Harold P. Freeman

History and principles of patient navigation

In 1971 President Richard Nixon declared a war on cancer and signed the National Cancer Act. During the past several decades since this declaration, the nation has made extraordinary progress toward a far better understanding of the molecular, cellular, and genetic changes resulting in cancer. We have also seen significant declines in overall and site-specific cancer mortality1. This decline in mortality has been attributed to improved cancer prevention, screening, and detection measures as well as the application of more effective and more targeted cancer treatments. However, some Americans (such as the poor, uninsured, and underinsured) have not shared sufficiently in this progress as measured by higher mortality, lower survival, and 5-year cancer survival2, 3. These findings suggest that there is a disconnect between the nation’s discovery and delivery enterprises; a disconnect between what we know and what we do (Fig 1). Figure 1 Discovery-Delivery Disconnect Disparities occur when beneficial medical interventions are not shared by all. Moreover, health disparities arise from a complex interplay of economic, social, and cultural factors. The model presented in (Fig. 2) illustrates the overlapping factors of poverty, culture, and social injustice as principal causes of health disparities. These causal factors impact on all aspects of the healthcare continuum from prevention, detection, diagnosis, treatment, and survival to the end of life. Disparities occur principally in individuals or populations who experience one or more of the following circumstances: insufficient resources, risk-promoting lifestyle and behavior, and social inequities. Approaches to reducing or eliminating disparities must necessarily take these factors into consideration. Figure 2 Causes of Health Disparities

Cancer of the breast in poor black women

The authors carried out a retrospective analysis of 708 patients (94% blacks) with breast cancer who were diagnosed, treated and/or followed at Harlem Hospital Center (New York) between 1964 and 1986: nearly all patients were of low economic status with almost 50% having no medical coverage. Surgical treatment was implemented in 512 patients (72%). Radiotherapy and/or chemotherapy alone were used in 94 patients (13%); 102 patients (14%) refused treatment or died before its initiation. The 5‐year and 10‐year survival rates for those treated surgically were 39% and 27%, respectively. For those patients undergoing surgery (47% of whom were in Stages III and IV), 5‐year and 10‐year survival rates were analyzed according to stage of the disease. They were 54% and 54%, respectively, for Stage I; 56% and 35%, respectively, for Stage II; 41% and 18%, respectively, for Stage III; and 11% and 0%, respectively, for Stage IV. There was significant difference in the 5‐year survival rates between patients with pathologically negative lymph nodes (64%) and a single positive lymph node (71%), compared to those with multiple positive lymph nodes (33%; P = 0.001). The 10‐year survival rates were 39%, 34%, and 15% (P = 0.001), respectively. The authors conclude that breast cancer survival in this population of poor black women is low compared to the survival rate of black women nationally and very low compared to white women.

Impact of a cancer screening program on breast cancer stage at diagnosis in a medically underserved urban community

BACKGROUND Our previous report showed that the disparity in breast carcinoma survival between black and white women because of advanced stage of disease at presentation in poor black women is related to their low socioeconomic status and lack of health insurance. This observation led to establishment of a community-oriented free cancer screening service. STUDY DESIGN To evaluate the impact of screening on breast cancer stage at diagnosis, analysis of data from the Harlem Hospital Tumor Registry between 1995 and 2000 was performed and compared with our 1964-1986 report. RESULTS Twenty-three percent of cancers (324 of 1,405) diagnosed between 1995 and 2000 were breast carcinoma. Data confirm that lack of insurance remains a major problem among poor black women. We observed a marked fall, from 49% in our earlier report to 21% in this study, in late-stage (III and IV) disease at presentation. This fall is associated with significant (p < 0.001) improvement in early detection of breast cancer, with 41% of cancers in stages 0 and I in this data compared with 6% in the previous study. Of note, 53% of women with breast carcinoma had breast-conserving surgery and 45% had modified radical mastectomy in this study; 71% had radical or modified radical mastectomy in the earlier report. CONCLUSIONS This study confirms the importance of a free cancer screening program in the improvement of early-stage breast cancer detection, treatment, and survival in a poor urban community.

Barriers to follow‐up of abnormal screening mammograms among low‐income minority women

OBJECTIVE To describe factors related to compliance diagnostic follow-up among minority women of low socioeconomic status with abnormal screening mammograms. METHODS A retrospective cross-sectional survey using a structured telephone interview. Three cancer screening clinics at an urban inner-city public hospital. All women with abnormal screening mammograms between September 1990 and January 1992 were eligible; women were interviewed in August 1992. Abnormal mammograms were those requiring specific, non-routine clinical follow-up; non-compliance was defined as delayed follow-up (four to six months after the date of the mammogram), or no follow-up at the time of interview (more than 6 months after abnormal). RESULTS Sixty-two of 442 screened women had abnormal results; the overall rate of non-compliance with follow-up was 50%. Among the 42 (68%) women who agreed to be interviewed, non-compliers were less likely to state that they had been told to receive follow-up than compliers (65% versus 100%; p = 0.008). Non-compliant women were less likely to have suspicious mammography interpretations (p = 0.05), and more likely to report barriers to follow-up, such as cost of lost wages and medical care, system barriers, or fears, than compliant women (61.9% versus 9%, p = 0.01). There were no differences between the two groups for age, education, insurance, source of care, family history, knowledge or attitudes. CONCLUSIONS These preliminary results suggest that follow-up of low income, minority women with abnormal screening mammograms could be enhanced by improved communication of results. Future studies should extend these findings with larger samples and in other settings and populations.

