Sandra San Miguel

Navigating Latinas with breast screen abnormalities to diagnosis: The Six Cities Study

Breast cancer is the leading cause of cancer‐related deaths in Latinas, chiefly because of later diagnosis. The time from screening to diagnosis is critical to optimizing cancer care, yet the efficacy of navigation in reducing it is insufficiently documented. Here, the authors evaluate a culturally sensitive patient navigation program to reduce the time to diagnosis and increase the proportions of women diagnosed within 30 days and 60 days.

Reducing time-to-treatment in underserved Latinas with breast cancer: The Six Cities Study

The interaction of clinical and patient‐level challenges following a breast cancer diagnosis can be a significant source of health care disparities. Failure to address specific cultural features that create or exacerbate barriers can lead to less‐than optimal navigation results, specifically in Hispanic/Latino women.

Abstract C09: A Patient Navigation Program in Mexico City as a model for overcoming barriers to accessing cancer care in Latin America

Background: Cancer mortality rates in developing countries such as Mexico are higher than in high-income countries, due in part to failure and delays in access to health care. The median delay from problem identification to start of treatment can be up to 7 months, which is largely related to shortcomings of a fragmented healthcare system. At least 7 public providers coexist within the Mexico City Metropolitan Area (MCMA). A cumbersome and inefficient system requires the referral of patients with suspicion or diagnosis of cancer between hospitals with different health coverage. A more coordinated delivery of cancer care or navigation of cancer patients is needed to achieve timely initiation of treatment. Here we report preliminary results of the first patient navigation (PN) program in Mexico City. We initiated this study with the objective of demonstrating that implementing a PN program at a second level hospital within the MCMA would be feasible and reduce time to initiation of tertiary cancer care treatment. Methods: Patients eligible for PN enrolment were aged >18 with either suspicion or confirmed diagnosis of cancer who required referral to a cancer center for further care. Baseline demographic and psychosocial data were collected. Patients were navigated by a dedicated patient navigator, who assisted them with scheduling; paperwork; obtaining results in a timely manner; transportation; and appropriate oncological diagnosis and/or treatment. Our statistical assumption was a sample size of 40 patients needed to demonstrate it was feasible to successfully navigate at least 70% of the patients within 3 months of the start of navigation. Results: Recruitment began in January 2016. Twenty-six patients have been accrued (median age 57 years [range 22 to 85]; 14 [53%] are male). Most common diagnoses are: genitourinary (35%, N= 9), hematologic (15%, N=4) and head and neck malignancies (15%, N4). Fourteen (53%) have Conclusion: Preliminary results indicate that a PN program aimed at improving referral between health systems and overcoming access barriers to cancer diagnosis and treatment in Mexico City is feasible, and that it decreases the time to referral to a cancer center. PN may be a solution to overcome barriers to healthcare access for underserved cancer patients and perhaps patients with other non-communicable diseases in developing countries. Citation Format: Yanin Chavarri Guerra, Enrique Soto Perez de Celis, Wendy A. Ramos Lopez, Alexandra Bukowski, Sandra San Miguel, Oscar Sanchez Gutierrez, Jesus A. Sanchez Gonzalez, Paul E. Goss. A Patient Navigation Program in Mexico City as a model for overcoming barriers to accessing cancer care in Latin America. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr C09.

Abstract A31: National Outreach Network Community Health Educators: An effective framework to reduce cancer health disparities among Latinos

