Integrating a Navigator Model to Expand Early Supportive Care for Latina and Black Women with Advanced Breast Cancer (ACCESS)

The ACCESS (Addressing Cancer Care Equity through Supportive Services) initiative is a community-based, navigator-led early supportive palliative care intervention designed for Black and Latina women with metastatic breast cancer (MBC). The goal is connect Black and Latina MBC patients with early palliative care services with the help of trained navigators. Black and Latina patients with MBC bear a disproportionate burden of pain, psychological distress, and unmet supportive care needs relative to White patients, disparities that persist through end of life (Mazor et al., 2025). Despite robust evidence that early palliative care integration improves quality of life and symptom control, access remains profoundly inequitable: concentrated in well-resourced settings, chronically delayed, and structurally inaccessible to the communities who stand to benefit most.

ACCESS was developed through a five-year National Cancer Institute (NCI) research program (funded by K08) that intentionally centered community partnership and iterative development. The first two years focused entirely on co-designing the intervention. Approximately 50 qualitative interviews were conducted with patients, caregivers, navigators, nurses, and physicians. These interviews provided an important opportunity to learn directly from the communities the researchers sought to support and to understand how patients experience supportive and palliative care in real-world contexts. A seven-member Community Advisory Board (CAB), composed of cancer survivors and community navigators, met monthly to guide the intervention’s development, while long-standing partnerships with community-based organizations and community scientists ensured the program reflected lived experiences. Please reference Mazor 2025 and Krishnamurthy 2024 for detailed findings from these interviews.

The program is currently concluding a pilot randomized controlled trial (55 participants enrolled as of June 2026) comparing navigator-supported patients with a group receiving structured information resources alone. The outcomes are feasibility, acceptability and preliminary efficacy on cancer-related distress and symptom burden.

Because the pilot randomized controlled trial is still ongoing, full quantitative outcomes data have not yet been published. The current iteration of the study assesses:

• Feasibility
• Acceptability
• Cultural relevance
• Recruitment and engagement patterns
• Implementation barriers and facilitators using established implementation science frameworks

Early findings suggest strong acceptability and meaningful patient engagement. However, recruitment patterns have fluctuated over time, reflecting broader social and policy shifts that may influence health care engagement among Hispanic communities. The study is also examining participation numbers, retention rates, and completion of intervention sessions to better understand reach and implementation effectiveness.

A central theme that emerged during the informational interviews was stigma surrounding the term “palliative care”. Many patients first associated it with death or “giving up”. As a result, the intervention often introduces “supportive care” first, building trust and clarifying that palliative care is an added layer of support. Relationship-building became the foundation of the model. Navigation was conceptualized not simply as information delivery but as culturally responsive, relational care that addresses both clinical and social needs.

Many patients enrolled in the program emphasized the need for trust before referrals. They feared being perceived as “difficult” if they spoke openly about their pain and symptoms with their clinicians. The navigator helped patients prepare prior to their oncology appointments, clarifying medical terminology, and encouraging them to ask questions more confidently. This preparation helped strengthen the communication with their clinician and improved overall engagement in care.

Despite the improvements made at the one-to-one patient-provider level, structural challenges remained. For example, even when the women participating were willing to engage with palliative care, services were not always accessible due to insurance barriers or logistical constraints. As one navigator reflected

This captures an important implementation challenge: improving awareness and willingness by the person does not always guarantee eligibility and enrollment.

Cancer is often experienced in the context of preexisting social and structural challenges. As shared during the interviews, cancer may be “just the latest thing that happened” in a patient’s life. When individuals are navigating concerns such as transportation instability,  employment/financial trade-offs between health care and basic social/economical needs; immigration-related fears; insurance limitations, food security and housing stability - it can be difficult to prioritize or consistently engage in specialty palliative care without additional support.

Program leaders also emphasized the importance of clearly defined roles amongst the members of the larger team - especially with the addition of a navigator. Successful integration required strong interprofessional collaboration and clarity about how navigators complement rather than duplicate existing services within oncology settings. The emotional labor and burnout risk among navigators and the care team was also mentioned as an area of potential concern.

The ACCESS model requires the following staffing roles:

• Trained community-based navigators
• Breast cancer oncologists
• Palliative care clinicians
• Social workers
• Administrative support for coordination and data collection
• Community Advisory Board members
• Partnerships with community organizations (in the case of the ACCESS program, these partners included SHARE Cancer Support, Women’s Cancer Resource Center, Community Advisory Board, Bellevue Navigation Program)

Navigators must receive training in cultural humility/competence, financial navigation, metastatic breast cancer care, and foundational palliative care principles prior to patient engagement. The intervention was designed to be flexible and adaptable while maintaining a structured “skeleton”. Core sessions focus on: understanding the patient’s story, exploring key palliative care domains, and addressing practical and emotional needs. The delivery of this intervention can be virtual, phone-based and/or in-person.

Several elements of ACCESS are potentially scalable:

• Early integration of supportive care into oncology through the use of community-based navigation
• Iterative intervention design informed by qualitative research (community feedback)
• Hybrid delivery formats
• Flexible yet structured implementation

Sustainability is embedded through structured “warm handoffs” to long-term institutional and community resources. Warm handoffs include anything from walking with the patient to the outpatient PC clinic to introduce to team to calling together for connection to sustainable navigational support thorugh CBOs (e.g., Cancer Hope Network, Unite for HER, SHARE, WCRC). The goal is not short-term navigation alone, but durable connections to support systems that extend beyond the study period.

However, long-term sustainability depends on:

• Institutional champions
• Reimbursement mechanisms for navigation services, with continued funding beyond career development awards (Note: CMS Principle Illness Navigation billing codes are one reimbursement method for these services. There are ongoing policy intitatives through ACS CAN to expand CMS reimbursement across the cancer continuum)
• Workforce support to prevent burnout
• Ongoing community partnerships

This model highlights that relational trust and community integration are not easily replicated without sustained investment.

• Build community partnerships prior to seeking funding
• Fairly compensate community collaborators for their time and expertise
• Train navigators in palliative care principles to help reduce stigma and build trust
• Introduce supportive care early in the cancer journey, not only at end of life
• Understand patients story and priorities and address patients’ transportation, financial strain, and other basic needs before introducing supporive canre and/or making specialty referrals
• Clearly define interprofessional team roles to ensure coordinated, seamless care
• Provide both institutional backing and emotional support for navigators in this work
• Recognize navigation as relational equity work, not simply logistical coordination

ACCESS demonstrates that improving accessibility in palliative care requires more than increasing referrals. It depends on building trusted relationships, providing culturally responsive communication, and creating systems flexible enough to meet patients' real-world needs. At the same time, the initiative highlights that relationship-based interventions alone cannot solve larger challenges such as workforce shortages and reimbursement gaps. Expanding equitable access to palliative care requires both community-centered innovation and meaningful structural reform.

• Melissa Mazor, PhD, MS, RN (Assistant Professor in the Division of General Internal Medicine and Associate Director of Community Outreach and Engagement for the Mount Sinai Tisch Cancer Center, a NCI-Designated Comprehensive Cancer Center)
  
• Sandra Morales (Patient Navigator, SHARE Cancer Support, Women’s Cancer Resource Center)

Funded by the National Cancer Institute (K08 Award) and the Rita and Alex Hillman Foundation.