Cost and activity analysis for a citywide patient navigation intervention to engage underserved patients in breast cancer treatment: Findings from the Translating Research Into Practice study

Short abstract

This study presents findings from a cost and activity analysis of a citywide hospital‐based patient navigation program to engage women in timely breast cancer treatment post‐diagnosis. The information may be useful for payors in reimbursing navigation activities and health systems in planning for high quality navigation programs to ensure patient‐centered and timely treatment for women diagnosed with breast cancer.

Abstract

Background

Patient navigation is an evidence‐based intervention for reducing delays in cancer care for underserved populations. There are limited economic evaluations of patient navigation in the US health care system and few have considered costs at various phases along the implementation spectrum. Having economic data, including costs and cost savings, can support sustainability of patient navigation programs. This study presents findings from a cost and activity analysis of a citywide hospital‐based patient navigation program to engage women in timely breast cancer treatment post‐diagnosis.

Methods

This study was conducted as part of Translating Research Into Practice (TRIP), a citywide patient navigation hybrid effectiveness‐implementation research study conducted at five cancer care hospitals in Boston, Massachusetts. The authors surveyed participating patient navigators and supervisors about their tasks and level of effort over consecutive 10‐day periods from 2019 to 2021. Patient navigators documented the time spent on activities in accordance with an 11‐step protocol across five sites. Cost data were collected from annual fiscal year end expenditure hospital administrative databases at concurrent time frames. Descriptive analyses were used to calculate average time on tasks, cost per activity and cost per outcome. Cost savings were estimated by calculating the additional persons engaged in timely entry to treatment compared to a matched control group with respect to hospitalization and emergency room costs averted.

Results

Average time spent per day on TRIP‐specific navigation activities was approximately 3 hours (range, 0–8 hours) and the average time per patient per day was 25 minutes (n = 7 navigators). Total costs for clinical site interventions were $218,394 for startup and $392,407 for maintenance costs over the study period. A total of 223 patients were served during the intervention period with an average cost per patient of $979 for startup and $1759 for maintenance. Potential costs savings with the TRIP navigation program from averted hospitalization and emergency room visits for 63 additional patients who received timely treatment is estimated at $21,798–$30,429 and $2536–$5692 per patient, respectively, compared to treatment as usual.

Conclusions

The economic evaluation in this study provides insight into startup and implementation costs for uptake and scalability of navigation programs across a citywide system. The information may be useful for payors in reimbursing navigation activities and health systems in planning for high quality navigation programs to ensure patient‐centered and timely treatment for women diagnosed with breast cancer.

INTRODUCTION

Despite the strong evidence for patient navigation as a key component for improving patient care and reducing disparities in cancer care, the investment of navigators as part of the cancer care team in health systems remains suboptimal. ¹ , ² , ³ , ⁴ Many navigation programs continue to depend on grant or philanthropic funding, which can lead to program interruptions with a resultant lack of continuity of care given high staff turnover. Having health care systems invest in navigation programs may support continuity and quality of care as well as potentially provide cost savings to the system.

However, economic evaluations for cancer patient navigation programs have tended to focus on screening ⁴ , ⁵ with fewer studies across the care continuum estimating the costs and cost per outcomes of a program. ⁴ , ⁵ , ⁶ , ⁷ , ⁸ Cost analysis provides information that can support decision makers in health care delivery systems and insurance plans for integrating navigation programs into service delivery as a sustainable position in the health care workforce. More evidence is needed to support a business case for navigation programs and provide health care system leaders with information for better planning services. ⁹ This is especially important as of January 2024 when Medicare began paying for navigation services. Cancer centers nationwide require guidance on what additional financial resources may be necessary for these lifesaving programs, even with the recent roll‐out of some allowable Medicare reimbursement. ¹⁰

In this article, we present findings from a cost and activity analysis for Translating Research into Practice (TRIP), a citywide patient navigation implementation study across five Boston‐area hospitals. This cluster‐randomized, stepped‐wedge type 1 hybrid effectiveness‐implementation study adopted a standardized 11‐step navigation protocol ¹¹ to address city‐wide disparities in breast cancer outcomes. ¹¹ , ¹² by prioritizing patients most likely to experience delays in care. Guided by Proctor’s framework on implementation outcomes, we share findings from our cost assessment. ¹³ , ¹⁴ For this study, our aim was to address the implementation research evidence gap on costs for integration of navigation programs into cancer care.

