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Zeballos Torrez CR, Gasior JA, Ginzberg SP, Nunes LW, Fayanju OM, Englander BS, Elmore LC, Edmonds CE. Identifying and Addressing Barriers to Screening Mammography in a Medically Underserved Community. Acad Radiol 2024; 31:2643-2650. [PMID: 38151382 DOI: 10.1016/j.acra.2023.12.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/05/2023] [Accepted: 12/05/2023] [Indexed: 12/29/2023]
Abstract
RATIONALE AND OBJECTIVES Breast cancer mortality is 40% higher for Black women compared to White women. This study seeks to assess knowledge of breast cancer screening recommendations and identify barriers to risk assessment and mammographic screening among a medically underserved, low-income, predominantly Black community in West Philadelphia. MATERIALS AND METHODS During a free mobile mammography screening event, women were offered surveys to assess perceptions of and barriers to breast cancer risk assessment and screening. Among those who subsequently underwent mobile screening, health insurance and time to additional diagnostic imaging and biopsy, when relevant, were retrospectively collected. RESULTS 233 women completed surveys (mean age 54 ± 13 years). Ninety-three percent of respondents identified as Black. The most frequently cited barrier to screening mammography was cost and/or lack of insurance coverage (30%). Women under 50 reported more barriers to screening compared to older women. Among those recalled from screening and recommended to undergo biopsy, there was a trend toward longer delays between screening and biopsy among those without a PCP (median 45 days, IQR 25-53) compared to those with a PCP (median 24 days, IQR 16-29) (p = 0.072). CONCLUSION In a study of a medically underserved community of primarily Black patients, barriers to breast cancer risk assessment, screening, and diagnosis were identified by self-report and by documented care delays. While free mobile mammography initiatives that bring medical professionals into communities can help mitigate barriers to screening, strategies for navigation and coordination of follow-up are critical to promote timely diagnostic resolution for all patients.
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Affiliation(s)
- Carla R Zeballos Torrez
- Department of Radiology, University of Pennsylvania Health System, 3400 Spruce Street, Philadelphia, PA (C.R.Z.T., L.W.N., B.S.E., C.E.E.).
| | - Julia Anna Gasior
- Department of Surgery, University of Pennsylvania Health System, 3400 Spruce Street, Philadelphia, PA (J.A.G., S.P.G., O.M.F., L.C.E.,)
| | - Sara P Ginzberg
- Department of Surgery, University of Pennsylvania Health System, 3400 Spruce Street, Philadelphia, PA (J.A.G., S.P.G., O.M.F., L.C.E.,); Penn Center for Cancer Care Innovation, University of Pennsylvania Health System, 3400 Civic Center Boulevard, Philadelphia PA (S.P.G.)
| | - Linda W Nunes
- Department of Radiology, University of Pennsylvania Health System, 3400 Spruce Street, Philadelphia, PA (C.R.Z.T., L.W.N., B.S.E., C.E.E.)
| | - Oluwadamilola M Fayanju
- Department of Surgery, University of Pennsylvania Health System, 3400 Spruce Street, Philadelphia, PA (J.A.G., S.P.G., O.M.F., L.C.E.,)
| | - Brian S Englander
- Department of Radiology, University of Pennsylvania Health System, 3400 Spruce Street, Philadelphia, PA (C.R.Z.T., L.W.N., B.S.E., C.E.E.)
| | - Leisha C Elmore
- Department of Surgery, University of Pennsylvania Health System, 3400 Spruce Street, Philadelphia, PA (J.A.G., S.P.G., O.M.F., L.C.E.,)
| | - Christine E Edmonds
- Department of Radiology, University of Pennsylvania Health System, 3400 Spruce Street, Philadelphia, PA (C.R.Z.T., L.W.N., B.S.E., C.E.E.)
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Ahsan MD, Webster EM, Wolfe IA, McGonigle R, Brewer JT, Chandler IR, Weiss JM, Enriquez A, Cantillo E, Holcomb K, Chapman-Davis E, Blank SV, Sharaf RN, Frey MK. Personalized survivorship care: Routine breast cancer risk assessment in the gynecologic oncology clinic. Gynecol Oncol 2024; 183:47-52. [PMID: 38503141 DOI: 10.1016/j.ygyno.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/01/2024] [Accepted: 03/05/2024] [Indexed: 03/21/2024]
Abstract
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.
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Affiliation(s)
| | - Emily M Webster
- Weill Cornell Medicine - 1300 York Ave, New York, NY 10065, United States
| | - Isabel A Wolfe
- Weill Cornell Medicine - 1300 York Ave, New York, NY 10065, United States
| | - Rylee McGonigle
- Weill Cornell Medicine - 1300 York Ave, New York, NY 10065, United States
| | - Jesse T Brewer
- Weill Cornell Medicine - 1300 York Ave, New York, NY 10065, United States
| | | | - Jessica M Weiss
- Weill Cornell Medicine - 1300 York Ave, New York, NY 10065, United States
| | - Allan Enriquez
- Weill Cornell Medicine - 1300 York Ave, New York, NY 10065, United States
| | - Evelyn Cantillo
- Weill Cornell Medicine - 1300 York Ave, New York, NY 10065, United States
| | - Kevin Holcomb
- Weill Cornell Medicine - 1300 York Ave, New York, NY 10065, United States
| | | | - Stephanie V Blank
- Icahn School of Medicine at Mount Sinai - 1 Gustave L. Levy Pl, New York, NY 10029, United States
| | - Ravi N Sharaf
- Weill Cornell Medicine - 1300 York Ave, New York, NY 10065, United States
| | - Melissa K Frey
- Weill Cornell Medicine - 1300 York Ave, New York, NY 10065, United States.
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3
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Kamil D, Wojcik KM, Smith L, Zhang J, Wilson OWA, Butera G, Jayasekera J. A Scoping Review of Personalized, Interactive, Web-Based Clinical Decision Tools Available for Breast Cancer Prevention and Screening in the United States. MDM Policy Pract 2024; 9:23814683241236511. [PMID: 38500600 PMCID: PMC10946080 DOI: 10.1177/23814683241236511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 02/04/2024] [Indexed: 03/20/2024] Open
Abstract
Introduction. Personalized web-based clinical decision tools for breast cancer prevention and screening could address knowledge gaps, enhance patient autonomy in shared decision-making, and promote equitable care. The purpose of this review was to present evidence on the availability, usability, feasibility, acceptability, quality, and uptake of breast cancer prevention and screening tools to support their integration into clinical care. Methods. We used the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews Checklist to conduct this review. We searched 6 databases to identify literature on the development, validation, usability, feasibility, acceptability testing, and uptake of the tools into practice settings. Quality assessment for each tool was conducted using the International Patient Decision Aid Standard instrument, with quality scores ranging from 0 to 63 (lowest-highest). Results. We identified 10 tools for breast cancer prevention and 9 tools for screening. The tools included individual (e.g., age), clinical (e.g., genomic risk factors), and health behavior (e.g., alcohol use) characteristics. Fourteen tools included race/ethnicity, but no tool incorporated contextual factors (e.g., insurance, access) associated with breast cancer. All tools were internally or externally validated. Six tools had undergone usability testing in samples including White (median, 71%; range, 9%-96%), insured (99%; 97%-100%) women, with college education or higher (60%; 27%-100%). All of the tools were developed and tested in academic settings. Seven (37%) tools showed potential evidence of uptake in clinical practice. The tools had an average quality assessment score of 21 (range, 9-39). Conclusions. There is limited evidence on testing and uptake of breast cancer prevention and screening tools in diverse clinical settings. The development, testing, and integration of tools in academic and nonacademic settings could potentially improve uptake and equitable access to these tools. Highlights There were 19 personalized, interactive, Web-based decision tools for breast cancer prevention and screening.Breast cancer outcomes were personalized based on individual clinical characteristics (e.g., age, medical history), genomic risk factors (e.g., BRCA1/2), race and ethnicity, and health behaviors (e.g., smoking). The tools did not include contextual factors (e.g., insurance status, access to screening facilities) that could potentially contribute to breast cancer outcomes.Validation, usability, acceptability, and feasibility testing were conducted mostly among White and/or insured patients with some college education (or higher) in academic settings. There was limited evidence on testing and uptake of the tools in nonacademic clinical settings.
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Affiliation(s)
- Dalya Kamil
- Health Equity and Decision Sciences Research Laboratory, Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Kaitlyn M. Wojcik
- Health Equity and Decision Sciences Research Laboratory, Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Laney Smith
- Frederick P. Whiddon College of Medicine, Mobile, AL, USA
| | | | - Oliver W. A. Wilson
- Health Equity and Decision Sciences Research Laboratory, Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Gisela Butera
- Office of Research Services, National Institutes of Health Library, Bethesda, MD, USA
| | - Jinani Jayasekera
- Health Equity and Decision Sciences Research Laboratory, Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
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Usher-Smith JA, Hindmarch S, French DP, Tischkowitz M, Moorthie S, Walter FM, Dennison RA, Stutzin Donoso F, Archer S, Taylor L, Emery J, Morris S, Easton DF, Antoniou AC. Proactive breast cancer risk assessment in primary care: a review based on the principles of screening. Br J Cancer 2023; 128:1636-1646. [PMID: 36737659 PMCID: PMC9897164 DOI: 10.1038/s41416-023-02145-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 01/05/2023] [Accepted: 01/06/2023] [Indexed: 02/05/2023] Open
Abstract
In the UK, the National Institute for Health and Care Excellence (NICE) recommends that women at moderate or high risk of breast cancer be offered risk-reducing medication and enhanced breast screening/surveillance. In June 2022, NICE withdrew a statement recommending assessment of risk in primary care only when women present with concerns. This shift to the proactive assessment of risk substantially changes the role of primary care, in effect paving the way for a primary care-based screening programme to identify those at moderate or high risk of breast cancer. In this article, we review the literature surrounding proactive breast cancer risk assessment within primary care against the consolidated framework for screening. We find that risk assessment for women under 50 years currently satisfies many of the standard principles for screening. Most notably, there are large numbers of women at moderate or high risk currently unidentified, risk models exist that can identify those women with reasonable accuracy, and management options offer the opportunity to reduce breast cancer incidence and mortality in that group. However, there remain a number of uncertainties and research gaps, particularly around the programme/system requirements, that need to be addressed before these benefits can be realised.
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Affiliation(s)
- Juliet A. Usher-Smith
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Sarah Hindmarch
- grid.5379.80000000121662407Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - David P. French
- grid.5379.80000000121662407Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Marc Tischkowitz
- grid.5335.00000000121885934Department of Medical Genetics, National Institute for Health Research Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Sowmiya Moorthie
- grid.5335.00000000121885934PHG Foundation, University of Cambridge, Cambridge, UK
| | - Fiona M. Walter
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK ,grid.4868.20000 0001 2171 1133Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Rebecca A. Dennison
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Francisca Stutzin Donoso
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Stephanie Archer
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK ,grid.5335.00000000121885934Department of Psychology, University of Cambridge, Cambridge, UK
| | - Lily Taylor
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jon Emery
- grid.1008.90000 0001 2179 088XCentre for Cancer Research and Department of General Practice, University of Melbourne, Melbourne, VIC Australia
| | - Stephen Morris
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Douglas F. Easton
- grid.5335.00000000121885934Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Antonis C. Antoniou
- grid.5335.00000000121885934Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Zhang J, McGuinness JE, He X, Jones T, Silverman T, Guzman A, May BL, Kukafka R, Crew KD. Breast Cancer Risk and Screening Mammography Frequency Among Multiethnic Women. Am J Prev Med 2023; 64:51-60. [PMID: 36137818 DOI: 10.1016/j.amepre.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 07/19/2022] [Accepted: 08/02/2022] [Indexed: 02/05/2023]
Abstract
INTRODUCTION In 2009, the U.S. Preventive Services Task Force updated recommended mammography screening frequency from annual to biennial for average-risk women aged 50-74 years. The association between estimated breast cancer risk and mammography screening frequency was evaluated. METHODS A single-center retrospective cohort study was conducted among racially/ethnically diverse women, aged 50-74 years, who underwent screening mammography from 2014 to 2018. Data on age, race/ethnicity, first-degree family history of breast cancer, previous benign breast biopsies, and mammographic density were extracted from the electronic health record to calculate Breast Cancer Surveillance Consortium 5-year risk of invasive breast cancer, with a 5-year risk ≥1.67% defined as high risk. Multivariable analyses were conducted to determine the association between breast cancer risk factors and mammography screening frequency (annual versus biennial). Data were analyzed from 2020 to 2022. RESULTS Among 12,929 women with a mean age of 61±6.9 years, 82.7% underwent annual screening mammography, and 30.7% met high-risk criteria for breast cancer. Hispanic women were more likely to screen annually than non-Hispanic Whites (85.0% vs 79.8%, respectively), despite fewer meeting high-risk criteria. In multivariable analyses adjusting for breast cancer risk factors, high- versus low/average-risk women (OR=1.17; 95% CI=1.04, 1.32) and Hispanic versus non-Hispanic White women (OR=1.46; 95% CI=1.29, 1.65) were more likely to undergo annual mammography. CONCLUSIONS A majority of women continue to undergo annual screening mammography despite only a minority meeting high-risk criteria, and Hispanic women were more likely to screen annually despite lower overall breast cancer risk. Future studies should focus on the implementation of risk-stratified breast cancer screening strategies.
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Affiliation(s)
- Jingwen Zhang
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Julia E McGuinness
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York; Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York.
| | - Xin He
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Tarsha Jones
- Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida
| | - Thomas Silverman
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Ashlee Guzman
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Benjamin L May
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
| | - Rita Kukafka
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York; Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York; Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, New York
| | - Katherine D Crew
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York; Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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6
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Huq MR, Woodard N, Okwara L, McCarthy S, Knott CL. Breast cancer knowledge & information seeking among African American women below screening age. PATIENT EDUCATION AND COUNSELING 2023; 106:194-200. [PMID: 36257892 DOI: 10.1016/j.pec.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 09/13/2022] [Accepted: 10/05/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES African American women below screening age disproportionately face greater mortality from breast cancer relative to peers of other races and African American women of screening age. The current study examines breast cancer knowledge and health information seeking of African American women below screening age. METHODS We collected survey data from 99 African American women below screening age on their breast cancer knowledge and health information seeking behaviors. As secondary analysis, we harmonized data from a previous study to compare breast cancer knowledge between African American women below and of (N = 209) screening age. RESULTS The average woman below screening age correctly answered 2.84 (SD=1.08) of six breast cancer knowledge items, 2.67 (SD=1.01) of five mammogram items, 1.44 (SD=0.86) of three treatment items, and had lower knowledge (p < .001) in each area relative to screening age women. Women below screening age sought information primarily from medical providers and the internet. CONCLUSIONS A strategy for eliminating early-onset breast cancer disparities impacting African American women is addressing the limited breast cancer knowledge in this age group. Practice Implications In addition to age-appropriate information for this group, guidance for medical providers would be beneficial, as providers are this group's most common source of health information.
