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Elson NC, Wernke K, Yoder LM, Fellner AN, Raque KM, Kuritzky AM, Wexelman BA. Universal genetic counseling in breast cancer patients significantly improves overall testing rates and improves completion rates in subpopulations. Breast Cancer Res Treat 2024; 207:25-32. [PMID: 38822953 DOI: 10.1007/s10549-024-07329-3] [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: 11/08/2023] [Accepted: 03/28/2024] [Indexed: 06/03/2024]
Abstract
PURPOSE The NCCN guidelines recommend genetic testing in those patients at increased risk of breast cancer in order to identify candidates for increased frequency of screening or prophylactic mastectomy. However, genetic testing may now identify patients who may benefit from recently developed targeted breast cancer therapy. In order to more widely identify these patients, we implemented genetic counseling for all patients diagnosed with breast cancer. METHODS In 2021, all patients evaluated within a Midwestern community hospital system diagnosed with breast cancer were offered genetic counseling. This group of patients was compared to a cohort of patients in 2021 who were offered genetic counseling based on NCCN guidelines. With Pearson's chi square, Fisher's Exact test, Mann-Whitney U, and multivariate regression as appropriate, individual demographic data and genetic testing completion between 2019 and 2021 were evaluated. RESULTS A total of 973 patients were reviewed. 439 were diagnosed with breast cancer in 2019 and 534 in 2021. Demographics and stage at diagnosis (p = 0.194) were similar between years. Completion of genetic testing increased from 204 (46.5%) in 2019 to 338 (63.3%) in 2021 (p < 0.01) with the universal counseling protocol. Specifically, genetic testing completion increased significantly in older patients (p = 0.041) and patients receiving Medicare benefits (p = 0.005). The overall pathogenic variants found increased from 32 to 39 with the most common including BRCA2 (n = 11), CFTR (n = 9), CHEK2 (n = 8), BRCA1 (n = 6). CONCLUSION Universal genetic counseling was related to a significant increase in genetic testing completion and an increase in pathogenic variants found among breast cancer patients, specifically in subpopulations which may have been previously excluded by traditional NCCN genetic testing screening guidelines.
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Affiliation(s)
- Nora C Elson
- Division of Breast Surgical Oncology, Department of Surgery, TriHealth Cancer Institute, 375 Dixmyth Avenue, Cincinnati, OH, 45220, USA.
| | - Karen Wernke
- Department of Genetics, TriHealth Precision Medicine and Genetic Services Institute, Cincinnati, OH, USA
| | - Lauren M Yoder
- Division of Breast Surgical Oncology, Department of Surgery, TriHealth Cancer Institute, 375 Dixmyth Avenue, Cincinnati, OH, 45220, USA
| | | | - Kathleen M Raque
- Division of Breast Surgical Oncology, Department of Surgery, TriHealth Cancer Institute, 375 Dixmyth Avenue, Cincinnati, OH, 45220, USA
| | - Anne M Kuritzky
- Division of Breast Surgical Oncology, Department of Surgery, TriHealth Cancer Institute, 375 Dixmyth Avenue, Cincinnati, OH, 45220, USA
| | - Barbara A Wexelman
- Division of Breast Surgical Oncology, Department of Surgery, TriHealth Cancer Institute, 375 Dixmyth Avenue, Cincinnati, OH, 45220, USA
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Verdial FC, Bartek MA, Anderson BO, Javid SH. Genetic testing and surgical treatment after breast cancer diagnosis: Results from a national online cohort. J Surg Oncol 2021; 123:1504-1512. [PMID: 33735483 DOI: 10.1002/jso.26372] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 12/21/2020] [Accepted: 12/27/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND Genetic testing for hereditary breast cancer has implications for breast cancer decision-making. We examined genetic testing rates, factors associated with testing, and the relationship between genetic testing and contralateral prophylactic mastectomy (CPM). METHODS Patients with breast cancer (2000-2015) from The Health of Women Study were identified and categorized as low, moderate, or high-likelihood of the genetic mutation using a previously published scale based on period-relevant national guidelines incorporating age and family history. Genetic testing and CPM rates were compared using univariate and multivariate logistic regression. RESULTS Among 4170 patients (median age 56-years), 38% were categorized as high-likelihood of having a genetic mutation. Among high-likelihood women, 67% underwent genetic testing, the odds of which were increased among women of higher-education and White-race (p < .001). Among 2028 patients reporting surgical treatment, 385 (19%) chose CPM. CPM rate was highest among mutation-positive women (41%), but 26% of women with negative tests still underwent CPM. Independent of test result, genetic testing increased the odds of CPM on multivariate analysis (adjusted-OR: 1.69; 95% CI: 1.29-2.22). CONCLUSIONS Genetic testing rates were higher among women at high-likelihood of mutation carriage, but one-third of these women were not tested. Racial disparities persisted, highlighting the need to improve testing in non-White populations. CPM rates were associated with mutation-carriage and genetic testing, but many women chose CPM despite negative testing, suggesting that well-educated women consider factors other than cancer mortality in selecting CPM.
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Affiliation(s)
- Francys C Verdial
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Matthew A Bartek
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Benjamin O Anderson
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA.,Public Health Sciences Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Sara H Javid
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington, USA
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Alberty-Oller JJ, Weltz S, Santos A, Pisapati K, Ru M, Weltz C, Schmidt H, Port E. Adherence to NCCN Guidelines for Genetic Testing in Breast Cancer Patients: Who Are We Missing? Ann Surg Oncol 2020; 28:281-286. [PMID: 32918176 DOI: 10.1245/s10434-020-09123-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 07/19/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Genetic predisposition accounts for 5-10% of all breast cancers (BC) diagnosed. NCCN guidelines help providers identify appropriate candidates for counseling and testing. Concerns about underutilization of genetic testing have spurred interest in broader peri-diagnostic testing. We evaluated surgeon adherence to NCCN guidelines and studied patterns of testing in newly diagnosed BC patients. METHODS A total of 397 patients were identified with newly diagnosed BC treated at our institution between 2016 and 2017 with no prior genetic testing. Eligibility for genetic testing based on NCCN criteria, referral, and patient compliance were recorded. RESULTS In total, 212 of 397 (53%) met NCCN testing criteria. Fifty-nine of 212 (28%) patients went untested despite meeting one or more criteria. Fourteen of 59 (24%) of these were referred but did not comply. Most common criteria for meeting eligibility for testing both in the overall cohort and among missed patients were family history-based. Age > 45 years old and non-Ashkenazi Jewish descent were predictive of missed referral (p < 0.01). We identified pathogenic mutations in 16 of 153 (10%) patients who did undergo testing (11 (7%) BRCA1 or 2 and 5 (3%) with other predisposition gene mutations) or 16 of 397 (4%) among the overall group. CONCLUSIONS Our data highlight the underutilization of genetic testing. Even in the setting of a full-service breast center with readily available genetic counseling, there is a substantial miss rate for identifying eligible patients, related to assessment of family history, patient age, and ethnicity, as well as patient compliance. Broader peri-diagnostic testing should be considered, and higher compliance rates with patients referred should be sought.
