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A Navigator Delivered Skills Intervention to Improve Communication and Decision-Making Among African American Breast Cancer Patients
Background: Although Black women have a lower incidence of breast cancer than White women, they are more likely to present with advanced disease and have greater mortality. Nowhere is this disparity more pronounced than in the nation’s capital. Despite comparable rates of mammography, Black women’s mortality rate (42.6) is twice that of Whites. Disparities in access to treatment, such as adjuvant chemotherapy have been noted. Communication and shared decision-making (SDM) may increase rates of optimal treatment and improve cancer outcomes. Several unique factors may affect the quality of communication and SDM for Blacks such as less participatory encounters, provider bias, cultural and psychosocial barriers (e.g., fatalism, distrust) and experiences of institutional racism. Cancer navigators have been effective in improving access to cancer screening and follow-up in minority populations. We propose to build upon our current work to extend this paradigm to cancer treatment for newly diagnosed black breast cancer patients. The aims of this two-year project are to: 1) Describe black women’s attitudes towards chemotherapy, and to evaluate the role of cultural factors (i.e., fatalism), age, and socioeconomic status on chemotherapy attitudes (Year I); 2) Develop and test the feasibility and acceptability of a patient targeted communication and SDM skills intervention (Year II); 3) Explore the role of a culturally tailored patient skills intervention in improving intermediate outcomes (i.e., decision satisfaction, decision anxiety), short-term quality of life and use of chemotherapy (Year II). Study Design. A pretest-posttest design will be used. In the first phase, qualitative data will be collected from 37 breast cancer survivors, to develop a patient skills booklet. In the second phase 80 newly diagnosed breast cancer patients will complete a baseline survey that will include validated items regarding (e.g., Functional Assessment of Cancer Therapy). Patients will receive a face-to-face session with a trained navigator (survivor) assisted by the patient skills workbook. Topics covered will include improving patients’ understanding of chemotherapy and communicating with physicians. Within three months, women will be contacted to assess intermediate outcomes (e.g., decision satisfaction), short-term quality of life, and chemotherapy adherence. Outcomes/Benefits. Participants will benefit by enhancing their communication and decision-making skills.
A diagnosis of breast cancer can elicit fear, anxiety and uncertainty about which treatments to take. For many black women, this experience is exacerbated by late stage diagnosis and inadequate access to care. Disparities in access to treatment have been noted with black women receiving less aggressive and standard treatments when compared to whites. Furthermore, reports indicate that black women have less participatory medical consultations than whites and poorer patient-provider communication. Improving communication skills during treatment particularly for older and low income black women may help to improve adherence to recommendations, thereby improving rates of cancer survival.
Cancer navigators have proven effective in improving access to cancer screening and follow-up in minority populations. We propose to extend this paradigm to cancer treatment. Specifically we will design and tailor navigation decision support for newly diagnosed black women that will include face-to-face skills training and educational workbooks to assist black women in communicating with their providers about breast cancer treatment. We will collect qualitative data to determine the decision-making preferences of this priority population and to identify breast cancer communication barriers and facilitators. Using this information, we will develop a culturally tailored patient skills intervention and conduct a process evaluation of its acceptability with peer navigators, breast cancer patients and providers. We will also explore the intervention’s preliminary impact on women’s use of chemotherapy.
To evaluate the intervention, we will establish participants' baseline communication competency, decisional anxiety, and then record their improvements in these areas. We will also assess patients’ acceptance of and satisfaction with the navigation intervention and compare women’s baseline and follow-up intermediate and treatment outcomes.