BUSI 619 Week 7 Literature Review Final Example

Patient Navigation After an Abnormal Cancer Screening Result: A Final Literature Review for a Safety-Net Health System

Introduction

A screening test is only the first half of cancer prevention. When a mammogram, Pap test or stool test returns an abnormal result, the patient still needs further testing to learn whether cancer is present, and the value of screening depends on how quickly that happens. In our safety-net system, nearly 40% of patients with abnormal results waited longer than three months for a diagnosis last year, and about one in seven had no follow-up recorded at all. The patients most affected were uninsured, older, managing several chronic illnesses or living in the poorest neighborhoods we serve.

Delays of this kind are not simply a scheduling problem. Each abnormal result opens a series of steps, a referral, an authorization, an appointment for a diagnostic mammogram or colonoscopy, preparation, transportation and a follow-up visit to discuss results, and a patient can fall out of the process at any one of them. Our clinics send results by letter and rely on patients to call for appointments, a design that works for patients with stable housing, reliable phones and flexible jobs and fails many of the patients we serve. Patient navigation is a structured response to that problem. A navigator, often a trained lay health worker, follows a patient from the abnormal result to diagnostic resolution, the moment further testing settles the matter as cancer or as something benign, and helps remove obstacles along the way, from appointment scheduling and transportation to insurance questions and fear. This review asks: for safety-net adults whose breast, cervical or colorectal screen has come back abnormal, does patient navigation, set against standard follow-up, bring patients to a diagnosis sooner and leave fewer of them unresolved after twelve months? Melnyk and Fineout-Overholt (2015) describe evidence-based decision making as combining the best available research with organizational knowledge and patient preferences, and this review is intended to supply the research half of that combination for a decision our leaders now face.

Search History

I searched PubMed and CINAHL between Module/Week 1 and Module/Week 5 using combinations of the terms patient navigation, patient navigator, abnormal screening, diagnostic resolution, time to diagnosis, follow-up colonoscopy and fecal immunochemical test. Limits were English language and adult populations, with no date limit, since the largest trials were conducted between 2007 and 2012. After duplicates were dropped, 214 records remained. A title and abstract review set aside 166 of them, most because they studied navigation during cancer treatment, navigation for screening uptake only or settings outside the United States. Of the 48 full texts reviewed, I excluded 36: 14 were reviews or commentaries, 11 measured neither the interval to diagnosis nor whether follow-up was finished, 7 lacked a comparison group and 4 reported the same data as an included study. Twelve primary studies remained. Following the textbook's evidence hierarchy, six are randomized or controlled trials, four are secondary analyses of trial data and two are recent trials or program evaluations of centralized outreach.

Theme 1: A Real Benefit That Appears After the First Months

Every randomized study in the review found that navigation improved diagnostic follow-up, and the studies agree on an unexpected detail: the benefit is delayed. The national Patient Navigation Research Program pooled results from several centers, covering 10,521 people whose screens were abnormal, and found no advantage for navigation during the first 90 days, followed by a significant advantage from 91 to 365 days, with a pooled adjusted hazard ratio of 1.51 for reaching resolution (Freund et al., 2014). Its metaregression showed that navigation helped most at centers where usual care left patients waiting longest. Ohio's trial, which randomized 18 clinics rather than patients, saw the gap between arms turn significant at roughly the half-year mark and grow until, at 15 months, patients at navigation clinics were resolving at a rate about two thirds higher (Paskett et al., 2012). Tampa Bay's breast trial showed nothing for a quarter of a year and then a hazard ratio of 2.8 (Lee et al., 2013), and the colorectal trial showed only a marginal benefit that took a year to reach significance (Lee et al., 2014).

The Denver Health trial, the only one that randomized individual patients rather than clinics, reported a shorter overall time to resolution with navigation for breast, colorectal and prostate abnormalities, though not for the highest-risk mammogram findings, which clinicians tend to pursue urgently without help (Raich et al., 2012). One account fits all five studies: patients who were going to finish their workup promptly gain little from a navigator, while those headed for the cracks gain a great deal. The strength of evidence for this theme is high, since it rests on randomized trials, though clinic-level randomization and the dominance of a single research program mean the findings may travel less well to other settings.

Theme 2: Greater Benefit Where Burdens Are Heaviest, and Barriers Navigation Cannot Remove

Analyses of trial data show that navigation's effect is not uniform. Among 6,349 participants, patients with a comorbidity score of 2 or more experienced longer delays than those without chronic conditions, and they also gained the most from navigation (Whitley et al., 2017). Age did not blunt the effect: in Ohio, patients 65 and over who had a navigator were resolved by six months at more than twice the rate of their peers without one, roughly matching the gain among younger adults (DeSalvo et al., 2018). These subgroup findings sit below the trials themselves in the evidence hierarchy, but they agree with Theme 1: navigation's value grows with the difficulty a patient faces.