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Affiliation(s)
- J Jaime Alberty-Oller
- Dubin Breast Center, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY, USA.
| | - Sarah Weltz
- Dubin Breast Center, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY, USA
| | - Antonio Santos
- Dubin Breast Center, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY, USA
| | - Kereeti Pisapati
- Dubin Breast Center, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY, USA
| | - Meng Ru
- Dubin Breast Center, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY, USA
| | - Christina Weltz
- Dubin Breast Center, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY, USA
| | - Hank Schmidt
- Dubin Breast Center, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY, USA
| | - Elisa Port
- Dubin Breast Center, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, NY, USA
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Adherence to National Comprehensive Cancer Network Guidelines for BRCA testing among high risk breast Cancer patients: a retrospective chart review study. Hered Cancer Clin Pract 2020; 18:13. [PMID: 32518611 PMCID: PMC7275608 DOI: 10.1186/s13053-020-00144-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 05/26/2020] [Indexed: 11/28/2022] Open
Abstract
Background Testing for BRCA variants can impact treatment decisions for breast cancer patients and affect surveillance and prevention strategies for both patients and their relatives. National Comprehensive Cancer Network (NCCN) guidelines recommend testing for patients at heightened risk of BRCA pathogenic variant. We examined the BRCA testing rate among high risk breast cancer patients treated in community oncology practices. Methods We conducted a retrospective medical chart review among community-based US oncologists using a physician panel approach. High risk breast cancer patients with a known family history of cancer and diagnosis with breast cancer at age ≥ 18 years between January 2013–October 2017 were included. We assessed the proportions of patients tested for BRCA variants in accordance with NCCN guidelines. Results Charts from 63 physicians, averaging 16 years of practice, were included; 97% were medical oncologists and 66.7% had a genetic counselor in their practice. We analyzed data for 410 randomly-selected patients with mean age of 52 years; 95% were female, 74% were White, and 19% had Ashkenazi Jewish ancestry. Among all patients, 94% were tested for BRCA variants. The testing rate ranged from 78 to 100% in various high risk groups; lower rates were observed among Black patients (91%), men (92%), and patients meeting NCCN criteria based on family history of male breast cancer (78%) and prostate cancer (87%). We observed a higher testing rate in patients treated by physicians with a genetic counselor in their practice (95% versus 91%). Conclusions Adherence to NCCN BRCA testing guidelines is high in this group of predominantly medical oncologists with extensive experience, with a high proportion having a genetic counselor in practice. Testing rates can be improved in patients with risk factors related to male relatives. High level of compliance to guidelines in a community setting is possible with a delivery model for genetic counseling and testing.
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Chen L, Fu F, Huang M, Lv J, Zhang W, Wang C. The spectrum of BRCA1 and BRCA2 mutations and clinicopathological characteristics in Chinese women with early-onset breast cancer. Breast Cancer Res Treat 2020; 180:759-766. [PMID: 32072338 DOI: 10.1007/s10549-020-05573-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 02/07/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE BRCA1/2 mutations represent a high risk of breast cancer and are related to early-onset breast cancer. However, few studies have reported the relationship between BRCA1/2 mutations and their clinical characteristics in early-onset breast cancers. This study is the first article that characterizes the risk factor profiles in Chinese patients selected by the age of onset (≤ 40 years old). We found some differences in the prevalence of germline BRCA1/2 mutations between Asian and Western countries. METHODS A total of 1371 consecutive unselected Chinese early-onset breast cancer patients were enrolled from the Fujian Medical University Union Hospital, China, and screened for germline BRCA1/2 mutations. Full-exome sequencing in next-generation sequencing technology was performed in all patients to examine BRCA1/2 mutations. RESULTS In our study, 25 (1.8%) and 61 (4.4%) patients were identified with BRCA1 and BRCA2 mutations, respectively, among the unselected early-onset breast cancer patients. BRCA1 mutations were associated with pregnancies (p = 0.026), and BRCA1 carriers had a higher likelihood of being HR positive (p < 0.001), HER2 negative (p < 0.001), or high grade (p = 0.002) than noncarriers. Among BRCA2 mutations, the age of onset was younger in carriers than in noncarriers (p = 0.017), and BRCA2 carriers were more likely to have lymph node metastasis (p = 0.004). HR-positive or HER2-negative patients were likely to be positive for BRCA2 mutations (p < 0.001). Overall, 14 BRCA1 mutations and 8 BRCA2 mutations were first reported in our study CONCLUSION: This study provided some information about the spectrum of BRCA1/2 mutations and characterized the risk factors for early-onset breast cancer in China.
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Affiliation(s)
- Lili Chen
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Fangmeng Fu
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Meng Huang
- Fujian Center for Disease Control and Prevention, Fuzhou, China
| | - Jinxing Lv
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Wenzhe Zhang
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China
| | - Chuan Wang
- Department of Breast Surgery, Fujian Medical University Union Hospital, Fuzhou, Fujian, China.
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Abstract
Purpose
A significant subset of patients (12 per cent) with triple negative breast cancer (TNBC) is BRCA mutation carriers, which can be identified through genetic testing. The purpose of this paper is to evaluate the referral practice for TNBC patients with reference to New South Wales (NSW) referral guidelines at the time of diagnosis and to assess the effectiveness of such guidelines in identifying BRCA mutations. Robust health governance requires monitoring of adherence to evidence-based guidelines such as those that underpin referral for cancer genetic testing in this clinical scenario.
Design/methodology/approach
The authors conducted a retrospective clinical audit of identified TNBC patients at St Vincent’s Hospital (SVH) between 2006 and 2016 in NSW, comparing referral practice to guidelines extant at the time of diagnosis. Family history was considered for age guideline-inappropriate referrals to SVH while the results of BRCA gene testing were assessed for all referred.
Findings
Overall, of the 17 patients eligible for referral based on the age criterion, 10 (58.5 per cent) were referred appropriately; however, there were substantial improvements from 2012 with 100 per cent referred. Of note, 12 (33.4 per cent) of 36 patients referred to SVH were referred outside of guidelines, pointing to other reasons for referral, such as patient age (OR 0.945; 95% CI 0.914–0.978) and calendar year (OR: 1.332; 95% CI: 1.127–1.575) at TNBC diagnosis. Referral guidelines captured 66.67 per cent of identified deleterious BRCA mutations in those tested.
Originality/value
Substantial under-referral of guideline-eligible patients was identified, with evidence-based guidelines effective in identifying high-risk individuals for BRCA mutation testing. There was, however, a substantial proportion of guideline-inappropriate referrals.
