Lung Cancer Screening Navigation Services is sponsored by Connecticut Department of Public Health (DPH). The Connecticut DPH is seeking proposals from healthcare systems and hospitals in Connecticut to participate in the delivery of lung cancer screening navigation services through the CT Lung Cancer Screening Program (CLCSP).

This randomized clinical trial examines whether patient navigation improves lung cancer screening completion among people experiencing homelessness. ## [](https://pmc. ncbi.

nlm. nih. gov/articles/PMC11165412/)Key Points Does providing patient navigation improve lung cancer screening completion in a homeless health care setting?

In this randomized clinical trial that included 260 patients in a large Health Care for the Homeless program from 2020 to 2023, patient navigation in addition to usual care produced a statistically significant 4. 7-fold increase in lung cancer screening receipt at 6 months compared with usual care alone (43. 4% vs 9.

2%). Study findings suggest that patient navigation may be an effective tool for promoting lung cancer screening engagement among people experiencing homelessness. ## [](https://pmc.

ncbi. nlm. nih.

gov/articles/PMC11165412/)Abstract People experiencing homelessness die of lung cancer at rates more than double those in the general population. Lung cancer screening (LCS) with low-dose computed tomography (LDCT) reduces lung cancer mortality, but the circumstances of homelessness create barriers to LCS participation.

To determine whether patient navigation, added to usual care, improved LCS LDCT receipt at a large Health Care for the Homeless (HCH) program.

### Design, Setting, and Participants This parallel group, pragmatic, mixed-methods randomized clinical trial was conducted at Boston Health Care for the Homeless Program (BHCHP), a federally qualified HCH program that provides tailored, multidisciplinary care to nearly 10 000 homeless-experienced patients annually.

Eligible individuals had a lifetime history of homelessness, had a BHCHP primary care practitioner (PCP), were proficient in English, and met the pre-2022 Medicare coverage criteria for LCS (aged 55-77 years, ≥30 pack-year history of smoking, and smoking within the past 15 years). The study was conducted between November 20, 2020, and March 29, 2023.

Participants were randomized 2:1 to usual BHCHP care either with or without patient navigation. Following a theory-based, patient-centered protocol, the navigator provided lung cancer education, facilitated LCS shared decision-making visits with PCPs, assisted participants in making and attending LCS LDCT appointments, arranged follow-up when needed, and offered tobacco cessation support for current smokers.

### Main Outcomes and Measures The primary outcome was receipt of a 1-time LCS LDCT within 6 months after randomization, with between-group differences assessed by χ 2 analysis. Qualitative interviews assessed the perceptions of participants and PCPs about the navigation intervention. In all, 260 participants (mean [SD] age, 60.

5 [4. 7] years; 184 males [70. 8%]; 96 non-Hispanic Black participants [36.

9%] and 96 non-Hispanic White participants [36. 9%]) were randomly assigned to usual care with (n = 173) or without (n = 87) patient navigation. At 6 months after randomization, 75 participants in the patient navigation arm (43.

4%) and 8 of those in the usual care–only arm (9. 2%) had completed LCS LDCT (_P_< . 001), representing a 4.

7-fold difference. Interviews with participants in the patient navigation arm and PCPs identified key elements of the intervention: multidimensional social support provision, care coordination activities, and interpersonal skills of the navigator. ### Conclusions and Relevance In this randomized clinical trial, patient navigation support produced a 4.

7-fold increase in 1-time LCS LDCT completion among HCH patients in Boston. Future work should focus on longer-term screening participation and outcomes. ClinicalTrials.

gov Identifier: NCT04308226 ## [](https://pmc. ncbi. nlm.

nih. gov/articles/PMC11165412/)Introduction In 2020, more than 580 000 people experienced homelessness on a single night in the US, and 1. 25 million experienced homelessness at some point during the year.

1 Cancer is a major cause of death in this population at rates 38% to 88% higher than in the general population. 2,3,4,5,6,7 Lung cancer contributes heavily to this disparity as the leading type of incident cancer and cancer death among people experiencing homelessness, exceeding general population lung cancer incidence and mortality rates by more than 2-fold.

