Proactive breast cancer risk assessment in primary care: a review based on the principles of screening

Digital innovation for cancer risk assessment allows large-scale service redevelopment of regional cancer genetics service delivery

Family-history assessment can identify individuals above population-risk for cancer to enable targeted Screening, Prevention and Early Detection (SPED). The online patient-facing cancer Family History Questionnaire Service (cFHQS) is a digitalised, resource efficient tool for family history data capture to facilitate this. The capturing of digital data from cFHQS allows for data interrogation of patients referred to Clinical Genetics for the purposes of service improvement. Digital data from 4,044 cFHQS respondents over a three-year period was collected and interrogated with respect to the number and type of familial tumour diagnoses to enable service improvement and streamlining of referral pathways. 81% of colorectal and 71% of breast screening assessments were population- or moderate-risk. Most patients who completed cFHQS reported more than one diagnosis of cancer/tumour/polyps in their family. 2.5% of family history assessment patients had a second indication that required assessment that would have been missed if single tumour type assessment was undertaken. Implementation of an innovative, digital family history data collection pathway has allowed large scale interrogation of referral patterns and assessment outcomes to enable service development. The high volume of inappropriate referrals to Clinical Genetics for population and moderate risk patients highlighted the need for dedicated secondary care pathway provision for these patients. The use of cFHQS streamlined family history assessment allows for redistribution of resources to improve equity and access to genetic cancer risk assessment.

Development of a breast cancer risk assessment and primary prevention pathway for women aged 30-39 years: Views of UK primary care providers on the role of primary care

BACKGROUND

Identifying women aged 30-39 years at increased risk of developing breast cancer would allow them to receive screening and prevention offers. For this to be feasible, the practicalities of organising risk assessment and primary prevention must be acceptable to the healthcare professionals who would be responsible for delivery. It has been proposed that primary care providers are best placed to deliver a breast cancer risk assessment and primary prevention pathway. The present study aimed to investigate a range of primary care provider's views on the development and implementation of a breast cancer risk assessment and primary prevention pathway within primary care for women aged 30-39 years.

METHODS

Twenty-five primary care providers working at general practices in either Greater Manchester or Cambridgeshire and Peterborough participated in five focus groups (n = 18) and seven individual interviews. Data were analysed thematically and organised using a framework approach.

RESULTS

Three themes were developed. Challenges with delivering a breast cancer risk assessment and primary prevention pathway within primary care highlights that primary care are willing to facilitate but not lead delivery of such a pathway given the challenges with existing workload pressures and concerns about ensuring effective clinical governance. Primary care's preferred level of involvement describes the aspects of the pathway participants thought primary care could be involved in, namely co-ordinating data collection for risk assessment and calculating and communicating risk. Requirements for primary care involvement captures the need to provide a training and education package to address deficits in knowledge prior to involvement. Additionally, the reservations primary care have about being involved in the management of women identified as being at increased risk are discussed and suggestions are provided for facilitating primary care to take on this role.

CONCLUSIONS

Despite optimism that primary care might lead a breast cancer risk assessment and primary prevention pathway, participants had a range of concerns that should be considered when developing such a pathway.

Women's experiences of risk-stratified breast cancer screening in the MyPeBS trial: a qualitative comparative study across two European countries

OBJECTIVE

Risk-stratification should improve the benefits-to-harms ratio for breast screening, whereby higher-risk women receive additional screening and low-risk women are screened less. This study investigated the effects of healthcare context by comparing how women in England and France experienced risk-based breast screening.

METHODS AND MEASURES

Fifty-two women were purposively sampled from participants who underwent risk-based screening in the MyPeBS trial. Women received objectively-derived 5-year breast cancer risk estimates (low = < 1%, average = 1-1.66%, high = ≥ 1.67 to <6%, very-high-risk = ≥ 6%). This determined future trial-related screening schedules and prevention options. Semi-structured interviews were transcribed for thematic framework analysis.