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Affiliation(s)
- Maisha R Huq
- Department of Behavioral and Community Health, University of Maryland, College Park, College Park, MD, USA.
| | - Nathaniel Woodard
- Department of Behavioral and Community Health, University of Maryland, College Park, College Park, MD, USA
| | - Leonore Okwara
- Department of Behavioral and Community Health, University of Maryland, College Park, College Park, MD, USA
| | - Sharon McCarthy
- Department of Behavioral and Community Health, University of Maryland, College Park, College Park, MD, USA
| | - Cheryl L Knott
- Department of Behavioral and Community Health, University of Maryland, College Park, College Park, MD, USA; Community Outreach and Engagement in the University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD, USA
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7
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Nadler MB, Corrado AM, Desveaux L, Neil-Sztramko SE, Wilson BE, Desnoyers A, Amir E, Ivers N. Determinants of guideline-concordant breast cancer screening by family physicians for women aged 40-49 years: a qualitative analysis. CMAJ Open 2022; 10:E900-E910. [PMID: 36257683 PMCID: PMC9616605 DOI: 10.9778/cmajo.20210266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Although the current Canadian Task Force on Preventive Health Care guideline recommends that physicians should inform women aged 40-49 years of the potential benefits and harms of screening mammography to support individualized decisions, previous reports of variation in clinical practice at the physician level suggest a lack of guideline-concordant care. We explored determinants (barriers and facilitators) of guideline-concordant care by family physicians regarding screening mammography in this age group. METHODS We conducted qualitative semi-structured interviews by phone with family physicians in the Greater Toronto Area from January to November 2020. We structured interviews using the Theoretical Domains Framework to explore determinants (barriers and facilitators) of 5 physician screening behaviours, namely risk assessment, discussion regarding benefits and harms, decision or referral for mammography, referral for genetic counselling and referral to high-risk screening programs. Two independent researchers iteratively analyzed interview transcripts and deductively coded for each behaviour by domain to identify key behavioural determinants until saturation was reached. RESULTS We interviewed 18 physicians (mean age 48 yr, 72% self-identified as women). Risk assessment was influenced by physicians' knowledge of risk factors, skills to synthesize risk and beliefs about utility. Physicians had beliefs in their capabilities to have informed patient-centred discussions, but insufficient knowledge regarding the harms of screening. The decision or referral for mammography was affected by emotions related to past patient outcomes, social influences of patients and radiology departments, and knowledge and beliefs about consequences (benefits and harms of screening). Referrals for genetic counselling and to high-risk screening programs were facilitated by their availability and by the knowledge and skills to complete forms. Lack of knowledge regarding which patients qualify and beliefs about consequences were barriers to referral. INTERPRETATION Insufficient knowledge and skills for performance of risk assessment, combined with a tendency to overestimate benefits of screening relative to harms affected provision of guideline-concordant care. These may be effective targets for future interventions to improve guideline-concordant care.
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Affiliation(s)
- Michelle B Nadler
- Division of Medical Oncology & Hematology, Department of Medicine (Nadler, Wilson, Desnoyers, Amir), Princess Margaret Cancer Centre; Department of Medicine (Nadler, Wilson, Desnoyers, Amir), University of Toronto; The Peter Gilgan Centre for Women's Cancers (Corrado, Ivers), Women's College Hospital; Institute for Better Health (Desveaux), Trillium Health Partners; Institute of Health Policy, Management and Evaluation (Desveaux, Amir, Ivers), Dalla Lana School of Public Health, University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Desveaux), Toronto, Ont.; Department of Health Research Methods, Evidence & Impact, Faculty of Health Sciences (Neil-Sztramko), McMaster University, Hamilton Ont.; University of New South Wales (Wilson, Ivers), Sydney, Australia; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont.
| | - Ann Marie Corrado
- Division of Medical Oncology & Hematology, Department of Medicine (Nadler, Wilson, Desnoyers, Amir), Princess Margaret Cancer Centre; Department of Medicine (Nadler, Wilson, Desnoyers, Amir), University of Toronto; The Peter Gilgan Centre for Women's Cancers (Corrado, Ivers), Women's College Hospital; Institute for Better Health (Desveaux), Trillium Health Partners; Institute of Health Policy, Management and Evaluation (Desveaux, Amir, Ivers), Dalla Lana School of Public Health, University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Desveaux), Toronto, Ont.; Department of Health Research Methods, Evidence & Impact, Faculty of Health Sciences (Neil-Sztramko), McMaster University, Hamilton Ont.; University of New South Wales (Wilson, Ivers), Sydney, Australia; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
| | - Laura Desveaux
- Division of Medical Oncology & Hematology, Department of Medicine (Nadler, Wilson, Desnoyers, Amir), Princess Margaret Cancer Centre; Department of Medicine (Nadler, Wilson, Desnoyers, Amir), University of Toronto; The Peter Gilgan Centre for Women's Cancers (Corrado, Ivers), Women's College Hospital; Institute for Better Health (Desveaux), Trillium Health Partners; Institute of Health Policy, Management and Evaluation (Desveaux, Amir, Ivers), Dalla Lana School of Public Health, University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Desveaux), Toronto, Ont.; Department of Health Research Methods, Evidence & Impact, Faculty of Health Sciences (Neil-Sztramko), McMaster University, Hamilton Ont.; University of New South Wales (Wilson, Ivers), Sydney, Australia; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
| | - Sarah E Neil-Sztramko
- Division of Medical Oncology & Hematology, Department of Medicine (Nadler, Wilson, Desnoyers, Amir), Princess Margaret Cancer Centre; Department of Medicine (Nadler, Wilson, Desnoyers, Amir), University of Toronto; The Peter Gilgan Centre for Women's Cancers (Corrado, Ivers), Women's College Hospital; Institute for Better Health (Desveaux), Trillium Health Partners; Institute of Health Policy, Management and Evaluation (Desveaux, Amir, Ivers), Dalla Lana School of Public Health, University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Desveaux), Toronto, Ont.; Department of Health Research Methods, Evidence & Impact, Faculty of Health Sciences (Neil-Sztramko), McMaster University, Hamilton Ont.; University of New South Wales (Wilson, Ivers), Sydney, Australia; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
| | - Brooke E Wilson
- Division of Medical Oncology & Hematology, Department of Medicine (Nadler, Wilson, Desnoyers, Amir), Princess Margaret Cancer Centre; Department of Medicine (Nadler, Wilson, Desnoyers, Amir), University of Toronto; The Peter Gilgan Centre for Women's Cancers (Corrado, Ivers), Women's College Hospital; Institute for Better Health (Desveaux), Trillium Health Partners; Institute of Health Policy, Management and Evaluation (Desveaux, Amir, Ivers), Dalla Lana School of Public Health, University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Desveaux), Toronto, Ont.; Department of Health Research Methods, Evidence & Impact, Faculty of Health Sciences (Neil-Sztramko), McMaster University, Hamilton Ont.; University of New South Wales (Wilson, Ivers), Sydney, Australia; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
| | - Alexandra Desnoyers
- Division of Medical Oncology & Hematology, Department of Medicine (Nadler, Wilson, Desnoyers, Amir), Princess Margaret Cancer Centre; Department of Medicine (Nadler, Wilson, Desnoyers, Amir), University of Toronto; The Peter Gilgan Centre for Women's Cancers (Corrado, Ivers), Women's College Hospital; Institute for Better Health (Desveaux), Trillium Health Partners; Institute of Health Policy, Management and Evaluation (Desveaux, Amir, Ivers), Dalla Lana School of Public Health, University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Desveaux), Toronto, Ont.; Department of Health Research Methods, Evidence & Impact, Faculty of Health Sciences (Neil-Sztramko), McMaster University, Hamilton Ont.; University of New South Wales (Wilson, Ivers), Sydney, Australia; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
| | - Eitan Amir
- Division of Medical Oncology & Hematology, Department of Medicine (Nadler, Wilson, Desnoyers, Amir), Princess Margaret Cancer Centre; Department of Medicine (Nadler, Wilson, Desnoyers, Amir), University of Toronto; The Peter Gilgan Centre for Women's Cancers (Corrado, Ivers), Women's College Hospital; Institute for Better Health (Desveaux), Trillium Health Partners; Institute of Health Policy, Management and Evaluation (Desveaux, Amir, Ivers), Dalla Lana School of Public Health, University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Desveaux), Toronto, Ont.; Department of Health Research Methods, Evidence & Impact, Faculty of Health Sciences (Neil-Sztramko), McMaster University, Hamilton Ont.; University of New South Wales (Wilson, Ivers), Sydney, Australia; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
| | - Noah Ivers
- Division of Medical Oncology & Hematology, Department of Medicine (Nadler, Wilson, Desnoyers, Amir), Princess Margaret Cancer Centre; Department of Medicine (Nadler, Wilson, Desnoyers, Amir), University of Toronto; The Peter Gilgan Centre for Women's Cancers (Corrado, Ivers), Women's College Hospital; Institute for Better Health (Desveaux), Trillium Health Partners; Institute of Health Policy, Management and Evaluation (Desveaux, Amir, Ivers), Dalla Lana School of Public Health, University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Desveaux), Toronto, Ont.; Department of Health Research Methods, Evidence & Impact, Faculty of Health Sciences (Neil-Sztramko), McMaster University, Hamilton Ont.; University of New South Wales (Wilson, Ivers), Sydney, Australia; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
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8
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Primary care physician referral practices regarding BRCA1/2 genetic counseling in a major health system. Breast Cancer Res Treat 2022; 195:153-160. [PMID: 35842521 DOI: 10.1007/s10549-022-06523-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 01/16/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE The United States Preventive Services Task Force recommends primary care physicians refer patients at high risk for BRCA1/2 mutations to genetic testing when appropriate. The objective of our study was to describe referrals for BRCA1/2 testing in a large integrated health system and to assess factors associated with referral. METHODS This retrospective cohort study includes female patients between 18 and 50 years who had a primary care visit in the Cleveland Clinic Health System between 2010 and 2019. We used multivariable logistic regression to estimate differences in the odds of a woman being referred for BRCA1/2 testing by patient factors and referring physician specialty. We also assessed variation in referrals by physicians. RESULTS Among 279,568 women, 5% were high risk. Of those, 22% were referred for testing. Black patients were significantly less likely to be referred than white patients (aOR 0.87; 95% CI 0.77, 0.98) and Jewish patients were more likely to be referred than non-Jewish patients (aOR 2.13; 95% CI 1.68, 2.70). Patients primarily managed by OB/GYN were significantly more likely to be referred than those cared for via Internal/Family Medicine (aOR 1.45; 95% CI 1.30, 1.61). Less than a quarter of primary care physicians ever referred a patient for testing. CONCLUSION The majority of primary care patients at high risk for a BRCA1/2 mutation were not referred for testing, and over a decade, most physicians never referred a single patient. Internal/Family Medicine physicians, in particular, need support in identifying and referring women who could benefit from testing.
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9
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Pederson HJ, ElSherif A, Allyn B, Grobmyer SR. Twenty-two–year evolution of a Medical Breast Service: Filling the important gaps between breast surgery and medical oncology. Surgery 2022; 172:494-499. [DOI: 10.1016/j.surg.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 03/30/2022] [Accepted: 04/05/2022] [Indexed: 11/26/2022]
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10
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Arun BK, Peterson SK, Sweeney LE, Bluebond RD, Tidwell RSS, Makhnoon S, Kushwaha AC. Increasing referral of at-risk women for genetic counseling and BRCA testing using a screening tool in a community breast imaging center. Cancer 2022; 128:94-102. [PMID: 34424535 PMCID: PMC8678171 DOI: 10.1002/cncr.33866] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 05/05/2021] [Accepted: 05/06/2021] [Indexed: 01/03/2023]
Abstract
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.
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Affiliation(s)
- Banu K. Arun
- Departments of Breast Medical Oncology and Clinical Cancer Genetics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Susan K. Peterson
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lilian E. Sweeney
- Houston Breast Screening Network, Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rachel D. Bluebond
- Department of Clinical Cancer Genetics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rebecca SS Tidwell
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sukh Makhnoon
- Department of Behavioral Science, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Anne C. Kushwaha
- Houston Breast Screening Network, Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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11
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Taber P, Ghani P, Schiffman JD, Kohlmann W, Hess R, Chidambaram V, Kawamoto K, Waller RG, Borbolla D, Del Fiol G, Weir C. Physicians' strategies for using family history data: having the data is not the same as using the data. JAMIA Open 2021; 3:378-385. [PMID: 34632321 PMCID: PMC7660959 DOI: 10.1093/jamiaopen/ooaa035] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 06/02/2020] [Indexed: 12/12/2022] Open
Abstract
Objective To identify needs in a clinical decision support tool development by exploring how primary care providers currently collect and use family health history (FHH). Design Survey questionnaires and semi-structured interviews were administered to a mix of primary and specialty care clinicians within the University of Utah Health system (40 surveys, 12 interviews). Results Three key themes emerged regarding providers' collection and use of FHH: (1) Strategies for collecting FHH vary by level of effort; (2) Documentation practices extend beyond the electronic health record's dedicated FHH module; and (3) Providers desire feedback from genetic services consultation and are uncertain how to refer patients to genetic services. Conclusion Study findings highlight the varying degrees of engagement that providers have with collecting FHH. Improving the integration of FHH into workflow, and providing decision support, as well as links and tools to help providers better utilize genetic counseling may improve patient care.