A Self-Help Smoking Cessation Program for Inner-City African Americans: Results from the Harlem Health Connection Project

The authors develop and test a culturally sensitive, low-intensity smoking cessation intervention for low-socioeconomic African Americans. African American adult smokers were randomly assigned to receive either a multicomponent smoking cessation intervention comprising a printed guide, a video, and a telephone booster call or health education materials not directly addressing tobacco use. The results of the study were mixed. Although no significant effects were observed for the entire treatment cohort, the results of post hoc analyses suggest that culturally sensitive self-help smoking cessation materials plus a single phone contact can produce short-term cessation rates similar to those reported for majority populations. This conclusion should be tempered by the low completion rate for the booster call and several design limitations of the study.

Analysis of benign breast lesions in blacks

A clinicopathologic analysis of 202 benign breast lesions in black women is presented. The study shows that the peak incidence of fibroadenoma occurs at an earlier age in black than in white patients. Fibrocystic disease is most frequent in both black and white patients between 25 and 45 years of age. It is noteworthy that nulliparous adolescent blacks have a higher risk of fibroadenoma developing and our findings confirm the observation made by Funderburk et al [5] and Nigro and Organ [6] that the incidence of fibroadenoma in blacks is high. The low incidence of fibrocystic disease in our patients does not reflect the clinical incidence of the disease because most patients with fibrocystic disease do not undergo biopsy. We are unable to draw any conclusions about the relation between the use of oral contraceptives and the incidence of benign breast disease. In conclusion, a review of the literature and an analysis of our data suggest a relatively higher incidence of fibroadenoma among black patients. In contrast to the finding in the white population, it appears that in blacks fibroadenoma is more common than carcinoma of the breast.

Patient navigation for breast and colorectal cancer in 3 community hospital settings

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.

The impact of clinical trial protocols on patient care systems in a large city hospital. Access for the socially disadvantaged.

Some Americans suffer a higher cancer incidence and mortality than those in mainstream American society, and, in general, do not enjoy the same health status. Black Americans, for example, have higher cancer incidence and lower survival rates than do white Americans. To date, there is no known genetic basis to account for the disparities in cancer incidence and outcome between these races. Controlling for socioeconomic status greatly reduces, and sometimes nearly eliminates, the apparent contrast in cancer mortality and incidence between ethnic groups. Poverty clearly is associated with diminished access to health care, an increased incidence of cancer, and 10–15% lower 5‐year survival rates. Diminished access often is manifested by low quality and inadequate continuity of health care, as well as insufficient access to methods of disease detection, diagnosis, treatment, and rehabilitation. Poor people tend to concentrate on day‐today survival, often feel hopeless and powerless, and may become socially isolated. It is more difficult to conduct cancer treatment trials in a population characterized by such dramatic socioeconomic and cultural differences. Lack of insurance and lack of compliance become triallimiting issues. This paper examines what must be done to tear down the economic and cultural barriers to prevention, early detection, and treatment of cancer.

Smoking Prevalence in Harlem, New York.

Cigarette smoking and its physiologic sequelae differ considerably among African-Americans, whites, and Hispanics? 4 Among adolescents and young adults, smoking rates are lower among African-Americans than among whites or Hispanics. 2,5 Among persons aged 35 and older, however, African-Americans have the highest rates. 2 The higher smoking rates among African-Pmaerican adults may be related to lower quit rates 6,7 and later initiation, s Black-white differences in adult smoking and consequent mortality appear greater for men thanfor women 1,3,4 and are largely attributable to socioeconomicg12 and psychologic ~’m4 factors, rather than race per se. l°,l~-2] Reducing smoking among low-income African-Americans is a national health priority. ~2

Pneumatic antishock garment-associated compartment syndrome in uninjured lower extremities.

Pneumatic antishock garment-associated compartment syndrome is a rare and yet underrecognized complication that when it occurs, frequently results in myonecrosis and loss of limb function, and occasionally loss of a limb or even death. We report a case of pneumatic antishock garment-associated compartment syndrome in a trauma patient without lower extremity injury and review similar published reports. It is only with a high index of suspicion, early recognition, and prompt treatment of this complication by fasciotomy and proper wound care that associated morbidity and potential mortality of this complication can be prevented or minimized.