Color Coding Navigation in Patients Requiring Primary Chemotherapy

November 2019 Vol 10, No 11
Carol-Ann Benn, MB.BCh (Wits) FCS(SA)
Netcare Breastcare Centre of Excellence, Milpark Hospital;
Helen Joseph Hospital, Johannesburg;
Faculty of Health Sciences, University of the Witwatersrand,
Johannesburg, South Africa
Dominic van Loggerenberg
Netcare Breastcare Centre of Excellence, Milpark Hospital,
South Africa
Kyara Bergstrom
Netcare Breastcare Centre of Excellence, Milpark Hospital,
South Africa
Z. Muguli
Netcare Breastcare Centre of Excellence, Milpark Hospital,
South Africa

Background: The Netcare Breast Care Centre in Johannesburg, South Africa, has been operational and running as a multidisciplinary breast care center since 2000. All newly diagnosed patients are discussed in a multidisciplinary meeting (MDM) prior to starting any treatment arms.

The unit sees approximately 437 newly diagnosed breast cancer patients per year; 99 underwent primary chemotherapy.* The unit has many navigators providing different services, with 3 who focus on ensuring adherence with primary chemotherapy.

Objective: To assess whether a file coding system for patients on primary chemotherapy aids navigation and improves chemotherapy compliance.

Methods: Each patient undergoing primary chemotherapy has clinical and navigation assessments:

  • Clinical: presenting doctor and independent oncological assessment;
  • Navigation: triages the patient’s opinion and willingness to comply.

These assessments divide patients into 3 groups:

  • Code green: Compliant
  • Code yellow: Reservations about treatment and side effects with potential noncompliance
  • Code red: Unwilling to undergo primary chemotherapy

The code red patients are further subcategorized in terms of reasons for noncompliance:

  • Code red 1: Fear of chemotherapy side effects
  • Code red 2: The belief that chemotherapy kills the patient
  • Code red 3: Interest in “alternative treatment regimens”
  • Code red 4: Barriers to treatment (logistic/financial/family)

Each patient is followed up within 48 hours of a chemotherapy session and is reassessed and then recoded. If the patient is code red or yellow, they are met by a navigator at the chemotherapy site for assessment and management of barriers to treatment. Code red patients refusing treatment are assigned a specific navigator who focuses on complementary navigation and stays in contact with the patient discussing potential treatment until the patient is compliant or contact is refused. These code red patients undergo regular ultrasound follow-up quarterly until treatment is accepted and completed or they request to be removed from the program.

Results: The system allows the navigation team to focus on which patients require specific navigation and to coordinate with the oncologists. The code yellow patients are managed by early involvement of the survivorship team to ensure careful handling of side effects with the addition of complementary services. Code red 1 and 2 patients are managed by a “buddies network” of patients who have been through similar treatment regimens in coordination with the navigation team. Code red 3 patients are managed by a complementary health specialist who understands the value of chemotherapy. Code red 4 patients are managed by the patient navigator who refers them to the appropriate services in the community or within the health system. At any one moment there are 100 patients split between 5 center oncologists. The following breakdown existed over a 6-month period: code green: 65%; code yellow: 25%; code red: 10%. A further breakdown of the code red will be presented.

Conclusions: This system provides the MDM with the opportunity to evaluate patient adherence with primary chemotherapy; 75% of the code red patients eventually agreed to recommended treatment.


  • *Data have been approved and permission was given by patients to be used for research. Numerous patient exclusion criteria were applied including but not limited to: site-only patient diagnosed and treated at the primary center; consent signed by patients.
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Last modified: August 10, 2023

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