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Affiliation(s)
- Peter Taber
- VA Salt Lake City Health Care System, Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS 2.0), Salt Lake City, Utah, USA
| | - Parveen Ghani
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Joshua D Schiffman
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA.,Family Cancer Assessment Clinic, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Wendy Kohlmann
- Family Cancer Assessment Clinic, Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA.,Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Rachel Hess
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah, USA.,Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Valli Chidambaram
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Kensaku Kawamoto
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Rosalie G Waller
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Damian Borbolla
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Charlene Weir
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
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12
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Kathrens-Gallardo A, Propst L, Linn E, Pothast R, Wicklund C, Arjunan A. OB/GYN residents' training, attitudes, and comfort level regarding genetics. J Assist Reprod Genet 2021; 38:2871-2880. [PMID: 34515898 DOI: 10.1007/s10815-021-02310-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 08/30/2021] [Indexed: 12/14/2022] Open
Abstract
PURPOSE While the availability, utility, and complexity of genetic testing expands, limited information exists regarding obstetrician-gynecologist (OB/GYN) residents' knowledge of genetics and confidence in providing genetic services. This study examined OB/GYN residents' educational and clinical experiences with genetics during residency, personal attitudes regarding the value of genetics and its role in their practice, level of comfort with genetic counseling, and potential motivators for learning about genetics. METHODS Eligible participants included residents currently enrolled in a CREOG-associated OB/GYN training program in the USA or Canada. A link to an anonymous 49-question RedCap survey was emailed to program coordinators in October 2017 to be forwarded to all OB/GYN residents. RESULTS Eighty-two OB/GYN residents representing all postgraduate years of training completed the survey. Residents indicated learning about genetics through discussions with attending physicians, lectures/courses, and publications. While residents felt their attendings valued (81%) and were knowledgeable about (85%) genetics, 28% felt their attendings did not reinforce concepts that were learned in coursework. Residents valued staying informed about the field of genetics and felt providing genetic services was within their scope of practice; however, there were deficiencies in self-reported comfort level, particularly regarding hereditary cancer counseling. Residents cited accessibility of information as a top motivator to stay informed. CONCLUSIONS Clinically relevant, accessible didactic information about genetics reinforced in the clinical setting may increase residents' level of comfort with providing genetic services.
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Affiliation(s)
| | - Lauren Propst
- BillionToOne, Inc, Medical Affairs, Menlo Park, CA, USA
| | - Edward Linn
- Rush Medical College, Obstetrics and Gynecology, Chicago, IL, USA
| | - Rachel Pothast
- Northwestern University Feinberg School of Medicine, Clinical Genetics, Chicago, IL, USA
| | - Catherine Wicklund
- Northwestern University Feinberg School of Medicine, Clinical Genetics, Chicago, IL, USA
| | - Aishwarya Arjunan
- Myriad Women's Health, Medical Affairs, South San Francisco, CA, USA.
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13
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Bellhouse S, Hawkes RE, Howell SJ, Gorman L, French DP. Breast Cancer Risk Assessment and Primary Prevention Advice in Primary Care: A Systematic Review of Provider Attitudes and Routine Behaviours. Cancers (Basel) 2021; 13:4150. [PMID: 34439302 PMCID: PMC8394615 DOI: 10.3390/cancers13164150] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 08/16/2021] [Accepted: 08/17/2021] [Indexed: 12/20/2022] Open
Abstract
Implementing risk-stratified breast cancer screening is being considered internationally. It has been suggested that primary care will need to take a role in delivering this service, including risk assessment and provision of primary prevention advice. This systematic review aimed to assess the acceptability of these tasks to primary care providers. Five databases were searched up to July-August 2020, yielding 29 eligible studies, of which 27 were narratively synthesised. The review was pre-registered (PROSPERO: CRD42020197676). Primary care providers report frequently collecting breast cancer family history information, but rarely using quantitative tools integrating additional risk factors. Primary care providers reported high levels of discomfort and low confidence with respect to risk-reducing medications although very few reported doubts about the evidence base underpinning their use. Insufficient education/training and perceived discomfort conducting both tasks were notable barriers. Primary care providers are more likely to accept an increased role in breast cancer risk assessment than advising on risk-reducing medications. To realise the benefits of risk-based screening and prevention at a population level, primary care will need to proactively assess breast cancer risk and advise on risk-reducing medications. To facilitate this, adaptations to infrastructure such as integrated tools are necessary in addition to provision of education.
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Affiliation(s)
- Sarah Bellhouse
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK; (R.E.H.); (D.P.F.)
| | - Rhiannon E. Hawkes
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK; (R.E.H.); (D.P.F.)
| | - Sacha J. Howell
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK;
| | - Louise Gorman
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester Academic Health Science Centre, Manchester M13 9PL, UK;
| | - David P. French
- Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PL, UK; (R.E.H.); (D.P.F.)
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14
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Padamsee TJ, Meadows R, Hils M. Layers of information: interacting constraints on breast cancer risk-management by high-risk African American women. ETHNICITY & HEALTH 2021; 26:787-810. [PMID: 30589360 PMCID: PMC9529154 DOI: 10.1080/13557858.2018.1562053] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 11/20/2018] [Indexed: 06/09/2023]
Abstract
Objectives: To understand how various decision-making dynamics interact to shape the risk-management choices of African American women at high-risk of breast cancer, and to explore whether African American and White women have differential access to the information and interactions that promote proactive, confident risk-management behavior.Design: This paper draws on 50 original in-depth, semi-structured interviews with African American and White women at elevated risk of breast cancer. We used inductive grounded-theory methodology to explore the processes by which women make risk-management decisions and to compare those processes between racial groups. Moving backward from women's decisions about whether or not to engage in specific risk-management behaviors, we explored the patterns that underlie behavioral decisions.Results: We find that decisions to engage in risk-management behavior rest on three accumulated layers of information. The layer most proximal to making risk-management decisions involves specific information about risk-management options; the middle layer involves general information about managing breast cancer risk; and the foundational layer involves personal perceptions of breast cancer risk and prevention. African American and White women experience distinct dynamics at each of these levels, and these differences may help explain racial differences in risk-management behavior. Compared to their White counterparts, African American women faced additional burdens at every step along the risk-management journey.Conclusion: These findings suggest that information gathering is more complex than has previously been addressed, that information access and provider access are closely related, and that African American women may be systematically disadvantaged with respect to information-generating experiences. Preventing cancer morbidity and mortality requires that all high-risk women have access to the layers of information necessary to engage in cancer screenings and preventive interventions. These results exemplify the ways that structural, social, and interpersonal inequalities combine to influence risk-management choices.
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Affiliation(s)
- Tasleem J. Padamsee
- Corresponding Author. 280F Cunz Hall, 1841 Neil Avenue, Columbus, OH 43210, United States; ; Phone: 1-614-688-0986; Fax: 1-614-247-1846
| | - Rachel Meadows
- Suite 525 Gateway Building C, 1590 N High Street, Columbus, OH 43201, United States
| | - Megan Hils
- 282-2 Cunz Hall, 1841 Neil Avenue, Columbus, OH 43210, United States
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15
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Jahan N, Jones C, Rahman RL. Endocrine prevention of breast cancer. Mol Cell Endocrinol 2021; 530:111284. [PMID: 33882282 DOI: 10.1016/j.mce.2021.111284] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 04/04/2021] [Accepted: 04/12/2021] [Indexed: 01/01/2023]
Abstract
Breast cancer (BC) is the most common non-cutaneous malignancy among women worldwide and is a significant cause of morbidity, mortality, and national health care expenditure. Unfortunately, with few exceptions like alcohol consumption, obesity, and physical activity, most BC risk factors are unmodifiable. Antiestrogen endocrine therapy, commonly known as BC chemoprevention, is an effective method of BC prevention. In multiple randomized trials, two selective estrogen receptor modulators - tamoxifen and raloxifene, and two aromatase inhibitors - exemestane and anastrozole have reduced BC incidence by 50%-65% in high-risk women. An estimated 15% of the US women between 35 and 79 years of age may qualify as high risk for BC, yet a small percentage of these women will ever have a formal BC risk assessment or a discussion of endocrine prevention options. The etiology of underutilization of endocrine prevention of BC is multifactorial - infrequent use of BC risk assessment tools in the primary care settings, insufficient knowledge of BC risk assessment tools and antiestrogen agents among primary care providers, concerns of side effects, inadequate time for counseling during primary care visit, and lack of predictive biomarkers may play significant roles. Many small studies incorporating risk assessment tools and decision-making aids showed minimal success in enhancing endocrine prevention. One critical factor for underutilization of endocrine prevention is low uptake of endocrine prevention by high-risk women even when appropriately recommended. Furthermore, adherence to BC endocrine prevention is unsatisfactorily low. Despite the current infrequent usage, endocrine prevention has the potential to reduce the public health burden of BC significantly. Innovative approaches like finding new agents, alternative dosing and schedule of currently available agents, transdermal medication delivery, increased public and professional awareness, and policymakers' commitments may bring the desired changes.
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Affiliation(s)
- Nusrat Jahan
- Division of Hematology-Oncology, Department of Internal Medicine, Texas Tech University Health Sciences Center, 3601 4th St, Lubbock, Tx, 79430, USA.
| | - Catherine Jones
- Division of Hematology-Oncology, Department of Internal Medicine, Texas Tech University Health Sciences Center, 3601 4th St, Lubbock, Tx, 79430, USA
| | - Rakhshanda Layeequr Rahman
- Department of Surgery, Texas Tech University Health Sciences Center, 3601 4th St, Lubbock, Tx, 79430, USA
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16
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Manning M, O'Neill S, Purrington K. Physicians' perceptions of breast density notification laws and appropriate patient follow-up. Breast J 2021; 27:586-594. [PMID: 33991030 DOI: 10.1111/tbj.14240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 04/20/2021] [Accepted: 04/22/2021] [Indexed: 12/19/2022]
Abstract
Breast density notification laws have been adopted in the absence of consistent guidelines for post-notification follow-up. This can lead to inconsistent and potentially deficient management of women's health due to inconsistent physician practices. We examined physicians' knowledge and practices regarding follow-up for patients who receive density notifications. Physicians who referred patients to a Michigan hospital network for screening mammograms were recruited to participate in survey study; 105 (29.8%) responded. The survey assessed physicians' demographics, knowledge, and awareness of breast density and breast cancer risk and of density notification laws, and perceptions of appropriate follow-up behaviors for their patients who received density notifications. Most physicians (75%) knew about the notification law, and they were generally comfortable responding to breast density questions and deciding on follow-up. Most indicated that additional breast imaging (68.0%), followed by assessing breast cancer risk (24.7%) were appropriate follow-up responses. Physicians who performed breast cancer risk assessments, and who were more comfortable with breast density questions and follow-up decision making, were more likely to propose additional imaging. Male physicians were less likely to propose assessing breast cancer risk, and less likely to propose clinical and/or breast self-examinations. Divergence between practice and guidelines when it comes to supplemental breast cancer screening, coupled with density notification language that promotes additional screening in the absence of consistent evidence, remains concerning. Improved understanding of how density notification recipients and their physicians make decisions about supplemental screening is warranted to ensure that breast cancer risk is properly considered.
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Affiliation(s)
- Mark Manning
- Department of Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, USA
| | - Suzanne O'Neill
- Department of Oncology, Lombardi Cancer Center, Georgetown University, Washington, DC, USA
| | - Kristen Purrington
- Department of Oncology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, USA
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A streamlined model for use in clinical breast cancer risk assessment maintains predictive power and is further improved with inclusion of a polygenic risk score. PLoS One 2021; 16:e0245375. [PMID: 33481864 PMCID: PMC7822550 DOI: 10.1371/journal.pone.0245375] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 12/29/2020] [Indexed: 11/19/2022] Open
Abstract
Five-year absolute breast cancer risk prediction models are required to comply with national guidelines regarding risk reduction regimens. Models including the Gail model are under-utilized in the general population for various reasons, including difficulty in accurately completing some clinical fields. The purpose of this study was to determine if a streamlined risk model could be designed without substantial loss in performance. Only the clinical risk factors that were easily answered by women will be retained and combined with an objective validated polygenic risk score (PRS) to ultimately improve overall compliance with professional recommendations. We first undertook a review of a series of 2,339 Caucasian, African American and Hispanic women from the USA who underwent clinical testing. We first used deidentified test request forms to identify the clinical risk factors that were best answered by women in a clinical setting and then compared the 5-year risks for the full model and the streamlined model in this clinical series. We used OPERA analysis on previously published case-control data from 11,924 Gail model samples to determine clinical risk factors to include in a streamlined model: first degree family history and age that could then be combined with the PRS. Next, to ensure that the addition of PRS to the streamlined model was indeed beneficial, we compared risk stratification using the Streamlined model with and without PRS for the existing case-control datasets comprising 1,313 cases and 10,611 controls of African-American (n = 7421), Caucasian (n = 1155) and Hispanic (n = 3348) women, using the area under the curve to determine model performance. The improvement in risk discrimination from adding the PRS risk score to the Streamlined model was 52%, 46% and 62% for African-American, Caucasian and Hispanic women, respectively, based on changes in log OPERA. There was no statistically significant difference in mean risk scores between the Gail model plus risk PRS compared to the Streamlined model plus PRS. This study demonstrates that validated PRS can be used to streamline a clinical test for primary care practice without diminishing test performance. Importantly, by eliminating risk factors that women find hard to recall or that require obtaining medical records, this model may facilitate increased clinical adoption of 5-year risk breast cancer risk prediction test in keeping with national standards and guidelines for breast cancer risk reduction.