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Bednar EM, Walsh MT, Baker E, Muse KI, Oakley HD, Krukenberg RC, Dresbold CS, Jenkinson SB, Eppolito AL, Teed KB, Klein MH, Morman NA, Bowdish EC, Russ P, Wise EE, Cooper JN, Method MW, Henson JW, Grainger AV, Arun BK, Lu KH. Creation and Implementation of an Environmental Scan to Assess Cancer Genetics Services at Three Oncology Care Settings. J Genet Couns 2018; 27:10.1007/s10897-018-0262-4. [PMID: 29770910 PMCID: PMC6240000 DOI: 10.1007/s10897-018-0262-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 05/06/2018] [Indexed: 02/03/2023]
Abstract
An environmental scan (ES) is an efficient mixed-methods approach to collect and interpret relevant data for strategic planning and project design. To date, the ES has not been used nor evaluated in the clinical cancer genetics setting. We created and implemented an ES to inform the design of a quality improvement (QI) project to increase the rates of adherence to national guidelines for cancer genetic counseling and genetic testing at three unique oncology care settings (OCS). The ES collected qualitative and quantitative data from reviews of internal processes, past QI efforts, the literature, and each OCS. The ES used a data collection form and semi-structured interviews to aid in data collection. The ES was completed within 6 months, and sufficient data were captured to identify opportunities and threats to the QI project's success, as well as potential barriers to, and facilitators of guideline-based cancer genetics services at each OCS. Previously unreported barriers were identified, including inefficient genetic counseling appointment scheduling processes and the inability to track referrals, genetics appointments, and genetic test results within electronic medical record systems. The ES was a valuable process for QI project planning at three OCS and may be used to evaluate genetics services in other settings.
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Affiliation(s)
- Erica M Bednar
- The Department of Clinical Cancer Genetics, The University of Texas MD Anderson Cancer Center, Unit 1362 P.O. Box 301439, Houston, TX, 77230-1439, USA.
- The Cancer Prevention and Control Platform, Moon Shots Program™, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Michael T Walsh
- The Cancer Prevention and Control Platform, Moon Shots Program™, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ellen Baker
- The Cancer Prevention and Control Platform, Moon Shots Program™, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kimberly I Muse
- The Department of Clinical Cancer Genetics, The University of Texas MD Anderson Cancer Center, Unit 1362 P.O. Box 301439, Houston, TX, 77230-1439, USA
| | - Holly D Oakley
- The Department of Clinical Cancer Genetics, The University of Texas MD Anderson Cancer Center, Unit 1362 P.O. Box 301439, Houston, TX, 77230-1439, USA
| | | | - Cara S Dresbold
- Oncology Genetic Counseling, Community Health Network, Indianapolis, IN, USA
| | - Sandra B Jenkinson
- Oncology Genetic Counseling, Community Health Network, Indianapolis, IN, USA
| | | | - Kelly B Teed
- Piedmont Cancer, Piedmont Healthcare, Atlanta, GA, USA
| | - Molly H Klein
- Piedmont Cancer, Piedmont Healthcare, Atlanta, GA, USA
| | | | | | - Pauline Russ
- Genetic Counseling Program, OhioHealth, Columbus, OH, USA
| | - Emaline E Wise
- Genetic Counseling Program, OhioHealth, Columbus, OH, USA
| | - Julia N Cooper
- Genetic Counseling Program, OhioHealth, Columbus, OH, USA
| | - Michael W Method
- Gynecologic Cancer Care, Community Health Network, Indianapolis, IN, USA
| | - John W Henson
- Piedmont Cancer, Piedmont Healthcare, Atlanta, GA, USA
| | | | - Banu K Arun
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Karen H Lu
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Carbine NE, Lostumbo L, Wallace J, Ko H. Risk-reducing mastectomy for the prevention of primary breast cancer. Cochrane Database Syst Rev 2018; 4:CD002748. [PMID: 29620792 PMCID: PMC6494635 DOI: 10.1002/14651858.cd002748.pub4] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Recent progress in understanding the genetic basis of breast cancer and widely publicized reports of celebrities undergoing risk-reducing mastectomy (RRM) have increased interest in RRM as a method of preventing breast cancer. This is an update of a Cochrane Review first published in 2004 and previously updated in 2006 and 2010. OBJECTIVES (i) To determine whether risk-reducing mastectomy reduces death rates from any cause in women who have never had breast cancer and in women who have a history of breast cancer in one breast, and (ii) to examine the effect of risk-reducing mastectomy on other endpoints, including breast cancer incidence, breast cancer mortality, disease-free survival, physical morbidity, and psychosocial outcomes. SEARCH METHODS For this Review update, we searched Cochrane Breast Cancer's Specialized Register, MEDLINE, Embase and the WHO International Clinical Trials Registry Platform (ICTRP) on 9 July 2016. We included studies in English. SELECTION CRITERIA Participants included women at risk for breast cancer in at least one breast. Interventions included all types of mastectomy performed for the purpose of preventing breast cancer. DATA COLLECTION AND ANALYSIS At least two review authors independently abstracted data from each report. We summarized data descriptively; quantitative meta-analysis was not feasible due to heterogeneity of study designs and insufficient reporting. We analyzed data separately for bilateral risk-reducing mastectomy (BRRM) and contralateral risk-reducing mastectomy (CRRM). Four review authors assessed the methodological quality to determine whether or not the methods used sufficiently minimized selection bias, performance bias, detection bias, and attrition bias. MAIN RESULTS All 61 included studies were observational studies with some methodological limitations; randomized trials were absent. The studies presented data on 15,077 women with a wide range of risk factors for breast cancer, who underwent RRM.Twenty-one BRRM studies looking at the incidence of breast cancer or disease-specific mortality, or both, reported reductions after BRRM, particularly for those women with BRCA1/2 mutations. Twenty-six CRRM studies consistently reported reductions in incidence of contralateral breast cancer but were inconsistent about improvements in disease-specific survival. Seven studies attempted to control for multiple differences between intervention groups and showed no overall survival advantage for CRRM. Another study showed significantly improved survival following CRRM, but after adjusting for bilateral risk-reducing salpingo-oophorectomy (BRRSO), the CRRM effect on all-cause mortality was no longer significant.Twenty studies assessed psychosocial measures; most reported high levels of satisfaction with the decision to have RRM but greater variation in satisfaction with cosmetic results. Worry over breast cancer was significantly reduced after BRRM when compared both to baseline worry levels and to the groups who opted for surveillance rather than BRRM, but there was diminished satisfaction with body image and sexual feelings.Seventeen case series reporting on adverse events from RRM with or without reconstruction reported rates of unanticipated reoperations from 4% in those without reconstruction to 64% in participants with reconstruction.In women who have had cancer in one breast, removing the other breast may reduce the incidence of cancer in that other breast, but there is insufficient evidence that this improves survival because of the continuing risk of recurrence or metastases from the original cancer. Additionally, thought should be given to other options to reduce breast cancer risk, such as BRRSO and chemoprevention, when considering RRM. AUTHORS' CONCLUSIONS While published observational studies demonstrated that BRRM was effective in reducing both the incidence of, and death from, breast cancer, more rigorous prospective studies are suggested. BRRM should be considered only among those at high risk of disease, for example, BRCA1/2 carriers. CRRM was shown to reduce the incidence of contralateral breast cancer, but there is insufficient evidence that CRRM improves survival, and studies that control for multiple confounding variables are recommended. It is possible that selection bias in terms of healthier, younger women being recommended for or choosing CRRM produces better overall survival numbers for CRRM. Given the number of women who may be over-treated with BRRM/CRRM, it is critical that women and clinicians understand the true risk for each individual woman before considering surgery. Additionally, thought should be given to other options to reduce breast cancer risk, such as BRRSO and chemoprevention when considering RRM.
