Effect of Apoyo con Cariño (Support With Caring) Trial of a Patient Navigator Intervention to Improve Palliative Care Outcomes for Latino Adults With Advanced Cancer

Abstract

IMPORTANCE Strategies to increase access to palliative care, particularly for racial/ethnic minorities, must maximize primary palliative care and community-based models to meet the ever-growing need in a culturally sensitive and congruent manner. OBJECTIVE To investigate if a culturally tailored patient navigator intervention can improve palliative care outcomes for Latino adults with advanced cancer. DESIGN, SETTING, AND PARTICIPANTS The Apoyo con Cariño (Support With Caring) randomized clinical trial was conducted from July 2012 to March 2016. The setting was clinics across the state of Colorado, including an academic National Cancer Institute-designated cancer center, community cancer clinics (urban and rural), and a safety-net cancer center. Participants were adults who self-identified as Latino and were being treated for advanced cancer. INTERVENTION Culturally tailored patient navigator intervention. MAIN OUTCOMES AND MEASURES Primary outcome measures were advance care planning in the medical record, the Brief Pain Inventory, and hospice use. Secondary outcome measures included the McGill Quality of Life Questionnaire (MQOL), hospice length of stay, and aggressiveness of care at the end of life. This study used an intent-to-treat design. RESULTS In total, 223 Latino adults enrolled (mean [SD] age, 58.1 [13.6] years; 55.6% female) and were randomized to control (n = 111) or intervention (n = 112) groups. Intervention group patients were more likely to have a documented advance directive compared with control group patients (73 of 112 [65.2%] vs 40 of 111 [36.0%], P < .001). Both groups reported mild pain intensity (mean pain rating of 3 on a scale of 0-10). Intervention group patients had a mean (SD) reported change from baseline in the Brief Pain Inventory pain severity subscale score (range, 0-10) of 0.1 (2.6) vs 0.2 (2.7) in control group patients (P = .88) and a mean (SD) reported change from baseline in the Brief Pain Inventory pain interference subscale score of 0.1 (3.2) vs −0.2 (3.0) in control group patients (P = .66). Hospice use was similar in both groups. Secondary outcomes of overall MQOL score and aggressiveness of care at the end of life showed no significant differences between groups. The MQOL physical subscale showed a mean (SD) significant change from baseline of 1.4 (3.1) in the intervention group vs 0.1 (3.0) in the control group (P = .004). CONCLUSIONS AND RELEVANCE The intervention had mixed results. The intervention increased advance care planning and improved physical symptoms; however, it had no effect on pain management and hospice use or overall quality of life. Further research is needed to determine the role and scope of lay navigators in palliative care. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01695382

Patient Navigation to Improve Early Access to Supportive Care for Patients with Advanced Cancer in Resource-Limited Settings: A Randomized Controlled Trial

“…Approximately 17 million people with cancer are in need of supportive and palliative care, of which almost 80% live in low-and middle-income countries (LMIC) [2]. The early provision of palliative care can improve QoL, symptoms, advance care planning, and survival among patients with advanced cancer, and the American Society of Clinical Oncology (ASCO), among others, has recommended implementing multidisciplinary specialized supportive and palliative care early in the course of the disease [1,[3][4][5][6]. Unfortunately, this early integration of supportive and palliative care seldom happens in LMIC due to a lack of training and infrastructure, and most palliative care interventions are provided near the end of life [7,8].…”

Puente para cuidar (bridge to caring): A palliative care patient navigator and counseling intervention to improve distress in Latino/as with advanced cancer

“…Because the counseling and the patient navigator intervention demonstrated efficacy on several outcomes in multisite trials, the purpose of the pilot was to assess feasibility specific to the integrated intervention, such as the use of both a counselor and patient navigator, culturally adapted counseling, video visits, and video vignettes. The eligibility criteria included adults (≥18 y of age) who self‐identified as Latino/a and were (a) diagnosed with stage III/IV cancer, (b) receiving treatment for their cancer and not enrolled in hospice, (c) not incarcerated or pregnant, and (d) experiencing at least moderate distress (≥4 on the National Comprehensive Cancer Network Distress Thermometer) or had a positive screen for depression (Patient Health Questionnaire‐2 [PHQ‐2] score ≥ 3) or anxiety (Generalized Anxiety Disorder‐2 [GAD‐2] score ≥ 3) .…”

“…To address these gaps, we developed an integrated care program that combines two successful interventions that previously demonstrated efficacy on complementary outcomes in multisite randomized clinical trials . The first intervention, Collaborative Care to Alleviate Symptoms and Adjust to Illness (CASA), improved depression ( d = −0.34; 95% CI, −0.60 to −0.08; P = .01) and anxiety ( d = −0.28; 95% CI, −0.53 to −0.03; P < .001) in patients with symptomatic heart failure at 3 months.…”

“…While the CASA study enrolled a diverse population, the CASA counseling intervention content and materials were not culturally tailored and only delivered in English. The second intervention, Apoyo con Cariño (Support through Caring): Improving Palliative Care for Latino/as Adults with Advanced Cancer using a Patient Navigator Intervention (Apoyo), increased advance directive documentation in Latino/as with advanced cancer (65.2%) compared with the control group (36.0%, P < .001) . The Apoyo intervention was delivered through lay patient navigators.…”

Top Ten Tips Palliative Care Clinicians Should Know About Integrating Population Health Principles into Practice

“…Patient navigators-who may or may not have a clinical background-aim at ensuring timely access to needed health care services by guiding patients through the increasingly complex health care system and helping them to overcome barriers to care. 22,23 The flexible longitudinal relationships that care managers and patient navigators have with patients and caregivers uniquely position members of this workforce as sources of support for navigating serious illness.…”