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18
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Jones S, Hogan B, Patel K, Ooi S, Turton P, Achuthan R, Kim B. Identification of factors that influence the decision to take chemoprevention in patients with a significant family history of breast cancer: results from a patient questionnaire survey. Breast Cancer Res Treat 2021; 187:207-213. [PMID: 33389407 DOI: 10.1007/s10549-020-06046-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/02/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE Chemoprevention reduces the risk of developing breast cancer in women with increased family history (FH) risk of breast cancer. However, chemoprevention uptake remains low and the reasons for this remain unclear. METHODS Patients with moderate- or high-risk FH of breast cancer were counselled about chemoprevention (n = 1620; September 2015 to July 2018) in breast clinics. A postal questionnaire survey was subsequently sent to these patients in order to explore the potential factors influencing their decision on chemoprevention uptake. RESULTS 518 patients (32%) completed the questionnaire survey; 75% were pre-menopausal and the majority had moderate as opposed to high-risk FH (87.5% vs. 12.5%). Breast cancer chemoprevention uptake rate was 10.8% (56/518). The identified incentives were more commonly stated for patients who took chemoprevention when compared to those who refused chemoprevention. The commonest incentives were breast cancer prevention (89.3% vs. 61.7%; p = 0.001), belief in the effectiveness of chemoprevention (76.8% vs. 63.4%; p = 0.048), and personal perception of breast cancer risk (67.9% vs. 45.5%; p = 0.002). Similarly, the identified barriers were more commonly stated for patients who refused chemoprevention when compared to those who took chemoprevention. The commonest barriers were side effects (79.4% vs. 55.4%; p = 0.001) and lack of information (53% vs. 28.6%; p = 0.001). CONCLUSION Despite its proven efficacy, chemoprevention uptake in patients with a significant FH of breast cancer remains low. We have identified important factors which influence the patient's decision making. Future clinic consultations should focus on exploring these factors to aid patient decision making.
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Affiliation(s)
- Stacey Jones
- Department of Oncoplastic Breast and Reconstructive Surgery, St. James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK.
| | - Brian Hogan
- Department of Oncoplastic Breast and Reconstructive Surgery, St. James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
| | - Kirtida Patel
- Department of Oncoplastic Breast and Reconstructive Surgery, St. James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
| | - Shiwei Ooi
- Department of Oncoplastic Breast and Reconstructive Surgery, St. James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
| | - Philip Turton
- Department of Oncoplastic Breast and Reconstructive Surgery, St. James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
| | - Rajgopal Achuthan
- Department of Oncoplastic Breast and Reconstructive Surgery, St. James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
| | - Baek Kim
- Department of Oncoplastic Breast and Reconstructive Surgery, St. James's University Hospital, Beckett Street, Leeds, LS9 7TF, UK
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Long-Term Evaluation of Women Referred to a Breast Cancer Family History Clinic (Manchester UK 1987-2020). Cancers (Basel) 2020; 12:cancers12123697. [PMID: 33317064 PMCID: PMC7763143 DOI: 10.3390/cancers12123697] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 12/02/2020] [Accepted: 12/05/2020] [Indexed: 12/20/2022] Open
Abstract
Simple Summary This study reports the management of women at high risk for breast cancer over a 33 years period. The aim was to summarize the numbers seen and to report the results of our studies on gene testing, the outcomes of screening and the success of preventive methods including lifestyle change, chemoprevention and risk-reducing mastectomy. We also discuss how the clinical Family History Service may be improved in the future. Abstract Clinics for women concerned about their family history of breast cancer are widely established. A Family History Clinic was set-up in Manchester, UK, in 1987 in a Breast Unit serving a population of 1.8 million. In this review, we report the outcome of risk assessment, screening and prevention strategies in the clinic and propose future approaches. Between 1987–2020, 14,311 women were referred, of whom 6.4% were from known gene families, 38.2% were at high risk (≥30% lifetime risk), 37.7% at moderate risk (17–29%), and 17.7% at an average/population risk who were discharged. A total of 4168 (29.1%) women were eligible for genetic testing and 736 carried pathogenic variants, predominantly in BRCA1 and BRCA2 but also other genes (5.1% of direct referrals). All women at high or moderate risk were offered annual mammographic screening between ages 30 and 40 years old: 646 cancers were detected in women at high and moderate risk (5.5%) with a detection rate of 5 per 1000 screens. Incident breast cancers were largely of good prognosis and resulted in a predicted survival advantage. All high/moderate-risk women were offered lifestyle prevention advice and 14–27% entered various lifestyle studies. From 1992–2003, women were offered entry into IBIS-I (tamoxifen) and IBIS-II (anastrozole) trials (12.5% of invitees joined). The NICE guidelines ratified the use of tamoxifen and raloxifene (2013) and subsequently anastrozole (2017) for prevention; 10.8% women took up the offer of such treatment between 2013–2020. Since 1994, 7164 eligible women at ≥25% lifetime risk of breast cancer were offered a discussion of risk-reducing breast surgery and 451 (6.2%) had surgery. New approaches in all aspects of the service are needed to build on these results.
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Maschke A, Paasche-Orlow MK, Kressin NR, Schonberg MA, Battaglia TA, Gunn CM. Discussions of Potential Mammography Benefits and Harms among Patients with Limited Health Literacy and Providers: "Oh, There are Harms?". JOURNAL OF HEALTH COMMUNICATION 2020; 25:951-961. [PMID: 33455518 PMCID: PMC8062298 DOI: 10.1080/10810730.2020.1845256] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Starting breast cancer screening at age 40 versus 50 may increase potential harms frequency with a small mortality benefit. Younger women's screening decisions, therefore, may be complex. Shared decision-making (SDM) is recommended for women under 50 and may support women under 55 for whom guidelines vary. How women with limited health literacy (LHL) approach breast cancer screening decision-making is less understood, and most SDM tools are not designed with their input. This phenomenological study sought to characterize mammography counseling experiences among women with LHL and primary care providers (PCPs). Women ages 40-54 with LHL who had no history of breast cancer or mammogram within 9 months were approached before a primary care visit at a safety-net hospital. PCPs at this site were invited to participate. Qualitative interviews explored mammography counseling experiences. Patients also reviewed sample information materials. A constant comparison technique generated four themes salient to 25 patients and 20 PCPs: addressing family history versus comprehensive risk assessment; potential mammography harms discussions; information delivery preferences; and integrating pre-visit information tools. Findings suggest that current counseling techniques may not be responsive to patient-identified needs. Opportunities exist to improve how mammography information is shared and increase accessibility across the health literacy spectrum.
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Affiliation(s)
- Ariel Maschke
- Women's Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, MA, USA
| | - Michael K Paasche-Orlow
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Nancy R Kressin
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Mara A Schonberg
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Tracy A Battaglia
- Women's Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, MA, USA
| | - Christine M Gunn
- Women's Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, MA, USA
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, MA, USA
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Macdonald C, Saunders CM, Keogh LA, Hunter M, Mazza D, McLachlan SA, Jones SC, Nesci S, Friedlander ML, Hopper JL, Emery JD, Hickey M, Milne RL, Phillips KA. Breast Cancer Chemoprevention: Use and Views of Australian Women and Their Clinicians. Cancer Prev Res (Phila) 2020; 14:131-144. [PMID: 33115784 DOI: 10.1158/1940-6207.capr-20-0369] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/27/2020] [Accepted: 10/15/2020] [Indexed: 11/16/2022]
Abstract
Guidelines endorse the use of chemoprevention for breast cancer risk reduction. This study examined the barriers and facilitators to chemoprevention use for Australian women at increased risk of breast cancer, and their clinicians. Surveys, based on the Theoretical Domains Framework, were mailed to 1,113 women at ≥16% lifetime risk of breast cancer who were enrolled in the Kathleen Cuningham Foundation Consortium for Research into Familial Breast Cancer cohort study (kConFab), and their 524 treating clinicians. Seven hundred twenty-five women (65%) and 221 (42%) clinicians responded. Only 10 (1.4%) kConFab women had ever taken chemoprevention. Three hundred seventy-eight (52%) kConFab women, two (3%) breast surgeons, and 51 (35%) family physicians were not aware of chemoprevention. For women, the strongest barriers to chemoprevention were side effects (31%) and inadequate information (23%), which operate in the Theoretical Domains Framework domains of "beliefs about consequences" and "knowledge," respectively. Strongest facilitators related to tamoxifen's long-term efficacy (35%, "knowledge," "beliefs about consequences," and "goals" domains), staying healthy for family (13%, "social role" and "goals" domains), and abnormal breast biopsy (13%, "environmental context" domain). The strongest barrier for family physicians was insufficient knowledge (45%, "knowledge" domain) and for breast surgeons was medication side effects (40%, "beliefs about consequences" domain). The strongest facilitators for both clinician groups related to clear guidelines, strong family history, and better tools to select patients ("environmental context and resources" domain). Clinician knowledge and resources, and beliefs about the side-effect consequences of chemoprevention, are key domains that could be targeted to potentially enhance uptake. PREVENTION RELEVANCE: Despite its efficacy in reducing breast cancer incidence, chemoprevention is underutilised. This survey study of Australian women and their clinicians used behavioural change theory to identify modifiable barriers to chemoprevention uptake, and to suggest interventions such as policy change, educational resources and public campaigns, that may increase awareness and use.See related Spotlight by Vogel, p. 1.
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Affiliation(s)
- Courtney Macdonald
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
| | | | - Louise A Keogh
- Centre for Health Equity, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Morgan Hunter
- Centre for Biostatistics and Clinical Trials, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Danielle Mazza
- Department of General Practice, Monash University, Melbourne, Australia
| | - Sue-Anne McLachlan
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Melbourne, Australia.,Department of Medical Oncology, St Vincent's Hospital, Fitzroy, Melbourne, Australia
| | - Sandra C Jones
- ACU Engagement, Australian Catholic University, Melbourne, Australia
| | - Stephanie Nesci
- Department of Medical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Michael L Friedlander
- Prince of Wales Clinical School University of New South Wales, Sydney, Australia.,Department of Medical Oncology, Prince of Wales Hospital, Randwick, NSW, Australia
| | - John L Hopper
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - Jon D Emery
- Department of General Practice and Centre for Cancer Research, University of Melbourne, Victorian Comprehensive Cancer Centre, Melbourne, Australia.,School of Primary, Aboriginal and Rural Health Care, University of Western Australia, Perth, Australia
| | - Martha Hickey
- Department of Obstetrics and Gynaecology, University of Melbourne and the Royal Women's Hospital, Melbourne, Australia
| | - Roger L Milne
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia.,Cancer Epidemiology Division, Cancer Council Victoria, Melbourne, Australia.,Precision Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Melbourne, Australia
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Forrest LE, Forbes Shepherd R, Young MA, Keogh LA, James PA. Finding the five-year window: A qualitative study examining young women's decision-making and experience of using tamoxifen to reduce BRCA1/2 breast cancer risk. Psychooncology 2020; 30:159-166. [PMID: 33006205 DOI: 10.1002/pon.5556] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/16/2020] [Accepted: 09/21/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Tamoxifen has been demonstrated to reduce breast cancer risk in high-risk, premenopausal women. Yet, very few young women with hereditary breast and ovarian cancer syndrome in Australia use tamoxifen, despite this being a less-invasive option compared to risk-reducing mastectomy. This study aims to examine young women's decision-making about and experience of taking tamoxifen to reduce their breast cancer risk. METHODS Young women with a BRCA1/2 mutation participated in semi-structured qualitative interviews, recruited mainly from a metropolitan clinical genetics service. Data were analysed using an inductive, team-based approach to thematic analysis. RESULTS Forty interviews with women aged 20-40 years with a BRCA1/2 mutation were conducted. Eleven women could not recall discussing tamoxifen with their healthcare provider or were too young to commence cancer risk management. Twenty-three women chose not to use tamoxifen because it is contraindicated for pregnancy or because it did not offer immediate and great enough risk reduction compared to bilateral risk-reducing mastectomy. Six women who were definite about not wanting to have children during the following 5-year period chose to use tamoxifen, and most experienced none or transient side effects. CONCLUSIONS Decision-making about tamoxifen was nuanced and informed by considerations characteristic of young adulthood, especially childbearing. Therefore, clinical discussions about tamoxifen with young women with a BRCA1/2 mutation must include consideration of their reproductive plans.
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Affiliation(s)
- Laura E Forrest
- Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia
| | - Rowan Forbes Shepherd
- Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia
| | - Mary-Anne Young
- Kinghorn Centre for Clinical Genomics, Garvan Institute of Medical Research, Darlinghurst, New South Wales, Australia
| | - Louise A Keogh
- Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia
| | - Paul A James
- Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia
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A Pre-Test-Post-Test Trial of a Breast Cancer Risk Report for Women in Their 40s. Am J Prev Med 2020; 59:343-354. [PMID: 32828322 DOI: 10.1016/j.amepre.2020.04.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 03/31/2020] [Accepted: 04/05/2020] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Guidelines recommend individualized breast cancer screening and prevention interventions for women in their 40s. Yet, few primary care clinicians assess breast cancer risk. STUDY DESIGN Pretest-Posttest trial. SETTING/PARTICIPANTS Women aged 40-49 years were recruited from one large Boston-based academic primary care practice between July 2017 and April 2019. INTERVENTION Participants completed a pretest, received a personalized breast cancer risk report, saw their primary care clinician, and completed a posttest. MAIN OUTCOME MEASURES Using mixed effects models, changes in screening intentions (0-100 scale [0=will not screen to 100=will screen]), mammography knowledge, decisional conflict, and receipt of screening were examined. Analyses were conducted from June 2019 to February 2020. RESULTS Patient (n=337) mean age was 44.1 (SD=2.9) years, 61.4% were non-Hispanic white, and 76.6% were college graduates; 306 (90.5%) completed follow-up (203 with 5-year breast cancer risk <1.1%). Screening intentions declined from pre- to post-visit (79.3 to 68.0, p<0.0001), especially for women with 5-year risk <1.1% (77.2 to 63.3, p<0.0001), but still favored screening. In the 2 years prior, 37.6% had screening mammography compared with 41.8% over a mean 16 months follow-up (p=0.17). Mammography knowledge increased and decisional conflict declined. Eleven (3.3%) women met criteria for breast cancer prevention medications (ten discussed medications with their clinicians), 22 (6.5%) for MRI (19 discussed MRI with their clinician), and 67 (19.8%) for genetic counseling (47 discussed with the clinician). CONCLUSIONS Receipt of a personalized breast cancer report was associated with women in their 40s making more-informed and less-conflicted mammography screening decisions and with high-risk women discussing breast cancer prevention interventions with clinicians. TRIAL REGISTRATION This study is registered at www.clinicaltrials.govNCT03180086.