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Affiliation(s)
- Nora E Carbine
- Georgetown University Lombardi Cancer CenterTranslational Breast Cancer Research Consortium (TBCRC)WashingtonD.C.USA20007
| | | | | | - Henry Ko
- University of SydneyNHMRC Clinical Trials CentreK25 ‐ Medical Foundation Building92‐94 Parramatta Rd.,CamperdownNSWAustralia2050
- Academic Medicine Research Institute, Duke‐NUS Graduate Medical SchoolCentre for Health Services Research, SingHealthSingaporeSingapore169857
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Murphy AE, Hussain L, Ho C, Dunki-Jacobs E, Lee D, Tameron A, Huelsman K, Rice C, Wexelman BA. Preoperative Panel Testing for Hereditary Cancer Syndromes Does Not Significantly Impact Time to Surgery for Newly Diagnosed Breast Cancer Patients Compared with BRCA1/2 Testing. Ann Surg Oncol 2017; 24:3055-3059. [DOI: 10.1245/s10434-017-5957-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Indexed: 11/18/2022]
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10
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Adherence Patterns to National Comprehensive Cancer Network Guidelines for Referral of Women With Breast Cancer to Genetics Professionals. Am J Clin Oncol 2017; 39:363-7. [PMID: 24710121 DOI: 10.1097/coc.0000000000000073] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Genetic predisposition is responsible for 5% to 10% of breast cancer. The National Comprehensive Cancer Network (NCCN) established guidelines delineating appropriate candidates for genetic counseling. This study aims to determine referral patterns for genetic counseling in women who met such guidelines. MATERIALS AND METHODS Utilizing an institutional tumor registry, patients from an academic oncology program who met a subset of NCCN guidelines for genetic referrals between 2004 and 2010 were identified (breast cancer diagnosis ≤50 y without a known BRCA mutation). A retrospective chart review was conducted. Statistics were analyzed using SAS version 9.2. RESULTS A total of 314 patients were identified and 107 (34.1%) were referred for genetic counseling. Median age at diagnosis was younger for those referred versus not referred (43 and 46 y; P<0.0001). Women were more likely referred with a family history suspicious for an inherited cancer syndrome (67.3% vs. 36.2%; P<0.0001). There was no difference in stage at diagnosis, insurance, or race among women referred. Those patients who choose prophylactic contralateral mastectomy were likely to have been referred for genetic counseling (63.6% vs. 36.4%, P<0.0001). Among patients referred, 77.6% consulted with a genetics counselor, 95.2% underwent genetic testing, and 16.5% had a BRCA mutation. CONCLUSIONS Genetic counseling and testing is being underutilized in women who meet NCCN referral guidelines. Age and family history were noted to be predictive of referral for genetic evaluation. Further research is needed to determine additional factors that may impact not only referral rates but subsequent care for women with possible genetic predispositions to cancer.
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Rosenberg SM, Ruddy KJ, Tamimi RM, Gelber S, Schapira L, Come S, Borges VF, Larsen B, Garber JE, Partridge AH. BRCA1 and BRCA2 Mutation Testing in Young Women With Breast Cancer. JAMA Oncol 2017; 2:730-6. [PMID: 26867710 DOI: 10.1001/jamaoncol.2015.5941] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
IMPORTANCE BRCA testing is recommended for young women diagnosed as having breast cancer, but little is known about decisions surrounding testing and how results may influence treatment decisions in young patients. OBJECTIVES To describe the use of BRCA testing and to evaluate how concerns about genetic risk and use of genetic information affect subsequent treatment decisions in young women with breast cancer. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional analysis of data collected following the opening of the study to accrual from October 10, 2006, through December 31, 2014, as part of the Helping Ourselves, Helping Others: Young Women's Breast Cancer Study, an ongoing prospective cohort study. Study participants included 897 women aged 40 years and younger at breast cancer diagnosis from 11 academic and community medical centers. MAIN OUTCOMES AND MEASURES Frequency and trends in the use of BRCA testing and how genetic information is used to make treatment decisions among women who test positive vs negative for a BRCA mutation. RESULTS A total of 780 (87.0%) of 897 women reported BRCA testing by 1 year after breast cancer diagnosis (mean age at diagnosis, 35.3 vs 36.9 years for untested women; P < .001), with the frequency of testing increasing among women diagnosed from August 1, 2006, through December 31, 2013. Of 39 women who were diagnosed as having breast cancer in 2006, 30 (76.9%) reported testing. In 2007, a slightly lower percentage of women (87 of 124 [70.2%]) reported testing; however, the proportion tested increased each subsequent year, with 141 (96.6%) of 146 and 123 (95.3%) of 129 women diagnosed as having breast cancer in 2012 and 2013, respectively, reporting BRCA testing (P < .001). Among untested women, 37 (31.6%) of 117 did not report discussion of the possibility that they might have a mutation with a physician and/or genetic counselor, and 43 (36.8%) of 117 were thinking of testing in the future. A total of 248 (29.8%) of 831 women said that knowledge or concern about genetic risk influenced treatment decisions; among these women, 76 (86.4%) of 88 mutation carriers and 82 (51.2%) of 160 noncarriers chose bilateral mastectomy (P < .001). Fewer women reported that systemic treatment decisions were influenced by genetic risk concern. CONCLUSIONS AND RELEVANCE Rates of BRCA1 and BRCA2 mutation testing are increasing in young women with breast cancer. Given that knowledge and concern about genetic risk influence surgical decisions and may affect systemic therapy trial eligibility, all young women with breast cancer should be counseled and offered genetic testing, consistent with the National Comprehensive Cancer Network guidelines.
