Patient Navigation to Improve Early Access to Supportive Care for Patients with Advanced Cancer in Resource-Limited Settings: A Randomized Controlled Trial.
Enrique Soto-Perez-de-Celis, Yanin Chavarri-Guerra, Wendy Alicia Ramos-Lopez, Jacqueline Alcalde-Castro, Alfredo Covarrubias-Gomez, África Navarro-Lara, Paulina Quiroz-Friedman, Sofía Sánchez-Román, Natasha Alcocer-Castillejos, José Carlos Aguilar-Velazco, Alexandra Bukowski, Juan Alberto Chávarri-Maldonado, Sergio Contreras-Garduño, Lindsay Krush, Itoro Inoyo, Andrea Medina-Campos, María Luisa Moreno-García, Viridiana Perez-Montessoro, María T Bourlon, Roberto de la Peña-Lopez, Héctor de la Mora-Molina, Eucario León-Rodriguez, Alejandro Mohar, Paul E Goss
Author Information
Enrique Soto-Perez-de-Celis: Department of Geriatrics, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico. ORCID
Yanin Chavarri-Guerra: Department of Hematology and Oncology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico.
Wendy Alicia Ramos-Lopez: Department of Geriatrics, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico.
Jacqueline Alcalde-Castro: Department of Hematology and Oncology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico.
Alfredo Covarrubias-Gomez: Department of Pain and Palliative Care Medicine, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico.
África Navarro-Lara: Physical Therapy Service, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico.
Paulina Quiroz-Friedman: Department of Neurology and Psychiatry, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico.
Sofía Sánchez-Román: Department of Neurology and Psychiatry, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico.
Natasha Alcocer-Castillejos: Department of Neurology and Psychiatry, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico.
José Carlos Aguilar-Velazco: Department of Geriatrics, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico.
Alexandra Bukowski: Global Cancer Institute, Boston, Massachusetts, USA.
Juan Alberto Chávarri-Maldonado: Universidad Autónoma de Ciudad Juárez, Cd Juárez, Mexico.
Sergio Contreras-Garduño: Department of Geriatrics, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico.
Lindsay Krush: Global Cancer Institute, Boston, Massachusetts, USA.
Itoro Inoyo: Global Cancer Institute, Boston, Massachusetts, USA.
Andrea Medina-Campos: Physical Therapy Service, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico.
María Luisa Moreno-García: Department of Geriatrics, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico.
Viridiana Perez-Montessoro: Department of Geriatrics, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico.
María T Bourlon: Department of Hematology and Oncology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico.
Roberto de la Peña-Lopez: Department of Hematology and Oncology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico.
Héctor de la Mora-Molina: Department of Hematology and Oncology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico.
Eucario León-Rodriguez: Department of Hematology and Oncology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico.
Alejandro Mohar: Unidad de Investigación Biomédica, Instituto Nacional de Cancerología Universidad Nacional Autónoma de México, Tlalpan, Mexico City, Mexico.
Paul E Goss: Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
BACKGROUND: The early integration of supportive care in oncology improves patient-centered outcomes. However, data are lacking regarding how to achieve this in resource-limited settings. We studied whether patient navigation increased access to multidisciplinary supportive care among Mexican patients with advanced cancer. MATERIALS AND METHODS: This randomized controlled trial was conducted between August 2017 and April 2018 at a public hospital in Mexico City. patients aged ≥18 years with metastatic tumors ≤6 weeks from diagnosis were randomized (1:1) to a patient navigation intervention or usual care. patients randomized to patient navigation received personalized supportive care from a navigator and a multidisciplinary team. patients randomized to usual care obtained supportive care referrals from treating oncologists. The primary outcome was the implementation of supportive care interventions at 12 weeks. Secondary outcomes included advance directive completion, supportive care needs, and quality of life. RESULTS: One hundred thirty-four patients were randomized: 67 to patient navigation and 67 to usual care. Supportive care interventions were provided to 74% of patients in the patient navigation arm versus 24% in usual care (difference 0.50, 95% confidence interval [CI] 0.34-0.62; p < .0001). In the patient navigation arm, 48% of eligible patients completed advance directives, compared with 0% in usual care (p < .0001). At 12 weeks, patients randomized to patient navigation had less moderate/severe pain (10% vs. 33%; difference 0.23, 95% CI 0.07-0.38; p = .006), without differences in quality of life between arms. CONCLUSION: patient navigation improves access to early supportive care, advance care planning, and pain for patients with advanced cancer in resource-limited settings. IMPLICATIONS FOR PRACTICE: The early implementation of supportive care in oncology is recommended by international guidelines, but this might be difficult to achieve in resource-limited settings. This randomized clinical trial including 134 Mexican patients with advanced cancer demonstrates that a multidisciplinary patient navigation intervention can improve the early access to supportive and palliative care interventions, increase advance care planning, and reduce symptoms compared with usual oncologist-guided care alone. These results demonstrate that patient navigation represents a potentially useful solution to achieve the adequate implementation of supportive and palliative care in resource-limited settings globally.
