Adaptation and Implementation of an Evidence-Based Patient Navigation Intervention for Adolescent and Young Adult Cancer Survivors

PROJECT SUMMARY/ABSTRACT Extraordinary advances in cancer detection and treatment have led to an unprecedented number of cancer survivors, particularly those diagnosed between 15-39 years of age. This growing population of adolescent and young adult (AYA) cancer survivors have complex health care needs requiring coordinated care, including surveillance for cancer recurrence, management of long-term and late effects, and appropriate preventive and primary care. AYAs are at unique developmental and life stages regarding their emotional, cognitive, and social development, and cancer diagnosis and treatment is highly disruptive to establishing families, completing education, and/or starting employment. Serious gaps in care have been identified for AYA survivors, including underuse of guideline-recommended surveillance such as mammography, colonoscopy, and screenings based on treatment exposures, as well as underuse of primary care services such as vaccinations and disease screenings. Additionally, AYA survivors experience significant disparities in care and outcomes associated with race, ethnicity, and socioeconomic status. High-quality, equitable, comprehensive AYA cancer survivorship care requires primary care-based patient navigation. Team-based primary care with patient navigation has been shown to improve receipt of cancer screening, surveillance, and primary care services in other patient populations, particularly in underserved populations at higher risk for gaps in care, and can address common barriers associated with health disparities including insurance and financial barriers, coordination, transportation, language, and lack of social support. However, there are few, if any, patient navigation models of survivorship care focused on AYA cancer survivors. Following the structure of the NCI two-phase cooperative agreement we propose to: 1) Adapt an existing cancer-focused patient navigation program to the AYA survivor population; and 2) Conduct a pragmatic stepped wedge hybrid effectiveness- implementation trial within a large integrated healthcare system, Kaiser Permanente Southern California. We will adapt an existing, evidence-based patient navigation program guided by a novel combination of implementation frameworks, including RE-AIM, the Framework for Reporting Adaptations and Modifications, and Escoffery's 11 steps of adaptation. Once adapted, the program will be assessed using a pragmatic stepped wedge hybrid type-2 effectiveness implementation trial in 35 primary care clinics with an estimated 850 AYA survivors, designed using the PRECIS-2. The primary clinical effectiveness outcome is quality of care, based on National Comprehensive Cancer Network guidelines for surveillance and the United States Preventive Services Task Force recommendations for preventive care. The primary implementation outcomes are based on Proctor's Implementation Outcomes Framework. We will also assess if mechanisms of effect are moderated by patient, clinician, or clinic-level factors. Our results will provide definitive evidence on the effectiveness of a scalable primary care team-based patient navigation program for AYA cancer survivors.