What Is patientINFORM?

Emory University researchers have developed a two-pronged outreach program that appears to significantly improve early-stage breast cancer detection among African American women. The program, which emphasizes health education and patient support, owes its success in large part to the work of specially-trained Community Health Advocates, who encourage women to get screened for breast cancer, and Patient Navigators, who help women if they're diagnosed.

"This is an example of a cancer-control intervention that works," said Otis Brawley, MD, Chief Medical Officer of the American Cancer Society. "It demonstrates that health outreach, combined with changes in hospital programs, make screening more accessible to people."

Developed at the AVON Comprehensive Breast Center at Grady Memorial Hospital in Atlanta, Georgia, the program has two arms. Specially-trained Community Health Advocates (CHAs) conduct programs in local churches, workplaces, and health fairs that address misconceptions about breast cancer screening and encourage women to schedule regular mammograms. Patient Navigators (PNs), themselves breast cancer survivors, help patients who have already been diagnosed with breast cancer pursue medical care, from assisting them with financial concerns to matching them with appropriate support services. They also encourage women to keep their medical appointments.

From 2001 to 2004 (the study period), more than 10,000 participants attended CHA-related programs, and a total of 487 women were diagnosed and/or treated for breast cancer at Grady Hospital. The vast majority of those women (89%) were African American. To get a snapshot of how well the programs were working, the researchers looked at stage-at-diagnosis among the patients. During the study period, the researchers saw the proportion of stage 0 breast cancer diagnoses rise from 12.4% to 25.8%, and a decline in stage IV diagnoses from 16.8% to 9.4%. Earlier stage breast cancers are easier to treat, and women are more likely to survive.

The researchers can't say with certainty whether the outreach program actually caused the improvements in stage-at-diagnosis because of limitations in the study design (not all of the women in the community education component received breast cancer screening or treatment at Grady, and the study did not control for other factors that may have positively affected outcome). However, according to lead researcher Sheryl G.A. Gabram-Mendola, MA, MBA, FACS, Director of the AVON Comprehensive Breast Center at Grady Hospital, "it was a major change in the Grady Health Care System and may be linked to the trend."

Breast cancer is more common among white women, but African American women are more likely to get the disease when they're younger (under age 40). They're also less likely to survive it. According to Cancer Facts & Figures for African Americans 2007-2008, the 5-year survival rate for breast cancer among African American women is 77%, compared to 90% among white women. The difference has been attributed in large part to later stages of diagnosis and worse stage-specific survival.

Late-stage diagnosis in African Americans has also been linked to a number of barriers to care, including inadequate access to care, lack of access to health information, and misconceptions about screening.

This program aims to tackle all three--and it's a reproducible model.

"I could see this model in all the major urban centers--Chicago, New York City, Washington DC, Detroit," said Brawley.

Gabram-Mendola says researchers are currently conducting additional studies of the program to determine whether having a Patient Navigator has an effect on what kind of care women get, whether they stick to all their appointments, and whether they complete treatment. Some work is also being done to track how many patients follow breast cancer screening guidelines after participating in a CHA program.

Citation: "Effects of an Outreach and Internal Navigation Program on Breast Cancer Diagnosis in an Urban Cancer Center with a Large African-American Population." Published online June 23, 2008 in Cancer. First author: Sheryl G.A. Gabram, MD, Emory University School of Medicine.