7 Lung cancer screening (LCS) with annual low-dose computed tomography (LDCT) reduces lung cancer mortality by 20% among selected high-risk individuals8 and carries a grade B recommendation from the US Preventive Services Task Force to offer or provide this service. 9 Evidence suggests that when presented with the concept of LCS, individuals experiencing homelessness are strongly interested in it.

10 However, translating this interest into screening completion poses challenges. Individuals experiencing homelessness face multilevel barriers to cancer screening,11 contributing to suboptimal rates of screening participation12,13,14,15,16,17 and later-stage diagnosis of screening-detectable malignant neoplasms compared with housed individuals.

7 These barriers are likely to be heightened in the setting of LCS, a multistep process with several potential sources of participation drop-off that may disproportionately impact socioeconomically disadvantaged individuals. 18 Without specific efforts to mitigate these barriers, disparities in lung cancer mortality between homeless and housed populations are likely to widen further.

Patient navigation is an evidence-based practice for guiding people through complex health systems and reducing barriers to care across the cancer continuum for those at risk of experiencing delays in care. 19,20 Numerous studies have shown that patient navigation interventions improve cancer screening participation in vulnerable populations.

21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38 However, the effectiveness of patient navigation in homeless health care settings is less well established.

Pre-post studies of patient navigation for homeless-experienced patients in New York City39 and rural Kentucky40 have shown promising results for improving breast, cervical, and colorectal cancer screening completion, but the nonexperimental nature of these studies limits causal inference.

To address this gap in evidence, we conducted a pragmatic trial of patient navigation for LCS at a large Health Care for the Homeless (HCH) program in Boston, Massachusetts. ## [](https://pmc. ncbi.

nlm. nih. gov/articles/PMC11165412/)Methods From November 20, 2020, to March 29, 2023, we conducted the Investigating Navigation to Help Advance Lung Equity (INHALE) study, a 2-arm, parallel-group, pragmatic, mixed-methods randomized clinical trial of patient navigation for LCS among homeless-experienced individuals.

The trial protocol, including a detailed description of all study procedures, pragmatic features, and intervention components, has been published41 and is available in Supplement 1. The following sections summarize the key elements of the trial in accordance with the Consolidated Standards of Reporting Trials (CONSORT) reporting guideline.

The study was approved by the Mass General Brigham Institutional Review Board, and enrolled participants provided verbal informed consent to participate. ### Participants and Setting The trial was conducted at Boston Health Care for the Homeless Program (BHCHP), a federally qualified HCH program that serves nearly 10 000 patients each year across more than 30 service sites in greater Boston.

42 Individuals were recruited through a combination of in-person and phone-based outreach as well as referrals from BHCHP primary care practitioners (PCPs). Eligible participants had a lifetime history of homelessness, had a BHCHP PCP, were proficient in English, and met the pre-2022 Medicare coverage criteria for LCS: aged 55 to 77 years, at least a 30 pack-year smoking history, and smoking within the past 15 years.

43 Exclusion criteria included CT of the chest in the past 12 months, a personal history of lung cancer, symptoms concerning for lung cancer (eg, hemoptysis), or having the principal investigator (T. P. B.)

as their PCP. Participants were randomized 2:1 to usual care with or without patient navigation. Randomization was stratified by 4 variables ascertained by self-report during screening and enrollment: smoking status (current vs former), homelessness status (current vs former), prior discussion of LCS with their PCP (yes vs no), and primary clinical site where they see their PCP (BHCHP headquarters vs satellite sites).

Randomization occurred in computer-generated permuted blocks of 6 (4 persons assigned to the navigation arm and 2 persons assigned to the usual care–only arm) with an allocation sequence that was concealed from study staff. Blinding was not possible due to the nature of the intervention.

All participants had access to usual care at BHCHP, which is regarded as an exemplar in the delivery of highly tailored, multidisciplinary health care services for individuals experiencing homelessness. 44,45 Participants in the patient navigation arm were additionally offered access to an LCS patient navigator.

Patient navigators were college graduates who underwent focused education and training in patient navigation, LCS, and tobacco counseling. 41 The patient navigation intervention was based on the Health Belief Model46,47 and incorporated the input of frontline workers and academic experts.

