Self administered screening for hereditary cancers in conjunction with mammography and ultrasound

Personalized survivorship care: Routine breast cancer risk assessment in the gynecologic oncology clinic

INTRODUCTION

Gynecologic and breast cancers share several risk factors. Breast cancer risk assessment tools can identify those at elevated risk and allow for enhanced breast surveillance and chemoprevention, however such tools are underutilized. We aim to evaluate the use of routine breast cancer risk assessment in a gynecologic oncology clinic.

METHODS

A patient-facing web-based tool was used to collect personal and family history and run four validated breast cancer risk assessment models (Tyrer-Cuzick (TC), Gail, BRCAPRO, and Claus) in a gynecologic oncology clinic. We evaluated completion of the tools and identification of patients at elevated risk for breast cancer using the four validated models.

RESULTS

A total of 99 patients were included in this analysis. The BRCAPRO model had the highest completion rate (84.8%), followed by the TC model (74.7%), Gail model (74.7%), and the Claus model (52.1%). The TC model identified 21.6% of patients completing the model as having ≥20% lifetime risk of breast cancer, compared to 6.8% by the Gail model, and 0% for both the BRCAPRO and Claus models. The Gail model identified 52.5% of patients as having ≥1.67% 5-year risk of breast cancer. Among patients identified as high-risk for breast cancer and eligible for screening, 9/9 (100%) were referred to a high-risk breast clinic.

CONCLUSION

Among patients that completed the TC breast cancer risk assessment in a gynecologic oncology clinic, approximately 1 in 5 were identified to be at significantly elevated lifetime risk for breast cancer. The gynecologic oncologist's office might offer a convenient and feasible setting to incorporate this risk assessment into routine patient care, as gynecologic oncologists often have long-term patient relationships and participate in survivorship care.

Increasing referral of at-risk women for genetic counseling and BRCA testing using a screening tool in a community breast imaging center

BACKGROUND

Genetic evaluation and testing for hereditary breast and ovarian cancer (HBOC) remain suboptimal. The authors evaluated the feasibility of using a screening tool at a breast imaging center to increase HBOC assessment referrals.

METHODS

A brief questionnaire based on the National Comprehensive Cancer Network HBOC genetic counseling referral guidelines was developed and added to the standard intake forms of patients undergoing mammography at a community breast imaging center from 2012 through 2015. Patients who met the criteria in the guidelines were referred for genetic counseling.

RESULTS

A total of 34,851 patients were screened during the study period, and 1246 (4%) patients were found to be eligible for referral; 245 of these patients made a genetic counseling appointment, and 142 patients received genetic counseling. Forty patients (28%) had a personal history of breast cancer but were not previously tested. Following counseling, 105 patients were tested for BRCA1/2. Eight patients (8%) tested positive for a pathogenic mutation and nine (9%) had a variant of unknown significance. Although they tested negative, many patients met the criteria to add breast magnetic resonance imaging to their screening due to greater than 20% lifetime breast cancer risk based on their family cancer history. This study led to improved clinical risk management in 67% of the patients who underwent genetic counseling.

CONCLUSIONS

This study shows that large-scale screening of patients for HBOC syndromes at time of breast imaging is practical and highly feasible. The screening tool identified women with actionable BRCA1/2 mutations and mutation-negative but high-risk women, leading to significant changes in their risk management; these women would otherwise have been missed.

LAY SUMMARY

Hereditary breast and ovarian cancer (HBOC) caused by pathogenic mutations in breast cancer genes (BRCA1/BRCA2) increase an individual's lifetime risk of getting HBOC. Identifying these high-risk individuals and using proven preventive clinical risk management strategies can significantly reduce their lifetime risk of HBOC. Using an innovative family cancer history questionnaire, 34,000 women were screened at a community breast imaging center, and genetic counseling and testing were provided to eligible women from the screening. Several women at high risk for HBOC were identified and this led to positive clinical risk management changes. These women would have been missed if not for intervention.

Impact of Age, Race, and Socioeconomic Status on Women's Perceptions and Preferences Regarding Communication of Estimated Breast Cancer Risk

RATIONALE AND OBJECTIVES

Performing breast cancer risk assessment at the time of screening mammography has potential to increase high-risk identification, appropriate supplemental screening, and risk management. The study's goal is to investigate women's interest in risk assessment and preferred method of risk communication in a diverse patient population.