Purpose: The National Cancer Institute9s (NCI) Center to Reduce Cancer Health Disparities (CRCHD) has been working to strengthen community outreach capacity through Community Health Educators (CHEs) of the NCI National Outreach Network (NON). The NON CHEs, based at academic and cancer centers across the country, strengthen NCI9s ability to develop and disseminate culturally appropriate, evidence-based cancer information that is tailored to the specific needs and expectations of underserved communities. Over the past five years, NON CHEs have developed, adapted, and tested community education and outreach interventions that effectively reach underserved communities to address local and regional cancer health disparity issues. Methods: A subset of NON CHEs have focused on outreach and educational interventions to reduce disparities specifically among Latino populations at high risk of cancer or cancer survivors in community settings from inner cities to rural areas. In 2010, these CHEs, based at more than 12 cancer centers and academic institutions across the country, established a working group to support one another. The NON CHE Latino Working Group shares best practices for disseminating culturally sensitive, evidence-based cancer prevention, screening, and survivorship information tailored to the specific needs of their respective Latino communities. The Latino Working Group9s interventions and campaigns targeted breast, cervical, colorectal, prostate, and lung cancers, and also explored and addressed the key issue of research participation by the Latino community. The group utilized various evidence-based programs, such as the Cancer 101 curriculum and the inflatable colon. The NON CHE Latino Working Group conducted needs assessments, gathered qualitative and quantitative data to inform the adaptation of interventions, implemented and evaluated community education and outreach projects, and published findings from their work. They developed multiple educational materials, including one in collaboration with the NCI9s Geographical Management of Cancer Health Disparities Program (GMaP) Region 4 program: The Clinical Trials Outreach for Latinos (CTOL): Program Replication Manual. Preliminary Results: We will present outcomes from the NON CHE Latino Working Group9s diverse projects including needs assessment and intervention testing results, review feedback from focus groups conducted in the United States and Puerto Rico, discuss the success of various evidence-based programs put into practice, share information on health education classes focusing on diet and nutrition, and the community9s receptivity to participate in research. We will present data collected on over 5,000 Latinos who participated in the different NON CHE programs. The NON CHE Latino WG will also discuss lessons learned, challenges and best practices. Conclusion: Although Latinos have lower incidence rates of certain cancers, they also suffer from higher mortality rates. Latino communities at risk of developing cancer and affected by cancer are often marginalized due to multiple factors and barriers, including inadequate health education, language barriers, lack of access to healthcare, and mistaken cultural beliefs about cancer. Latinos often do not engage in regular screening procedures resulting in worse health outcomes when compared to the Non-Hispanic White population. Major framework efforts, such as the established NCI/CRCHD NON CHE program, have a major impact in reducing cancer health disparities among this underserved population by offering culturally sensitive interventions that improve delivery of and/or promote practices in cancer education, prevention, screening, treatment and survivorship services. Citation Format: Sandra L. San Miguel, Aleli Ayala-Marin, Katherine J. Briant, Niyati Desai, Leticia Gatus, Diego Gomez-Aristizabal, Evelyn Gonzalez, Martha E. Gonzalez, Natalia I. Heredia, Nadia Lazo, Rosa Ortiz, Lizette Rangel, Yonaira Rivera, Janet Sanchez, Mayra Serrano, Rose A. Trevino Whitaker. National Outreach Network Community Health Educators: An effective framework to reduce cancer health disparities among Latinos. [abstract]. In: Proceedings of the Eighth AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 13-16, 2015; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2016;25(3 Suppl):Abstract nr A31.

Abstract P1-09-22: Improving quality of life among Latino breast cancer survivors: A national randomized control trial of patient navigators using LIVESTRONG's Cancer Navigation Center

Purpose: Latina breast cancer survivors experience an unequal burden of unmet needs after treatment, which compromise their health care and wellness, experts recommend providing psychological services as an integral part of quality cancer care. Methods: Redes En Accion: The National Latino Cancer Research Network and LIVESTRONG partnered to conduct a randomized control trial utilizing trained, bilingual, bicultural patient navigators to improve wellness and access to psychosocial services among non-metastatic Latino breast cancer survivors from Texas and Chicago. The trial tests the efficacy of patient navigation (PN) in improving general and disease-specific quality of life (QoL), treatment compliance, and identification of mechanisms that may promote quality of life. The study involves a 2 X 4 randomized repeated measures design with an experimental condition (combined PN over three months with access to the LIVESTRONG Cancer Navigation Center [LCNC] services [PN+LCNC]) versus a control condition (PN only) as the between-groups factor, and time-point (baseline/pre-randomization [T1]; post-PN [3-months post T1; T2], and 6 [T3] and 12 months [T4] follow up after T2) as the within groups factor. LCNC provides free, bilingual support to U.S. cancer survivors throughout the cancer journey. LCNC also refers to survivors to services addressing their medical, economic and psychosocial needs, and monitors client contact and access outcomes. Preliminary Results: A total of 128 Latina women with early stage breast cancer have been randomized into either our control (Standard Patient Navigation; PN) or our experimental (Enhanced Patient Navigation; EPN) conditions. Complete data for multiple regression analysis on 76 randomized Latina women who completed baseline and first follow up assessment is available. At baseline, we identified major stated needs by our participants. These included fear of recurrence, more information regarding their disease, and assistance in communicating with the medical team. The top three physical functioning concerns stated by our participants included lack of energy/fatigue, interference with daily routines and poor physical well-being. Consistent with prior work with Hispanic cancer survivors, our sample reported significantly lower (over 1.5 standard deviation below) general health related quality of life, physical well-being and emotional well-being as measured by the FACT-G. Exploratory analyses have begun to reveal that there are several significant moderators of the effects of the intervention across several outcomes. At conference, we will present quality of life data on breast cancer participants, exploratory analysis, and lessons learned. Discussion: Limited work has addressed the psychosocial needs of Latina breast cancer survivors. Culturally sensitive patient navigation (PN) could address these needs and significantly improve breast cancer survivorship. Citation Format: Amelie G Ramirez, Edgar Munoz, Sandra San Miguel, Kip Gallion, Arely Perez, Leo Castillo, Sarah R Arvey, Frank Penedo. Improving quality of life among Latino breast cancer survivors: A national randomized control trial of patient navigators using LIVESTRONG9s Cancer Navigation Center [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-09-22.