Core duties of the navigator included providing lung cancer education, facilitating PCP visits for shared decision-making around LCS, assisting in scheduling LCS LDCT appointments, facilitating LDCT appointment attendance through reminder phone calls and transportation assistance, arranging follow-up studies or office visits when needed, offering tobacco cessation support for current smokers, and coordinating care with PCPs, referral specialists, and other care team members.

The navigator provided basic education on the benefits and risks of LCS, but an individualized decision about the appropriateness of LCS was ultimately made by the patient and their PCP. The navigation protocol was structured yet flexible. Some patient-facing components were partially scripted, but the navigator could adapt or tailor the delivery to patients’ needs and preferences.

The number, frequency, and duration of navigation interactions were patient directed rather than prescribed. The navigator documented all activities performed with or on behalf of patients using a standardized checklist in addition to free-text notes. Participants completed a baseline survey on enrollment.

Self-reported sociodemographic measures included age, gender, race and ethnicity (Hispanic or Latinx, non-Hispanic Black [hereafter, Black], non-Hispanic White [hereafter, White], or non-Hispanic other [including American Indian or Alaska Native or multiple races]), housing status, and health insurance status.

Data on race and ethnicity were collected because of the complex interplay among race and ethnicity, homelessness, and health outcomes. 48,49 eAppendix 1 in Supplement 2 provides definitions of the homelessness (lifetime, current, or former homelessness) and housing status (precariously or stably housed) variables.

Self-efficacy was assessed with the General Self-Efficacy Scale (score range, 10-40; higher scores represent greater self-efficacy).

50,51 Brief, pragmatic measures of health included a single-item assessment of self-rated health,52,53 the Alcohol Use Disorders Identification Test–Concise (score range, 0-12; higher scores represent greater alcohol use),54,55 the 10-item Drug Abuse Screening Test (score range, 0-10; higher scores represent a greater degree of problems related to drug use),56,57 and the 6-item Kessler Psychological Distress Scale (score range, 0-24; higher scores represent more severe mental health symptoms).

58,59 Smoking history was assessed with questions about age of initiation, cigarettes per day, periods of abstinence, and, if no longer smoking, age at cessation. Pack-years were calculated by multiplying the number of years of smoking by the typical number of packs per day consumed during those years. The primary outcome was receipt of a 1-time LCS LDCT within 6 months (26 weeks) after randomization.

Chest CT scans obtained for reasons other than LCS were not included in the primary outcome. At the time of enrollment, participants provided consent to access their BHCHP health records and were additionally asked to sign a Health Insurance Portability and Accountability Act (HIPAA)–compliant release of information form permitting study staff to obtain radiology records from Boston-area facilities that offer LCS LDCT.

Outcome ascertainment was based on a standardized blinded review of participants’ medical records as described in eAppendix 2 in Supplement 2. Other outcomes of interest were also assessed. Among participants who underwent LCS LDCT, we recorded the date of the study, the Lung Imaging Reporting and Data System (Lung-RADS) score,60 and the recommended follow-up interval.

(Lung-RADS scores are explained in the eTable in Supplement 2.)

Among participants with Lung-RADS scores of 3 or greater meriting earlier than annual follow-up (typically 6 months for Lung-RADS 3, 3 months for Lung-RADS 4A, and immediate for Lung-RADS 4B/X60), we assessed whether patients obtained the recommended follow-up test or evaluation within 1 month (4 weeks) of the advised time frame (ie, 7 months, 4 months, and 1 month for scores of 3, 4A, and 4B/X, respectively).

Additionally, among navigation arm participants, we examined navigator checklist logs to assess completion of various navigation tasks related to LCS facilitation and care coordination. ### Qualitative Assessment Using a sequential explanatory mixed-methods approach,61 we conducted semistructured interviews with navigation arm participants who did (n = 20) and did not (n = 11) attain the primary outcome.

The goal of these interviews was to assess how the patient navigator affected participants’ LCS decision-making and experience surrounding obtaining LCS. In addition, we conducted interviews with BHCHP PCPs (n = 10) to elicit their perceptions of the navigator’s impact on the LCS process.

