Implementation and Outcomes of a Multidisciplinary High-Risk Breast Cancer Program: The William Beaumont Hospital Experience

Factors influencing U.S. women's interest and preferences for breast cancer risk communication: a cross-sectional study from a large tertiary care breast imaging center

BACKGROUND

Breast imaging clinics in the United States (U.S.) are increasingly implementing breast cancer risk assessment (BCRA) to align with evolving guideline recommendations but with limited uptake of risk-reduction care. Effectively communicating risk information to women is central to implementation efforts, but remains understudied in the U.S. This study aims to characterize, and identify factors associated with women's interest in and preferences for breast cancer risk communication.

METHODS

This is a cross-sectional survey study of U.S. women presenting for a mammogram between January and March of 2021 at a large, tertiary breast imaging clinic. Survey items assessed women's interest in knowing their risk and preferences for risk communication if considered to be at high risk in hypothetical situations. Multivariable logistic regression modeling assessed factors associated with women's interest in knowing their personal risk and preferences for details around exact risk estimates.

RESULTS

Among 1119 women, 72.7% were interested in knowing their breast cancer risk. If at high risk, 77% preferred to receive their exact risk estimate and preferred verbal (52.9% phone/47% in-person) vs. written (26.5% online/19.5% letter) communications. Adjusted regression analyses found that those with a primary family history of breast cancer were significantly more interested in knowing their risk (OR 1.5, 95% CI 1.0, 2.1, p = 0.04), while those categorized as "more than one race or other" were significantly less interested in knowing their risk (OR 0.4, 95% CI 0.2, 0.9, p = 0.02). Women 60 + years of age were significantly less likely to prefer exact estimates of their risk (OR 0.6, 95% CI 0.5, 0.98, p < 0.01), while women with greater than a high school education were significantly more likely to prefer exact risk estimates (OR 2.5, 95% CI 1.5, 4.2, p < 0.001).

CONCLUSION

U.S. women in this study expressed strong interest in knowing their risk and preferred to receive exact risk estimates verbally if found to be at high risk. Sociodemographic and family history influenced women's interest and preferences for risk communication. Breast imaging centers implementing risk assessment should consider strategies tailored to women's preferences to increase interest in risk estimates and improve risk communication.

Endocrine prevention of breast cancer

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.

Implementation of a High-Risk Breast Clinic for Comprehensive Care of Women With Elevated Breast Cancer Risk Identified by Risk Assessment Models in the Community

INTRODUCTION

Many radiology centers perform risk assessment at time of screening mammography. The Massachusetts General Hospital North Shore Cancer Center (MGHNS) developed a nurse practitioner (NP)-led high-risk breast clinic (HRBC) to provide comprehensive care for patients with elevated breast cancer risk by a validated tool.

PATIENTS AND METHODS

Patient and administrative data from the MGHNS HRBC was collected to evaluate clinical and implementation outcomes. We compared patients from the HRBC with those identified as having ≥ 20% lifetime risk at 5 community imaging centers.

RESULTS

From March 2018 to February 2019, 318 patients were seen in the HRBC; 264 (83%) had ≥ 20% lifetime risk, 13 (4%) had prior atypia/lobular carcinoma in situ, 9 (3%) had ≥ 1.7% 5-year risk, and 32 (10%) had no indication of elevated risk. Genetic testing was recommended for 159 patients (50%); 33 (21%) completed testing with 1 mutation identified. Chemoprevention was discussed with 99 patients (31%); 9 (9%) initiated treatment. Screening magnetic resonance imaging (MRI) was recommended for 284 patients (89%); 184 (65%) had MRI performed with 2 mammographically occult cancers identified. During this time period, 215,112 patients had risk assessment performed at time of breast imaging; of these, 1,170 were found to have ≥ 20% lifetime risk. Compared with those identified as high risk in the community, patients seen in the HRBC were more likely to be white (94.3% v 85.4%; P < .001) and have a family history of ovarian cancer (16.4% v 9.4%; P < .001).

CONCLUSION

We demonstrate the feasibility of an NP-led HRBC. Follow-through of recommendations by patients was highest for screening MRI; use of genetic testing and chemoprevention was lower than anticipated. In our community, uptake of the HRBC by referring providers remains a barrier, with only a minority of identified high-risk patients assessed in our clinic.

Baseline Screening MRI Uptake and Findings in Women with ≥ 20% Lifetime Risk of Breast Cancer

BACKGROUND

The American Cancer Society recommends screening magnetic resonance imaging (MRI) for patients with a ≥ 20% lifetime breast cancer risk. This study assesses the outcomes of baseline MRI screens in women from a high-risk breast clinic (HRBC).