RESULTS

Two overarching themes were produced: the importance of supported risk communication and accessibility of risk management. Overall, risk-based breast screening was viewed positively. However, trial procedures, especially in risk estimate provision, differed across sites. Women at increased risk were more reassured when appointments were with specialist healthcare professionals (HCP). When absent, this resulted in reduced satisfaction with risk communication and greater uncertainty about its personal relevance. Low-risk women's views on extended mammogram schedules seemed linked to how health services are organised differently.

CONCLUSIONS

Context is an important consideration regarding acceptability of healthcare innovations such as risk-stratified screening: it should not be assumed that findings from one country apply universally.

Implementation of risk assessment process for breast cancer risk in primary care

Background

Current cancer prevention guidelines recommend assessing breast cancer risk using validated risk calculators such as Tyrer-Cuzick and assessing genetic testing eligibility with NCCN. Women at high-risk of breast cancer may be recommended to undergo additional or earlier screening. Risk assessment is not consistently implemented in the primary care setting resulting in increased morbidity and mortality in unidentified high-risk individuals.

Methods

A single-arm interventional study was conducted in an academic primary care clinic for women 25-50 years old presenting for primary care appointments. Pre-visit workflows evaluated breast cancer risk using the Cancer Risk Assessment (CRA) Tool and information was provided to the clinician with guideline-based recommendations. Post-visit questionnaires and chart review were conducted.

Results

The survey response rate was 24.5% (144/587) with 80.3% of responses completed online (94/117). The average age of respondents was 35.8 years with 50.4% White and 35.9% Black. There were no differences in response rate based on race. Risk discussion was documented in the medical record in 15.4% of cases with a higher rate of documentation in high-risk patient based on risk assessment as compared with average risk respondents (34.6% vs. 9.7%, p<0.01). In the high-risk women identified 11.4% (4/35) were seen by the high-risk breast clinic, and 5.7% (2/35) were referred for genetic evaluation. None had previously obtained MRI screening or genetic testing.

Conclusions

There is limited identification and evaluation of women at high risk for breast cancer. Pre-visit surveys can be used as a tool to assess breast cancer risk in the primary care setting; however additional strategies are needed to implement systematic risk assessment and facilitate appropriate treatment based on risk level.

Joint ABS-UKCGG-CanGene-CanVar consensus regarding the use of CanRisk in clinical practice

BACKGROUND

The CanRisk tool, which operationalises the Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm (BOADICEA) is used by Clinical Geneticists, Genetic Counsellors, Breast Oncologists, Surgeons and Family History Nurses for breast cancer risk assessments both nationally and internationally. There are currently no guidelines with respect to the day-to-day clinical application of CanRisk and differing inputs to the model can result in different recommendations for practice.

METHODS

To address this gap, the UK Cancer Genetics Group in collaboration with the Association of Breast Surgery and the CanGene-CanVar programme held a workshop on 16th of May 2023, with the aim of establishing best practice guidelines.

RESULTS

Using a pre-workshop survey followed by structured discussion and in-meeting polling, we achieved consensus for UK best practice in use of CanRisk in making recommendations for breast cancer surveillance, eligibility for genetic testing and the input of available information to undertake an individualised risk assessment.

CONCLUSIONS

Whilst consensus recommendations were achieved, the meeting highlighted some of the barriers limiting the use of CanRisk in clinical practice and identified areas that require further work and collaboration with relevant national bodies and policy makers to incorporate wider use of CanRisk into routine breast cancer risk assessments.

Multicancer screening test based on the detection of circulating non haematological proliferating atypical cells

BACKGROUND

the problem in early diagnosis of sporadic cancer is understanding the individual's risk to develop disease. In response to this need, global scientific research is focusing on developing predictive models based on non-invasive screening tests. A tentative solution to the problem may be a cancer screening blood-based test able to discover those cell requirements triggering subclinical and clinical onset latency, at the stage when the cell disorder, i.e. atypical epithelial hyperplasia, is still in a subclinical stage of proliferative dysregulation.