We originally powered the trial to detect what we deemed to be a clinically meaningful increase in LCS LDCT completion from 5% among participants in the usual care–only group to 15% among participants in the patient navigation group. We estimated that a sample size of 300 participants (100 in the usual care–only arm and 200 in the navigation arm) would provide 80% power to detect such an effect at a 2-tailed _P_< . 05.

However, delays during the COVID-19 pandemic eventually led to a revised sample size target of 260 due to time and resource limitations. This revised sample size afforded 68. 6% power to detect the original effect size (5% vs 15%) and 82% power to detect an effect size of 5% vs 17%, each at a 2-tailed _P_< .

05. #### Quantitative Analysis We used the χ 2 test to assess the difference between the usual care–only arm and the patient navigation arm on attainment of the primary outcome. We then used logistic regression to increase the precision of the patient navigation effect estimate by adjusting for stratifying variables, variables of a priori importance, and other significant factors related to the primary outcome.

In a prespecified supplement to the primary analysis,41 we produced Kaplan-Meier curves and used the log-rank test to compare the time to LCS LDCT completion (censored at 6 months after randomization) between the usual care–only and patient navigation arms. We conducted sensitivity analyses of the primary outcome focusing on 2 issues.

First, 5 participants (3 in the navigation arm and 2 in the usual care–only arm) did not provide a signed release of information after enrollment, precluding review of outside medical records for primary outcome ascertainment. In the primary analysis, we assumed these individuals did not attain the primary outcome.

We examined a worst-case imputation scenario wherein the 3 navigation arm participants were assumed not to have attained the primary outcome and the 2 usual care–only arm participants were assumed to have attained the primary outcome.

Second, during medical records review for primary outcome ascertainment, 7 individuals (4 in the navigation arm and 3 in the usual care–only arm) were found to have had a chest CT within 12 months prior to enrollment and therefore should have been ineligible to participate. These 7 individuals were included in the primary analysis and excluded in a sensitivity analysis.

In all cases, these sensitivity analyses did not alter the magnitude or significance of the findings. We analyzed follow-up of abnormal LCS LDCT results and navigation process measures using descriptive statistics. Quantitative analyses were conducted using SAS, version 9.

4 (SAS Institute Inc). #### Qualitative Analysis We used the framework method62 with a combination of inductive and deductive approaches to analyze the qualitative interview data. Using a multistep process described in eAppendix 3 in Supplement 2, coding was conducted independently by trained study staff and continued iteratively until a high level of reliability (κ ≥ 0.

80) was achieved. Codes were reviewed as a team, grouped into higher-order categories where applicable, and organized into a working analytic framework that was revised, finalized, and applied to the entire dataset over several rounds of discussion. We then identified major explanatory themes that crossed codes and categories from both patient and PCP interviews.

We used NVivo, version 1. 7 (Lumivero) for qualitative analyses. ## [](https://pmc.

ncbi. nlm. nih.

gov/articles/PMC11165412/)Results Of 579 screened individuals, 272 were eligible and 260 were randomized to usual care with (n = 173) or without (n = 87) patient navigation (Figure 1). Randomized participants had a mean (SD) age of 60. 5 (4.

7) years; 184 (70. 8%) were male, 74 (28. 5%) were female, and 2 (0.

8%) identified as other (nonbinary or genderqueer or undefined); and 38 (14. 6%) were Hispanic or Latinx, 96 (36. 9%) were Black, 96 (36.

9%) were White, and 26 (10%) were of other race (Table 1). Approximately one-third (84 individuals [32. 3%]) were currently experiencing homelessness, and the remainder were formerly homeless, including 61 individuals (23.

5%) who were precariously housed. Overall, 132 individuals (50. 8%) reported fair or poor health, and sizable percentages screened positive for a mental health disorder (75 of 258 individuals [29.

1%]), alcohol use disorder (62 of 258 [24. 0%]), or drug use disorder (72 of 259 [27. 8%]).

Eighty-five percent (221 of 260 individuals) were current smokers, and the entire cohort had a mean (SD) of 48. 1 (19. 5) pack-years of smoking.

### Figure 1. CONSORT Diagram. BHCHP indicates Boston Health Care for the Homeless Program; CT, computed tomography; and PCP, primary care practitioner.

a Individuals could be ineligible for more than 1 reason. b Eligibility could not be determined because patients did not complete all screening items. ### Table 1.

