November 7, 2014

Nurse navigators may aid colon cancer screening follow-up

After positive screening test, they may help Group Health patients get needed diagnosis

SEATTLE—Group Health patients with a positive screening test for colon cancer (a stool test or sigmoidoscopy) tended to be more likely to get the recommended follow-up test, a diagnostic colonoscopy, if nurse navigators contacted them than if they got usual care. This is according to “Results of Nurse Navigator Follow-up After Positive Colorectal Cancer Screening Test: A Randomized Trial” in the November-December Journal of the American Board of Family Medicine, led by Beverly B. Green, MD, MPH, a Group Health physician and a Group Health Research Institute associate investigator. 

“The effect didn’t reach statistical significance, partly because rates of screening and follow-up were already so high at Group Health—among the highest reported,” said Dr. Green, who is also an associate clinical professor at the University of Washington (UW) School of Medicine. The reason follow-up rates were already so high at Group Health is that usual care includes a reminder system that alerts patients’ doctors when follow-up testing is needed and hasn’t been done.

“Our study showed that combining this systems approach with nurse navigation resulted in colonoscopy follow-up rates exceeding 92 percent,” she said, “with 10 percent of that attributable to the nurse navigators.”

In 2013 Dr. Green showed that colon cancer screening rates doubled at Group Health with systematic use of electronic health records. The new study is a follow-up trial within that larger Systems of Support to Increase Colorectal Cancer Screening Study (SOS).

Group Health uses the electronic medical record to offer a yearly stool test or a colonoscopy every decade to patients of average risk of cancer of the colon and rectum. When the SOS trial was done, sigmoidoscopy was also an option that patients could choose for screening.

Dr. Green has shown that systematically mailing stool tests to patients each year is a promising way to help prevent disparities in colon cancer screening.

“Screening for colorectal cancer saves lives,” Dr. Green said, “but only if people are screened—and if they receive prompt diagnostic testing to follow up on screening tests that suggest that cancer might be present.” Around one in three people who have a positive stool test or positive sigmoidoscopy turn out to have either colorectal cancer or an advanced pre-cancer that can be removed during colonoscopy.

Award R01CA121125 from the National Cancer Institute supported this research.

Dr. Green’s coauthors were Jessica Chubak, PhD, associate investigator, Melissa L. Anderson, MS, senior biostatistician, and Sharon Fuller of Group Health Research Institute; Ching-Yun Wang, of the Fred Hutchinson Cancer Research Center in Seattle; Sally W. Vernon, PhD, of the University of Texas School of Public Health in Houston; and Richard T. Meenan, PhD, of the Center for Health Research at Kaiser Permanente Northwest in Portland, OR. Dr. Chubak is also an affiliate associate professor of epidemiology at the UW School of Public Health. The nurse navigators were Group Health’s nurses, Sandy Randles, RN, and Diana Griffith, RN.

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Jessica Chubak, PhD

Senior Investigator
Kaiser Permanente Washington Health Research Institute

Melissa L. Anderson, MS

Principal Collaborative Biostatistician
Kaiser Permanente Washington Health Research Institute