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Affiliation(s)
- Shoshana M Rosenberg
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | | | - Rulla M Tamimi
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Shari Gelber
- Department of Biostatistics and Computational Biology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Lidia Schapira
- Division of Hematology-Oncology, Massachusetts General Hospital, Boston
| | - Steven Come
- Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Virginia F Borges
- Division of Medical Oncology, University of Colorado Cancer Center, Denver
| | - Bryce Larsen
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Judy E Garber
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Ann H Partridge
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
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Rapiti E, Pinaud K, Chappuis PO, Viassolo V, Ayme A, Neyroud-Caspar I, Usel M, Bouchardy C. Opportunities for improving triple-negative breast cancer outcomes: results of a population-based study. Cancer Med 2017; 6:526-536. [PMID: 28211614 PMCID: PMC5345677 DOI: 10.1002/cam4.998] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 11/30/2016] [Accepted: 11/30/2016] [Indexed: 12/19/2022] Open
Abstract
Triple‐negative breast cancer (TNBC) is associated with a poor prognosis. Surgery, radiotherapy, chemotherapy, and referral for genetic counseling are the standard of care. We assessed TNBC prevalence, management, and outcome using data from the population‐based Geneva cancer registry. 2591 women had a first invasive stage I‐III breast cancer diagnosed between 2003 and 2011. We compared TNBC to other breast cancers (OBC) by χ2‐test and logistic regression. Kaplan–Meier survival curves, up to 31‐12‐2014, were compared using log‐rank test. TNBC risk of mortality overall (OS) and for breast cancer (BCSS) was evaluated through Cox models. Linkage with the Oncogenetics and Cancer Prevention Unit (OCPU) database of the Geneva University Hospitals provided genetic counseling information. TNBC patients (n = 192, 7.4%) were younger, more often born in Africa or Central‐South America than OBC, had larger and more advanced tumors. 18% of TNBC patients did not receive chemotherapy. Thirty‐one (17%) TNBC women consulted the OCPU, 39% among those aged <40 years. Ten‐year survival was lower in TNBC than OBC (72% vs. 82% for BCSS; P < 0.001; 80% vs. 91% for OS; P < 0.001). The mortality risks remained significant after adjustment for other prognostic variables. The strongest determinants of mortality were age, place of birth, and lymph node status. A substantial proportion of TNBC patients in Geneva did not receive optimal care. Over 60% of eligible women did not receive genetic counseling and 18% did not receive chemotherapy. To improve TNBC prognosis, comprehensive care as recommended by standard guidelines should be offered to all patients.
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Affiliation(s)
| | - Kim Pinaud
- Geneva Cancer Registry, University of Geneva, Geneva, Switzerland
| | - Pierre O Chappuis
- Oncogenetics and Cancer Prevention Unit, Division of Oncology, Geneva University Hospitals, Geneva, Switzerland.,Division of Genetic Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Valeria Viassolo
- Oncogenetics and Cancer Prevention Unit, Division of Oncology, Geneva University Hospitals, Geneva, Switzerland
| | - Aurélie Ayme
- Oncogenetics and Cancer Prevention Unit, Division of Oncology, Geneva University Hospitals, Geneva, Switzerland.,Molecular Clinical Pathology Unit, Division of Clinical Pathology, Geneva University Hospitals, Geneva, Switzerland
| | | | - Massimo Usel
- Geneva Cancer Registry, University of Geneva, Geneva, Switzerland
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Oberguggenberger A, Sztankay M, Morscher RJ, Sperner-Unterweger B, Weber I, Hubalek M, Kemmler G, Zschocke J, Martini C, Egle D, Dünser M, Gamper E, Meraner V. Psychosocial outcomes and counselee satisfaction following genetic counseling for hereditary breast and ovarian cancer: A patient-reported outcome study. J Psychosom Res 2016; 89:39-45. [PMID: 27663109 DOI: 10.1016/j.jpsychores.2016.08.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Revised: 08/02/2016] [Accepted: 08/07/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE We investigated the psychosocial consequences of genetic counseling and testing (GCT) for hereditary breast and ovarian cancer (HBOC) at follow-up in a "real-life" sample of counselees at an Austrian tertiary care center. METHODS The study cohort included counselees who had undergone genetic counseling for HBOC and completed a follow-up self-report questionnaire battery on psychosocial outcomes (quality of life, psychological distress, satisfaction with counseling and decisions). For comparison of distress, we recruited a reference sample of breast cancer survivors (BCS; n=665) who had not requested GCT in the same setting. RESULTS Overall, counselees did not exhibit increased levels of anxiety and depression when compared to BCS. No specific follow-up deleterious psychosocial consequences were detected among the former group. Of the 137 counselees, 22.6% and 9.8% experienced clinically relevant levels of anxiety and depression, respectively, at an average follow-up time of 1.8years. However, both anxiety and depression significantly decreased with time and were alike between counselees with and without cancer diagnosis. Follow-up cancer worry seems to be significantly higher among counselees who had not undergone genetic testing or were undecided about it than among counselees who had been tested. CONCLUSION Our results strongly support GCT as part of routine care for patients with HBOC. The risk factors of increased distress in specific subgroups of counselees, such as recent cancer diagnosis or uncertainty about testing, warrant further exploration and specific attention in clinical routines. Particularly, the psychological needs of undecided counselees warrant ongoing attention and potential follow-ups.
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Affiliation(s)
- Anne Oberguggenberger
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical University of Innsbruck, Innsbruck, Austria.
| | - Monika Sztankay
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical University of Innsbruck, Innsbruck, Austria
| | - Raphael Johannes Morscher
- Division of Human Genetics, Medical University of Innsbruck, Austria; Research Program for Receptor Biochemistry and Tumor Metabolism, Paracelsus Medical University, Salzburg, Austria
| | - Barbara Sperner-Unterweger
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical University of Innsbruck, Innsbruck, Austria
| | - Ingrid Weber
- Division of Human Genetics, Medical University of Innsbruck, Austria
| | - Michael Hubalek
- Department of Obstetrics and Gynecology, Medical University of Innsbruck, Innsbruck, Austria
| | - Georg Kemmler
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical University of Innsbruck, Innsbruck, Austria
| | - Johannes Zschocke
- Division of Human Genetics, Medical University of Innsbruck, Austria
| | - Caroline Martini
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical University of Innsbruck, Innsbruck, Austria
| | - Daniel Egle
- Department of Obstetrics and Gynecology, Medical University of Innsbruck, Innsbruck, Austria
| | - Martina Dünser
- Department of Visceral, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Eva Gamper
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical University of Innsbruck, Innsbruck, Austria
| | - Verena Meraner
- Department of Psychiatry, Psychotherapy and Psychosomatics, Medical University of Innsbruck, Innsbruck, Austria
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Wauters A, Van Hoyweghen I. Global trends on fears and concerns of genetic discrimination: a systematic literature review. J Hum Genet 2016; 61:275-82. [PMID: 26740237 DOI: 10.1038/jhg.2015.151] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 10/12/2015] [Accepted: 11/11/2015] [Indexed: 12/29/2022]
Abstract
Since the 1990s, developments in the field of genetics have led to many questions on the use and possible misuse of genetic information. 'Genetic discrimination' has been defined as the differential treatment of asymptomatic individuals or their relatives on the basis of their real or assumed genetic characteristics. Despite the public policy attention around genetic discrimination, there is currently still much confusion surrounding this phenomenon. On the one hand, there is little evidence of the occurrence of genetic discrimination. On the other hand, it appears that people remain concerned about this theme, and this fear influences their health and life choices. This article makes use of a systematic literature review to investigate what is already known about the nature, extent and background of these fears and concerns. The 42 included studies have found considerable levels of concerns about genetic discrimination. Concerns dominate in insurance contexts and within personal interactions. The extent of concerns appears to vary depending on the type of genetic illness. Furthermore, installed laws prohibiting genetic discrimination do not seem to alleviate existing fears. This raises important questions as to the origins of these fears. Based on the findings, recommendations for future research are made. First, research on the background of fears is needed. Second, future research needs to assess more fully all different forms (for example, direct and indirect) of genetic discrimination. Thirdly, it has to be studied whether genetic discrimination is a form of discrimination that is distinguishable from discrimination based on an illness or disability. Finally, a last element that should be addressed in future research is the most recent developments in research on genomics, such as next-generation sequencing or genome-wide association studies.