Some barriers, however, persist even with a navigator. In the Ohio trial data, patients of federally qualified health centers resolved more slowly than patients of an academic medical center, a gap explained by insurance, education and age rather than clinic type, with private insurance, a college education, higher income and older age each linked to faster resolution (Krok-Schoen et al., 2015). Place mattered as well: for the 801 Ohio women studied by neighborhood, each step up in local deprivation stretched the wait for a diagnosis (Plascak et al., 2014). Navigation helps patients move through these barriers, but it does not remove the poverty, distance and insurance gaps that create them, so programs that pair navigators with transportation, interpreter services and financial counseling are likely to reach further than navigation alone.

Theme 3: Navigation Inside Centralized Outreach, and the Problem of Reach

Recent studies test navigation as one part of centralized programs, usually for colorectal screening. At 12 North Carolina health center sites, a randomized trial that mailed stool kits and then assigned navigators to anyone testing positive lifted screening completion roughly threefold, and among those whose stool test was positive, colonoscopy followed within half a year for 68.8% in the outreach arm against 44.4% in usual care, though the small number of positive results left the follow-up comparison uncertain (Reuland et al., 2024). In 28 rural Oregon clinics serving Medicaid enrollees, a combined mailed-test and navigation program raised six-month screening completion from 4.5% to 11.8%, but fewer than six in ten patients with an abnormal result were ever offered a navigator (Coronado et al., 2025). Reaching patients takes work: in a large health center navigation study, 79.7% of patients assigned to a navigator were reached within 18 call attempts, nearly all of them within six (Gautom et al., 2024).

For a system like ours, which already runs a central call center for appointment reminders, this is encouraging, because navigation could build on staff and technology already in place. The newer trials confirm that navigation still works when a central team does it by phone, and they add a sober lesson: an intervention can only help the patients it actually reaches. The evidence for this theme is moderate, since the outcome in both trials was whether a colonoscopy happened, not how long resolution took, and positive tests were few.

Appraisal of the Body of Evidence

Taken as a whole, the evidence is stronger than most health services research can claim, but it has three weaknesses a decision maker should weigh. The first is design. Clinic- or center-level randomization was the norm, a choice that protects against navigators influencing control patients in the same clinic but can leave differences between sites, such as staffing or imaging capacity, that affect results. Only the Denver trial randomized individuals. The second is dependence: nine of the twelve studies came from the national research program or its sites, used similar navigation models and were conducted in the same years, so their agreement is partly a product of shared design rather than independent confirmation. The third is age. The main trials enrolled patients between 2007 and 2012, before patient portals, text reminders and centralized scheduling changed how follow-up is arranged. The two recent trials partly answer that concern, though both tracked whether a colonoscopy was done rather than the days it took. On the evidence hierarchy Melnyk and Fineout-Overholt (2015) set out, this literature rates strong for the existence of a benefit, moderate for its size in current practice and weak for questions of cost and long-term outcomes.

Biblical Integration

Jesus described a shepherd who leaves the ninety-nine in the open country to search for the one sheep that wandered, and who rejoices on finding it (English Standard Version Bible, 2001/2016, Luke 15:4-7). The parable fits the evidence closely. Navigation adds little for the patients who would have found their way, and it matters most for the few who would otherwise be lost: the patient with diabetes and heart failure, the older adult without a ride and the woman in the most deprived neighborhood. A health system that funds navigation is choosing to go after the one, and the research suggests that is exactly where the effort pays off. For a Christian administrator, that is both a stewardship argument and a moral one.

Implications for Our System

The findings speak directly to the design of our program. Because the benefit appears late, the program's first quarterly report will probably show little difference between patients with and without a navigator, and leaders should be told that in advance. Because the benefit is concentrated, four navigators should not be spread evenly across all 14 clinics; they should start where delays are longest and where patients carry the heaviest burdens. Because reach determines results, the program needs a registry that lists every abnormal result, assigns it to a navigator and records each contact attempt, so that no patient is missed simply because the referral never arrived. And because social barriers persist, the navigation budget should include a modest fund for rides and interpreter time, which the research suggests may decide whether navigation works for the poorest patients.

Conclusion and Recommendations

The answer to the review's question is yes, with qualifications. Patient navigation shortens the time to diagnostic resolution for safety-net patients with abnormal screening results, but its effect appears after the first few months, it is largest for patients with the heaviest burdens and it depends on reaching patients and addressing the barriers navigation cannot remove by itself. Missing from the literature are any estimate of what each additional resolved patient costs and any follow-up long enough to show effects on cancer stage or survival, and most trials were run before centralized telephone navigation became common.

Three recommendations follow for our system. First, evaluate the navigation program over at least twelve months, measuring time to resolution and the share resolved within a year, so that an early, misleading verdict does not end a working program. Second, assign navigators first to patients with two or more chronic conditions, adults aged 65 and older and patients with prior missed appointments. Third, track reach, the share of eligible patients actually contacted and offered help, as closely as outcomes, and pair navigation with transportation and interpreter support at the clinics serving the most deprived neighborhoods.

