Using Navigators to Improve Care of Underserved
Current Practices and Approaches
Daniel Dohan, Ph.D.1
Deborah Schrag, M.D., M.P.H.2
1Institute for Health Policy Studies and Depart-
ment of Anthropology, History, and Social Medi-
cine, University of California–San Francisco, San
2Department of Epidemiology and Biostatistics,
Memorial Sloan-Kettering Cancer Center, New
York, New York.
Supported by Mount Zion Health Fund (D. Dohan).
Address for reprints: Daniel Dohan, Ph.D., Institute
for Health Policy Studies, University of California–
San Francisco, Box 0936, 3333 California Street,
Suite 265, San Francisco, CA 94118; Fax: (415)
476-0705; E-mail: firstname.lastname@example.org
Received November 18, 2004; revision received
February 18, 2005; accepted March 25, 2005.
BACKGROUND. Logistic, cultural, educational, and other barriers can impede the
delivery of high-quality cancer care to underserved patients. Patient navigation
services represent one innovation for addressing perceived barriers to care en-
countered by disadvantaged patients. In this report, the authors have 1) defined
patient navigation, distinguishing it from other cancer support services; 2) de-
scribed how programs are organized; and 3) discussed the need for research on
METHODS. Information was examined on navigation programs published in the
scientific literature and on line. Qualitative research also was conducted, consist-
ing of direct observation of patient care in cancer clinics with and without navi-
gators in northern California, in-person interviews with personnel and patients in
the clinics observed, and telephone interviews with navigators at four sites across
the United States.
RESULTS. The authors found that navigation services have been implemented at all
stages of cancer care: prevention, screening, treatment, and survival. Navigators
differ from other cancer support personnel in their orientation toward flexible
problem solving to overcome perceived barriers to care rather than the provision
of a predefined set of services. There are no rigorous demonstrations of the effects
and effectiveness of navigation, although such studies are underway.
CONCLUSIONS. Currently, patient navigation is understudied, and literature docu-
menting its effects and effectiveness is scant. Rigorous studies are needed of the
navigator role and program costs and benefits. Such studies will facilitate an
assessment of program effectiveness, feasibility across a range of health care
settings, and performance relative to alternative approaches for addressing barriers
to care among the underserved. Cancer 2005;104:848–55.
© 2005 American Cancer Society.
KEYWORDS: continuity of patient care, social support, health services needs and
demands, poverty, health promotion, health education.
nativity.1,2These social factors shape cancer morbidity and mortality
in complex ways through effects on incidence, disease stage at diag-
nosis, prognosis, and outcome.3–7In terms of disease stage at presen-
tation and 5-year survival rates, a disproportionate burden of disease
falls on members of racial and ethnic minority groups, those of lower
SES, and recent immigrants—groups that, together, may be consid-
ered medically underserved or disadvantaged.2These disparities fuel
dissatisfaction among patients and raise concerns that the health care
system perpetuates, perhaps even exacerbates, social inequity.8
n the United States, the burden of cancer is distributed unequally
with respect to race and ethnicity, socioeconomic status (SES), and
© 2005 American Cancer Society
Published online 11 July 2005 in Wiley InterScience (www.interscience.wiley.com).
4. Chu KC, Anderson WF, Fritz A, Ries LA, Brawley OW. Fre-
quency distributions of breast cancer characteristics classi-
fied by estrogen receptor and progesterone receptor status
for eight racial/ethnic groups. Cancer. 2001;92:37–45.
Lannin DR, Mathews HF, Mitchell J, Swanson MS, Swanson
FH, Edwards MS. Influence of socioeconomic and cultural
factors on racial differences in late-stage presentation of
breast cancer. JAMA. 1998;279:1801–1807.
Bach PB, Schrag D, Brawley OW, Galaznik A, Yakren S, Begg
CB. Survival of blacks and whites after a cancer diagnosis.
Richardson LC, Schulman J, Sever LE, Lee NC, Coate RJ.
Early-stage breast cancer treatment among medically un-
derserved women diagnosed in a national screening pro-
gram, 1992–1995. Breast Cancer Res Treat. 2001;69:133–142.
President’s Cancer Panel. Report of the chairman 2000–
2001. Voices of a broken system: real people, real problems.
Bethesda: National Cancer Institute, National Institutes of
Breen N, Kessler LG, Brown ML. Breast cancer control
among the underserved—an overview. Breast Cancer Res
10. Harper AP. Mammography utilization in the poor and med-
ically underserved. Cancer. 1993;72(4 Suppl):1478–1482.
11. Richardson LC. Treatment of breast cancer in medically
underserved women: a review. Breast J. 2004;10:2–5.
