In this issue of CA: A Cancer Journal for Clinicians, Chan and colleagues¹ describe an umbrella review of 61 systematic reviews published between 2012 and 2022, along with a review of 53 primary studies published globally since 2021. Patient navigation (PN) has many definitions, and, in this, review PN was defined according to the definition of Wells et al.² combined with that of Dalton et al.,³ which expanded the definition of PN to also include care coordination. Their primary research question focused on evaluating the effectiveness and cost-effectiveness of different cancer navigation models and programs. Multiple databases were searched to find quantitative PN intervention studies with any comparator as well as qualitative, mixed-methods, and systematic reviews. The Joanna Briggs Institute’s JBI Critical Appraisal Checklist for Systematic Review and Research Syntheses was used to examine the risk of bias for each of the systematic reviews. Findings of this umbrella review indicated that the risk of bias of the included systematic reviews seemed low; however, fewer than one half of the included reviews reported the likelihood of publication bias. The review concluded that PN is effective in increasing uptake or adherence to cancer screening, reducing the time from screening abnormality to diagnosis, increasing rates of diagnostic resolution, reducing the time from diagnostic resolution to treatment initiation, increasing treatment completion, increasing treatment adherence, increasing survivorship surveillance appointments for breast or cervical cancer, increasing quality of life, and increasing satisfaction with care. Furthermore, the review pointed to a lack of evidence regarding PN in palliative care and end-of-life phases. The review also concluded that most effectiveness and cost-effectiveness data for PN interventions were collected in the United States; therefore, Chan and colleagues call for additional research to evaluate the effectiveness and cost-effectiveness of PN outside of the United States, in survivorship and palliative care phases of the cancer continuum, for indigenous populations, and for individuals affected by rare cancers, hematologic malignancies, as well as advanced or metastatic cancer.¹

Although this review has many important contributions to the literature, there are points that need to be addressed. First, although Chan and colleagues updated the more recent literature, their conclusions do not differ from those of the myriad of other reviews. Now is the time for the implementation of PN in health care because the amount and consistency of evidence is sufficient demonstrating the impact of PN across the cancer continuum. This report solidifies the evidence—when can we all agree that enough evidence is enough and that PN needs to be an integral part of usual clinical care with reimbursement? The next phase of studies should collect and report on the implementation of PN in usual care.

Second, Chan and colleagues correctly point out the need for a consistent definition of PN. In our view, researchers and practitioners do PN a disservice when they do not use the definition of PN established and vetted by leading organizations like the American Cancer Society (ACS) National Navigation Roundtable (NNRT).⁴ The use of inconsistent PN definitions and lumping together patient navigators with other categories of health care providers are important barriers to acceptance of PN as a billable service.

Third, on the same theme, including others who provide PN-like services in care and research studies of PN does not strengthen the evidence for PN but, instead, weakens it. Patient navigators have defined competencies, with formal training, certification, and the potential for accreditation: The Academy of Oncology Nurse and Patient Navigators (AONN) certification examinations are led by the AONN+ Foundation for Learning (https://aonnffl.org/); and certifications for Oncology Nurse Navigator–Certified Generalists and Oncology Patient Navigator–Certified Generalists are accredited through the ANSI National Accreditation Board (https://anabpd.ansi.org/). If other individuals who are not trained, certified, or accredited are performing this role, then (1) it weakens evidence of the effectiveness of the patient navigator‘s role in those individuals without adequate training who are performing this role, and (2) it weakens the case for reimbursement for a specific PN job code.

With the wide-ranging and successful research and evaluation efforts that have been conducted over the last few decades, the evidence supporting the impact of oncology navigation on a range of patient-related outcomes across the cancer continuum is extensive. Now, these efforts must shift to strategies and research focused on implementation, adaptation, scaling up, and sustainability. Implementation is complex and requires attention to the context for adaptation to local and institutional needs, assessing readiness for implementation, and understanding the enablers of implementation, planning for sustainability, and scaling of interventions.⁵ These are dynamic processes that require ongoing evaluation and dissemination of lessons learned. We need to build on emerging efforts, such as the recent Centers for Disease Control and Prevention’s Community Guide recommendations for breast, cervical, and colorectal cancer screening based on a systematic review of the evidence,⁶ the Centers for Medicare & Medicaid Services Enhanced Oncology Model,⁷ and the ACS capacity-building navigation grants and learning community.⁸ Now, the need is to build evidence about successful implementation strategies at multiple levels and within different contexts to reach the goal of ensuring that this evidence-based intervention is integrated into all oncology care.