References

Coronado, G. D., Petrik, A. F., Leo, M. C., Coury, J., Durr, R., Badicke, B., Thompson, J. H., Edelmann, A. C., & Davis, M. M. (2025). Mailed outreach and patient navigation for colorectal cancer screening among rural Medicaid enrollees: A cluster randomized clinical trial. JAMA Network Open, 8(3), e250928. https://doi.org/10.1001/jamanetworkopen.2025.0928

DeSalvo, J. M., Young, G. S., Krok-Schoen, J. L., & Paskett, E. D. (2018). Characterizing time to diagnostic resolution after an abnormal cancer screening exam in older adult participants in the Ohio Patient Navigation Research Program. Journal of Aging and Health, 30(8), 1284-1304. https://doi.org/10.1177/0898264317715184

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Freund, K. M., Battaglia, T. A., Calhoun, E., Darnell, J. S., Dudley, D. J., Fiscella, K., Hare, M. L., LaVerda, N., Lee, J., Levine, P., Murray, D. M., Patierno, S. R., Raich, P. C., Roetzheim, R. G., Simon, M., Snyder, F. R., Warren-Mears, V., Whitley, E. M., Winters, P., . . . Paskett, E. D. (2014). Impact of patient navigation on timely cancer care: The Patient Navigation Research Program. Journal of the National Cancer Institute, 106(6), dju115. https://doi.org/10.1093/jnci/dju115

Gautom, P., Rosales, A. G., Petrik, A. F., Thompson, J. H., Slaughter, M. T., Mosso, L., Hussain, S. A., Jimenez, R., & Coronado, G. D. (2024). Evaluating the reach of a patient navigation program for follow-up colonoscopy in a large federally qualified health center. Cancer Prevention Research, 17(7), 325-333. https://doi.org/10.1158/1940-6207.CAPR-23-0498

Krok-Schoen, J. L., Kurta, M. L., Weier, R. C., Young, G. S., Carey, A. B., Tatum, C. M., & Paskett, E. D. (2015). Clinic type and patient characteristics affecting time to resolution after an abnormal cancer-screening exam. Cancer Epidemiology, Biomarkers & Prevention, 24(1), 162-168. https://doi.org/10.1158/1055-9965.EPI-14-0692

Lee, J. H., Fulp, W., Wells, K. J., Meade, C. D., Calcano, E., & Roetzheim, R. (2013). Patient navigation and time to diagnostic resolution: Results for a cluster randomized trial evaluating the efficacy of patient navigation among patients with breast cancer screening abnormalities, Tampa, FL. PLOS ONE, 8(9), e74542. https://doi.org/10.1371/journal.pone.0074542

Lee, J. H., Fulp, W., Wells, K. J., Meade, C. D., Calcano, E., & Roetzheim, R. (2014). Effect of patient navigation on time to diagnostic resolution among patients with colorectal cancer-related abnormalities. Journal of Cancer Education, 29(1), 144-150. https://doi.org/10.1007/s13187-013-0561-2

Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing and healthcare: A guide to best practice (3rd ed.). Wolters Kluwer.

Paskett, E. D., Katz, M. L., Post, D. M., Pennell, M. L., Young, G. S., Seiber, E. E., Harrop, J. P., DeGraffinreid, C. R., Tatum, C. M., Dean, J. A., & Murray, D. M. (2012). The Ohio Patient Navigation Research Program: Does the American Cancer Society patient navigation model improve time to resolution in patients with abnormal screening tests? Cancer Epidemiology, Biomarkers & Prevention, 21(10), 1620-1628. https://doi.org/10.1158/1055-9965.EPI-12-0523

Plascak, J. J., Llanos, A. A., Pennell, M. L., Weier, R. C., & Paskett, E. D. (2014). Neighborhood factors associated with time to resolution following an abnormal breast or cervical cancer screening test. Cancer Epidemiology, Biomarkers & Prevention, 23(12), 2819-2828. https://doi.org/10.1158/1055-9965.EPI-14-0348

Raich, P. C., Whitley, E. M., Thorland, W., Valverde, P., & Fairclough, D. (2012). Patient navigation improves cancer diagnostic resolution: An individually randomized clinical trial in an underserved population. Cancer Epidemiology, Biomarkers & Prevention, 21(10), 1629-1638. https://doi.org/10.1158/1055-9965.EPI-12-0513

Reuland, D. S., O'Leary, M. C., Crockett, S. D., Farr, D. E., Ferrari, R. M., Malo, T. L., Moore, A. A., Randolph, C. M., Ratner, S., Stradtman, L. R., Stylianou, C., Su, K., Tan, X., Tang, V., Wheeler, S. B., & Brenner, A. T. (2024). Centralized colorectal cancer screening outreach in federally qualified health centers: A randomized clinical trial. JAMA Network Open, 7(11), e2446693. https://doi.org/10.1001/jamanetworkopen.2024.46693

Whitley, E. M., Raich, P. C., Dudley, D. J., Freund, K. M., Paskett, E. D., Patierno, S. R., Simon, M., Warren-Mears, V., & Snyder, F. R. (2017). Relation of comorbidities and patient navigation with the time to diagnostic resolution after abnormal cancer screening. Cancer, 123(2), 312-318. https://doi.org/10.1002/cncr.30316