METHODS

We retrospectively reviewed patients from our institution's HRBC, excluding those with prior breast cancer and predisposing genetic mutations. Screening MRI was recommended for a lifetime risk of ≥ 20% using the Tyrer-Cuzick model. We determined baseline MRI results, biopsy rates, and frequency of MRI-detected high-risk lesions (HRLs) and breast cancers.

RESULTS

Overall, 319 women attended our HRBC; median age was 48 years and 4.7% had prior atypia/lobular carcinoma in situ. Screening MRI was recommended for 282 patients, of whom 196 (69.5%) completed a baseline screen. A Breast Imaging-Reporting and Data System (BIRADS) 3 or 4 finding occurred in 19.6% of patients; 23 (12.3%) required 6-month follow-up MRI, 16 (8.6%) underwent core biopsy, and 4 (2.1%) underwent excisional biopsy after initial core. An additional 7 (3.7%) patients had a non-breast incidental finding. An HRL was identified in 2 (1.1%) patients (atypical ductal and lobular hyperplasia, respectively), and 2 (1.1%) were diagnosed with T1N0 breast cancers.

CONCLUSIONS

In the setting of an HRBC, 70% of women with a ≥ 20% lifetime risk of breast cancer pursued screening MRI when recommended. On baseline screen, the rate of MRI-detected breast cancer was low (1%); however, malignancies were mammographically occult and identified at an early stage. Despite a low cancer rate, nearly one in four women required additional diagnostic investigation. Prescreening counselling should include a discussion of this possibility, and longer-term follow-up of screening MRI is needed in this high-risk population.

Interprofessional work in early detection of breast cancer: An integrative review

OBJECTIVES

To identify the roles of health care staff in interprofessional work related to breast cancer detection and diagnosis.

KEY FINDINGS

A comprehensive search was performed using PICO to support inclusion and exclusion criteria. A shortened version of the STROBE checklist ensured evaluation of the studies. 21 included studies resulted in three main categories describing the role of health care professionals; (1) Communicating breast cancer awareness; (2) The Professional's tasks; (3) Efficacy of Interprofessional Teamwork relative to the profession and the individuals.

CONCLUSIONS

Health care professionals' roles in the breast cancer diagnostic process were described mostly from each professional's viewpoint. Support from leadership and management is needed in order to promote interprofessional work, which will benefit health care professions, professionals, and the patient.

Implementing a Population-Based Breast Cancer Risk Assessment Program

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.

Development and validation of a scoring system to identify individuals at high risk for advanced colorectal neoplasms who should undergo colonoscopy screening

BACKGROUND & AIMS

Screening the population for colorectal cancer (CRC) by colonoscopy could reduce the disease burden. However, targeted screening of individuals at high risk could increase its cost effectiveness.

METHODS

We developed a scoring system to identify individuals with at least 1 advanced adenoma, based on easy-to-collect risk factors among 7891 participants of the German screening colonoscopy program. The system was validated in an independent sample of 3519 participants. Multiple logistic regression was used to develop the algorithm, and the regression coefficient-based scores were used to determine individual risks. Relative risk and numbers of colonoscopies needed for detecting one or more advanced neoplasm(s) were calculated for quintiles of the risk score. The predictive ability of the scoring system was quantified by the area under the curve.

RESULTS

We identified 9 risk factors (sex, age, first-degree relatives with a history of CRC, cigarette smoking, alcohol consumption, red meat consumption, ever regular use [at least 2 times/wk for at least 1 y] of nonsteroidal anti-inflammatory drugs, previous colonoscopy, and previous detection of polyps) that were associated significantly with risk of advanced neoplasms. The developed score was associated strongly with the presence of advanced neoplasms. In the validation sample, individuals in the highest quintile of scores had a relative risk for advanced neoplasm of 3.86 (95% confidence interval, 2.71-5.49), compared with individuals in the lowest quintile. The number needed to screen to detect 1 or more advanced neoplasm(s) varied from 20 to 5 between quintiles of the risk score. In the validation sample, the scoring system identified patients with CRC or any advanced neoplasm with area under the curve values of 0.68 and 0.66, respectively.

CONCLUSIONS

We developed a scoring system, based on easy-to-collect risk factors, to identify individuals most likely to have advanced neoplasms. This system might be used to stratify individuals for CRC screening.