This clinical trial studies whether tailored patient navigation (PN) works to improve the uptake of lung cancer screening (LCS) in tribal communities in western Washington state. Lung cancer is the leading cause of cancer death in the United States among American Indian (AI) and Alaska Native (AN) people, and the incidence of lung cancer is higher in this population in the Northern and Southern Plains, Alaska, and Pacific Coast regions. In Washington state, AI/AN people also have twice the rate of commercial cigarette smoking than the overall population. LCS with annual low-dose chest computed tomography (CT) can reduce lung cancer death and is recommended in people 50-80 years of age with current or recent (within 15 years) tobacco use and a 20 pack-year or greater smoking history. Despite this, AI and AN people are less likely to receive LCS which may be due to barriers they face making it difficult to receive LCS. PN services are designed to guide a patient through the healthcare system and reduce barriers to timely screening, follow-up, diagnosis, treatment, and supportive care. The PN services in this trial have been tailored for the tribal communities in western Washington state. The services are designed to help participants overcome the unique barriers that their tribal communities face and improve the uptake of LCS.
OUTLINE: Participants are randomized to 1 of 2 arms. ARM 1: Participants receive tailored PN activities in support of the uptake and follow-up of LCS for 21 months. Participants also receive an educational handout on LCS on study. ARM 2: Participants receive enhanced usual care consisting of an educational handout on LCS and a warm hand-off to discuss LCS with their primary care physician (PCP) for 6 months. Participants then receive tailored PN services in support of the uptake and follow-up of LCS for 15 months.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
SCREENING
Masking
SINGLE
Enrollment
237
Receive tailored PN activities
Receive LCS educational handout
Receive enhanced usual care
Ancillary studies
Ancillary studies
Ancillary studies
Muckleshoot Tribal Clinic
Auburn, Washington, United States
South Puget Intertribal Planning Agency (SPIPA)
Shelton, Washington, United States
Completion of chest computed tomography (CT) (Aim 1.2)
Will be compared between arms using the Cochran-Mantel-Haenszel (CMH) test, accounting for the stratification variables used during randomization. Completion rates will also be estimated in each arm and 95% confidence intervals for the rates and their difference will be calculated using Wilson's score method. The single primary outcome will be tested using two-sided α = 0.05.
Time frame: Up to 6 months
Completion of low dose computed tomography of the chest (Aim 1.2)
Will be compared between arms using the CMH test. Will be tested using two-sided α = 0.05 without adjustment for multiplicity.
Time frame: Up to 21 months
Lung cancer screening (LCS) knowledge (Aim 1.2)
Will be compared between arms using a stratified Wilcoxon rank-sum test (van Elteren test). Will be tested using two-sided α = 0.05 without adjustment for multiplicity.
Time frame: At 21 months
Health-related quality of life (Aim 1.2)
Will be measured using the Short Form 36 Health Survey questionnaire. Will be compared between arms using a stratified Wilcoxon rank-sum test (van Elteren test). Will be tested using two-sided α = 0.05 without adjustment for multiplicity.
Time frame: At 21 months
Rate of reported 30-day cessation period (Aim 1.2)
The impact of navigation on tobacco cessation will be explored by the rates of a reported 30-day cessation period during the intervention period as measured by self-reported 30-day floating abstinence.
Time frame: Up to 6 months
Completion of chest CT (Aim 2)
Quantitative analyses will use structural equation models (SEM) to understand the relationships between measured and latent variables representing barriers, facilitators and social determinants of health and the outcome of CT completion.
Time frame: Up to 6 months
Navigation care engagement (Aim 2)
Quantitative analyses in this aim will use SEM to understand the relationships between measured and latent variables representing barriers, facilitators and social determinants of health and the outcome of navigation care engagement. Measure of reach will be operationalized as an ordinal scale based on care completion activities along the LCS continuum as documented in the electronic health record.
Time frame: Up to 21 months
Completion of chest CT (Aim 3)
The rate of chest CT completion during the maintenance phase in the control arm (after navigation is offered) will be estimated and compared with the rate during the trial phase (before navigation was offered) using Poisson regression with the log link. The phase (trial versus maintenance) will be modeled using a time varying covariate, where each participant will contribute an outcome for each phase in which they are still "at risk" for completing CT (i.e., until first CT completion or end of follow-up). Models will include additional key covariates, including clinical site, smoking status, and prior reported LCS. Generalized estimating equations will be used to account for multiple periods per participant and potential overdispersion.
Time frame: Up to 15 months
Completion of next diagnostic step in LCS follow-up
Adherence to follow-up will be assessed as binary completion of the next step in follow-up among those with a completed chest CT during the randomized controlled trial. Appropriate next step in follow-up is determined through the Lung CT Screening Reporting and Data System (Lung-RADS) system, with most participants having negative initial CT (Lung-RADS 1 or 2) with follow-up assessed at 11-15 months. Adherence rates will be estimated as a proportion with 95% confidence intervals, summarized overall and stratified by Lung-RADS.
Time frame: Up to 15 months
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