The oncology nurse in population cancer screening – Expanding the navigator role

Abstract

Emerging trends in oncology nursing literature indicate an increasing need for specialized roles. The increasing complexity of cancer care presents a unique opportunity to expand the cancer patient navigator role to population cancer screening programs. Existing oncology nurse navigation competencies can be leveraged to improve cancer screening participation and reduce waiting times for access to diagnostic and treatment pathways. By expanding the scope of practice for oncology nurse navigators to include roles such as community engagement and improved access to care, nurse navigators in cancer screening programs can play a pivotal role in reducing cancer burden and improve health outcomes at a population level.

In 2019, Newfoundland and Labrador’s (NL) Provincial Cancer Care Program introduced a Screening Navigator position within its Population Screening Programs and specified community engagement and outreach as key requirements within the role. In 2021, a second screening navigator position was added. This article will highlight the expanded responsibilities of oncology nurse navigators in NL’s Population Screening Program to facilitate improved participant access, continuity of screening and diagnostic pathways and community engagement. By expanding the navigator scope to include cancer screening, community engagement, and improved access to care, oncology nurse navigators play a key role in reducing cancer burden and improve health outcomes at a population level.

INTRODUCTION AND BACKGROUND

Emerging trends in oncology nursing literature indicate an increasing need for specialized roles. The increasing complexity of cancer care presents a unique opportunity to expand the cancer patient navigator role to population cancer screening programs. Existing oncology nurse navigation competencies can be leveraged to improve cancer screening participation and reduce waiting times for access to diagnostic and treatment pathways. By expanding the scope of practice for oncology nurse navigators to include roles such as community engagement and improved access to care, nurse navigators in cancer screening programs can play a pivotal role in reducing cancer burden and improve health outcomes at a population level. This article will highlight the expanded responsibilities of oncology nurse navigators in Newfoundland and Labrador’s Population Screening Program to facilitate improved participant access, continuity of screening and diagnostic pathways and community engagement.

LITERATURE REVIEW

As an initial step to inform the work, a comprehensive PUBMED literature review was completed focused on the roles of the oncology nurse navigator within the realm of population cancer screening. The review focused on North American literature within the last 10 years, limiting search terms to ‘cancer screening navigation’, ‘oncology nursing in cancer screening’ and ‘population screening’. The review targeted oncology literature and intentionally excluded literature from women’s health, community health, and health promotion disciplines.

Nursing roles in cancer screening programs are not new. An abundance of literature exists, largely from the disciplines of women’s health, community health and health promotion, that describes the nursing role in screening, primarily for breast and cervical cancers. These role descriptions often focus on the clinical competencies of the nurse with limited information regarding the full extent of the nurse’s practice regarding engagement, recruitment and navigation; nor the qualifications of the nurse.

A 2013 article by Benito et al. provides a descriptive review of the literature outlining the core responsibilities and sets of activities of the nurse in cancer screening: management, clinical, education, promotion of health, and training. Benito et al. describe the nursing role using a case management approach, “the collaborative process of assessment, planning, facilitation and advocacy for options and services that meet an individuals’ health needs through communication and available resources to promote high-quality and cost-effective outcomes.” These roles and responsibilities within this case management approach are similar to the roles of cancer patient navigators in Canada. The goal of the navigator role is described in the CANO/ACIO position statement on patient navigation in cancer care, “...improve outcomes such as improved access to care, continuity of care, clinical efficiencies, patient engagement, and improved patient experience.”

LITERATURE SUMMARY

A number of emerging trends were observed in the review of the oncology nursing literature published over the last 10 years (See Table 1). Cummings (2018) highlighted the need for more specialized roles in oncology nursing to address the future challenges the discipline would face. Cox et al. (2017) engaged patients in their research and identified the importance of prioritizing cancer prevention, screening, early detection and psychological care across the cancer trajectory in oncology nursing research.

Table 1.

Articles Highlighted in Literature Review

Author/Date	Publication	Themes
Cummings G. (2017)	CONJ	Evolution of roles More specialized roles
Cox, Arbor et al. (2017)	Oncology Nursing Forum	Prioritize prevention, screening and early detection
Shockney, L. (2018)	“Team Based Oncology Care: The Pivotal Role of Oncology Navigation” AONN	Evolving roles Community outreach Improving access
Yates et al. (2020)	EJON	“Call to Action” Role of nurses in reducing cancer burden
Sheldon & Booker (2023)	Annals of Palliative Medicine	Evolving roles to address increasing complexity of care Access to care for underserved and marginalized populations
Kelly & Cable (2024)	Journal of Advanced Nursing	Role of nursing in reducing cancer burden “Call to Action” Meet needs of cancer patients across the lifespan
Fitch, M. (2024)	CONJ	“Call to Action” Emerging trends: changes in screening & diagnosis, implications of same health care systems stretched need for collective action and collaboration
Katerenchuk & Santos Salas (2023)	CONJ	Integrative review Role domains Responsibilities

In 2018 the literature introduced the use of patient navigators to improve access to screening and improving wait times. Shockney (2018) discussed the need for oncology nursing expertise in community resources and the social determinants of health as an asset to improving access to cancer screening and related services.