Key components to measuring the effectiveness and replicability of evidence-based interventions in PN are standard measures and approaches, such as those outlined in the AONN Standardized Metrics and Certifications.⁹ These metrics provide a common framework for assessing program quality across the domains of patient satisfaction, clinical outcomes, and return on investment. Ongoing investment in assessing the scalability of navigation through the reporting of standard measures must be prioritized by institutions, health systems, and national organizations.

With the consistent evidence in favor of PN in oncology care further solidified by this comprehensive review of systematic reviews, it is our opinion that now is the time to turn our resources and attention to ensuring the adoption of evidence-based PN practices across our complex, multilayered health care system. Figure 3 in the review by Chan and colleagues clearly summarizes the barriers and facilitators across these multiple levels that must be addressed to support best-practice implementation and crystalizes the complexity of realizing the promise of oncology navigation. In other words, the health system needs to be ready to accept, adopt, and scale evidence-based PN.

The ACS NNRT was established in 2017 and is a national coalition of 80 member organizations to advance navigation efforts that eliminate barriers to quality care, reduce disparities, and foster ongoing health equity across the cancer continuum. In 2021, the NNRT established a 5-year aim to pursue the development of a sustainable model for oncology PN that would achieve health equity across the continuum of cancer care.¹⁰ The NNRT has long recognized the importance of patient navigator role definitions, a competent PN workforce, and reimbursement of patient navigators as vital to the sustainability of PN. This new 5-year sustainability aim also recognizes that our complex health care systems and the oncology provider community must embrace a collective approach to successfully integrate navigation evidence into our everyday practice. Reimbursement of navigation services alone, without parallel efforts to eliminate barriers to the adoption of evidence-based practices, will not advance cancer equity. Indeed, it may well perpetuate existing inequities. The sustainability of PN will require collaboration across leaders from every level of the health care system, from policy makers to payors and, most importantly, health system administrators and oncology providers. Together, these stakeholders must hold each other accountable to adopt the unmistakable evidence before us. The time is now, the patient cancer care experience depends upon it.

在本期《CA：临床医生癌症杂志》中，Chan 及其同事¹描述了对 2012 年至 2022 年间发表的 61 项系统综述的总体综述，以及对 2021 年以来全球发表的 53 项初步研究的综述。患者导航 (PN) 有很多定义，并且在此，审查 PN 是根据 Wells 等人的定义定义的。²与 Dalton 等人的观点相结合，³扩大了 PN 的定义，使其还包括护理协调。他们的主要研究问题集中在评估不同癌症导航模型和计划的有效性和成本效益。我们检索了多个数据库来查找具有任何比较器的定量 PN 干预研究以及定性、混合方法和系统评价。乔安娜布里格斯研究所的 JBI 系统评价和研究综合批判性评估清单用于检查每项系统评价的偏倚风险。该总体评价的结果表明，所纳入的系统评价的偏倚风险似乎很低；然而，不到一半的纳入评论报告了发表偏倚的可能性。审查得出的结论是，PN 可有效提高癌症筛查的采用率或依从性，缩短从筛查异常到诊断的时间，提高诊断解决率，缩短从诊断解决到开始治疗的时间，提高治疗完成率，提高治疗依从性，提高治疗的有效性。乳腺癌或宫颈癌的生存监测预约，提高生活质量并提高护理满意度。此外，审查指出缺乏有关姑息治疗和临终阶段 PN 的证据。审查还得出结论，大多数 PN 干预措施的有效性和成本效益数据是在美国收集的；因此，Chan 及其同事呼吁进行更多研究，以评估美国以外的 PN 在癌症连续体的生存和姑息治疗阶段、对土著居民以及受罕见癌症、血液恶性肿瘤影响的个人的有效性和成本效益，以及晚期或转移性癌症。¹

尽管这篇综述对文献有许多重要贡献，但仍有一些问题需要解决。首先，尽管陈和同事更新了最新的文献，但他们的结论与无数其他评论的结论没有什么不同。现在是在医疗保健中实施 PN 的时候了，因为证据的数量和一致性足以证明 PN 对整个癌症连续体的影响。这份报告巩固了证据——我们什么时候才能一致认为足够的证据就足够了，并且 PN 需要成为常规临床护理和报销的一个组成部分？下一阶段的研究应收集并报告 PN 在常规护理中的实施情况。

