Comprehensive patient navigation is associated with increased active treatment retention in lung cancer care in rural Appalachia

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Background: Lung cancer mortality is disproportionately concentrated in rural Appalachia. Patient navigation may improve access, but evidence supporting comprehensive lung cancer navigation across all diagnostic pathways remains limited. We evaluated an all-pathway navigation program at a community cancer center serving a high-burden, predominantly publicly insured Appalachian population. Methods: We conducted a retrospective cohort study of 470 patients diagnosed with lung cancer at a single Commission on Cancer (CoC)-accredited community center between 2018 and 2022. In January 2019, a respiratory therapist-led program expanded to cover screening-detected, incidentally detected, and symptomatic presentations. The primary outcome was active treatment retention at the diagnosing institution, ascertained from the institutional cancer registry. Results: Treatment retention was higher in the navigation era than before navigation [83.4% vs. 68.1%; absolute difference 15.3 percentage points; number needed to treat (NNT) approximately 7; odds ratio (OR) =2.36, 95% confidence interval (CI): 1.43–3.89; P=0.001]. The association persisted after multivariable adjustment (OR =2.67), under inverse-probability weighting (OR =2.29), and under conservative bounding of patients absent from the registry (worst-case OR =1.63, still significant); single-year contrasts were underpowered and non-significant. Median diagnosis-to-treatment time was 22 days, without prolongation during coronavirus disease 2019 (COVID-19). Survival showed no detectable insurance gradient (an underpowered comparison) despite predominantly public coverage (approximately 77% Medicare or Medicaid); active treatment [time-averaged hazard ratio (HR) =0.47] and stage IV disease (3.42) were the strongest survival predictors. Conclusions: In a high-burden Appalachian population, comprehensive all-pathway navigation was associated with higher treatment retention at the diagnosing institution; navigation itself was not independently associated with survival, which was more strongly associated with treatment receipt, consistent with an indirect care-delivery mechanism. These findings show that a respiratory therapist-led, all-pathway navigation program can be built and sustained in a small community center, and support further consideration of navigation as core community cancer infrastructure.

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