MATERIALS AND METHODS

Data sources and/or collection

Our cost‐related methodology and study protocol were published previously. ¹⁵ In brief, we used a community‐engaged approach, collaborating with participating navigators and supervisors, to design and implement the cost and activity data collection. For the activity analysis, a self‐administered time motion survey was conducted at each site during a 10‐day consecutive period between 2019 and 2021 to assess navigator and supervisor tasks and time allocated. Survey data included four domains in accordance with an 11‐step navigator protocol. ¹¹ These domains included: patient management activities (identifying eligible patients, tracking patients, and monitoring caseloads); direct patient contact (social needs assessments, accompaniment to medical visits, counseling/education about treatment, and insurance‐related calls); navigation on behalf of patients (contact such as communicating and meeting with community providers about resources and calls with physicians about patient treatment plan); and other navigation‐related activities (such as participation in training and supervision‐related opportunities). For supervisors, additional survey categories included: project administration (TRIP‐related meetings); patient enrollment (identifying TRIP eligible patients); administrative supervision (time managing navigator case load and work hours); clinical supervision (patient case conferencing and treatment plans and team communication and coordination); quality assurance (monitoring social determinants of health and patient registry data); and other study‐related activities to support navigators (including time and travel for meeting).

Navigators and supervisors participated in the survey design and self‐tracked their time spent on each activity in 15‐minute increments for up to 8 hours per day once during the 10‐day data collection period. Staff also reported the number of TRIP patients served each day, if applicable. Members of the research team reviewed the records and met with teams to resolve any discrepant values and verify data quality.

For the cost analysis, we used a micro costing approach ¹⁶ , ¹⁷ , ¹⁸ to collect program expenditure data using a standardized administrative record worksheet. Site administrators/financial managers completed the worksheet using administrative reports with cost elements during a specific fiscal time period from 2019 to 2021 based on each site’s startup and implementation periods. The worksheet included the following domains: fixed labor costs, fixed nonlabor costs, and variable nonlabor costs including supplies and equipment. Site administrators documented costs related to startup and implementation phases of the intervention and across two stakeholder levels: 1) an administrative core that included a clinical advisory panel (CAP) team that was responsible for overall planning, guidance, and technical assistance to participating site navigation teams at the five sites; and 2) the clinical site teams who implemented the intervention across the five hospitals. The time motion survey and cost analysis worksheet are available at https://link.springer.com/article/10.1186/s12913‐022‐08192‐y#Sec12.

Cost measurements

Startup costs included personnel costs, meeting time for design of the social determinants of health (SDoH) screening tool and registry in collaboration with CAP members, technical support for the development of the patient registry, and training for the navigation protocol across the five hospitals. Training costs were collected from workshops conducted by the administrative core team at each site and total and average costs were calculated based on the hourly rates of the navigators. Implementation costs for clinical sites included personnel costs for the navigators and key supervision personnel, ongoing training, fringe benefits, supplies, equipment, and overhead costs. Intervention costs for the administrative core team included personnel costs, supplies, and equipment for administrative support for CAP and navigator meetings, and on‐going data management and training activities related to the standardized navigation protocol.

Activity and cost analysis

We performed an economic analysis of the TRIP navigation program from a health system and organization perspective, using costs associated with the participating institutions. We did not include the cost for the patients or the nonhealth‐related costs. ¹⁹ , ²⁰ , ²¹ For the activity analysis, we used descriptive analyses gathered from the time motion survey to assess average and total time spent on activities per day and per patient, and by navigator type (patient vs. nurse navigator). We used the Winsor method ²² to adjust for influential observations of one patient navigator when the amount of time exceeded 8 hours/day. This adjustment was to the “patient management” domain given this was the category that had exceeded 8 hours. First, we calculated the time exceeding 8 hours/day. Next, we calculated the percentage of time for each activity of the total patient management category. Then using this percentage, we calculated the estimated time exceeded for each activity and then subtracted from the total time exceeded for all patient management activities.