A 2023 article by Booker and Kennedy-Sheldon acknowledged the evolution of roles in oncology nursing in response to the increasing complexity of cancer care and the growing needs of the discipline. This article also highlighted the importance of oncology nurses in improving access to cancer care, including cancer screening.

In 2020, Yates presented one of the first “calls to action” to appear in the recent oncology nursing literature. She asserted cancer nursing’s potential to reduce the growing burden of cancer across the world. Yates highlighted the importance of oncology nursing as a key part of global cancer control and having impact across the spectrum of the cancer trajectory. The burden of cancer and the importance of oncology nurses in reducing this burden was also presented in Kelly’s 2024 editorial in the Journal of Advanced Nursing. Kelly et al. acknowledged the increasing cancer incidence and the emergence of specialist roles and oncology sub-specialties to improve quality care for patients and families across the cancer continuum.

A 2024 CONJ Editorial by Fitch also highlighted the emerging trends, as presented by the American Psychosocial Oncology Society, acknowledging the complex changing landscape in cancer care and how these changes impact screening and diagnostic pathways. There are implications for the public’s recruitment to screening, access to diagnostic pathways, and patient management and education.

Katerenchuk and Salas (2023), in a review of cancer navigation roles in Canada, outline the key role domains within oncology nurse navigation practice: care coordinator, change agent, and supporters of wellbeing. Navigators within population screening fulfill these key roles with participants who are on screening and diagnostic pathways. The authors contend that within population screening, the roles and responsibilities of the navigator should be expanded to include engagement and improved access to care.

HEALTH TRANSFORMATION IN NEWFOUNDLAND AND LABRADOR

In 2022, the Newfoundland Health Accord was released, outlining a 10-year plan for the realignment of healthcare delivery in the province. A number of objectives of the Health Accord were relevant to the Population Screening Programs: the development of a strategy to decrease cancer mortality in the province, the optimization of population screening programs, and an enhanced hub and spoke model of care delivery within the province.

A research poll, conducted by the Newfoundland and Labrador Medical Association in November 2022, reported that in excess of approximately 24% of the 125,000 residents of the province were without a family doctor. It is a vision of the Health Accord that all residents of NL have access to comprehensive primary care through the establishment of Family Care Teams; primary care hubs are intended to increase access to primary care in all areas of the province. Family care teams are multidisciplinary to meet all client needs. Primary care clinics dedicated to underserved clients within communities such as refugees, high-risk/vulnerable urban populations, and first nations’ communities have also been established. Primary care also includes the BETTER program, whose objective is the prevention of chronic disease within the province, including cancer.

PARTNERSHIPS AND ENGAGEMENT

The Provincial Cancer Care Program in NL partnered with the Canadian Partnership Against Cancer (CPAC) on a number of key strategic initiatives focused on improving access and the cancer care experience for the people of NL. These projects include community engagement with indigenous populations and other high-risk, underserved communities, transition to HPV primary screening, and a readiness assessment to support a potential provincial lung screening program. Screening navigators had key roles as project leads with these initiatives, identifying priorities for care and ensuring project objectives and outcomes were met.

Identifying those at risk for colon cancer is an important first step to tailoring strategies to mitigate the risk and increase screening participation. The NL colon screening program partnered with CPAC to develop strategies to increase colon screening participation for the under screened in the province. With this project the screening navigator utilized current colon screening and diagnostic analytics to inform engagement strategies and identify areas within the province where opportunities to improve colon screening existed.

Engagement and community out-reach by the screening navigator began in 2020 at the start of the COVID-19 public health protections. Engagement activities targeted stakeholders such as managers, educators and clinicians within primary care and family care teams with information regarding the population screening programs, access, recruitment, and pathway navigation. Virtual education sessions were then offered by the screening navigator throughout the various provincial health zones. Following these sessions, the screening navigator conducted more targeted community profiles and clinic needs assessments to allow for a more specific, community-informed approach to screening promotion. This collaboration utilized the ‘hub and spoke’ model endorsed by the Health Accord. As new family care teams are introduced, the Population Screening Program supports the on-boarding and orientation of new primary care staff to support them in their promotion and recruitment of participants to the population screening programs.