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Tanner JA, Hensel J, Davies PE, Brown LC, Dechairo BM, Mulsant BH. Economic Burden of Depression and Associated Resource Use in Manitoba, Canada. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2020; 65:338-346. [PMID: 31835904 PMCID: PMC7265616 DOI: 10.1177/0706743719895342] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES To characterize the health-care utilization and economic burden associated with depression in Manitoba, Canada. METHODS Patient-level data were retrieved from the Manitoba Centre for Health Policy administrative, clinical, and laboratory databases for the study period of January 1, 1996, through December 31, 2016. Patients were assigned to the depression cohort based on diagnoses recorded in hospitalizations and outpatient physician claims, as well as antidepressant prescription drug claims. A comparison cohort of nondepressed subjects, matched with replacement for age, gender, place of residence (urban vs. rural), and index date, was created. Demographics, comorbidities, intentional self-harm, mortality, health-care utilization, prescription drug utilization, and costs of health-care utilization and social services were compared between depressed patients and matched nondepressed patients, and incidence rate ratios and hazard ratios were reported. RESULTS There were 190,065 patients in the depression cohort and 378,177 patients in the nondepression cohort. Comorbidities were 43% more prevalent among depressed patients. Intentional self-harm, all-cause mortality, and suicide mortality were higher among patients with depression than the nondepression cohort. Health-care utilization-including hospitalizations, physician visits, physician-provided psychotherapy, and prescription drugs-was higher in the depression than the nondepression cohort. Mean health-care utilization costs were 3.5 times higher among depressed patients than nondepressed patients ($10,064 and $2,832, respectively). Similarly, mean social services costs were 3 times higher ($1,522 and $510, respectively). Overall, depression adds a total average cost of $8,244 (SD = $40,542) per person per year. CONCLUSIONS Depression contributes significantly to health burden and per patient costs in Manitoba, Canada. Extrapolation of the results to the entire Canadian health-care system projects an excess of $12 billion annually in health system spending.
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Affiliation(s)
- Julie-Anne Tanner
- Tanenbaum Pharmacogenetics Centre, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada
- Department of Psychiatry, University of Toronto, Ontario, Canada
- Assurex Health Ltd., Toronto, Ontario, Canada
| | - Jennifer Hensel
- Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | | | | | - Benoit H. Mulsant
- Department of Psychiatry, University of Toronto, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
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Gunn C, Maschke A, Bickmore T, Kennedy M, Hopkins MF, Fishman MDC, Paasche-Orlow MK, Warner ET. Acceptability of an Interactive Computer-Animated Agent to Promote Patient-Provider Communication About Breast Density: a Mixed Method Pilot Study. J Gen Intern Med 2020; 35:1069-1077. [PMID: 31919723 PMCID: PMC7174461 DOI: 10.1007/s11606-019-05622-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 12/13/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Half of women undergoing mammography have dense breasts. Mandatory dense breast notification and educational materials have been shown to confuse women, rather than empower them. OBJECTIVE This study used a mixed method, multi-stakeholder approach to assess acceptability of an interactive, computer-animated agent that provided breast density information to women and changes in knowledge, satisfaction, and informational needs. DESIGN A pre-post survey and qualitative focus groups assessed the acceptability of the computer-animated agent among women. An anonymous, online survey measuring acceptability was delivered to a multi-stakeholder group. PARTICIPANTS English-speaking, mammography-eligible women ages 40-74 were invited and 44 women participated in one of nine focus groups. In addition, 14 stakeholders representing primary care, radiology, patient advocates, public health practitioners, and researchers completed the online survey. INTERVENTIONS A prototype of a computer-animated agent was delivered to women in a group setting; stakeholders viewed the prototype independently. MAIN MEASURES Data collected included open-ended qualitative questions that guided discussion about the content and form of the computer-animated agent. Structured surveys included domains related to knowledge, acceptability, and satisfaction. Stakeholder acceptability was measured with a series of statements about aspects of the intervention and delivery approach and are reported as the proportion of respondents who endorsed each statement. KEY RESULTS Six of 12 knowledge items demonstrated improvement post-intervention, satisfaction with the agent was high (81%), but the number of unanswered questions did not improve (67% vs. 54%, p = 0.37). Understanding of the distinction between connective and fatty tissue in the breast did not increase (30% vs. 26%, p = 0.48). Results of the multi-stakeholder survey suggest broad acceptability of the approach and agent. CONCLUSIONS Findings highlight the benefits of a brief interactive educational exposure as well as misperceptions that persisted. Results demonstrate the need for an evidence-based, accessible intervention that is easy to understand for patients.
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Affiliation(s)
- Christine Gunn
- Department of Medicine, Section of General Internal Medicine, Women's Health Unit, Boston University School of Medicine, 801 Massachusetts Avenue, First Floor, Boston, MA, 02118, USA.
| | - Ariel Maschke
- Department of Medicine, Section of General Internal Medicine, Women's Health Unit, Boston University School of Medicine, 801 Massachusetts Avenue, First Floor, Boston, MA, 02118, USA
| | - Timothy Bickmore
- Khoury College of Computer Sciences, Northeastern University, Boston, USA
| | | | | | - Michael D C Fishman
- Department of Radiology, Boston Medical Center, Section of Breast Imaging, Boston University School of Medicine, Boston, USA
| | - Michael K Paasche-Orlow
- Department of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston University School of Medicine, Boston, USA
| | - Erica T Warner
- Department of Medicine, Massachusetts General Hospital, Boston, USA
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Vogel VG. Breast cancer risk reduction: Notable achievements and remaining challenges. Breast J 2020; 26:86-91. [PMID: 31971344 DOI: 10.1111/tbj.13717] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 10/04/2019] [Indexed: 12/26/2022]
Abstract
Millions of women in the United States are at increased risk of breast cancer. Multiple prospective, randomized clinical trials have demonstrated both the efficacy and safety of selective estrogen receptor modulators and aromatase inhibitors in reducing substantially the risk of invasive breast cancer in women at increased risk. Published tables are available to aid clinicians in shared decision-making regarding drug interventions with their patients who are at increased risk of breast cancer. Both professional and governmental agencies have advised that these interventions should be offered to women at increased risk of breast cancer. Doing so would reduce breast cancer morbidity substantially.
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Affiliation(s)
- Victor G Vogel
- Breast Medical Oncology/Research, Geisinger Health System, Danville, Pennsylvania
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Morgan S, Hanna J, Yousef GM. Knowledge Translation in Oncology: The Bumpy Ride From Bench to Bedside. Am J Clin Pathol 2020; 153:5-13. [PMID: 31836881 DOI: 10.1093/ajcp/aqz099] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES Knowledge translation (KT) is the dynamic process of mobilizing best-practice evidence to guide health care decisions. METHODS Using a PubMed search, challenges were identified and milestones defined. RESULTS Substantial challenges exist in integrating discoveries into patient care, including technical limitations related to genomic testing like turnaround time, standardization, reproducibility, and results interpretation. Other challenges include lack of proper training in genetic counseling for health care providers, clarity of scientific evidence, and ethical, legal and social considerations. In addition, most health care systems lack accessibility to genetic testing services. Moving forward, KT should be addressed at three main frontiers. The first is patients centered for proper understanding and decision making; the second is directed toward health care professionals, including clinical decision support and clarity of roles; and the third addresses resources of health care systems. CONCLUSIONS Implementing KT requires developing strategies to enhance awareness and promote behavioral changes congruent with research evidence, designing a systematic approach by health care providers and stakeholders to achieve patient-centered care.
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Affiliation(s)
- Sarah Morgan
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
- Department of Paediatric Laboratory Medicine, Hospital for Sick Children, Toronto, Canada
| | - Jessica Hanna
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
- Department of Paediatric Laboratory Medicine, Hospital for Sick Children, Toronto, Canada
| | - George M Yousef
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Canada
- Department of Paediatric Laboratory Medicine, Hospital for Sick Children, Toronto, Canada
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Ball S, Arevalo M, Juarez E, Payne JD, Jones C. Breast cancer chemoprevention: An update on current practice and opportunities for primary care physicians. Prev Med 2019; 129:105834. [PMID: 31494144 DOI: 10.1016/j.ypmed.2019.105834] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2019] [Revised: 09/01/2019] [Accepted: 09/05/2019] [Indexed: 12/15/2022]
Abstract
Several risk assessment models have been validated for the estimation of risk of breast cancer in women. Chemoprevention through hormonal therapy is an effective way to reduce the incidence of breast cancer in women with high risk. Selective estrogen receptor modulators, tamoxifen and raloxifene, are approved for this indication by the United States Food and Drug Administration, and aromatase inhibitors have also shown promise in recent studies. These medications are generally well tolerated, except for reported increased rates of fractures and venous thromboembolic events. Despite strong recommendations from several regulatory bodies, advocacy for chemoprevention has been inadequate in practice, more so among the primary care physicians. Studies have identified several barriers in physicians, patients, and the system, contributing to this problem. Lack of knowledge about risk assessment models and chemoprevention options preclude physicians from prescribing these medications with confidence. Fear of potential adverse events, confusion regarding the purpose of the therapy, and need for continued adherence for five years are among the principal reasons for reduced chemoprevention uptake and early discontinuation among patients. Multifaceted interventions directed at education and training of health care professionals, proper counseling of women at high risk, and promotion of the development of improved medications might help ensure better chemoprevention uptake in the target population.
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Affiliation(s)
- Somedeb Ball
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA.
| | - Meily Arevalo
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Edna Juarez
- Department of Internal Medicine, Memorial Medical Center, Las Cruces, NM, USA
| | - J Drew Payne
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Catherine Jones
- Division of Hematology and Medical Oncology, Texas Tech University Health Sciences Center, Lubbock, TX, USA
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Goldstein KM, Fisher DA, Wu RR, Orlando LA, Coffman CJ, Grubber JM, Rakhra-Burris T, Wang V, Scheuner MT, Sperber N, Datta SK, Nelson RE, Strawbridge E, Provenzale D, Hauser ER, Voils CI. An electronic family health history tool to identify and manage patients at increased risk for colorectal cancer: protocol for a randomized controlled trial. Trials 2019; 20:576. [PMID: 31590688 PMCID: PMC6781340 DOI: 10.1186/s13063-019-3659-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 08/14/2019] [Indexed: 12/11/2022] Open
Abstract
Background Colorectal cancer is the fourth most commonly diagnosed cancer in the United States. Approximately 3–10% of the population has an increased risk for colorectal cancer due to family history and warrants more frequent or intensive screening. Yet, < 50% of that high-risk population receives guideline-concordant care. Systematic collection of family health history and decision support may improve guideline-concordant screening for patients at increased risk of colorectal cancer. We seek to test the effectiveness of a web-based, systematic family health history collection tool and decision support platform (MeTree) to improve risk assessment and appropriate management of colorectal cancer risk among patients in the Department of Veterans Affairs primary care practices. Methods In this ongoing randomized controlled trial, primary care providers at the Durham Veterans Affairs Health Care System and the Madison VA Medical Center are randomized to immediate intervention or wait-list control. Veterans are eligible if assigned to enrolled providers, have an upcoming primary care appointment, and have no conditions that would place them at increased risk for colorectal cancer (such as personal history, adenomatous polyps, or inflammatory bowel disease). Those with a recent lower endoscopy (e.g. colonoscopy, sigmoidoscopy) are excluded. Immediate intervention patients put their family health history information into a web-based platform, MeTree, which provides both patient- and provider-facing decision support reports. Wait-list control patients access MeTree 12 months post-consent. The primary outcome is the risk-concordant colorectal cancer screening referral rate obtained via chart review. Secondary outcomes include patient completion of risk management recommendations (e.g. colonoscopy) and referral for genetic consultation. We will also conduct an economic analysis and an assessment of providers’ experience with MeTree clinical decision support recommendations to inform future implementation efforts if the intervention is found to be effective. Discussion This trial will assess the feasibility and effectiveness of patient-collected family health history linked to decision support to promote risk-appropriate screening in a large healthcare system such as the Department of Veterans Affairs. Trial registration ClinicalTrials.gov, NCT02247336. Registered on 25 September 2014. Electronic supplementary material The online version of this article (10.1186/s13063-019-3659-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Karen M Goldstein
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, 508 Fulton Street, Durham, NC, 27705, USA. .,Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA.