For the cost analysis, we calculated the total startup and implementation costs associated with developing and implementing the navigation shared registry and SDoH screening systems, training and materials costs and navigator personnel costs. Total costs combined the administrative core and the clinical site intervention team costs. Costs were annualized in 2019 dollars.

For this cost analysis, we used the clinical outcome of timely treatment that we defined as initiation of any treatment (medical, surgical, or radiation) within 60 days of diagnosis for triple‐negative and HER2+ cancers and 90 days for all others. Other outcomes included patient emergency room visits and hospitalizations during the first year after diagnosis. All outcome data were gathered from chart abstraction for the subset of TRIP participants between 2019 and 2021. The subset of TRIP participants served was calculated to align with the cost data collected at each of the five sites.

We examined five cost measures: total costs, cost per patient served, average cost per site, cost per protocol activity, and cost per additional patient engaged in primary breast cancer treatment. Cost per protocol activity included patient management tasks, direct patient contact, including patient education, navigating without patient contact (coordination with providers only), and other navigation‐related activities. This cost was calculated from a supervisor and navigator survey on the estimated time spent on activities multiplied by the wage and fringe rates paid at each health care system.

For cost per outcome, we calculated the cost per additional patient engaged in timely treatment compared to the control group. To adjust for risk, intervention, and control group patients were matched on age, race, ethnicity, language, insurance status, and geographic residence (Boston vs. Greater Boston area). We first examined the difference in proportion for timely initiation of treatment for navigation versus the matched control group. Using this difference in proportions, we estimated the additional number of patients from the matched control that would have received timely treatment had they been assigned a navigator and estimated the savings in treatment costs for delays.

Cost savings were defined as cost per hospitalizations and emergency room visits averted using MassHealth reimbursement rates. We extracted reimbursement rates based on diagnostic codes from the Commonwealth of Massachusetts, Executive Office of Health and Human Services 101 CMR 317.00: Rates for Medicine Services. ²³ Hospital stays included initial care, observation/day evaluation/day and discharge for a total of $346 (patient of moderate severity) to $483 (patient of high severity). Emergency room visit rates were $40.26–$90.36 for patients with moderate to high severity. All rates were effective July 2021. ²³

The analysis was conducted only within the study period and did not include discounting of future costs or effects. We did not assess cost‐effectiveness because no comparable control cost data exist to assess incremental costs between the navigation intervention and the historical control groups.

All human subjects research was conducted in accordance with the guidelines of the Boston University/Boston University Medical Center (BUMC/IRB) institutional review board. The study was approved and granted a waiver of informed consent by BUMC IRB (protocol H‐37314).

RESULTS

A total of seven navigators (two nurse navigators and five nonclinical patient navigators) and three supervisors completed the survey across the 5 participating sites. During the 2019–2021 study period a total of 223 patients received TRIP navigation services as documented in the patient registry and aligned with the cost data collection period.

Activity and time on navigator and supervisor tasks

Table 1 describes the activity analysis across the navigators and supervisors from the time motion survey. Among the seven participating navigators, an average of 3 hours per day was spent on TRIP navigation activities. The greatest amount of time was spent on patient management tasks, a total of 56 hours per week and an average of 94 minutes per day (range, 0–135 minutes). Approximately 36 hours per work week were spent on direct patient contact, with an average of 54 minutes/day (range, 0–240 minutes) per work week. We found no differences in activities by navigation type. For supervisors, the greatest amount of time was spent on administrative supervision (average, 27.7 minutes [0–60 minutes]) followed by administrative documenting on TRIP (average, 15.0 minutes [0–60 minutes]), navigating without patient contact (average, 14.4 minutes [0–30 minutes]), and clinical supervision (average, 13.3 minutes [0–60 minutes]). The average patient caseload per navigator per day ranged from one to three TRIP participants (0–4 participants) across the five sites. Supervisors saw on average one patient per day.