Abstract A68: What do they do? The art and science of patient navigation among underserved Latina minorities: The significance of language

Background: Patient Navigation has evolved to reduce cancer health disparities by eliminating barriers to diagnosis, treatment, and survivorship services. Attempts have been made to describe barriers to care and navigator actions. Little attention has been paid to the unique needs of underserved minorities. Here we describe barriers to care reported by Latina survivors in the context of a social-ecological framework, actions taken by navigators to resolve those barriers, and the consequences of those activities. Methods: We evaluated 399 barriers to care reported by Latinas diagnosed with cancer as part of Redes En Accion: The National Latino Cancer Research Network from July 2008-January 2011. Navigators maintained monthly logs of encounters with patients and recorded reported barriers to care and actions taken to overcome each barrier. Spearman Correlation, Chi-squared analysis and Cox proportional hazards models were used to assess the barriers and actions. Results: The most common barrier to care was needed Spanish-English translation (55.6%). Personal (e.g. fear) and system barriers (e.g. insurance) accounted for the remainder. 85% of all Latinas reported one or more barriers; 37% reported more than one. Multiple (2+) barriers resulted in slightly longer time to treatment (aHR [adjusted Hazard Ratio]= 0.871; p Conclusions: Barriers reported by Latinas are predominantly linguistic in nature. Multiple barriers appear to result in a delay between diagnosis and treatment initiation; however this effect disappears when accounting for the effects of a language barrier. Health care systems must attend to the special needs of underserved minorities when planning and improving programs. Citation Format: Amelie G. Ramirez, Eliseo J. Perez-Stable, Frank Penedo, Gregory A. Talavera, J. Emilio Carrillo, Maria Fernandez, Alan E. C. Holden, Edgar Munoz, Sandra San Miguel, Kipling Gallion. What do they do? The art and science of patient navigation among underserved Latina minorities: The significance of language. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr A68.

Abstract B07: Advocacy for an underserved minority: Patient navigation for Latino cancer survivors