其次，Chan 及其同事正确地指出了对 PN 进行一致定义的必要性。我们认为，如果研究人员和从业者不使用由美国癌症协会 (ACS) 国家导航圆桌会议 (NNRT) 等领先组织制定和审查的 PN 定义，那么他们就会对 PN 造成伤害。⁴使用不一致的 PN 定义以及将患者导航员与其他类别的医疗保健提供者混为一谈是接受 PN 作为计费服务的重要障碍。

第三，在同一主题上，将其他在 PN 的护理和研究中提供类似 PN 服务的人纳入进来，并不会加强 PN 的证据，相反，会削弱它。患者导航员具有明确的能力，包括正式培训、认证和认证潜力：肿瘤护士和患者导航员学院 (AONN) 认证考试由 AONN+ 学习基金会 (https://aonnffl.org/) 领导；肿瘤科护士导航员认证通才和肿瘤科患者导航员认证通才的认证均通过 ANSI 国家认证委员会 (https://anabpd.ansi.org/) 认证。如果未经培训、认证或认可的其他个人正在履行这一职责，那么 (1) 它削弱了患者导航员角色对于那些未经充分培训但正在履行这一职责的个人的有效性的证据，并且 (2) 它削弱了患者导航员角色的有效性。特定 PN 工作代码的报销案例。

随着过去几十年进行的广泛且成功的研究和评估工作，有大量证据支持肿瘤学导航对整个癌症连续体中一系列患者相关结果的影响。现在，这些努力必须转向专注于实施、适应、扩大和可持续性的战略和研究。实施是复杂的，需要关注适应当地和机构需求的背景、评估实施的准备情况、了解实施的推动因素、可持续性规划和干预措施的规模。⁵这些是动态过程，需要不断评估和传播经验教训。我们需要以新兴努力为基础，例如最近疾病控制和预防中心基于对证据的系统审查提出的关于乳腺癌、宫颈癌和结直肠癌筛查的社区指南建议，6 医疗保险和医疗补助服务中心增强的^肿瘤学模型、⁷以及 ACS 能力建设导航补助金和学习社区。⁸现在，需要在多个层面和不同背景下建立关于成功实施策略的证据，以实现确保将这种基于证据的干预措施纳入所有肿瘤护理的目标。

衡量 PN 循证干预措施有效性和可复制性的关键组成部分是标准措施和方法，例如 AONN 标准化指标和认证中概述的措施和方法。⁹这些指标提供了一个通用框架，用于评估患者满意度、临床结果和投资回报等领域的项目质量。机构、卫生系统和国家组织必须优先考虑通过报告标准措施来评估导航可扩展性的持续投资。

通过对系统评价的全面审查，进一步巩固了支持肿瘤学护理中 PN 的一致证据，我们认为现在是时候将我们的资源和注意力转向确保在我们复杂的、复杂的、多层次的医疗保健体系。Chan 及其同事的评论中的图 3 清楚地总结了这些多个层面的障碍和促进因素，必须解决这些障碍和促进因素，以支持最佳实践的实施，并具体化实现肿瘤学导航承诺的复杂性。换句话说，卫生系统需要做好接受、采用和扩大基于证据的 PN 的准备。

ACS NNRT 成立于 2017 年，是一个由 80 个成员组织组成的全国联盟，旨在推进导航工作，消除优质护理的障碍，减少差异，并促进整个癌症连续体的持续健康公平。2021 年，NNRT 制定了一个 5 年目标，致力于开发可持续的肿瘤 PN 模型，从而在整个癌症护理过程中实现健康公平。¹⁰ NNRT 长期以来一直认识到患者导航员角色定义、称职的 PN 员工队伍以及患者导航员报销的重要性，这些对于 PN 的可持续性至关重要。这一新的 5 年可持续发展目标还认识到，我们复杂的医疗保健系统和肿瘤学提供者社区必须采取集体方法，将导航证据成功整合到我们的日常实践中。仅对导航服务进行补偿，而不同时努力消除采用循证实践的障碍，不会促进癌症公平。事实上，它很可能会延续现有的不平等现象。PN 的可持续性需要医疗保健系统各个层面的领导者之间的合作，从政策制定者到付款人，最重要的是卫生系统管理员和肿瘤学提供者。这些利益相关者必须共同要求彼此负责，以采用我们面前的明确无误的证据。现在是时候了，患者的癌症护理体验取决于此。