Baseline Characteristics of Participants, Overall and by Study Arm. Abbreviations: LCS, lung cancer screening; PCP, primary care practitioner. Includes participants who selected nonbinary or genderqueer or other (undefined).

Includes participants who reported not being of Hispanic or Latino descent and who selected American Indian or Alaska Native (n = 3), multiple races (n = 15), or other race (undefined) (n = 8). Currently homeless individuals met the federal criteria for homelessness. Formerly homeless individuals had a lifetime history of homelessness but were not homeless at the time of enrollment.

Precariously housed individuals were formerly homeless but living in a situation with markers of residential instability. Stably housed individuals were formerly homeless and living in nonprecarious housing. See eAppendix 1 in Supplement 2 for additional details.

As assessed by the General Self-Efficacy Scale (score range, 10-40; higher scores represent greater self-efficacy). Defined as a score of 13 or greater on the 6-item Kessler Psychological Distress Scale (score range, 0-24; higher scores represent more severe mental health symptoms); data missing for 2 participants due to item nonresponse.

Defined as a score on the Alcohol Use Disorders Identification Test–Concise as 3 or greater for females and 4 or greater for males and other sexes (score range, 0-12; higher scores represent greater alcohol use); data missing for 2 participants due to item nonresponse.

Defined as a score of 2 or greater on the Drug Abuse Screening Test (score range, 0-10; higher scores represent a greater degree of problems related to drug use); data missing for 1 participant due to item nonresponse. At 6 months, 8 of the 87 participants in the usual care–only arm (9. 2%) and 75 of the 173 participants in the patient navigation arm (43.

4%) had completed an LCS LDCT (_P_< . 001; Figure 2A); this represents a 4. 7-fold increase in LCS LDCT completion at 6 months in the patient navigation arm.

In multivariable analyses controlling for stratifying variables, age, race and ethnicity, self-efficacy, and measures of general health, mental health, alcohol use, and drug use, patient navigation was associated with 8. 51 (95% CI, 3. 69-19.

6) higher odds of LCS LDCT completion. In the time-to-event analysis, participants in the navigation arm attained LCS LDCT sooner than participants in the usual care–only arm, with the Kaplan-Meier curves separating 4 weeks after randomization (Figure 2B). #### Figure 2.

Lung Cancer Screening (LCS) Low-Dose Computed Tomography (LDCT) Completion. ### Lung-RADS Scores and Follow-Up The distribution of Lung-RADS scores among participants who completed LCS LDCT is provided in the eTable in Supplement 2. Of 6 participants in the navigation arm with Lung-RADS 3 (probably benign) scores, none underwent follow-up imaging within 7 months of randomization.

Of 2 participants in the navigation arm with Lung-RADS 4A (suspicious) scores, both received follow-up within 4 months, including 1 who was diagnosed with early-stage lung cancer and underwent surgical resection.

One additional participant in the navigation arm had their Lung-RADS score revised from 2 (benign) to 4B (very suspicious) after the navigator terminated involvement; the case was reviewed within 1 month by a hospital-based multidisciplinary team, but the patient was delayed (>1 month) in receiving follow-up imaging, which showed benign findings.

Among the 173 participants in the navigation arm, the navigator established contact with 163 (94. 2%) and had a mean (SD) of 9. 6 (8.

5) contacts per patient, the vast majority of which were by phone (Table 2). Most participants in the navigation arm received LCS counseling and education (120 individuals [69. 4%]), facilitation of LCS shared decision-making visits with PCPs (130 [75.

1%]), facilitation of LCS referrals (136 [78. 6%]), and assistance with scheduling LCS appointments (122 [70. 5%]).

The navigator coordinated care with PCPs for 159 of the 173 participants (91. 9%) in the navigation arm, with a mean (SD) of 5. 0 (4.

1) PCP communications per patient. #### Table 2. Patient Navigation Activities Completed Among Navigation Arm Participants, Overall and Stratified by Attainment of the Primary Outcome.

Abbreviations: LCS, lung cancer screening; PCP, primary care practitioner. Three themes emerged from the patient and PCP interviews (Table 3). First, the navigator provided patients with multiple forms of social support.