| | - Deborah A Fisher
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - R Ryanne Wu
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA.,Durham Cooperative Studies Program Epidemiology Center, Durham Veterans Affairs Health Care System, Durham, NC, USA.,Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Lori A Orlando
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA.,Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Cynthia J Coffman
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, 508 Fulton Street, Durham, NC, 27705, USA.,Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Janet M Grubber
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
| | - Tejinder Rakhra-Burris
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Virginia Wang
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, 508 Fulton Street, Durham, NC, 27705, USA.,Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Maren T Scheuner
- Division of Medical Genetics, University of California at San Francisco, San Francisco, CA, USA.,Division of Hematology-Oncology, San Francisco Veterans Affairs Health Care System, San Francisco, CA, USA
| | - Nina Sperber
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, 508 Fulton Street, Durham, NC, 27705, USA.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Santanu K Datta
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA.,Health Services Research, Management and Policy, University of Florida College of Public Health and Health Professions, Gainesville, FL, USA
| | - Richard E Nelson
- IDEAS Center, VA Salt Lake City Healthcare System, Salt Lake City, UT, USA.,Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Elizabeth Strawbridge
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, 508 Fulton Street, Durham, NC, 27705, USA
| | - Dawn Provenzale
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA.,Durham Cooperative Studies Program Epidemiology Center, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Elizabeth R Hauser
- Durham Cooperative Studies Program Epidemiology Center, Durham Veterans Affairs Health Care System, Durham, NC, USA.,Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Corrine I Voils
- William S Middleton Memorial Veterans Hospital, Madison, WI, USA.,Department of Surgery, University of Wisconsin, Madison, WI, USA
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Allen CG, Roberts M, Guan Y. Exploring Predictors of Genetic Counseling and Testing for Hereditary Breast and Ovarian Cancer: Findings from the 2015 U.S. National Health Interview Survey. J Pers Med 2019; 9:E26. [PMID: 31083288 PMCID: PMC6616387 DOI: 10.3390/jpm9020026] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 04/26/2019] [Accepted: 04/29/2019] [Indexed: 12/13/2022] Open
Abstract
Despite efforts to increase the availability of clinical genetic testing and counseling for Hereditary Breast and Ovarian (HBOC)-related cancers, these services remain underutilized in clinical settings. There have been few efforts to understand the public's use of cancer genetic services, particularly for HBOC-related cancers. This analysis is based on data from the 2015 National Health Interview Survey (NHIS), a U.S.-based nationwide probability sample, to better understand the public's use of HBOC-related clinical cancer genetic services. Bivariate analyses were used to compute percentages and examine the associations of familial cancer risk for three genetic services outcomes (ever had genetic counseling for cancer risk, ever discussed genetic testing for cancer risk with a provider, and ever had genetic testing for cancer risk). Multivariable logistic regression models were used to estimate the association of familial cancer risk and other demographic and health variables with genetic services. Most women (87.67%) in this study were at low risk based on self-reported family history of breast and ovarian cancer, 10.65% were at medium risk, and 1.68% were at high risk. Overall, very small numbers of individuals had ever had genetic counseling (2.78%), discussed genetic testing with their physician (4.55%) or had genetic testing (1.64%). Across all genetic services outcomes, individuals who were at higher familial risk were more likely to have had genetic counseling than those at lower risk (high risk: aOR = 5.869, 95% CI = 2.911-11.835; medium risk: aOR = 4.121, 95% CI = 2.934-5.789), discussed genetic testing (high risk: aOR = 5.133, 95% CI = 2.699-9.764; medium risk: aOR = 3.649, 95% CI = 2.696-4.938), and completed genetic testing (high risk: aOR = 8.531, 95% CI = 3.666-19.851; medium risk aOR = 3.057, 95% CI = 1.835-5.094). Those who perceived themselves as being more likely to develop cancer than the average woman were more likely to engage in genetic counseling (aOR = 1.916, 95% CI = 1.334-2.752), discuss genetic testing (aOR = 3.314, 95% CI = 2.463-4.459) or have had genetic testing (aOR = 1.947, 95% CI = 1.13-3.54). Personal cancer history was also a significant predictor of likelihood to have engaged in genetic services. Our findings highlight: (1) potential under-utilization of cancer genetic services among high risk populations in the U.S. and (2) differences in genetic services use based on individual's characteristics such as self-reported familial risk, personal history, and beliefs about risk of cancer. These results align with other studies which have noted that awareness and use of genetic services are low in the general population and likely not reaching individuals who could benefit most from screening for inherited cancers. Efforts to promote public awareness of familial cancer risk may lead to better uptake of cancer genetic services.
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Affiliation(s)
- Caitlin G Allen
- Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA 30307, USA.
| | - Megan Roberts
- Division of Cancer Control and Population Sciences, National Cancer Institute, 9609 Medical Center Drive, Rockville, MD 20850, USA.
| | - Yue Guan
- Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, GA 30307, USA.
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31
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Yadav S, Hartkop S, Cardenas PY, Ladkany R, Halalau A, Shoichet S, Maddens M, Zakalik D. Utilization of a breast cancer risk assessment tool by internal medicine residents in a primary care clinic: impact of an educational program. BMC Cancer 2019; 19:228. [PMID: 30871497 PMCID: PMC6416938 DOI: 10.1186/s12885-019-5418-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Accepted: 02/27/2019] [Indexed: 01/11/2023] Open
Abstract
Background Despite strong evidence of benefit, breast cancer risk assessment and chemoprevention are underutilized by primary care physicians. This study evaluates the impact of an educational program on knowledge and utilization of the NCI Breast Cancer Risk Assessment Tool (BCRAT) by internal medicine residents. Methods Internal medicine residents at the primary care clinic at William Beaumont Hospital participated in an educational program on breast cancer risk assessment and chemoprevention. A questionnaire was used to assess knowledge and practice before and after participation. Electronic health records of women between the ages of 35 and 65 who were seen by participating residents for annual health exams between Dec 15, 2015 and Dec 14, 2016 were reviewed. Utilization of BCRAT by the residents was compared pre- and post-educational program. Results A total of 43 residents participated in the study. 31 (72.1%) residents reported no prior knowledge about BCRAT. The remaining 12 (27.9%) reported limited knowledge of BCRAT, but the majority of these (n = 10, 83.3%) had not used it in the last six months. For each question on the pre-educational knowledge assessment, fewer than 10% of the residents responded correctly. After implementation of the educational program, there was a significant increase in the proportion of residents who answered correctly (Range: 67 to 100%, p < 0.001). Electronic health records of 301 clinic patients were reviewed, 118 (39.2%) in the pre-educational program group and 183 (60.8%) in the post-educational program group. There was a higher use of BCRAT in the post-educational program group compared to the pre-intervention group (3.8% vs. 0%, p < 0.05). However, a majority (n = 294, 98.7%) of eligible patients from both groups did not undergo breast cancer risk assessment. Conclusions Our study demonstrates that an educational intervention improved residents’ knowledge of BCRAT. Despite this improvement, a significant proportion of patients did not undergo breast cancer risk assessment. Expanding the scope and duration of this intervention and combining it with innovative use of technology to improve utilization should be the subject of future investigation. Electronic supplementary material The online version of this article (10.1186/s12885-019-5418-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Siddhartha Yadav
- Division of Medical Oncology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Sarah Hartkop
- Department of Internal Medicine, Beaumont Health, 3601 W 13 Mile Rd, Royal Oak, MI, 48073, USA
| | - Paola Yumpo Cardenas
- Nancy and James Grosfeld Cancer Genetics Center, Beaumont Cancer Institute, Beaumont Health, 3577 W 13 Mile Rd, Suite 140, Royal Oak, MI, 48073, USA
| | - Rand Ladkany
- Department of Internal Medicine, Beaumont Health, 3601 W 13 Mile Rd, Royal Oak, MI, 48073, USA.,Nancy and James Grosfeld Cancer Genetics Center, Beaumont Cancer Institute, Beaumont Health, 3577 W 13 Mile Rd, Suite 140, Royal Oak, MI, 48073, USA
| | - Alexandra Halalau
- Department of Internal Medicine, Beaumont Health, 3601 W 13 Mile Rd, Royal Oak, MI, 48073, USA.,Oakland University William Beaumont School of Medicine, 2200 N Squirrel Rd, Rochester, MI, 48309, USA
| | - Sandor Shoichet
- Department of Internal Medicine, Beaumont Health, 3601 W 13 Mile Rd, Royal Oak, MI, 48073, USA.,Oakland University William Beaumont School of Medicine, 2200 N Squirrel Rd, Rochester, MI, 48309, USA
| | - Michael Maddens
- Department of Internal Medicine, Beaumont Health, 3601 W 13 Mile Rd, Royal Oak, MI, 48073, USA.,Oakland University William Beaumont School of Medicine, 2200 N Squirrel Rd, Rochester, MI, 48309, USA
| | - Dana Zakalik
- Nancy and James Grosfeld Cancer Genetics Center, Beaumont Cancer Institute, Beaumont Health, 3577 W 13 Mile Rd, Suite 140, Royal Oak, MI, 48073, USA. .,Oakland University William Beaumont School of Medicine, 2200 N Squirrel Rd, Rochester, MI, 48309, USA.
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32
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Implementing a Population-Based Breast Cancer Risk Assessment Program. Clin Breast Cancer 2019; 19:246-253.e2. [PMID: 31072694 DOI: 10.1016/j.clbc.2019.02.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Revised: 02/03/2019] [Accepted: 02/24/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Personalized breast cancer risk assessment is important in identifying and managing women at increased risk for breast cancer. However, there has been little evaluation of the practical aspects of implementing a population-based program that identifies and refers high-risk patients for further evaluation. PATIENTS AND METHODS We implemented a semiautomated approach to collect personal and family history to identify women at high risk of breast cancer. On the basis of the survey, women identified as elevated risk received letters inviting them to telephone consultations with licensed breast health genetic counselors (BHGCs). High-risk women's history was verified and counseling and referrals provided, as appropriate. RESULTS Among 20,558 women screened, 2000 (9.7%) women were identified as high risk on the basis of patient initial report. However, most (1,580) were excluded from receiving risk communication after BHGC review of risk information with the woman or because of previous attention to breast cancer risk or an abnormal mammogram. Among 420 subjects who received risk letters, 225 received a BHGC consultation. Of these 225 women, 63 were reclassified as average risk, 158 were referred to high-risk clinics, and 5 consultations were incomplete after determining that further information was needed. Of the 158 women referred to high-risk breast clinics, 51 attended an appointment. CONCLUSION This study highlights the complex nature of a population-based breast cancer screening program in a clinical setting and shows the substantial effort needed to identify newly discovered women at high risk for breast cancer and refer them to appropriate services.
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Samimi G, Heckman-Stoddard BM, Kay SS, Bloodgood B, Coa KI, Robinson JL, Tennant B, Ford LG, Szabo E, Minasian L. Acceptability of Localized Cancer Risk Reduction Interventions Among Individuals at Average or High Risk for Cancer. Cancer Prev Res (Phila) 2019; 12:271-282. [PMID: 30824471 DOI: 10.1158/1940-6207.capr-18-0435] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 01/28/2019] [Accepted: 02/22/2019] [Indexed: 12/30/2022]
Abstract
Individuals at high risk for cancer, including those already diagnosed with premalignant lesions, can potentially benefit from chemopreventive interventions to reduce cancer risk. However, uptake and acceptability have been hindered due to the risk of systemic toxicity and other adverse effects. Locally delivered chemopreventive agents, where direct action on the primary organ may limit systemic toxicity, are emerging as an option for high-risk individuals. While a number of clinical trials support the development of chemopreventive agents, it is crucial to understand the factors and barriers that influence their acceptability and use. We conducted 36 focus groups with 198 individuals at average and high risk of breast/ovarian, gynecologic, and head/neck/oral and lung cancers to examine the perceptions and acceptability of chemopreventive agents. Participants' willingness to use chemopreventive agents was influenced by several factors, including perceived risk of cancer, skepticism around prevention, previous knowledge of chemopreventive agents, support from trusted sources of health information, participation in other cancer-related risk-reduction activities, previous experience with similar modalities, cost, regimen, side effects, and perceived effectiveness of the preventive intervention. Our findings indicate that individuals may be more receptive to locally delivered chemopreventive agents if they perceive themselves to be at high risk for cancer and are given the necessary information regarding regimen and side effects to make an informed decision. Clinical trials that collect additional patient-centered data including side effects and how these interventions fit into an individual's lifestyle are imperative to improve uptake of chemopreventive agents.
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Affiliation(s)
- Goli Samimi
- Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland.
| | | | | | | | | | | | | | - Leslie G Ford
- Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland
| | - Eva Szabo
- Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland
| | - Lori Minasian
- Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland
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34
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Fung SM, Wong XY, Lee SX, Miao H, Hartman M, Wee HL. Performance of Single-Nucleotide Polymorphisms in Breast Cancer Risk Prediction Models: A Systematic Review and Meta-analysis. Cancer Epidemiol Biomarkers Prev 2018; 28:506-521. [DOI: 10.1158/1055-9965.epi-18-0810] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 10/30/2018] [Accepted: 12/03/2018] [Indexed: 11/16/2022] Open
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35
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Plourde N, Brown HK, Vigod S, Cobigo V. The Association Between Continuity of Primary Care and Preventive Cancer Screening in Women With Intellectual Disability. AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES 2018; 123:499-513. [PMID: 30421970 DOI: 10.1352/1944-7558-123.6.499] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Women with intellectual disability have low screening rates for breast and cervical cancer. This population-based cohort study examined the association between the level of primary care continuity and breast and cervical cancer screening rates in women with intellectual disability. Data were obtained from the Institute for Clinical Evaluative Sciences and the Ontario Ministry of Community and Social Services. Neither high (adjusted OR [aOR] = 1.06; 95% CI: 0.88-1.29) nor moderate (aOR = 1.11; 95% CI: 0.91-1.36) continuity of care were associated with mammography screening. Women were less likely to receive a Pap test with high (aOR = 0.70; 95% CI: 0.64-0.77) and moderate (aOR = 0.81, 95% CI 0.74-0.89) versus low continuity of care. Improving continuity of care may not be sufficient for increasing preventive screening rates.
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Affiliation(s)
- Natasha Plourde
- Natasha Plourde, University of Ottawa, Canada; Hilary K. Brown, University of Toronto Scarborough, Canada; Simone Vigod, Women's College Hospital, Canada; and Virginie Cobigo, University of Ottawa, Canada
| | - Hilary K Brown
- Natasha Plourde, University of Ottawa, Canada; Hilary K. Brown, University of Toronto Scarborough, Canada; Simone Vigod, Women's College Hospital, Canada; and Virginie Cobigo, University of Ottawa, Canada
| | - Simone Vigod
- Natasha Plourde, University of Ottawa, Canada; Hilary K. Brown, University of Toronto Scarborough, Canada; Simone Vigod, Women's College Hospital, Canada; and Virginie Cobigo, University of Ottawa, Canada
| | - Virginie Cobigo
- Natasha Plourde, University of Ottawa, Canada; Hilary K. Brown, University of Toronto Scarborough, Canada; Simone Vigod, Women's College Hospital, Canada; and Virginie Cobigo, University of Ottawa, Canada
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36
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Pinsky PF, Miller E, Heckman-Stoddard B, Minasian L. Use of raloxifene and tamoxifen by breast cancer risk level in a Medicare-eligible cohort. Am J Obstet Gynecol 2018; 218:606.e1-606.e9. [PMID: 29630889 PMCID: PMC5970073 DOI: 10.1016/j.ajog.2018.03.031] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 02/21/2018] [Accepted: 03/24/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Raloxifene and tamoxifen are Food and Drug Administration-approved for breast cancer risk reduction; in 2013, the US Preventive Services Task Force recommended these drugs for breast cancer risk reduction in high-risk women. Information on the use of raloxifene and tamoxifen for breast cancer risk reduction in the general population indicates that the risk is believed to be low; however, there is little literature. OBJECTIVE The purpose of this study was to assess the use of breast cancer risk reduction medications by breast cancer risk level in an older cohort of women. STUDY DESIGN Women who were enrolled in the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial were assessed for the use of raloxifene, tamoxifen, and other medications. The data sources for use of the drugs were a mailed medication use questionnaire in 2013 and linked Medicare Part D claims files from 2010-2014. Estimated breast cancer risk within 5 years was assessed with the use of the modified Gail model and self-reported breast cancer risk factors; comorbidities were assessed through a questionnaire. RESULTS A total of 22,235 women completed the medication use questionnaire; of these, 13,640 women (61%) had linked Part D data. In 2013, 45% of the women were 65-74 years old, and 55% of the women were 75-84 years old. From the medication use questionnaire, raloxifene use (past month) was 1.8%, 2.5%, and 4.0% for women with breast cancer risk within 5 years of <1.66%, 1.66-3.0%, and ≥3%, respectively (probability value trend, <.0001). From Part D, for any use during the period among women with coverage, raloxifene rates were 3.3%, 4.0%, and 6.6% for the 3 categories for breast cancer risk within 5 years (probability value trend, <.0001); use was 7.4% and 3.3% in women with and without osteoporosis, respectively. Raloxifene use significantly decreased from 2010-2014, and specifically from 2012-2014, both for all women and for women with breast cancer risk within 5 years of ≥3%. Tamoxifen use from Part D was 0.36%, 0.45%, and 0.85% for the 3 categories for breast cancer risk within 5 years (probability value trend, .009). CONCLUSION Raloxifene use was low overall but increased modestly with breast cancer risk, and usage decreased from 2010-2014. Tamoxifen use was very low.
