Patient navigation programs have been primarily undertaken within the breast cancer setting
[5, 37]. Because prostate cancer differs in disease progression and quality of life implications, however, the investigation of the efficacy of patient navigation within the prostate cancer continuum is warranted. Weinrich et al. previously reported that the use of a prostate cancer education program combined with a navigator resulted in increased prostate cancer screening rates among African American men
. Yet, to date, no studies have been published on the effect of patient navigation on compliance with prostate cancer diagnosis or treatment among men with an abnormal prostate screening test. Our study is the first to evaluate these outcomes.
Given equivocal evidence presented in the PLCO and ERSPC studies on the efficacy of prostate cancer screening in reducing mortality
[39, 40], attention needs to be directed at intervention entry points (screening, cancer diagnosis, treatment), particularly for prostate patient navigation interventions. It is well settled that an elevated PSA can represent several medical conditions beyond prostate cancer, including prostatitis and benign prostatic hypertrophy. PSA can also be artificially and transiently elevated by recent digital rectal examination, prostate needle biopsy, and recent sexual activity. Therefore, the limitations of an abnormal PSA test alone must be taken into consideration when implementing a navigation intervention. Our study adequately addressed this concern, as it focused on men whose prostate cancer screening results, history, and clinical presentation to the urologist reflected a high probability of prostate cancer, thus resulting in a referral for biopsy.
In addition, our study was uniquely implemented at a VA hospital, an equal-access setting with a range of preventive and treatment services. Prior to implementation of the PNRP, most studies reporting on efficacy of navigation on screening, diagnosis, or treatment had been conducted in the community clinic setting
[5, 37]. Despite reduced financial barriers to entry, however, a study examining over thirteen thousand veterans with an abnormal prostate cancer screening test result found that one-third received incomplete follow-up
. Our study site involved rotating resident physicians from two large academic research hospitals, at times introducing disconnect in provider-patient relationships, which may impact resolution rate
[42, 43]. Our patient navigators filled this gap by building rapport and trust through the tenure of the patient’s cancer care continuum to ensure that abnormal screens reached resolution.
While the methods we outlined in this study were compatible with our clinic site, they may not be generalizable across non-VA facilities, facilities with multiple genders, different geographic regions, and non-urban settings. Given centralized care at the VA, we chose a hospital-based framework, whereas other PNRP programs extended into patients’ homes and communities to best meet the needs of their targeted populations
. Additionally, the average age of men in our study was 65, mandating clinical considerations more specific to the elderly and the weighing of risks and benefits of the more aggressive therapies usually reserved for and selected by younger patients, particularly within the VA
. While caution relative to overtreatment resonates across all age groups in the literature, some studies raise the issue of under treatment of cancer among the elderly and support risk-stratified approaches to prostate cancer care management
[46, 47]. Against this backdrop, a large component of our patient navigation intervention focused on facilitating patient education and connecting patients with resources to guide them through the treatment decision-making process.
Throughout the implementation of the intervention, we learned many valuable lessons that may benefit emerging navigation programs. First, as previously described, in response to repetition between the roles of our initial nurse practitioner navigator and clinic-based nurses, we adapted our model to include a social worker and lay health navigator who worked closely with the VA nurses to facilitate clinical needs. Programs planning navigation team composition should consider utilizing existing providers with the requisite knowledge. This approach supports a smooth clinical research transition and facilitates timely study initiation. Second, our project was originally designed to prospectively enroll navigated and control participants at two demographically similar VA outpatient clinics. Due to a hospital merger prior to accrual, we adapted our design to include a concurrent records-based control group drawn from the same VA clinic as the navigated patients. Future navigation studies should similarly be prepared to adapt quickly to unanticipated clinic site changes. Finally, since our navigators lacked access to the VA appointment scheduling system, they focused on patient adherence to scheduled visits to prevent delayed follow-up. Thus, intervention approaches that similarly comprise proactive measures—envisioning and actuating issues that could introduce delay—rather than reactively resolving patient-identified barriers can be invaluable in reaching targeted navigation goals.