TABLE 1.

Time spent by navigator and supervisors per activity per work week across five hospitals.

	Total time spent (hours) per week a	Mean time spent (minutes) per navigator per day (min/max) b	Mean time spent per navigator per patient/day d
Patient navigator type	108	180 (0–481)	81.0 c minutes
Nurse (n = 2)	7	39 (0–135)	24.5 minutes
Nonclinical (n = 5)	101	240 (0–481)
Navigator activity type
Patient management activities	56 hours	93.7 (0–135) min
Identify a participant	21	36.0 (0–135)
Tracking patient over time	18	30.7 (0–105)
Monitoring caseloads	16	27.2 (0–90)
Direct patient contact	36 hours	53.7 (0–240)
Social needs assessments	14	18.2 (0–60)
Intake	12	20.3 (0–150)
Follow‐up on regarding referrals	3	4.9 (0–30)
Missed appointment follow‐up	3	4.9 (0–30)
Patient education	3	5.5 (0–45)
Navigating without patient contact	7 hours	17.8 (0–90)
Communication with health care team and other navigators	4	7.2 (0–60)
Attempted follow‐up	3	4.7 (0–30)
Other	9	14.9 (0–75)
Training	1.5	2.3 e (0–60)
Time survey	7	11.9 (0–15)
Other TRIP meeting	1	1 (0–45)
Supervisor activity
Administrative
Documenting tasks on behalf of TRIP	6 hours	15.0 (0–60)
Direct patient contact	0.25	0.6 (0–15)
Navigating without patient contact	6.25	14.4 (0–30)
Supervision
Patient enrollment	0.25	0.6 (0–15)
Administrative supervision	12	27.7 (0–60)
Clinical supervision	5.8	13.3 (0–60)
Quality assurance	0	0
Training	0.25	0.6 (0–15)
Meetings	1.8	4.0 (0–60)
Cost survey	1.9	4.4 (0–30)

Abbreviation: TRIP, Translating Research Into Practice.

^a Time spent was assessed over a consecutive 10‐day working period for each navigator with total hour calculated for a 5‐day work week; mapped to navigation protocol.

^b Mean, SD, group median: lay navigator, 195 minutes (3.2 hours); nurse navigator, 30 minutes.

^c Based on only one nurse navigator.

^d Calculated as total time/#patients/#navigator.

^e Reported by three navigators.

Startup costs

During the startup phase, costs varied depending on the stakeholder group. The administrative core team, which oversaw the planning and training, had much higher costs ($400,515) compared to the clinical site teams ($218,394). The largest proportion of costs was for personnel. This cost included CAP members’ time for planning the program, training navigators at each site, supporting the social needs platform and for patient management tasks ($128,966). Total training costs were $1398 for startup and $9251 for maintenance with an average of $1775 across clinical sites. Details of training time and costs are included in Table S1.

Implementation costs

Implementation costs for maintaining the intervention included both the administrative core team and clinical sites. (Table 2) The administrative core team costs ($249,536) included strategic planning, monitoring of fidelity, and training for the intervention. Approximately $39,134 was allocated for maintenance of the social needs data collection platform. At the clinical sites, implementation costs were $392,407, of which $9251 were associated with training navigation staff. The largest proportion of maintenance costs were for personnel and institution indirect costs. A total of 223 patients were served during the implementation period across the five clinical sites. The average cost per patient was $979 for startup and $1759 for maintenance. Figure 1 shows the distribution of startup and maintenance costs across the five clinical sites. Start‐up costs ranged from $4295 to $114,667. Maintenance costs for the intervention ranged from $16,977 to $197,716.

TABLE 2.

Total and average costs for TRIP navigation program: startup versus maintenance.