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Affiliation(s)
- Paul F Pinsky
- Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, Bethesda, MD.
| | - Eric Miller
- Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Brandy Heckman-Stoddard
- Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Lori Minasian
- Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, Bethesda, MD
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37
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Gunn CM, Battaglia TA, Paasche-Orlow MK, West AK, Kressin NR. Women's perceptions of dense breast notifications in a Massachusetts safety net hospital: "So what is that supposed to mean?". PATIENT EDUCATION AND COUNSELING 2018; 101:1123-1129. [PMID: 29426765 DOI: 10.1016/j.pec.2018.01.017] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 01/19/2018] [Accepted: 01/24/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE Currently, 30 US states mandate that radiologists notify women when dense breast tissue is found on mammography. Little is understood about how notifications are perceived by recipients. This qualitative study sought to understand how dense breast notifications (DBNs) impact women's perceptions and their participation in follow-up care. METHODS We assessed rates of DBN recall and conducted semi-structured telephone interviews with 30 English-speaking women ages 40 to 74 after receiving a DBN from a Massachusetts hospital. Content coding characterized women's recall of the notification content, perceptions of breast density, and planned or actual participation in follow-up care. RESULTS Most women (81%) recalled receiving a DBN, but few could recall specific content. Women described struggling to understand the meaning of breast density and created their own explanatory models of dense breasts that differed from medical explanations. Many women planned to or did talk with their doctors about breast density as a result of receiving the notification. CONCLUSIONS Women receiving DBNs have limited knowledge and many misperceptions about the implications of having dense breasts. PRACTICE IMPLICATIONS Educational support is needed to promote informed decision- making about breast cancer screening that incorporates personal risk in the setting of dense breast legislation.
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Affiliation(s)
- Christine M Gunn
- Women's Health Unit, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA; Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA, USA.
| | - Tracy A Battaglia
- Women's Health Unit, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Michael K Paasche-Orlow
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA; Boston Medical Center, Boston, MA, USA
| | - Amanda K West
- Women's Health Unit, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Nancy R Kressin
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA; VA Boston Healthcare System, Jamaica Plain, MA, USA
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Murciano-Goroff YR, McCarthy AM, Bristol MN, Groeneveld P, Domchek SM, Motanya UN, Armstrong K. Uptake of BRCA 1/2 and oncotype DX testing by medical and surgical oncologists. Breast Cancer Res Treat 2018; 171:173-180. [PMID: 29737473 DOI: 10.1007/s10549-018-4810-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 04/30/2018] [Indexed: 01/30/2023]
Abstract
PURPOSE The diffusion of genomic testing is critical to the success of precision medicine, but there is limited information on oncologists' uptake of genetic technology. We aimed to assess the frequency with which medical oncologists and surgeons order BRCA 1/2 and Oncotype DX testing for breast cancer patients. METHODS We surveyed 732 oncologists and surgeons treating breast cancer patients. Physicians were from Florida, New York, New Jersey, and Pennsylvania, and were listed in the 2010 AMA Masterfile or identified by patients. RESULTS 80.6% of providers ordered BRCA 1/2 testing at least sometimes and 85.4% ordered Oncotype DX (p = 0.01). More frequent ordering of BRCA 1/2 was associated with more positive attitudes toward genetic innovation (OR 1.14, p = 0.001), a belief that testing was likely to be covered by patients' insurance (OR 2.84, p < 0.001), and more frequent ordering of Oncotype DX testing (OR 8.69, p < 0.001). More frequent use of Oncotype DX was associated with a belief that testing was likely to be covered by insurance (OR 7.33, p < 0.001), as well as with more frequent ordering of BRCA 1/2 testing (OR 9.48, p < 0.001). CONCLUSIONS Nearly one in five providers never or rarely ever ordered BRCA 1/2 testing for their breast cancer patients, and nearly 15% never or rarely ever ordered Oncotype DX. Less frequent ordering of BRCA 1/2 is associated with less frequent use of Oncotype DX testing, and vice versa. Those who do not order BRCA 1/2 testing report less positive attitudes toward genetic innovation. Further education of this subset of providers regarding the benefits of precision medicine may enable more rapid diffusion of genetic technology.
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Affiliation(s)
- Yonina R Murciano-Goroff
- Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA,, 02114, USA.
| | - Anne Marie McCarthy
- Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA,, 02114, USA
| | - Mirar N Bristol
- Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA,, 02114, USA
| | - Peter Groeneveld
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Susan M Domchek
- University of Pennsylvania Abramson Cancer Center, Philadelphia, USA
| | - U Nkiru Motanya
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Katrina Armstrong
- Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA,, 02114, USA
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Rainey L, van der Waal D, Jervaeus A, Wengström Y, Evans DG, Donnelly LS, Broeders MJM. Are we ready for the challenge of implementing risk-based breast cancer screening and primary prevention? Breast 2018. [PMID: 29529454 DOI: 10.1016/j.breast.2018.02.029] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Increased knowledge of breast cancer risk factors provides opportunities to shift from a one-size-fits-all screening programme to a personalised approach, where screening and prevention is based on a woman's risk of developing breast cancer. However, potential implementation of this new paradigm could present considerable challenges which the present review aims to explore. METHODS Bibliographic databases were searched to identify studies evaluating potential implications of the implementation of personalised risk-based screening and primary prevention for breast cancer. Identified themes were evaluated using thematic analysis. RESULTS The search strategy identified 5699 unique publications, of which 59 were selected for inclusion. Significant changes in policy and practice are warranted. The organisation of breast cancer screening spans several healthcare delivery systems and clinical settings. Feasibility of implementation depends on how healthcare is funded and arranged, and potentially varies between countries. Piloting risk assessment and prevention counselling in primary care settings has highlighted implications relating to the need for extensive additional training on risk (communication) and prevention, impact on workflow, and professionals' personal discomfort breaching the topic with women. Additionally, gaps in risk estimation, psychological, ethical and legal consequences will need to be addressed. CONCLUSION The present review identified considerable unresolved issues and challenges. Potential implementation will require a more complex framework, in which a country's healthcare regulations, resources, and preferences related to screening and prevention services are taken into account. However, with the insights gained from the present overview, countries expecting to implement risk-based screening and prevention can start to inventory and address the issues that were identified.
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Affiliation(s)
- Linda Rainey
- Radboud Institute for Health Sciences, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Daniëlle van der Waal
- Radboud Institute for Health Sciences, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Anna Jervaeus
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet & Theme Cancer, Karolinska University Hospital, Alfred Nobels allé 23, 23300, 14183, Huddinge, Sweden
| | - Yvonne Wengström
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet & Theme Cancer, Karolinska University Hospital, Alfred Nobels allé 23, 23300, 14183, Huddinge, Sweden
| | - D Gareth Evans
- Prevent Breast Cancer Research Unit, The Nightingale Centre, Manchester University NHS Foundation Trust, Southmoor Road, Manchester M23 9LT, United Kingdom; Genomic Medicine, Division of Evolution and Genomic Sciences, Manchester Academic Health Sciences Centre, Manchester University NHS Foundation Trust, Manchester M13 9WL, United Kingdom; The Christie NHS Foundation Trust, Withington, Manchester M20 4BX, United Kingdom
| | - Louise S Donnelly
- Prevent Breast Cancer Research Unit, The Nightingale Centre, Manchester University NHS Foundation Trust, Southmoor Road, Manchester M23 9LT, United Kingdom
| | - Mireille J M Broeders
- Radboud Institute for Health Sciences, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands; Dutch Expert Center for Screening, PO Box 6873, 6503 GJ Nijmegen, The Netherlands
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40
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Gunn CM, Kressin NR, Cooper K, Marturano C, Freund KM, Battaglia TA. Primary Care Provider Experience with Breast Density Legislation in Massachusetts. J Womens Health (Larchmt) 2018; 27:615-622. [PMID: 29338539 DOI: 10.1089/jwh.2017.6539] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Dense breasts on mammography independently increases breast cancer risk and decreases mammography sensitivity. Thirty-two states have adopted notification laws to raise awareness among women with dense breasts about supplemental screening. Little is known about these policies' impact on clinical practice among primary care providers (PCPs). MATERIALS AND METHODS This study explores PCP attitudes, knowledge, and the impact of the Massachusetts dense breast notification legislation on clinical practice after its enactment in 2015. An anonymous, online survey at two urban safety-net hospitals was administered in 2015-2016. Practicing MDs and nurse practitioners in primary care were invited to participate. RESULTS All 145 PCPs in general internal medicine at the two sites were e-mailed a survey link and 80 (55%) were completed. While 64 of 80 PCPs surveyed (80%) had some familiarity with the legislation, none identified the 8 required components of notifications contained in the Massachusetts legislation. Forty-nine percent (39/80) did not feel prepared to respond to patient questions about dense breasts. Forty-one percent (33/80) correctly identified that no current guidelines recommend the use of supplemental screening tests solely based on breast density and 85% (68/80) indicated interest in further training. Female and less experienced providers were more likely to be in favor of the legislation (49% vs. 11% by gender; 76% <5 years vs. 9%> 20 years). Women practitioners (55%) who were more likely than men (17%, p = 0.01) to agree with the policy changed their discussions of mammography results with patients. CONCLUSIONS PCPs feel underprepared to counsel women about breast density identified on mammography and its implications.
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Affiliation(s)
- Christine M Gunn
- 1 Women's Health Unit, Evans Department of Medicine, Section of General Internal Medicine, Boston Medical Center , Boston, Massachusetts.,2 Department of Health Law, Policy, and Management, Boston University School of Public Health , Boston, Massachusetts
| | - Nancy R Kressin
- 1 Women's Health Unit, Evans Department of Medicine, Section of General Internal Medicine, Boston Medical Center , Boston, Massachusetts.,3 Boston University School of Medicine , Evans Department of Medicine, Section of General Internal Medicine Boston, MA
| | - Kristina Cooper
- 1 Women's Health Unit, Evans Department of Medicine, Section of General Internal Medicine, Boston Medical Center , Boston, Massachusetts
| | - Cinthya Marturano
- 4 Division of Internal Medicine and Primary Care, Tufts Medical Center , Boston, Massachusetts
| | - Karen M Freund
- 4 Division of Internal Medicine and Primary Care, Tufts Medical Center , Boston, Massachusetts.,5 Institute for Clinical Research and Health Policy Studies , Tufts Medical Center, Boston, Massachusetts
| | - Tracy A Battaglia
- 1 Women's Health Unit, Evans Department of Medicine, Section of General Internal Medicine, Boston Medical Center , Boston, Massachusetts.,3 Boston University School of Medicine , Evans Department of Medicine, Section of General Internal Medicine Boston, MA
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Crew KD, Albain KS, Hershman DL, Unger JM, Lo SS. How do we increase uptake of tamoxifen and other anti-estrogens for breast cancer prevention? NPJ Breast Cancer 2017. [PMID: 28649660 PMCID: PMC5460136 DOI: 10.1038/s41523-017-0021-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Several randomized controlled trials of anti-estrogens, such as tamoxifen and aromatase inhibitors, have demonstrated up to a 50–65% decrease in breast cancerincidence among high-risk women. Approximately 15% of women, age 35–79 years, in the U.S. meet criteria for breast cancer preventive therapies, but uptake of these medications remain low. Explanations for this low uptake includelack of awareness of breast cancer risk status, insufficient knowledge about breast cancer preventive therapies among patients and physicians, and toxicity concerns. Increasing acceptance of pharmacologic breast cancer prevention will require effective communication of breast cancer risk, accurate representation about the potential benefits and side effects of anti-estrogens, targeting-specific high-risk populations most likely to benefit from preventive therapy, and minimizing the side effects of current anti-estrogens with novel administration and dosing options. One strategy to improve the uptake of chemoprevention strategies is to consider lessons learned from the use of drugs to prevent other chronic conditions, such as cardiovascular disease. Enhancing uptake and adherence to anti-estrogens for primary prevention holds promise for significantly reducing breast cancer incidence, however, this will require a significant change in our current clinical practice and stronger advocacy and awareness at the national level.