METHODS

a well-established procedure to identify proliferating circulating tumor cells was deployed to measure the cell proliferation of circulating non-haematological cells which may suggest tumor pathology. Moreover, the data collected were processed by a supervised machine learning model to make the prediction.

RESULTS

the developed test combining circulating non-haematological cell proliferation data and artificial intelligence shows 98.8% of accuracy, 100% sensitivity, and 95% specificity.

CONCLUSION

this proof of concept study demonstrates that integration of innovative non invasive methods and predictive-models can be decisive in assessing the health status of an individual, and achieve cutting-edge results in cancer prevention and management.

Feasibility and acceptability of offering breast cancer risk assessment to general population women aged 30-39 years: a mixed-methods study protocol

INTRODUCTION

Breast cancer incidence starts to increase exponentially when women reach 30-39 years, hence before they are eligible for breast cancer screening. The introduction of breast cancer risk assessment for this age group could lead to those at higher risk receiving benefits of earlier screening and preventive strategies. Currently, risk assessment is limited to women with a family history of breast cancer only. The Breast CANcer Risk Assessment in Younger women (BCAN-RAY) study is evaluating a comprehensive breast cancer risk assessment strategy for women aged 30-39 years incorporating a questionnaire of breast cancer risk factors, low-dose mammography to assess breast density and polygenic risk. This study will assess the feasibility and acceptability of the BCAN-RAY risk assessment strategy.

METHODS AND ANALYSIS

This study involves women undergoing risk assessment as part of the BCAN-RAY case-control study (n=750). They will be aged 30-39 years without a strong family history of breast cancer and invited to participate via general practice. A comparison of uptake rates by socioeconomic status and ethnicity between women who participated in the BCAN-RAY study and women who declined participation will be conducted. All participants will be asked to complete self-report questionnaires to assess key potential harms including increased state anxiety (State Trait Anxiety Inventory), cancer worry (Lerman Cancer Worry Scale) and satisfaction with the decision to participate (Decision Regret Scale), alongside potential benefits such as feeling more informed about breast cancer risk. A subsample of approximately 24 women (12 at average risk and 12 at increased risk) will additionally participate in semistructured interviews to understand the acceptability of the risk assessment strategy and identify any changes needed to it to increase uptake.

ETHICS AND DISSEMINATION

Ethical approval was granted by North West-Greater Manchester West Research Ethics Committee (reference: 22/NW/0268). Study results will be disseminated through peer-reviewed journals, conference presentations and charitable organisations.

TRIAL REGISTRATION NUMBER

NCT05305963.

Proactive familial cancer risk assessment: a service development study in UK primary care

BACKGROUND

Family history assessment can identify individuals above population-risk for cancer to enable targeted Screening, Prevention, and Early Detection (SPED). Family History Questionnaire Service (FHQS) is a resource-efficient patient-facing online tool to facilitate this. In the UK, cancer risk assessment is usually only offered to concerned individuals proactively self-presenting to their GP, leading to inequity in accessing SPED in the community.

AIM

To improve access to community cancer genetic risk assessment and explore barriers to uptake.

DESIGN & SETTING

Service development project of a digital pathway using the FHQS for cancer risk assessment across four general practices within the clinical remit of the South West Thames Centre for Genomics (SWTCG).

METHOD

3100 individuals aged 38-50 years were invited to complete the FHQS through either text message or email. A random selection of 100 non-responders were contacted to determine barriers to uptake.

RESULTS

In total, n = 304/3100 (10%) registered for the FHQS. Responders were more likely to be British (63% vs 47%, P<0.001), speak English as their main language (92% vs 76%, P<0.001), and not require an interpreter (99.6% vs 94.9%, P = 0.001). Of 304 responders, 158 (52%) were automatically identified as at population-risk without full family history review. Of the remaining 146 responders, 52 (36%) required either additional screening referral (n = 23), genetics referral (n = 15), and/or advice to relatives (n = 18). Of 100 non-responders contacted, eight had incorrect contact details and 53 were contactable. Reasons for not responding included not receiving invitation details (n = 26), losing the invitation (n = 5), or forgetting (n = 4).