	Total costs (annual)
	Start‐up	Maintenance
Administrative core
Personnel	$191,698	$210,402
Technical platforms (TRIP registry and Aunt Bertha)	$63,054	$0
Other direct costs, technical platform fees	$13,563	$0
Training costs	$737	$0
Indirect costs (office facility fees)	$131,463
Technical platform support	$0	$39,134
Total	$400,515	$249,536
Clinical site intervention
Personnel (including training)	$128,966 ($1398)	$184,754 ($9251)
Indirect costs	$89,428	$207,652
Total	$218,394	$392,407
No. of patients served	223
Average cost per patient	$979	$1759

Abbreviation: TRIP, Translating Research Into Practice.

FIGURE 1.

Startup and implementation costs by clinical site.

Table 3 highlights the costs per activity based on the average hourly wage for navigators and the time spent on specific tasks. The average cost per activity for patient management was the highest at $388 per patient followed by direct patient contact ($252), which includes assisting with referrals, follow‐up with missed appointments, and conducting an intake or social needs assessment.

TABLE 3.

Cost per activity per patient (annualized) (n = 223).

Patient management	$388.01
Identify a participant	$149.13
Tracking patient over time	$126.77
Monitoring caseloads	$112.11
Direct patient contact	$251.80
Social needs assessments	$101.63
Intake	$83.82
Follow‐up on regarding referrals	$20.26
Missed appointment follow‐up	$20.26
Patient education	$22.70
Navigating without patient contact	$47.15
Communication with health care team	$27.94
Attempted follow‐up	$19.21
Other activities	$60.07
Training	$9.78
Meetings	$49.59
Survey completion	$2.79

Note: Cost based on average hourly rate across sites; calculated as total hours for activity × hour rates.

Table 4 describes the differences in outcomes between a matched sample of patients from the historical controls and those participating in the TRIP intervention. TRIP patients on average had lower rates of hospitalizations and emergency room visits and a significantly higher proportion of TRIP patients received timely breast cancer treatment compared to a matched control group (94.9% vs. 82.7%, p < .05). This difference represents an estimated 63 patients who potentially could be reached for timely treatment in care. The potential cost savings from averted emergency room visits and hospitalizations from additional patients engaged in treatment is $2536–$5692 (emergency room visits) and $21,798–$30,429 (hospitalizations).

TABLE 4.

Differences in health outcomes for matched participants in historical controls versus TRIP intervention and potential cost savings in the health care system.

Outcome measure	Historical controls (n = 519)	TRIP intervention (n = 137)
Emergency room visits (mean, SD, range) per patient	1.37 (2.03, range 0–10)	0.80 (1.20, range 0–6)
Hospitalization (mean, SD)	1.06 (1.74, range 0–9)	0.31 (0.80, range 0–5)
No. and percentage of any timely treatment a	82.7% (n = 429/519)	94.9% (n = 130/137)
Additional patients receiving early treatment via TRIP intervention	63
Costs of emergency room visits averted (patient with low–high severity) from TRIP intervention b	$2536–$5692
Cost of hospitalization averted (patient with low–high severity) from TRIP intervention b	$21,798–$30,429

Abbreviation: TRIP, Translating Research Into Practice.

^a Significant p < .05.

^b Calculated based on additional patients engaged in timely treatment multiplied by the public payer rates for an emergency room visit and in patient hospitalization stay.

DISCUSSION

From a health care system perspective, the TRIP navigation activities reached and engaged an additional 63 patients in timely cancer treatment with an average cost of $2738 per patient, including startup and implementation costs. A previous study in 2014 by Bensink et al., ⁷ estimated the added cost of navigation at $275 per patient for timely access to cancer care. Our higher costs per patient may be attributed to lower patient volume, use of both nurse as well as nonclinical patient navigators and the inclusion of additional startup and maintenance costs related to implementing a citywide navigation program that included shared digital tools. These cost elements include time for clinical leadership to develop and implement standardized protocols for SDoH screenings and systems, training, and a shared registry that are critical for a sustainable workforce.

