Breast Navigator: “Superhero” of Patient Care, Identifying and Improving Timeliness of Care Through Process Improvement Regarding 21-Gene Assay Ordering

November 2019 Vol 10, No 11
Yovante Lynn Rabun, RN, BSN, OCN
Sarah Cannon (Tristar South Division) (Redmond Medical Center)

Background: Timeliness of care is of vital importance in breast cancer treatment. According to Gagliato and colleagues,1 breast cancer patients who receive chemotherapy within 30 days of surgery had better results in regard to survival and remaining disease-free. Avoidable delays in breast cancer care often create a negative impact on optimal care and satisfaction. In the past 20 years, the complexity of managing breast cancer has increased with the integration of genomics, and so has the wait times in treatment. The 21-gene assay, a diagnostic test that measures genes in breast tissue, has been integrated into clinical practice guidelines on biomarker use to guide treatment. This test has changed the landscape for ER-positive early breast cancer.2 However, it often introduces delays to treatment decisions and initial therapy. Vandergrift and colleagues3 showed an average 2.2-week increase in time associated with the 21-gene assay. The ability to identify delay in care and drive process improvement to offer patients the highest standard of care is part of the role of a highly functioning breast navigator. Therefore, process improvement related to genomic testing was initiated.

Objective: Surgeons and oncologists will utilize the breast navigator’s recommendations to have ordering of 21-gene assay moved from oncologists to surgeons, and through a consensus, develop guidelines for reflex ordering by the navigator. These processes will decrease the number of business days between final pathology results and the 21-gene assay and, therefore, decrease wait time to oncologist by 7 to 14 days within 6 months.

Methods: Evidence-based literature4 was used by the navigator to show physicians that shifting the 21-gene assay from oncologists to surgeons would be a good starting point for decreasing ordering time and then wait time to oncologist. The navigator met with physicians to develop criteria for navigator-initiated testing guidelines. Quantitative research was used by the navigator to examine a group of 16 patients—8 patients who had the 21-gene assay ordered prior to implementation of the streamlined process by the navigator, and 8 patients who had reflex ordering done by the navigator. The date the final surgical pathology was received and the date the 21-gene assay was ordered were obtained and intervals were measured.

Results: Implementation of surgeon-initiated 21-gene assays immediately reduced the wait time by 2 weeks. Data at the 6-month mark from navigator-initiated reflex ordering showed an added 6-day improvement. As a result of both, the patient wait time to oncologist appointment may be reduced approximately 3 weeks.

Conclusions: The navigator plays an important role often becoming the “superhero” of patient-centered care by identifying a barrier of care and eradicating it by driving process improvement. Implementing changes in the 21- gene assay ordering process has significantly reduced wait times, allowing patients to be seen in a more timely manner by the oncologist. This allows for an earlier initiation of treatment and, therefore, decreases patient stress and improves the patient experience.


  1. Gagliato D, Gonzalez-Angulo AM, Lei X, et al. Clinical impact of delaying initiation of adjuvant chemotherapy in patients with breast cancer. J Clin Oncol. 2014;32:735-744.
  2. Siow ZR, De Boer RH, Lindeman GJ, Mann GB. Spotlight on the utility of the Oncotype DX breast cancer assay. Int J Womens Health. 2018;10:89-100.
  3. Vandergrift JL, Niland JC, Theriault RL, et al. Time to adjuvant chemotherapy for breast cancer in National Comprehensive Cancer Network institutions. J Natl Cancer Inst. 2013;105:104-112.
  4. Losk K, Freedman RA, Lin NU, et al. Implementation of surgeon-initiated gene expression profile testing (Oncotype DX) among patients with early-stage breast cancer to reduce delays in chemotherapy initiation. J Oncol Pract. 2017;13:e815-e820.
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Last modified: August 10, 2023

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