MATERIALS AND METHODS

Surveys in English and five non-English languages were distributed to women presenting for screening mammography at eight screening mammography facilities between February and May 2019 to assess their interest in risk assessment, preferred method, and level of detail of estimated risk communication in hypothetical scenarios where estimated risks are average and elevated.

RESULTS

Among 683 survey respondents, 592 (87%) expressed interest in learning about their estimated lifetime risk of breast cancer. Controlling for age, race/ethnicity, and education, women with higher income were more interested in risk assessment than comparison group (p<0.05). The most preferred method of average risk communication was by a mailed letter accompanying mammographic results (57%), but more women exclusively preferred face-to-face communications of elevated risk than of average risk estimate (191, 28% vs. 128, 19%, p<0.0001). Phone communication was more preferred by younger women, electronic communication was less preferred by older women and those with lower income, and non-Hispanic blacks and older women preferred less detailed communication (p<0.05).

CONCLUSION

Sociodemographic factors influence women's interest in risk assessment and preference in risk communication about breast cancer. Screening Mammogram facilities implementing risk assessment should consider risk communication strategies that are most effective for their patient population.

Primary Care Providers Underutilize Breast Screening MRI for High-Risk Women

OBJECTIVE

Supplemental MRI screening for women at high risk for breast cancer is underutilized. Our study assessed how primary care providers in our healthcare network identify high-risk women and recommend high-risk screening breast MRI.

METHODS

An electronic survey was distributed to providers in OB/GYN, family, and internal medicine departments between 1/14/19 and 3/22/19. The survey inquired about methods used to assess breast cancer risk, familiarity with the American Cancer Society's definition of high-risk, and whether screening breast MRI is recommended for high-risk women.

RESULTS

Response rate was 17% (89/524). After excluding providers who ordered ≤10 mammograms per year, the study included 75 respondents, who mostly ordered 10-1000 mammograms per year and supported annual/biennial screening mammogram starting at age 40-50 years. More providers reported estimating breast cancer risk qualitatively (with family, clinical history, and/or breast density) than quantitatively with risk calculators (73/75, 97% vs 22/75, 29%). A minority of providers (23/75, 31%) correctly defined high lifetime risk. Only 9/75 (12%) providers recommended screening MRI for high-risk women. Use of quantitative risk calculators or ability to correctly define high-risk were not associated with likelihood of recommending MRI screening. More providers had recommended MRI for screening in the setting of dense breasts than for high-risk screening (23/75, 31% vs 9/75, 12%).

CONCLUSION

Primary care providers at our institution did not routinely recommend screening MRI for high-risk women. Risk assessment and reporting at the time of mammography may improve MRI utilization and is an opportunity for radiologists to add value and directly participate in patient-centered care.

Genetic Counseling and Testing in a Community Setting: Quality, Access, and Efficiency

There is an increasing need for genetic counseling and testing for individuals diagnosed with cancer, as treatment may be affected by the results. In addition, the identification of individuals before a diagnosis of cancer allows for optimal surveillance and early detection and prevention of cancer. With the recognition that as much as 10% of all cancers are hereditary, there is a growing need to improve access to genetic counseling and genetic testing, both before and at the time of diagnosis. This article focuses on models of identifying at-risk patients, including underserved communities; providing genetic counseling and testing in community practices; using telehealth; and collaborating with nongenetics health care providers and technological solutions to maximize efficiency and access.

A collaborative approach to cancer risk assessment services using genetic counselor extenders in a multi-system community hospital

PURPOSE

This study aimed to evaluate a unique approach to cancer risk assessment for improved access by smaller rural communities.

METHODS

Local, on-site nurse navigators were trained and utilized as genetic counselor extenders (GCEs) to provide basic risk assessment and offer BRCA1/2 genetic testing to select patients based on a triaging process in collaboration with board-certified genetic counselors (CGCs).