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Affiliation(s)
- Annet Wauters
- Life Sciences and Society Lab, Centre for Sociological Research, KU Leuven, Leuven, Belgium
| | - Ine Van Hoyweghen
- Life Sciences and Society Lab, Centre for Sociological Research, KU Leuven, Leuven, Belgium
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Hamann HA, Tiro JA, Sanders JM, Melhado TV, Funk RK, Carpentier MY, Bartholomew LK, Argenbright KE, Vernon SW. Validity of self-reported genetic counseling and genetic testing use among breast cancer survivors. J Cancer Surviv 2013; 7:624-9. [DOI: 10.1007/s11764-013-0301-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Accepted: 07/08/2013] [Indexed: 12/12/2022]
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Vig HS, McCarthy AM, Liao K, Demeter MB, Fredericks T, Armstrong K. Age at diagnosis may trump family history in driving BRCA testing in a population of breast cancer patients. Cancer Epidemiol Biomarkers Prev 2013; 22:1778-85. [PMID: 23917453 DOI: 10.1158/1055-9965.epi-13-0426] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Standard BRCA genetic testing criteria include young age of diagnosis, family history, and Jewish ancestry. The purpose of this study was to assess the effect of these criteria on BRCA test utilization in breast cancer patients. METHODS Breast cancer patients aged 18 to 64 years living in Pennsylvania in 2007 completed a survey on family history of breast and ovarian cancer and BRCA testing (N = 2,213). Multivariate logistic regression was used to estimate odds of BRCA testing by patient characteristics, and predicted probabilities of testing were calculated for several clinical scenarios. RESULTS Young age at diagnosis (<50 years) was strongly associated with BRCA testing, with women diagnosed before age 50 years having nearly five times the odds of receiving BRCA testing compared to women diagnosed at age 50 or older (OR = 4.81; 95% CI, 3.85-6.00; P < 0.001). Despite a similar BRCA mutation prevalence estimate (8-10%), a young Jewish patient <50 years with no family history had markedly higher predicted probability of testing (63%) compared with an older, non-Jewish breast cancer patient with more than one first-degree relative (43%). CONCLUSION Age at diagnosis, Jewish ancestry, and both maternal and paternal family history are strongly predictive of BRCA testing. However, among women diagnosed at age 50 or older, family history may be an underused criterion that may benefit from targeted intervention. IMPACT Robust methods specific to ascertaining detailed family history, such as through electronic medical records, are needed to accurately identify patients for BRCA testing.
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Affiliation(s)
- Hetal S Vig
- Authors' Affiliations: Cancer Institute of New Jersey, New Brunswick, New Jersey; and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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17
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McCarthy AM, Bristol M, Fredricks T, Wilkins L, Roelfsema I, Liao K, Shea JA, Groeneveld P, Domchek SM, Armstrong K. Are physician recommendations for BRCA1/2 testing in patients with breast cancer appropriate? A population-based study. Cancer 2013; 119:3596-603. [PMID: 23861169 DOI: 10.1002/cncr.28268] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Accepted: 06/06/2013] [Indexed: 11/06/2022]
Abstract
BACKGROUND To the best of the authors' knowledge, few population-based studies to date have examined the use of BRCA1/2 testing or patterns of physician recommendations for genetic testing among women diagnosed with breast cancer. The objective of the current study was to evaluate the rates and predictors of physician recommendation for BRCA1/2 testing among patients with breast cancer. METHODS Women aged 18 years to 64 years who were diagnosed with invasive breast cancer in 2007 were identified from the Pennsylvania Cancer Registry and mailed a survey regarding their family history of cancer, physician treatment recommendations, and BRCA1/2 testing. Of the 4009 women who were sent surveys, 2258 responded (56%). Based on age at diagnosis and family history, women were categorized as being at high, moderate, or low risk of BRCA1/2 mutations. RESULTS Nearly 25% of the participants were classified as being at high risk of carrying a BRCA1/2 mutation based on their age at the time of breast cancer diagnosis and family history of breast and/or ovarian cancer. Physician recommendations for BRCA1/2 testing were found to be strongly associated with risk of carrying a mutation, with 53% of high-risk women reporting a testing recommendation compared with 9% of low-risk women. In addition, physician recommendations were strongly correlated with the use of testing in all risk groups. Among high-risk women, the lack of a recommendation for BRCA1/2 testing was more common among older, low-income, and employed women. CONCLUSIONS Although BRCA1/2 testing recommendations appear to be appropriately correlated with mutation risk, a significant percentage of patients with breast cancer who meet criteria for BRCA1/2 testing may not receive a recommendation for such testing from their health care providers.
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Affiliation(s)
- Anne Marie McCarthy
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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18
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Thompson HS, Sussner K, Schwartz MD, Edwards T, Forman A, Jandorf L, Brown K, Bovbjerg DH, Valdimarsdottir HB. Receipt of genetic counseling recommendations among black women at high risk for BRCA mutations. Genet Test Mol Biomarkers 2012; 16:1257-62. [PMID: 23057569 DOI: 10.1089/gtmb.2012.0114] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Low use of BRCA counseling and testing services among black women has been reported in several studies, even though such services may play an important role in reducing racial disparities in breast cancer. Surprisingly, little is known about the extent to which black women at high risk for BRCA mutations actually receive recommendations for BRCA counseling. Thus, a primary goal of the current study was to identify sociodemographic and clinical factors associated with the receipt of physician recommendation for genetic counseling based on the self-report of black women at high risk for BRCA mutations. In this cross-sectional study, participants were 125 black women with a family history suggestive of a hereditary breast and/or ovarian cancer syndrome. Participants were asked about their receipt of genetic counseling recommendation or referral. Physician recommendation was reported by over two-thirds of the sample. Multivariate analyses revealed that older age and study recruitment source, specifically community-based recruitment, were significantly and independently associated with lower likelihood of physician recommendation. Findings highlight the need for additional research to identify subgroups of high-risk black women among whom physician recommendation of genetic counseling is low but would benefit from such counseling.
