Bautista González, Elysse; (2024) Delays in lung cancer care in Mexico and the role of patient navigation programmes in early diagnosis and treatment:a mixed methods protocol. Doctoral thesis (Ph.D), UCL (University College London).

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Abstract

BACKGROUND: Prolonged cancer care intervals are highly associated with advanced-stage disease at presentation and increased public health costs. Nonetheless, lung cancer care intervals have not been quantified in Mexico. Patient navigation programs (PNP) seem promising tools to achieve early lung cancer care. However, literature on patient navigation in Mexico is scarce and previous systematic reviews have mainly relied on randomised controlled trial design or have focused solely on lung cancer screening. Thus, evidence is limited to understand the role PNP have in reducing prolonged cancer care intervals across the continuum. AIM: This thesis aims to investigate diagnostic and treatment timeliness in lung cancer care in Mexico and the role of PNP in reducing prolonged lung cancer care. METHODS: First, a mixed-methods systematic review was conducted to retrieve evidence of the effect PNP has on diagnostic and treatment timeliness among lung cancer patients. Additionally, it critically appraised the content related to the design, population, activities, and evaluation outcomes. Secondly, stakeholders from PNP in Mexico were identified, interviewed, and case studies formulated to compare each programmes characteristics and impact on diagnostic and treatment timeliness in cancer across the continuum of care. Thirdly, a qualitative examination of patient journeys was conducted through structured interviews with lung cancer patients (N=46) admitted to the National Cancer Institute (INCAN) in 2021. Coding was conducted inductively and thematic analysis used. Journeys were classified into public, private and mixed. The profiles of typical and atypical patients were presented using joint-display of triangulated qualitative and quantitative data. Additionally, primary data was collected from electronic health records of 2645 patients admitted to the INCAN from 2004-2021 to measure intervals from symptom onset to treatment. Linear regression models evaluated the association of lung cancer care intervals with clinical characteristics and social-determinants of health. Due to skewness of data, values were fitted and log-transformed. Patients were right-censored and survival analysis undertaken. Lastly, through mixed methods, results from the interviews and the electronic health records were triangulated. RESULTS: Eleven articles were eligible for the systematic review. Lung cancer PNP more frequently focused on researching the treatment interval using quasi-experimental, observational and experimental designs. Non-experimental evidence supports that PNP can increase lung cancer care timeliness, while experimental studies did not. The lack of strong evidence can be explained by heterogeneity in PNP design and evaluation, rendering the analysis with biased results. A PNP typology is built to explain why heterogeneity in evaluation and lack of design standardisation limits research conducted through systematic reviews. Five PNP were identified in Mexico, classified under the proposed framework and found to be different types of navigational care. However, all did not measure impact in timeliness in cancer care, hindering understanding of their impact on early diagnosis and treatment. The most frequent symptom is cough. Prolonged lung cancer care intervals are shown to be influenced by symptom appraisal, "normalisation" and disease awareness, access challenges, misdiagnosis, regional infrastructure disparities and financial constraints. Family plays a crucial role in urging patients to seek care. The electronic health record data showed 74% of patients were diagnosed with advanced stage lung cancer. The median time from symptom onset to treatment was 192 days. Variations in the total interval were determined by characteristics such as: age (p-value 0.002), sex (p-value <0.0001), type of symptom (dyspnoea p-value <0.0001, chest-pain p-value= 0.044), cancer stage (stage IV p-value= 0.034) and cancer type (SCLC p-value= 0.010). However, the role of covariates varied in each of the intervals studied. Overall, women experienced lower hazard of dying than men (p-value= <0.0001). However, other characteristics evidence differences in survival outcomes such as: education (p-value= 0.001) and region (p-value <0.0001). CONCLUSIONS: Results from the thesis evidence complementary, expanded, discordant, and confirmed meta-inferences of the reasons for prolonged lung cancer care intervals at the INCAN in Mexico. However, due to unstandardised PNP implementation and research (both at the international and local level), evidence does not support PNP increase timeliness across lung cancer care.

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