Background: Latino cancer survivors experience an unequal burden of unmet needs following treatment. These include issues involving psychological issues, health care, wellness and ultimately, survival. Study Design: Redes En Accion: The National Latino Cancer Research Network and LIVESTRONG partnered to conduct a randomized control trial utilizing trained, bilingual, bicultural patient navigators to improve wellness and access to psychosocial services among non-metastatic Latino cancer survivors from Texas and Chicago. The trial tests the efficacy of patient navigation (PN) in improving general and disease-specific quality of life (QoL), treatment compliance, and identification of mechanisms that may promote quality of life. The study involves a 2 X 4 randomized repeated measures design with an experimental condition (combined PN over three months with access to the LIVESTRONG Cancer Navigation Center [LCNC] services [PN+LCNC]) versus a control condition (PN only) as the between-groups factor, and time-point (baseline/pre-randomization [T1]; post-PN [3-months post T1; T2], and 6 [T3] and 12 months [T4] follow up after T2) as the within groups factor. The unique combination of PN plus LCNC survivorship services is anticipated to show dramatic improvement in survivor-related measures. Results: LCNC provides free, bilingual support to U.S. cancer survivors throughout the cancer journey. It also refers survivors to services addressing their medical, economic and psychosocial needs, and monitors client contact and access outcomes. PN services are based on direct services provided by patient navigators, including but not limited to, securing transportation for clinic appointments, interpreting, completing complex medical forms, etc. Study implementation, needs assessment, community based participatory research, recruitment accrual to date, learned lessons, PN services offered, and referral to and effectiveness of the LCNC program and preliminary quality of life data analysis will be presented. Conclusions: Limited work has addressed the psychosocial needs of Latino cancer survivors. Culturally sensitive patient navigation (PN) could address these needs and significantly improve cancer survivorship. The results of the study will have immediate clinical relevance that could potentially highlight the importance of having patient navigators readily available to assist survivors within a clinic setting improving patients9 overall health outcomes and screening compliance. Citation Format: Amelie Ramirez, Sandra L. San Miguel, Edgar Munoz, Kip Gallion, Arely Perez, Leo Castillo, Sarah R. Arvey, Frank Penedo. Advocacy for an underserved minority: Patient navigation for Latino cancer survivors. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr B07.

Abstract 4450: Navigating Latinas with breast screen abnormalities to diagnosis: The Six Cities Study

Proceedings: AACR 103rd Annual Meeting 2012‐‐ Mar 31‐Apr 4, 2012; Chicago, IL BACKGROUND: We sought to compare time from initial abnormal breast screen to definitive diagnosis between navigated and non-navigated patients in racially/ethnically diverse Latina women in six U.S. cities. METHODS: Eligible Latinas had an abnormality of BIRADS 3, 4, or 5 detected on a mammogram, clinical breast exam, magnetic resonance imaging, or ultrasound between July 2008 and December 2010 in six U.S. cities (San Antonio, Miami, Houston, San Diego, New York, and San Francisco). Data were pooled for this analysis. Navigated patients received assistance by locally trained navigators using a patient-centered model suggested by Harold Freeman and endorsed by the Institute of Medicine. Non-navigated patient data was obtained via retrospective medical chart review. We used Log-Rank Chi-squared tests to evaluate bivariate associations with dependent variables and Kaplan-Meier and Cox Proportional Hazards analyses to compare time-to-diagnosis and timely diagnosis estimates between Navigated and Control group Latinas. RESULTS: Among 480 women with initial BIRADS 3, 4, or 5 results, follow-up data was available for 425 (88.5%). Radiologic classification of initial abnormality (BIRADS), rather than any other sociodemographic or clinical characteristic was the only significant predictor of overall and timely diagnosis. Data for women with an initial BIRADS 3 result were adjusted to control clinician-imposed diagnostic delays. Of all women, > 95% achieved definitive diagnosis within 180 days. Median time to definitive diagnosis was significantly reduced among navigated compared to non-navigated Latinas (20 days versus 27 days, hazard ratio [HR] 1.32, p = .007). This translates to a 132% increase in rates of diagnosis among navigated women. This effect was primarily observed in women with an initial BIRADS 3 result, especially when adjusted for clinically directed waiting periods between initial and follow-up screening examinations. Among navigated patients, only between-BIRADS variation rather than sociodemographic characteristics, number of barriers to care, insurance status or type or site-specific variables were associated with timely or time-to-diagnosis. CONCLUSIONS: Patient-centered navigation to assist Latina women with breast screening abnormalities reduces median time-to-diagnosis by approximately 25% when types of screening abnormality and barriers to care are addressed at patient level. Community-based interventions may be the most effective means to reduce cancer health disparities when addressing the needs of underserved populations. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 4450. doi:1538-7445.AM2012-4450

Abstract B51: Depression among Latino breast cancer survivors: A barrier to screening for colorectal and ovarian cancer