RESULTS

From August 2012 to July 2014, 12,477 family history questionnaires representing 8937 unique patients presenting for a screening mammogram or new oncology appointment were triaged. Of these, 8.2 % patients were identified at increased risk for hereditary breast cancer, and 4.2 % were identified at increased risk for other hereditary causes of cancer. A total of 75 of 1130 at-risk patients identified (6.6 %) completed a genetic risk assessment appointment; 23 with a GCE and 52 with a CGC. A review of the completed genetic test requisition forms from a 9-year pre-collaboration time period found that 16 % (20/125) did not appear to meet genetic testing criteria. Overall, there was a fourfold increase in patients accessing genetic services in this study period compared to the pre-collaboration time period. Efficiency of this model was assessed by determining time spent by the CGC in all activities related to the collaboration, which amounted to approximately 16 h/month. Adjustments have been made and the program continues to be monitored for opportunities to improve efficiency.

CONCLUSION

This study demonstrates the feasibility of CGCs and GCEs collaborating to improve access to quality services in an efficient manner.

Use of Mobile Clinical Decision Support Software by Junior Doctors at a UK Teaching Hospital: Identification and Evaluation of Barriers to Engagement

Background

Clinical decision support (CDS) tools improve clinical diagnostic decision making and patient safety. The availability of CDS to health care professionals has grown in line with the increased prevalence of apps and smart mobile devices. Despite these benefits, patients may have safety concerns about the use of mobile devices around medical equipment.

Objective

This research explored the engagement of junior doctors (JDs) with CDS and the perceptions of patients about their use. There were three objectives for this research: (1) to measure the actual usage of CDS tools on mobile devices (mCDS) by JDs, (2) to explore the perceptions of JDs about the drivers and barriers to using mCDS, and (3) to explore the perceptions of patients about the use of mCDS.

Methods

This study used a mixed-methods approach to study the engagement of JDs with CDS accessed through mobile devices. Usage data were collected on the number of interactions by JDs with mCDS. The perceived drivers and barriers for JDs to using CDS were then explored by interviews. Finally, these findings were contrasted with the perception of patients about the use of mCDS by JDs.

Results

Nine of the 16 JDs made a total of 142 recorded interactions with the mCDS over a 4-month period. Only 27 of the 114 interactions (24%) that could be categorized as on-shift or off-shift occurred on-shift. Eight individual, institutional, and cultural barriers to engagement emerged from interviews with the user group. In contrast to reported cautions and concerns about the impact of clinicians’ use of mobile phone on patient health and safety, patients had positive perceptions about the use of mCDS.

Conclusions

Patients reported positive perceptions toward mCDS. The usage of mCDS to support clinical decision making was considered to be positive as part of everyday clinical practice. The degree of engagement was found to be limited due to a number of individual, institutional, and cultural barriers. The majority of mCDS engagement occurred outside of the workplace. Further research is required to verify these findings and assess their implications for future policy and practice.

Tablet, web-based, or paper questionnaires for measuring anxiety in patients suspected of breast cancer: patients' preferences and quality of collected data

BACKGROUND

Electronic applications are increasingly being used in hospitals for numerous purposes.

OBJECTIVE

Our aim was to assess differences in the characteristics of patients who choose paper versus electronic questionnaires and to evaluate the data quality of both approaches.

METHODS

Between October 2012 and June 2013, 136 patients participated in a study on diagnosis-induced stress and anxiety. Patients were asked to fill out questionnaires at six different moments during the diagnostic phase. They were given the opportunity to fill out the questionnaires on paper or electronically (a combination of tablet and Web-based questionnaires). Demographic characteristics and completeness of returned data were compared between groups.

RESULTS

Nearly two-thirds of patients (88/136, 64.7%) chose to fill out the questionnaires on paper, and just over a third (48/136, 35.3%) preferred the electronic option. Patients choosing electronic questionnaires were significantly younger (mean 47.3 years vs mean 53.5 in the paper group, P=.01) and higher educated (P=.004). There was significantly more missing information (ie, at least one question not answered) in the paper group during the diagnostic day compared to the electronic group (using a tablet) (28/88 vs 1/48, P<.001). However, in the week after the diagnostic day, missing information was significantly higher in the electronic group (Web-based questionnaires) compared to the paper group (41/48 vs 38/88, P<.001).

CONCLUSIONS

Younger patients and patients with a higher level of education have a preference towards filling out questionnaires electronically. In the hospital, a tablet is an excellent medium for patients to fill out questionnaires with very little missing information. However, for filling out questionnaires at home, paper questionnaires resulted in a better response than Web-based questionnaires.