The Population Screening Program also participated in the Phase II work of the Journey Across the Island, a CPAC-funded initiative for the development of an Indigenous cancer framework. The screening navigator participated in a number of gatherings of key stakeholders that took place during this project. The gatherings provided the opportunity for the screening navigator to network and learn from stakeholders how best to collaborate to increase the profile of population screening within these communities. Arising from the gathering in the autumn of 2022 was a collaboration with Indigenous partners to coordinate a dedicated cervical screening clinic for Indigenous participants on the northeast Avalon Peninsula.

CERVICAL SCREENING INITIATIVES

The Population Screening Program is not the cervical screening service provider within NL, it does not host nor provide cervical screening clinics. The screening navigator within the Cervical Screening Initiatives (CSI) program supports initiatives that facilitate access to cervical screening clinics throughout the province. One initiative is the Access to Service Grants, which provides financial support for clinic managers and practitioners to assist with the cost of dedicated cervical screening clinics within their respective area. Many of these practitioners will then offer “open” cervical screening clinics, providing access to service for all participants whether they are attached to a primary care practitioner or not. CSI further supports increased access to service by maintaining the provincial list of open cervical clinics that participants can access for screening service and is available to participants through a public website and a toll-free telephone line.

Screening navigators within CSI also coordinate and collaborate with a number of dedicated primary care practitioners who travel to underserved communities throughout NL. These navigators provide cervical screening services or support existing practitioners in these areas with extensive lists of who may require clinical service support.

HPV primary screening is evolving in Canada as the standard of practice for cervical screening. The Population Screening Programs have been supported by CPAC to develop a business case outlining this transition within the province of NL. Screening navigation leadership will be instrumental in the development of clinical pathways, as well as the engagement and promotion plans associated with this initiative.

BREAST SCREENING

It is within the breast screening program whereby the challenges associated with participants’ lack of primary care is most pronounced. The screening navigator identifies these participants and collaborates with the breast screening Nurse Practitioner and Medical Director to ensure supplemental screening and diagnostic pathways are coordinated, results are communicated and the participant is informed and supported throughout the process. In the cases of breast malignancy resulting from screening and diagnostic investigations, the screening navigator ensures a patient-centered approach to coordination, communication, information and supportive care needs for the participant transitioning to a treatment pathway.

In 2024, the Government of NL announced the demographic expansion of breast screening services to include the 40- to 49-year age cohort. This transition will be implemented in 2025 with the population screening navigator playing a key role ensuring appropriate pathways are in place to support screen positive participants and an updated engagement and communication plan is ready for the promotion and recruitment for this expanded service.

LUNG SCREENING

In 2021, the Population Screening Program assumed administration of the Thoracic Triage Panel (TTP) of NL Health Services Eastern zone. The Panel is a multidisciplinary team whose objectives are to improve access, decrease wait times, improve care coordination, and communicate with individuals who have abnormal chest CT or x-rays. This panel has existed since 2014 with cancer patient navigators as clinical leads. Within the Population Screening Program, a second screening navigator position was established to lead TTP and inform the development of documentation, reporting, and analytics within Population Screening’s electronic health record. Resourcing the thoracic triage panel was strategic for the Population Screening Program, as it was the first step in informing pathways and processes that will potentially become a lung screening program for the province.

Lung cancer screening is evolving as a standard of practice in Canada with a number of provinces having already launched programs. The Population Screening Program in NL partnered again with CPAC to complete two phases of lung screening development. Phase I consisted of a readiness assessment project that culminated in the development of a business proposal for a provincial lung screening program in 2022. The second phase was the implementation of a pilot project between March 2024 and March 2025. This project reports almost 1,300 referrals requesting lung screening services from two health care zones within the province.

Screening navigators have leadership roles in all facets of lung screening program development: clinical leads for both the thoracic triage panel and lung screening pilot, development of the diagnostic clinical pathways, coordination of participant care: assessment of clinical, supportive, communication and learning needs of the participants, collaboration with primary care providers and program medical leads as well as development of engagement and recruitment strategies for the program.

CONCLUSION

Quality population cancer screening programs will be necessary to address the projected increases in cancer cases throughout the world. Recent calls to action by oncology leaders and researchers have challenged oncology nurses to assume lead roles in addressing the existing burden of cancer. Roles and competencies are well established for oncology nurse navigators in Canada and other jurisdictions and are well suited for the expansion of the navigator role into the realm of population cancer screening. Community outreach and engagement roles designed to improve access to care will be key requirements for the navigator in population screening. By expanding the navigator scope to include community engagement and improved access to care, oncology nurse navigators can play a pivotal role in reducing cancer burden and improve health outcomes at a population level. Navigators within population screening will ensure a patient-centred approach to care, ensuring eligible participants are identified and the many, often complex care needs of the participants are met through screening and diagnostic pathways.