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Affiliation(s)
- Hayley S Thompson
- Population Studies and Disparities Research Program, Karmanos Cancer Institute, Department of Oncology, Wayne State University School of Medicine, Detroit, MI 48201, USA.
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van Riel E, van Dulmen S, Ausems MGEM. Who is being referred to cancer genetic counseling? Characteristics of counselees and their referral. J Community Genet 2012; 3:265-74. [PMID: 22426886 DOI: 10.1007/s12687-012-0090-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Accepted: 03/06/2012] [Indexed: 01/29/2023] Open
Abstract
Both physician and patient play a role in the referral process for cancer genetic counseling. Access to such counseling is not optimal because some eligible patients are not being reached by current referral practice. We aimed to identify factors associated with the initiator of referral. During a 7-month period, we recorded demographic characteristics like gender, personal and family history of cancer, ethnicity and eligibility for genetic testing for 406 consecutive counselees using a specially designed questionnaire. Counselees were seen in a university hospital or a community hospital (n = 7) in the Netherlands. We also recorded educational level of each counselee, clinical setting and who initiated referral. Descriptive statistics were used to describe the counselees' general characteristics. We analysed the association between counselee characteristics and the initiator of referral by logistic regression. The majority of counselees seemed to have initiated referral themselves but were indeed eligible for genetic testing. In comparison to the general population in the Netherlands, the counselees had a higher level of education, and there were fewer immigrants, although a higher level of education was not found to be a facilitating factor for referral. The clinical setting where a counselee was seen was associated with initiator of referral, although this relationship was not straightforward. There is a complex interaction between clinical setting and initiator of referral, which warrants further research to elucidate the factors involved in this relationship. Patients seen in cancer genetic counseling do not reflect the general population in terms of educational level or ethnicity.
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Affiliation(s)
- E van Riel
- Department of Medical Genetics, University Medical Centre Utrecht, P.O. Box 85090, 3508 AB, Utrecht, The Netherlands,
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Quillin JM, Bodurtha JN, McClish D, Wilson DB. Genetic risk, perceived risk, and cancer worry in daughters of breast cancer patients. J Genet Couns 2011; 20:157-64. [PMID: 21132457 PMCID: PMC4870590 DOI: 10.1007/s10897-010-9336-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Accepted: 11/08/2010] [Indexed: 10/18/2022]
Abstract
This study explored relationships between worry, perceived risk for breast cancer, consulting a genetic counselor, having genetic testing, and genetic risk for women whose mothers had breast cancer. Analyses involved data from a community-based phone survey of women whose mothers had breast cancer. Participants were categorized as having low, intermediate, or high genetic risk based on their reported family history, in accordance with an accepted classification scheme. The Lerman Breast Cancer Worry Scale measured worry, and participants reported their perceived lifetime likelihood of breast cancer, risk compared to others, and chance from 1 to 100. ANOVA, chi-square, and multiple regression analyses were conducted as appropriate. One hundred-fifty women participated. Mean age was 38 years, and 81% were Caucasian. Fifty-two women had low, 74 had intermediate, and 24 had high genetic risk for breast cancer. There were no significant differences in worry or perceived risk by hereditary risk category. Most high-risk women (91%) had not spoken with a genetic counselor, and no one had previous genetic testing. These findings suggest perceived risk, worry about breast cancer, and use of expert consultation do not match the genetic contribution to risk. There is a need for effectively stratifying and communicating risk in the community and providing tailored reassurance or referral for high-risk assessment.
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Affiliation(s)
- John M Quillin
- Department of Human & Molecular Genetics and Massey Cancer Center, Virginia Commonwealth University, 1101 E. Marshall St, Richmond, VA 23298-0033, USA.
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21
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Rueth NM, McMahon M, Arrington AK, Swenson K, Leach J, Tuttle TM. Preoperative risk assessment among women undergoing bilateral prophylactic mastectomy for cancer risk reduction. Ann Surg Oncol 2011; 18:2515-20. [PMID: 21424371 DOI: 10.1245/s10434-011-1642-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Indexed: 01/01/2023]
Abstract
BACKGROUND Cancer risk assessment is an important decision-making tool for women considering irreversible risk-reducing surgery. Our objective was to determine the prevalence of BRCA testing among women undergoing bilateral prophylactic mastectomy (BPM) and to review the characteristics of women who choose BPM within a metropolitan setting. METHODS We retrospectively reviewed records of women who underwent BPM in the absence of cancer within 2 health care systems that included 5 metropolitan hospitals. Women with invasive carcinoma or ductal carcinoma in situ (DCIS) were excluded; neither lobular carcinoma in situ (LCIS) nor atypical hyperplasia (AH) were exclusion criteria. We collected demographic information and preoperative screening and risk assessment, BRCA testing, reconstruction, and associated cancer risk-reducing surgery data. We compared women who underwent BRCA testing to those not tested. RESULTS From January 2002 to July 2009, a total of 71 BPMs were performed. Only 25 women (35.2%) had preoperative BRCA testing; 88% had a BRCA mutation. Compared with tested women, BRCA nontested women were significantly older (39.1 vs. 49.2 years, P < 0.001), had significantly more preoperative biopsies and mammograms and had fewer previous or simultaneous cancer risk-reducing surgery (oophorectomy). Among BRCA nontested women, common indications for BPM were family history of breast cancer (n = 21, 45.6%) or LCIS or AH (n = 16, 34.8%); 9 nontested women (19.6%) chose BPM based on exclusively on cancer-risk anxiety or personal preference. CONCLUSION Most women who underwent BPM did not receive preoperative genetic testing. Further studies are needed to corroborate our findings in other geographic regions and practice settings.