The American Cancer Society’s National Navigation Roundtable (NNRT) calls for creating a sustainable oncology workforce to achieve health equity and for sharing evidence‐based practice and workforce development policies that increase the return on investment (net gains/total program costs). NNRT 5‐year aim includes standard training and certification and supporting standard reimbursement for patient navigation and community health workers services. ²⁴ One of the main barriers to sustainment of patient navigation programs is the inconsistency of data collection and reporting because of reliance on grant funding. This study can help to realize some of these challenges by documenting the clear activities and tasks that navigation programs perform and the costs to health systems. ²⁵ With the recent Centers for Medicare & Medicaid Services (CMS) rule to reimburse for patient navigation under medical supervision, ²⁶ our findings contribute to the evidence of tasks that patient navigators, specifically nonclinical navigators, can be reimbursed for support of patients in cancer care. ¹⁰ This is a key step in standardizing the role across the cancer continuum and ensuring a durable workforce.

Furthermore, our study findings expand the recent CMS rule and provide greater detail about the estimated costs for hospital providers on navigator tasks and costs. Although CMS allows Medicare coverage with a maximum fee schedule for patient illness navigation services for $79.44 for initial 60 minutes and $49.44 for additional 30 minutes and $18.66 for SDoH risk assessment, ²⁶ this may cover some, but not all, of the tasks that patient navigators provide to support patients with engaging in cancer treatment. Our study data found that direct patient care costs the system an average of $250/per patient navigated including follow‐up for referrals and there are significant administrative costs related to patient monitoring that need to be considered for reimbursement. These administrative costs should be considered when setting fee schedules by payors. Although this fee schedule represents a positive step in sustaining the navigation work force and potential cost savings for hospitals, additional data are warranted for the potential cost‐benefit of the program for patients and providers.

Our study also contributes to the evidence base on the cost and activity for navigator and supervisor tasks. These data could serve useful for insurance and government entities formulating equitable reimbursement practices for health care providers and health care systems who select to include navigator in the cancer care team. We found that patient management tasks, including identifying and following up with patients on referrals are time intensive for navigators and supervisors and essential to ensure patients with complex social and medical needs are engaged in appropriate treatment. Other studies found similar findings that at least 1 day a week on data collection (variety of sources) is an important part of their role. ²⁶ Including these patient management tasks in reimbursement and standard protocols in addition to screening, assessment, and education, are essential to ensure quality care and sustained engagement for patients, especially those who have been traditionally not reached for cancer care by the health care system.

Previous studies have also found the type of navigator may have different tasks with nonclinical navigators more likely to engage in outreach and screening than treatment compared to clinical (nurse/social worker) navigators. ²⁷ We did not assess for differences in the type of navigator by outcome because we found no significance differences in tasks and our sample was small and only one site employed nurse navigators, with only one nurse navigator having direct contact with TRIP patients during the data collection period. Our findings related to cost savings may be reduced given that nurse navigators had higher salaries (Table S1, site 1). Future studies could explore this impact and provide standards and guidelines for reimbursement for health care providers and payers.

A strength of our study is that we were able to gather costs related to both the startup phase and implementation. There has been a recent call for wider methods to be used in guiding economic evaluations of interventions across multiple sites and levels. ²⁸ Our study also captures the costs involved in having implementation agents (such as the clinical advisory panel) through administrative costs who support the fidelity and uptake of the model and provide recommendations for standardization of practice for navigators within clinical teams. We found considerable time and resources are needed for leadership to set up, train, and build data and communications systems within and across organizations. Other studies have found similar factors for successful implementation of patient navigation programs in cancer treatment. ²⁹ , ³⁰ This information can help health care systems and payers determine allocation of financial and staffing resources for patients with more complex social needs.

Another strength of our study is the inclusion of the role and tasks of supervisors in the scale up of TRIP activities. Powell et al. ³¹ identified clinical supervision as a key implementation strategy for adapting and replicating innovations in health care systems. Our study was integrated within each site’s organizational workflow and quantifies the role and tasks of supervisors in documenting and tracking patients as well as providing support to navigators. Four of five sites had TRIP patients integrated into assigned job responsibilities and patient caseloads. This information can be helpful to support health systems in planning for team responsibilities that enhance patient care.