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Affiliation(s)
- Katherine D Crew
- Columbia University Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY USA
| | - Kathy S Albain
- Loyola University Chicago Stritch School of Medicine, Cardinal Bernardin Cancer Center, Maywood, IL USA
| | - Dawn L Hershman
- Columbia University Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY USA
| | - Joseph M Unger
- SWOG Statistical Center, Fred Hutchinson Cancer Research Center, Seattle, WA USA
| | - Shelly S Lo
- Loyola University Chicago Stritch School of Medicine, Cardinal Bernardin Cancer Center, Maywood, IL USA
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Haas JS, Barlow WE, Schapira MM, MacLean CD, Klabunde CN, Sprague BL, Beaber EF, Chen JS, Bitton A, Onega T, Harris K, Tosteson ANA. Primary Care Providers' Beliefs and Recommendations and Use of Screening Mammography by their Patients. J Gen Intern Med 2017; 32:449-457. [PMID: 28070772 PMCID: PMC5377895 DOI: 10.1007/s11606-016-3973-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 12/12/2016] [Accepted: 12/15/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Revised breast cancer screening guidelines have fueled debate about the effectiveness and frequency of screening mammography, encouraging discussion between women and their providers. OBJECTIVE To examine whether primary care providers' (PCPs') beliefs about the effectiveness and frequency of screening mammography are associated with utilization by their patients. DESIGN Cross-sectional survey data from PCPs (2014) from three primary care networks affiliated with the Population-based Research Optimizing Screening through Personalized Regimens (PROSPR) consortium, linked with data about their patients' mammography use (2011-2014). PARTICIPANTS PCPs (n = 209) and their female patients age 40-89 years without breast cancer (n = 30,233). MAIN MEASURES Outcomes included whether (1) women received a screening mammogram during a 2-year period; and (2) screened women had >1 mammogram during that period, reflecting annual screening. Principal independent variables were PCP beliefs about the effectiveness of mammography and their recommendations for screening frequency. KEY RESULTS Overall 65.2% of women received >1 screening mammogram. For women 40-48 years, mammography use was modestly lower for those cared for by PCPs who believed that screening was ineffective compared with those who believed it was somewhat or very effective (59.1%, 62.3%, and 64.7%; p = 0.019 after controlling for patient characteristics). Of women with PCPs who reported they did not recommend screening before age 50, 48.1% were nonetheless screened. For women age 49-74 years, the vast majority were cared for by providers who believed that screening was effective. Provider recommendations were not associated with screening frequency. For women ≥75 years, those cared for by providers who were uncertain about effectiveness had higher screening use (50.7%) than those cared for by providers who believed it was somewhat effective (42.8%). Patients of providers who did not recommend screening were less likely to be screened than were those whose providers recommended annual screening, yet 37.1% of patients whose providers recommended against screening still received screening. CONCLUSIONS PCP beliefs about mammography effectiveness and screening recommendations are only modestly associated with use, suggesting other likely influences on patient participation in mammography.
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Affiliation(s)
- Jennifer S Haas
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA, 02120, USA.
- Harvard Medical School, Boston, MA, USA.
- Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | | | - Marilyn M Schapira
- University of Pennsylvania and the Philadelphia VA Medical Center, Philadelphia, PA, USA
| | | | - Carrie N Klabunde
- Office of Disease Prevention, Office of the Director, National Institutes of Health, Bethesda, MD, USA
| | | | | | - Jane S Chen
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA, 02120, USA
| | - Asaf Bitton
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA, 02120, USA
- Harvard Medical School, Boston, MA, USA
| | - Tracy Onega
- Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH, USA
| | - Kimberly Harris
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA, 02120, USA
| | - Anna N A Tosteson
- Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, NH, USA
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Skandarajah AR, Thomas S, Shackleton K, Chin-Lenn L, Lindeman GJ, Mann GB. Patient and medical barriers preclude uptake of tamoxifen preventative therapy in women with a strong family history. Breast 2017; 32:93-97. [DOI: 10.1016/j.breast.2017.01.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Revised: 01/08/2017] [Accepted: 01/09/2017] [Indexed: 01/26/2023] Open
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Haas JS. The Complexity of Achieving the Promise of Precision Breast Cancer Screening. J Natl Cancer Inst 2017; 109:2938663. [PMID: 28130476 DOI: 10.1093/jnci/djw301] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Accepted: 11/15/2016] [Indexed: 12/17/2022] Open
Affiliation(s)
- Jennifer S Haas
- Affiliation of author: Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA
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45
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Breast Cancer. Fam Med 2017. [DOI: 10.1007/978-3-319-04414-9_114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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46
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Haas JS, Baer HJ, Eibensteiner K, Klinger EV, St Hubert S, Getty G, Brawarsky P, Orav EJ, Onega T, Tosteson ANA, Bates DW, Colditz G. A Cluster Randomized Trial of a Personalized Multi-Condition Risk Assessment in Primary Care. Am J Prev Med 2017; 52:100-105. [PMID: 27639785 PMCID: PMC5167657 DOI: 10.1016/j.amepre.2016.07.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 06/17/2016] [Accepted: 07/15/2016] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Personal risk for multiple conditions should be assessed in primary care. This study evaluated whether collection of risk factors to generate electronic health record (EHR)-linked health risk appraisal (HRA) for coronary heart disease, diabetes, breast cancer, and colorectal cancer was associated with improved patient-provider communication, risk assessment, and plans for breast cancer screening. METHODS This pragmatic trial recruited adults with upcoming visits to 11 primary care practices during 2013-2014 (N=3,703). Pre-visit, intervention patients completed a risk factor and perception assessment and received an HRA; coded risk factor data were sent to the EHR. Post-visit, intervention patients reported risk perception. Pre-visit, control patients only completed the risk perception assessment; post-visit they also completed the risk factor assessment and received the HRA. No data were sent to the EHR for controls. Accuracy/improvement of self-perceived risk was assessed by comparing self-perceived to calculated risk. RESULTS The intervention was associated with improvement of patient-provider communication of changes to improve health (78.5% vs 74.1%, AOR=1.67, 99% CI=1.07, 2.60). There was a similar trend for discussion of risk (54.1% vs 45.5%, AOR=1.34, 95% CI=0.97, 1.85). The intervention was associated with greater improvement in accuracy of self-perceived risk for diabetes (16.0% vs 12.6%, p=0.006) and colorectal cancer (27.9% vs 17.2%, p<0.001) with a similar trend for coronary heart disease and breast cancer. There were no changes in plans for breast cancer screening. CONCLUSIONS Patient-reported risk factors and EHR-linked multi-condition HRAs in primary care can modestly improve communication and promote accuracy of self-perceived risk.
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Affiliation(s)
- Jennifer S Haas
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts; Department of Medicine, Harvard University Medical School, Boston, Massachusetts; Department of Social and Behavioral Sciences, Harvard University School of Public Health, Boston, Massachusetts.
| | - Heather J Baer
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts; Department of Medicine, Harvard University Medical School, Boston, Massachusetts; Department of Epidemiology, Harvard University School of Public Health, Boston, Massachusetts
| | - Katyuska Eibensteiner
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - Elissa V Klinger
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stella St Hubert
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - George Getty
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - Phyllis Brawarsky
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - E John Orav
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts; Department of Medicine, Harvard University Medical School, Boston, Massachusetts; Department of Biostatistics, Harvard University School of Public Health, Boston, Massachusetts
| | - Tracy Onega
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, New Hampshire
| | - Anna N A Tosteson
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, New Hampshire
| | - David W Bates
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts; Department of Medicine, Harvard University Medical School, Boston, Massachusetts; Department of Health Policy and Management, Harvard University School of Public Health, Boston, Massachusetts
| | - Graham Colditz
- Institute for Public Health, Washington University School of Medicine, St. Louis, Missouri
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Why Is Cancer Genetic Counseling Underutilized by Women Identified as at Risk for Hereditary Breast Cancer? Patient Perceptions of Barriers Following a Referral Letter. J Genet Couns 2016; 26:697-715. [DOI: 10.1007/s10897-016-0040-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 10/17/2016] [Indexed: 12/26/2022]
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Abstract
Despite their efficacy, uptake of selective estrogen receptor modulators for breast cancer chemoprevention remains low. Exemestane, an aromatase inhibitor, has recently been identified as a potential chemopreventive option with fewer serious side effects compared with selective estrogen receptor modulators in postmenopausal women. The purpose of this study was to assess the uptake of exemestane in a breast cancer prevention clinic. A retrospective chart review was conducted to capture chemoprevention uptake by postmenopausal women presenting to the Yale Breast Cancer Prevention Clinic between November 2011 and November 2012. Descriptive statistics of the study population have been presented. Statistical analyses were carried out using SAS 9.3 (SAS Institute Inc., Cary, North Carolina, USA) between December 2012 and February 2013. Of 90 postmenopausal women, 56 were eligible for chemoprevention. Their mean age was 56.8 years. Among the women, 39% had osteopenia or osteoporosis. Thirteen women chose to start chemoprevention medication (23%). Although 31% of the chemopreventive medication administered included exemestane, only four of 56 postmenopausal women opted for exemestane (7%). Chemoprevention uptake rates of postmenopausal women in the setting of a breast cancer prevention clinic are higher than that reported in the general population; however, they remain low overall despite the inclusion of exemestane as an option. A significant proportion of postmenopausal women have decreased bone density, which is a potential barrier to exemestane uptake. The results provide practical implications suggesting that exemestane may have limited impact on breast cancer chemoprevention uptake. Further investigations should focus on understanding the factors that influence, predict, and increase chemoprevention uptake.
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Hum S, Wu M, Pruthi S, Heisey R. Physician and Patient Barriers to Breast Cancer Preventive Therapy. CURRENT BREAST CANCER REPORTS 2016; 8:158-164. [PMID: 27617055 PMCID: PMC4995234 DOI: 10.1007/s12609-016-0216-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The uptake of selective estrogen receptor modulators (SERMs) and aromatase inhibitors (AIs) for the primary prevention of breast cancer is low, despite their proven efficacy in several randomized clinical trials. This review summarizes the latest data on physicians' and women's barriers to breast cancer preventive therapy. Physicians' challenges include: identifying suitable candidates for preventive therapy, inadequate training and confidence in risk assessment and counselling, insufficient knowledge of risk-reducing medications, and lack of time. High-risk women fear medication side effects, and they often weigh experiences of others more heavily than statistical probabilities to guide their decision-making. Despite decision aid interventions to help women make an informed decision, acceptance of preventive therapy will remain low until: risk/benefit profiles are more favorable, physicians are better educated and skilled in having these discussions, and suitable biomarkers to monitor drug efficacy and better clinical risk prediction models to assess true individual risk are available.
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Affiliation(s)
- Susan Hum
- Department of Family & Community Medicine, Women’s College Hospital, 76 Grenville St, Toronto, ON M5S 1B2 Canada
| | - Melinda Wu
- Department of Family & Community Medicine, University of Toronto, Women’s College Hospital, Princess Margaret Hospital, 76 Grenville St, Toronto, ON M5S 1B2 Canada
| | - Sandhya Pruthi
- Department of Medicine, Division of General Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905 USA
| | - Ruth Heisey
- Department of Family & Community Medicine, University of Toronto, Women’s College Hospital, Princess Margaret Hospital, 76 Grenville St, Toronto, ON M5S 1B2 Canada
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50
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Hoffman SJ, Guindon GE, Lavis JN, Randhawa H, Becerra-Posada F, Boupha B, Shi G, Turdaliyeva BS. Clinicians' knowledge and practices regarding family planning and intrauterine devices in China, Kazakhstan, Laos and Mexico. Reprod Health 2016; 13:70. [PMID: 27283191 PMCID: PMC4901518 DOI: 10.1186/s12978-016-0185-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 05/18/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is widely agreed that the practices of clinicians should be based on the best available research evidence, but too often this evidence is not reliably disseminated to people who can make use of it. This "know-do" gap leads to ineffective resource use and suboptimal provision of services, which is especially problematic in low- and middle-income countries (LMICs) which face greater resource limitations. Family planning, including intrauterine device (IUD) use, represents an important area to evaluate clinicians' knowledge and practices in order to make improvements. METHODS A questionnaire was developed, tested and administered to 438 individuals in China (n = 115), Kazakhstan (n = 110), Laos (n = 105), and Mexico (n = 108). The participants responded to ten questions assessing knowledge and practices relating to contraception and IUDs, and a series of questions used to determine their individual characteristics and working context. Ordinal logistic regressions were conducted with knowledge and practices as dependent variables. RESULTS Overall, a 96 % response rate was achieved (n = 438/458). Only 2.8 % of respondents were able to correctly answer all five knowledge-testing questions, and only 0.9 % self-reported "often" undertaking all four recommended clinical practices and "never" performing the one practice that was contrary to recommendation. Statistically significant factors associated with knowledge scores included: 1) having a masters or doctorate degree; and 2) often reading scientific journals from high-income countries. Significant factors associated with recommended practices included: 1) training in critically appraising systematic reviews; 2) training in the care of patients with IUDs; 3) believing that research performed in their own country is above average or excellent in quality; 4) being based in a facility operated by an NGO; and 5) having the view that higher quality available research is important to improving their work. CONCLUSIONS This analysis supports previous work emphasizing the need for improved knowledge and practices among clinicians concerning the use of IUDs for family planning. It also identifies areas in which targeted interventions may prove effective. Assessing opportunities for increasing education and training programs for clinicians in research and IUD provision could prove to be particularly effective.
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Affiliation(s)
- Steven J Hoffman
- Global Strategy Lab, Centre for Health Law, Policy & Ethics, Faculty of Law, University of Ottawa, Fauteux Hall, 57 Louis Pasteur Street, Ottawa, ON, K1N 6N5, Canada.
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada.
- McMaster Health Forum, McMaster University, Hamilton, ON, Canada.
- Department of Global Health & Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA.
| | - G Emmanuel Guindon
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada
- Centre for Health Economics & Policy Analysis, McMaster University, Hamilton, ON, Canada
| | - John N Lavis
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, ON, Canada
- McMaster Health Forum, McMaster University, Hamilton, ON, Canada
- Department of Global Health & Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
- Centre for Health Economics & Policy Analysis, McMaster University, Hamilton, ON, Canada
| | - Harkanwal Randhawa
- Global Strategy Lab, Centre for Health Law, Policy & Ethics, Faculty of Law, University of Ottawa, Fauteux Hall, 57 Louis Pasteur Street, Ottawa, ON, K1N 6N5, Canada
- McMaster Health Forum, McMaster University, Hamilton, ON, Canada
| | | | - Boungnong Boupha
- Foreign Affairs Committee and Women's Caucus, Laos National Assembly, Vientiane, Lao PDR
| | - Guang Shi
- Democratic Party of Peasants & Workers in China, Beijing, China
| | - Botagoz S Turdaliyeva
- Department of Health Policy & Management, Kazakh National Medical University, Almaty, Kazakhstan
- Evidence-Based Health Centre, Almaty, Kazakhstan
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