Medicaid (12), Medicare (23)
Private insurance (38)
411 (Women, 55%;
African American (1)
Public insurance: Medicaid (14), Medicare (67)
Private insurance (14)
African American (38)
Patient navigator; nurse-LPN; bilingual
outreach worker; project supervisor
Abbreviations: LPN, licensed practical nurse.
aAll personnel were full-time employees.
October 1, 2012
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October 1, 2012