12. Wolff M, Bates T, Beck B, Young S, Ahmed SM, Maurana C.
Cancer prevention in underserved African American com-
munities: barriers and effective strategies—a review of the
literature. Wisc Med J. 2003;102:36–40.
13. Lannin DR, Mathews HF, Mitchell J, Swanson MS. Impact-
ing cultural attitudes in African-American women to de-
crease breast cancer mortality. Am J Surg. 2002;184:418–
14. Aziz NM, Rowland JH. Cancer survivorship research among
ethnic minority and medically underserved groups. Oncol
Nurs Forum. 2002;29:789–801.
15. Brown CL. Screening patterns for cervical cancer: how best
to reach the unscreened population. J Natl Cancer Inst
16. Lantz PM, Dupuis L, Reding D, Krauska M, Lappe K. Peer
discussions of cancer among Hispanic migrant farm work-
ers. Public Health Rep. 1994;109:512–520.
17. Lantz PM, Reding D, Perez-Stable EJ. Cancer: beliefs and
attitudes of migrant Latinos. JAMA. 1994;272:31–32.
18. Trans-HHS Cancer Health Disparities Progress Review
Group. Making cancer health disparities history. Washing-
ton, DC: National Academy Press, 2004.
19. Freeman HP, Muth BJ, Kerner JF. Expanding access to can-
cer screening and clinical follow-up among the medically
underserved. Cancer Pract. 1995;3:19–30.
20. National Institutes of Health. Patient navigation research
program. Bethesda: United States Department of Health
and Human Services, National Institutes of Health, 2004.
21. Emerson RM, Fretz RI, Shaw LL. Writing ethnographic field
notes. Chicago: University of Chicago, 1995.
22. Lofland J. Analytic ethnography: features, failings and fu-
tures. J Contemp Ethnogr. 1995;24:30–67.
23. Centers for Medicare and Medicaid Services. Evidence Re-
port and Evidence-Based recommendations: cancer preven-
tion and treatment demonstration for ethnic and racial mi-
norities. Bethesda: United States Department of Health and
Human Services, 2003.
24. Canadian Breast Cancer Initiative. Investigation and assess-
ment of the “navigator role” in meeting the informational,
decisional and educational needs of women with breast
cancer in Canada. Ottawa: Public Health Agency Canada,
25. Bickell NA, Young GJ. Coordination of care for early-stage
breast cancer patients. J Gen Intern Med. 2001;16:737–742.
26. Engelstad LP, Stewart SL, Nguyen BH, et al. Abnormal Pap
smear follow-up in a high-risk population. Cancer Epide-
miol Biomarkers Prev. 2001;10:1015–1020.
27. Bird JA, McPhee SJ, Ha NT, Le B, Davis T, Jenkins CN.
Opening pathways to cancer screening for Vietnamese-
American women: lay health workers hold a key. Prev Med.
28. Eng E, Smith J. Natural helping functions of lay health
advisors in breast cancer education. Breast Cancer Res Treat.
29. Ell K, Vourlekis B, Muderspach L, et al. Abnormal cervical
screen follow-up among low-income Latinas: Project SAFE.
J Womens Health Gend Based Med. 2002;11:639–651.
30. Frelix GD, Rosenblatt R, Solomon M, Vikram B. Breast can-
cer screening in underserved women in the Bronx. J Natl
Med Assoc. 1999;91:195–200.
31. Black BL, Ades TB. American Cancer Society urban demon-
stration projects: models for successful intervention. Semin
Oncol Nurs. 1994;10:96–103.
32. Black BL, Schweitzer R, Dezelsky T. Report on the American
Cancer Society workshop on community cancer detection,
education, and prevention demonstration projects for un-
derserved populations. CA Cancer J Clin. 1993;43:226–233.
33. Ell K, Padgett D, Vourlekis B, et al. Abnormal mammogram
follow-up: a pilot study women with low income. Cancer
34. Hiatt RA, Pasick RJ, Stewart S, et al. Community-based can-
cer screening for underserved women: design and baseline
findings from the Breast and Cervical Cancer Intervention
Study. Prev Med. 2001;33:190–203.
35. Burhansstipanov L, Wound DB, Capelouto N, et al. Cultur-
ally relevant “navigator” patient support. The Native sisters.
Cancer Pract. 1998;6:191–194.
36. Weinrich SP, Boyd MD, Weinrich M, Greene F, Reynolds WA
Jr., Metlin C. Increasing prostate cancer screening in African
American men with peer-educator and client-navigator in-
terventions. J Cancer Educ. 1998;13:213–219.
37. Friedell GH, Rubio A, Maretzki A, et al. Community cancer
control in a rural, underserved population: the Appalachian
Leadership Initiative on Cancer Project. J Health Care Poor
38. Till JE. Evaluation of support groups for women with breast
cancer: importance of the navigator role. Health Qual Life
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