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Affiliation(s)
- Natasha M Rueth
- Department of Surgery, Division of Surgical Oncology, University of Minnesota, Minneapolis, MN, USA
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Abstract
BACKGROUND Recent progress in understanding the genetic basis of breast cancer has increased interest in prophylactic mastectomy (PM) as a method of preventing breast cancer. OBJECTIVES (i) To determine whether prophylactic mastectomy reduces death rates from any cause in women who have never had breast cancer and in women who have a history of breast cancer in one breast, and (ii) to examine the effect of prophylactic mastectomy on other endpoints, including breast cancer incidence, breast cancer mortality, disease-free survival, physical morbidity, and psychosocial outcomes. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL, 2002), MEDLINE and Cancerlit (1966 to June 2006), EMBASE (1974 to June 2006), and the WHO International Clinical Trials Registry Platform (WHO ICTRP) search portal (until June 2006). Studies in English were included. SELECTION CRITERIA Participants included women at risk for breast cancer in at least one breast. Interventions included all types of mastectomy performed for the purpose of preventing breast cancer. DATA COLLECTION AND ANALYSIS At least two authors independently abstracted data. Data were summarized descriptively; quantitative meta-analysis was not feasible due to heterogeneity of study designs and insufficient reporting. Data were analyzed separately for bilateral prophylactic mastectomy (BPM) and contralateral prophylactic mastectomy (CPM). MAIN RESULTS All 39 included studies were observational studies with some methodological limitations; randomized trials were absent. The studies presented data on 7,384 women with a wide range of risk factors for breast cancer who underwent PM.BPM studies on the incidence of breast cancer and/or disease-specific mortality reported reductions after BPM particularly for those with BRCA1/2 mutations. For CPM, studies consistently reported reductions in incidence of contralateral breast cancer but were inconsistent about improvements in disease-specific survival. Only one study attempted to control for multiple differences between intervention groups and this study showed no overall survival advantage for CPM at 15 years. Another study showed significantly improved survival following CPM but after adjusting for bilateral prophylactic oophorectomy, the CPM effect on all-cause mortality was no longer significant.Sixteen studies assessed psychosocial measures; most reported high levels of satisfaction with the decision to have PM but more variable satisfaction with cosmetic results. Worry over breast cancer was significantly reduced after BPM when compared both to baseline worry levels and to the groups who opted for surveillance rather than BPM.Case series reporting on adverse events from PM with or without reconstruction reported rates of unanticipated re-operations from 4% in those without reconstruction to 49% in patients with reconstruction. AUTHORS' CONCLUSIONS Sixteen studies have been published since the last version of the review, without altering our conclusions. While published observational studies demonstrated that BPM was effective in reducing both the incidence of, and death from, breast cancer, more rigorous prospective studies (ideally randomized trials) are needed. BPM should be considered only among those at very high risk of disease. There is insufficient evidence that CPM improves survival and studies that control for multiple confounding variables are needed.
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Affiliation(s)
- Liz Lostumbo
- National Breast Cancer Coalition, 10615 Great Arbor Dr, Potomac, Maryland, USA, 20854
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Ruddy K, Gelber S, Shin J, Garber J, Rosenberg R, Przypysny M, Partridge A. Genetic testing in young women with breast cancer: results from a Web-based survey. Ann Oncol 2010; 21:741-747. [DOI: 10.1093/annonc/mdp355] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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Metcalf MP, Tanner TB, Buchanan A. Effectiveness of an online curriculum for medical students on genetics, genetic testing and counseling. MEDICAL EDUCATION ONLINE 2010; 15:10.3402/meo.v15i0.4856. [PMID: 20174615 PMCID: PMC2823389 DOI: 10.3402/meo.v15i0.4856] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2009] [Revised: 12/21/2009] [Accepted: 12/21/2009] [Indexed: 05/06/2023]
Abstract
BACKGROUND It is increasingly important that physicians have a thorough understanding of the basic science of human genetics and the ethical, legal and social implications (ELSI) associated with genetic testing and counseling. METHODS The authors developed a series of web-based courses for medical students on these topics. The course modules are interactive, emphasize clinical case studies, and can easily be incorporated into existing medical school curricula. RESULTS Results of a 'real world' effectiveness trial indicate that the courses have a statistically significant effect on knowledge, attitude, intended behavior and self-efficacy related to genetic testing (p<0.001; N varies between 163 and 596 for each course). CONCLUSIONS The results indicate that this curriculum is an effective tool for educating medical students on the ELSI associated with genetic testing and for promoting positive changes in students' confidence, counseling attitudes and behaviors.
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Affiliation(s)
- Mary P Metcalf
- Clinical Tools Inc., 1506 E. Franklin Street #200, Chapel Hill, NC, USA.
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Vadaparampil ST, Quinn GP, Miree CA, Brzosowicz J, Carter B, Laronga C. Recall of and reactions to a surgeon referral letter for BRCA genetic counseling among high-risk breast cancer patients. Ann Surg Oncol 2009; 16:1973-81. [PMID: 19408048 DOI: 10.1245/s10434-009-0479-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2008] [Revised: 01/13/2009] [Accepted: 01/14/2009] [Indexed: 12/22/2022]
Abstract
BACKGROUND The oncology care setting represents an important opportunity to identify and refer women at increased risk for hereditary breast and ovarian cancer. However, little is known about the effectiveness of provider approaches to inform patients of hereditary cancer risk or patient uptake of genetic counseling (GC). This qualitative study examined the impact of a surgeon referral letter on recently diagnosed breast cancer patients' uptake of BRCA GC. METHODS Qualitative open-ended, in-depth interviews were conducted with 26 high-risk breast cancer patients sent a referral letter for BRCA GC by their surgeon. Data were analyzed by a grounded theory approach. RESULTS Most women (approximately 80%) recalled receiving the letter, and 62% of all (n = 16) women pursued GC. Recall of the letter did not seem to be associated with uptake of GC (P = .49, Fisher's exact test). The results highlight key areas for improvement that may help increase the impact of the letter. Half of the women in this sample believed that the letter was sent to all breast cancer patients, rather than those with specific risk factors. Few women mentioned any implications for the information obtained during GC or testing regarding their current breast cancer diagnosis or treatment. Of the women who did not attend, many perceived that dealing with the GC and testing process in the midst of a cancer diagnosis and treatment was overwhelming. Among the women who had chosen not to attend GC, most stated they would reconsider after completing their treatment. CONCLUSIONS Patient recall of a surgeon referral letter does not seem to increase the number of high-risk women who attend GC after a breast cancer diagnosis. The letter approach in its current format does not seem to be a wholly effective means of communicating with some patients who may be overwhelmed by their cancer diagnosis or unaware that GC and testing may have implications for their current treatment decisions, possibly resulting in a missed opportunity to engage in informed decision making.
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Vadaparampil ST, Quinn GP, Brzosowicz JP, Miree CA. Experiences of Genetic Counseling forBRCA1/2Among Recently Diagnosed Breast Cancer Patients: A Qualitative Inquiry. J Psychosoc Oncol 2008; 26:33-52. [DOI: 10.1080/07347330802359586] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Orr J, Kelley J, Dizon D, Escobar P, Fleming E, Gemignani M, Hetzel D, Hoskins W, Kieback D, Kilgore L, LaPolla J, Lewin S, Lucci J, Markman M, Pothuri B, Powell CB, Tejada-Berges T. Society of gynecologic oncologists position paper: breast cancer care. Gynecol Oncol 2008; 110:7-12. [PMID: 18589209 DOI: 10.1016/j.ygyno.2008.04.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2008] [Accepted: 04/04/2008] [Indexed: 10/21/2022]
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