There are limitations to our analysis and findings. Our study was conducted in the Boston region and represents five hospitals. Given that cost and hospital reimbursement rates were determined by one state and may not be generalizable to other health care systems in the United States or abroad. Furthermore, our study may only be generalizable to breast cancer care and not all types of cancer care. In addition, cost savings only included reimbursement rates from public payers and data on hospital charge ratios for inpatient stays and emergency room visits was not available. Furthermore, our costs were limited to wage rates for navigators and supervisors in the Boston region. Salary rates may be higher or lower depending on the geographic region. However, using a standard hourly rate provides information that may be useful for planning purposes. We intended to help decision makers in health care delivery and payers.

We did not include patient costs or a societal perspective and therefore our costs may be underestimated. Second, given the stepped wedge design, sites launched the intervention and outcome, and cost data were collected at varying times to minimize the impact of COVID pandemic. All administrative core and clinic site startup data were collected before March 2020. However, ongoing and maintenance outcome and cost data were collected at varying times post the height of the pandemic (March–June 2020). Two sites collected data from June 1, 2019 to May 31, 2020, and three sites collected data from June 1, 2020 to May 31, 2021. Although the sites and staff continued to recruit and engage patients in the intervention, the pandemic likely impacted patient engagement in treatment resulting in lower engagement and impacting costs during the study period. In addition, one site did not complete the implementation phase of the intervention due to the closure of its breast cancer practice and their patients were merged with a partner TRIP site.

In conclusion, our study findings provide information that may be useful in both fee‐for‐service and value‐based care systems, and especially for program managers to describe a position’s tasks, estimate the cost of navigation for budgets, and to make the business case for navigation in health systems. Our data provide insight into implementation costs for uptake and scalability of navigation programs across a citywide system. This information is necessary to support sustainability of oncology navigation programs nationwide.

AUTHOR CONTRIBUTIONS

Serena Rajabiun: Conceptualization; methodology; writing–original draft; writing–review and editing; formal analysis; and investigation. Howard J. Cabral: Conceptualization; investigation; writing–review and editing; and formal analysis. Clara A. Chen: Formal analysis; data curation; and writing–review and editing. Christine Lloyd‐Travaglini: Formal analysis; data curation; and writing–review and editing. Julianne N. Dugas: Formal analysis; data curation; and writing–review and editing. Deborah Amburgey: Project administration; and writing–review and editing. Madyson Fitzgerald: Project administration; and writing–review and editing. Stephenie C. Lemon: Conceptualization; writing–review and editing; funding acquisition; and investigation. Jennifer S. Haas: Conceptualization; writing–review and editing; funding acquisition; and investigation. Karen M. Freund: Conceptualization; writing–review and editing; and funding acquisition; investigation. Tracy Battaglia: Conceptualization; writing–review and editing; funding acquisition; and investigation. All authors reviewed final manuscripts.

CONFLICT OF INTEREST STATEMENT

Tracy Battaglia reports consulting fees from Roche Molecular Systems, Inc; fees for other professional activities from the American Cancer Society and Merck Company Foundation; and grant and/or contract funding from the American Cancer Society, Merck Company Foundation, and National Institutes of Health Clinical Center. Clara A. Chen reports grant and/or contract funding from the National Institutes of Health. Karen M. Freund reports grant and/or contract funding from the National Institutes of Health and the National Institutes of Health Clinical Center. Jennifer S. Haas reports grant and/or contract funding from the American Cancer Society. Christine Lloyd‐Travaglini reports grant and/or contract funding from the National Institutes of Health. The other authors declare no conflicts of interest.

Supporting information

Table S1

Rajabiun S, Cabral HJ, Chen CA, et al. Cost and activity analysis for a citywide patient navigation intervention to engage underserved patients in breast cancer treatment: findings from the Translating Research Into Practice study. Cancer. 2025;e35671. doi: 10.1002/cncr.35671

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.