Examples included educating patients on lung cancer and LCS (informational support), assisting patients with scheduling and attending LCS appointments (instrumental support), and serving as a listener, comforter, and advocate in the face of fears and concerns (emotional and affirmational support). Second, the navigator coordinated various aspects of patient care in both visible and nonvisible ways.

Examples included raising LCS awareness among patients and providers, identifying LCS-eligible patients, facilitating both general and LCS-specific care, and shifting tasks to off-load busy clinical teams. Third, the navigator’s interpersonal and professional qualities were appreciated by both patients and practitioners.

Highly prized attributes included accessibility, reliability, professionalism, kindness, and an easy-to-understand, low-pressure communication style. Favorable views of patient navigation were expressed by both individuals who completed LCS LDCT and those who did not, although the latter group generally offered less detail and cited personal circumstances that prevented them from completing LCS. #### Table 3.

Qualitative Themes and Representative Quotes From Patient and PCP Interviews. | **The navigator provided patients with multiple forms of social support** | | Instrumental (tangible) support (eg, scheduling, reminding, and facilitating LCS-related appointments) | * Patient: “[The navigator] did all the scheduling.

Basically, I just had to show up, and then he would even call me the morning before to make sure that I got there okay and stuff like that. ” * PCP: “I think [the patients] were more likely to get the screening done just because somebody was following up and making sure that it got scheduled, that they made it to the appointment, reminding them about the appointment and all that.

” | | Emotional or affirmational support (eg, addressing LCS-related fears, showing care and concern, enhancing motivation) | * Patient: “[The navigator] also told me… ’I know you’re scared. ’ I said I was kind of scared to do anything about it. So I find out I have it, oh, it would be devastating to know.

But I mean, I’ve got to deal with it. ” * Patient: “I mean, life’s a struggle especially when you’re poor and to have somebody that’s helping me, instead of me helping someone else, because I’m a mom. It was nice to have somebody, yeah, rooting me on and getting me motivated.

” | | Informational support (eg, explaining the LCS process and the pros and cons of screening) | * Patient: “[The navigator] was very good. I mean, she was very—she gave me a lot of knowledge about what was going to go on and how important it was to get it done and stuff like that. ” * PCP: “I didn’t have to start from the beginning.

It was more of a continuation of a conversation…. [Patients] are already saying, ‘I was told I need a [CT] scan. I was told I need lung cancer screening.

’ So the information was already there. When the information is there, I can already go on to chapter 2. I wasn’t starting on chapter 1.

” | | **The navigator coordinated various aspects of patient care in both visible and nonvisible ways** | | Raising PCPs’ LCS awareness (eg, identifying eligible patients who might have been missed, prioritizing LCS consideration) | * PCP: “Sometimes [the navigator] would catch patients who otherwise weren’t on my radar because I either hadn’t seen them in a while or I was focusing on other acute issues.

” * PCP: “[Patients] have someone to kind of take a step back for them and say, ‘Hey, look. What about your general health? What about cancer screening?

’ And they’re always like, ‘Oh, yeah. No one’s ever really talked to me about that. ’ And sometimes we do forget because you’re usually in crisis mode.

” | | Facilitating LCS-related PCP care (eg, shared decision-making visits, LCS ordering, LCS follow-up) | * Patient: “[The navigator] called my doctor. They spoke. And she told [my PCP] about it and that I had did the study.

” * PCP: “Sometimes [the navigator] will message me and let me know that it was done and that it’s been read and the report’s ready. And that’s great. And they’ll facilitate, like I said before, and, ‘Do you want to call them, or you want me to help them get here to plan with you?

’” | | Off-loading and task shifting (eg, supporting LCS process in ways not always visible to PCP) | * PCP: “I’m not sure what [the navigator] actually did. I mean, something that they must have determined themselves by talking to the patient. … I’m not sure how exactly; it’s like the Wizard of Oz.

They’re behind this big curtain. And they do what they need to do to make it happen. ” * PCP: ”I’d have a conversation and maybe sign a referral, and then I’d hand it off, and it would happen, which is nice.

… It helped me accomplish things that I otherwise wouldn’t have had the time or the ability to. ” | | General care coordination (eg, health care access, care transitions) | * Patient: “Well, there was a lot going on in my health care. ...