CONCLUSION

The FHQS can be used as part of a low-resource primary care pathway to identify individuals in the community above population-risk for cancer requiring action. This study highlighted barriers to uptake requiring consideration to maximise impact and minimise inequity.

Understanding the contribution of lifestyle in breast cancer risk prediction: a systematic review of models applicable to Europe

BACKGROUND

Breast cancer (BC) is a significant health concern among European women, with the highest prevalence rates among all cancers. Existing BC prediction models account for major risks such as hereditary, hormonal and reproductive factors, but research suggests that adherence to a healthy lifestyle can reduce the risk of developing BC to some extent. Understanding the influence and predictive role of lifestyle variables in current risk prediction models could help identify actionable, modifiable, targets among high-risk population groups.

PURPOSE

To systematically review population-based BC risk prediction models applicable to European populations and identify lifestyle predictors and their corresponding parameter values for a better understanding of their relative contribution to the prediction of incident BC.

METHODS

A systematic review was conducted in PubMed, Embase and Web of Science from January 2000 to August 2021. Risk prediction models were included if (i) developed and/or validated in adult cancer-free women in Europe, (ii) based on easily ascertained information, and (iii) reported models' final predictors. To investigate further the comparability of lifestyle predictors across models, estimates were standardised into risk ratios and visualised using forest plots.

RESULTS

From a total of 49 studies, 33 models were developed and 22 different existing models, mostly from Gail (22 studies) and Tyrer-Cuzick and co-workers (12 studies) were validated or modified for European populations. Family history of BC was the most frequently included predictor (31 models), while body mass index (BMI) and alcohol consumption (26 and 21 models, respectively) were the lifestyle predictors most often included, followed by smoking and physical activity (7 and 6 models respectively). Overall, for lifestyle predictors, their modest predictive contribution was greater for riskier lifestyle levels, though highly variable model estimates across different models.

CONCLUSIONS

Given the increasing BC incidence rates in Europe, risk models utilising readily available risk factors could greatly aid in widening the population coverage of screening efforts, while the addition of lifestyle factors could help improving model performance and serve as intervention targets of prevention programmes.

"I don't know what I'm feeling for": young women's beliefs about breast cancer risk and experiences of breast awareness

BACKGROUND

Younger women are often diagnosed with advanced breast cancer. Beliefs about risk are instrumental in motivating many health protective behaviours, but there may be confusion around which behaviour is appropriate to detect breast cancer earlier. Breast awareness, defined as an understanding of how the breasts look and feel so changes can be identified early, is widely recommended. In contrast, breast self-examination involves palpation using a specified method. We aimed to investigate young women's beliefs about their risk and experiences of breast awareness.

METHODS

Thirty-seven women aged 30-39 years residing in a North West region of England with no family or personal history of breast cancer participated in seven focus groups (n = 29) and eight individual interviews. Data were analysed using reflexive thematic analysis.

RESULTS

Three themes were generated. "Future me's problem" describes why women perceive breast cancer as an older woman's disease. Uncertainty regarding checking behaviours highlights how confusion about self-checking behaviour advice has resulted in women infrequently performing breast checks. Campaigns as a missed opportunity highlights the potential negative effects of current breast cancer fundraising campaigns and the perceived absence of educational campaigning about breast cancer for this demographic.

CONCLUSIONS

Young women expressed low perceived susceptibility to developing breast cancer in the near future. Women did not know what breast self-checking behaviours they should be performing and expressed a lack of confidence in how to perform a breast check appropriately due to limited knowledge about what to look and feel for. Consequently, women reported disengagement with breast awareness. Defining and clearly communicating the best strategy for breast awareness and establishing whether it is beneficial or not are essential next steps.