Background: In two previous studies, we observed that Latina women are unable to comply with recommendations for breast cancer care due in part to psychosocial barriers including inability to understand physicians and fear of recommendations. These are crucial findings, because ten percent of all new cancers are diagnosed in cancer survivors and second cancers are the sixth leading cause of cancer deaths. Breast cancer survivorship brings to the fore concern that survivors are obstructed from obtaining thorough preventive health screening services. Depression may also contribute to noncompliance via its inhibitory effect on vigilance and behavior change. Here we test a hypothesis that similar barriers in addition to depression level restrict breast cancer survivor screening for colorectal and ovarian cancer. Methods: We conducted a cross-sectional study of 117 Latina breast cancer survivors using self-report data. Proportions of respondents compliant and noncompliant with recommended screening protocols were compared. Reasons were coded “yes”-“no;” depression was measured with the Center for Epidemiologic Studies (CESD) instrument dichotomized at the usual cutoff of 16 points or higher signifying depression. Cancer screening compliance was determined by published NCI guidelines. Associations were determined via chi-squared analysis. Multivariate analysis was conducted using logistic regression. Results: Only 5 (4.2%) of participants were screened for both cancers, 43 (36.8%) for either cancer, and 69 (59.0%) were screened for neither cancer. Reported barriers to cancer care were generally high overall, but only “cannot understand English” (66% v 53%, p=.05) and “care is too expensive” (84% v 71%, p=.05) were associated with lack of ovarian cancer screening and none were associated significantly with lack of colorectal screening. Thirty-two percent of the sample met CESD criteria for depression, nearly twice the general population rate; it is associated with ovarian but not colorectal screening noncompliance. Factors including unemployment (74% v 57%, p=.03) and no familial history of cancer (75% v 53%, p=.02) are related to non-compliance with ovarian screening, but only unmarried status is related to non-compliance with colorectal screening (54% v 20%, p=.01). Separate multiple logistic regression analyses confirmed the independent significant association of these factors with ovarian and colorectal screening non-compliance, indicating good model fit and significant proportions of variance explained by the models. Discussion: There are significant impediments to cancer screening among Latina breast cancer survivors. They derive from multiple domains (demographic factors, psychosocial barriers, and affective states). For this reason they require further research to clearly identify them. Moreover we must develop an equally broad-based preventive strategy that addresses each of these domains to promote vigilance and increase healthy behaviors among Latina women. Acknowledgements: This research was possible by grants from the San Antonio Cancer Institute, San Antonio, Texas (P30-CA54174), the Susan G. Komen Breast Cancer Foundation (POP 2000 704), and the National Cancer Institute, Redes En Accion (U01-CA86117). Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):B51.

Abstract A35: Mothers and daughters: A key to acceptability of genetic testing for breast cancer among Latina women

Background: Breast cancer is a devastating disease. Identification of the BRCA1 and BRCA2 genetic mutations associated with it offer a potentially efficacious “early warning system.” However, investigators have expressed doubt that whether women are interested in knowing if they possess gene mutations, particularly minorities traditionally averse to dealing with a complex medical system. Additionally, effective means of addressing different levels of motivation among ethnic groups are unidentified. Here we determine the extent of interest in genetic testing among Latinas compared to non-Hispanic white (NHW) women. We also identify factors associated with interest in genetic testing. Finally, we show why differences in interest in genetic testing for breast cancer exist among groups of women. Material and Methods: We surveyed 290 women (153 Hispanic, 137 NHW) aged 26+ drawn from the catchment area of the San Antonio Cancer Therapy and Research Center. Targeted surveys included demographic information, measures assessing breast cancer knowledge, attitudes, behaviors, and medical and family history data. Based on verbal report, participants were assigned “high” or “moderate/low” cancer risk status according to American College of Medical Genetics Foundation guidelines. Pearson chi-square and student9s t-tests assessed bivariate relationships. Cochran Mantel-Haenszel chi-square identified analytic strata. Multivariate logistic regression revealed factors associated with interest in genetic testing. Results: 20% of women were not “very interested” in genetic testing for the BRCA1/BRCA2 mutation. Bivariate results showed ethnicity, use of nontraditional health care sources and negative perceptions of genetic testing were associated with low interest in genetic testing among all women. A multivariate model of genetic testing interest revealed several measures significantly associated with it, including Hispanic ethnicity (OR 5.74, p Conclusion: Genetic testing is generally acceptable to NHW and Hispanic women. However, Latinas are less likely to accept it than NHW. Whereas NHW women are influenced in their decision chiefly by use of nontraditional sources of medical care, Latinas are strongly influenced by perceptions of personal risk and having biological daughters. Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):A35.