[The navigator] helped me get a new primary care [provider] and helped me figure out how to navigate through [my insurance] to change everything over to there, too. So there’s a lot of bureaucracy to go through, but she helped me through all of it. Amazing.

… if it weren’t for [the navigator], I wouldn’t have any of that, so. It’s a lifesaver. ” | | **The navigator’s interpersonal and professional qualities were appreciated by both patients and practitioners** | | Accessibility and reliability (eg, available to patients and PCPs, reliable in following up) | * Patient: “[The navigator] always got back to me, so that was that.

You know, if I asked for something he would do it. ” * PCP: “Why I loved the navigators’ role, is because they followed up with the patient. ” | | Professionalism (eg, knowledgeable, conscientious, well organized) | * Patient: “[The navigator] was thoughtful, considerate, knowledgeable, well spoken, organized in his thoughts and what he had to say, just very professional.

” * Patient: “My navigator was very competent, empathic, informative mostly, and caring, honestly. ” | | Communication (eg, explained things in an understandable and low-pressure way, communicated effectively with PCPs) | * Patient: “[The navigator] was very nice and explained it to me very well so I can understand. ” * Patient: “It’s always no pressure, and it feels great.

…I don’t know how to explain it. [The navigator] just works with me and doesn’t pressure me. But when I look back, she’s actually motivated me to do things that I would put off.

” * PCP: “One thing that I wanted to add that was helpful too was—I mean, they were very—the communication was really good. ” | Abbreviations: CT, computed tomography; LCS, lung cancer screening; PCP, primary care practitioner. ## [](https://pmc.

ncbi. nlm. nih.

gov/articles/PMC11165412/)Discussion To our knowledge, this is the first randomized clinical trial of patient navigation for cancer screening in an HCH setting. We found that the navigation intervention produced a 4. 7-fold increase in LCS LDCT completion at 6 months compared with usual care alone.

These findings complement the results of nonexperimental studies in other homeless health care settings39,40 and add to a growing body of work demonstrating the impact of patient navigation for cancer screening in vulnerable populations.

21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38 A core strength of patient navigation is its inherent flexibility in providing multidimensional, personalized assistance to vulnerable patients across the cancer care continuum. Our mixed-methods data underscored this strength. Navigator log data showed the breadth of tasks, supports, and behavioral interventions performed by the navigator.

Qualitative interview data complemented this finding, highlighting the importance of the navigator both as a source of multifaceted social support63 and as a behind-the-scenes coordinator of care. Interpersonal skills were vital to this role, reinforcing the primacy of dignity, trust, and compassion in health care encounters with this patient population.

64 Although the number of individuals who completed LCS LDCT and had Lung-RADS scores of 3 or greater was relatively small, our data suggest that the navigator had differential success in promoting follow-up among these individuals.

The lack of timely follow-up imaging among participants with Lung-RADS scores of 3 or greater may relate to the label _probably benign_ being applied to such findings, the challenges of sustaining contact with this patient population over the 6-month follow-up interval recommended for Lung-RADS 3 scores, delays related to missed appointments and competing life priorities,65 and the need for insurance approval of follow-up tests in some instances.

In contrast, participants with a Lung-RADS 4 score achieved diagnostic resolution (2 timely, 1 delayed), including 1 patient who underwent curative surgery for newly diagnosed lung cancer. These results point toward the value of patient navigation in promoting more urgent follow-up of overtly concerning findings while highlighting the need for strategies to improve follow-up of less urgent or more ambiguous findings.

Our study was conducted within a large, urban HCH program with a well-established track record in the delivery of highly tailored health care services to individuals experiencing homelessness. 44,45 While this likely created a best-case scenario for the usual care–only group, it could have also benefitted the navigation arm by creating a more optimal environment in which to deploy the intervention.

As of 2022, there were 299 federally funded HCH programs serving more than 940 000 patients across the US,66 and these programs vary widely in their clinical services, staffing structure, patient volume, resources, and geographic setting. 67,68 As a result, the generalizability of these findings to other HCH settings is uncertain.

Due to heavy reliance on phone-based recruitment during the COVID-19 pandemic, our study sample contained a higher-than-expected proportion