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Crew KD, Anderson GL, Arnold KB, Stieb AP, Amenta JN, Collins N, Law CW, Pruthi S, Sandoval-Leon A, Bertoni D, Grosse Perdekamp MT, Colonna S, Krisher S, King T, Yee LD, Ballinger TJ, Braun-Inglis C, Mangino D, Wisinski KB, DeYoung CA, Ross M, Floyd J, Kaster A, Vander Walde L, Saphner T, Zarwan C, Lo S, Graham C, Conlin A, Yost K, Agnese D, Jernigan C, Hershman DL, Neuhouser ML, Arun B, Kukafka R. Making Informed Choices On Incorporating Chemoprevention into carE (MiCHOICE, SWOG 1904): Design and methods of a cluster randomized controlled trial. Contemp Clin Trials 2024; 142:107564. [PMID: 38704119 PMCID: PMC11180561 DOI: 10.1016/j.cct.2024.107564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 04/15/2024] [Accepted: 05/01/2024] [Indexed: 05/06/2024]
Abstract
INTRODUCTION Women with atypical hyperplasia (AH) or lobular carcinoma in situ (LCIS) have a significantly increased risk of breast cancer, which can be substantially reduced with antiestrogen therapy for chemoprevention. However, antiestrogen therapy for breast cancer risk reduction remains underutilized. Improving knowledge about breast cancer risk and chemoprevention among high-risk patients and their healthcare providers may enhance informed decision-making about this critical breast cancer risk reduction strategy. METHODS/DESIGN We are conducting a cluster randomized controlled trial to evaluate the effectiveness and implementation of patient and provider decision support tools to improve informed choice about chemoprevention among women with AH or LCIS. We have cluster randomized 26 sites across the U.S. through the SWOG Cancer Research Network. A total of 415 patients and 200 healthcare providers are being recruited. They are assigned to standard educational materials alone or combined with the web-based decision support tools. Patient-reported and clinical outcomes are assessed at baseline, after a follow-up visit at 6 months, and yearly for 5 years. The primary outcome is chemoprevention informed choice after the follow-up visit. Secondary endpoints include other patient-reported outcomes, such as chemoprevention knowledge, decision conflict and regret, and self-reported chemoprevention usage. Barriers and facilitators to implementing decision support into clinic workflow are assessed through patient and provider interviews at baseline and mid-implementation. RESULTS/DISCUSSION With this hybrid effectiveness/implementation study, we seek to evaluate if a multi-level intervention effectively promotes informed decision-making about chemoprevention and provide valuable insights on how the intervention is implemented in U.S. CLINICAL SETTINGS TRIAL REGISTRATION NCT04496739.
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Affiliation(s)
- K D Crew
- Columbia University Irving Medical Center, New York, NY, USA.
| | - G L Anderson
- SWOG Statistics and Data Management Center, Seattle, WA, USA
| | - K B Arnold
- SWOG Statistics and Data Management Center, Seattle, WA, USA
| | - A P Stieb
- Columbia University Irving Medical Center, New York, NY, USA
| | - J N Amenta
- Columbia University Irving Medical Center, New York, NY, USA
| | - N Collins
- Columbia University Irving Medical Center, New York, NY, USA
| | - C W Law
- Columbia University Irving Medical Center, New York, NY, USA
| | - S Pruthi
- Mayo Clinic, Rochester, MN, United States of America
| | - A Sandoval-Leon
- Miami Cancer Institute at Baptist Health South Florida, Miami, FL, USA
| | - D Bertoni
- Good Samaritan Hospital Corvallis, Corvallis, OR , USA
| | | | - S Colonna
- Huntsman Cancer Institute / University of Utah Medical Center, Salt Lake City, UT, USA
| | - S Krisher
- Holy Redeemer Hospital and Medical Center, Meadowbrook, PA, USA
| | - T King
- Dana-Farber Brigham Cancer Center, Brigham and Women's Hospital, Boston, MA, USA
| | - L D Yee
- City of Hope Comprehensive Cancer Center, Duarte, CA, USA
| | - T J Ballinger
- Indiana University Simon Comprehensive Cancer Center, Indianapolis, IN, USA
| | | | - D Mangino
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - K B Wisinski
- University of Wisconsin Carbone Cancer Center, Madison, WI, USA
| | | | - M Ross
- Virginia Commonwealth University, Richmond, VA, USA
| | - J Floyd
- Cancer Care Specialists of Illinois, Heartland NCORP, Decatur, IL, USA
| | - A Kaster
- Sanford Roger Maris Cancer Center, Fargo, ND, United States of America
| | - L Vander Walde
- Baptist Memorial Health Care, Memphis, TN, United States of America
| | | | - C Zarwan
- Lahey Hospital & Medical Center, Burlington, MA, USA
| | - S Lo
- Loyola University Stritch School of Medicine, Maywood, IL, USA
| | - C Graham
- Emory University Hospital/Winship Cancer Institute, Atlanta, GA, USA
| | - A Conlin
- Providence Cancer Institute, Portland, OR, USA
| | - K Yost
- Cancer Research Consortium of West Michigan NCORP, Kalamazoo, MI, USA
| | - D Agnese
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - C Jernigan
- SWOG Statistics and Data Management Center, Seattle, WA, USA
| | - D L Hershman
- Columbia University Irving Medical Center, New York, NY, USA
| | | | - B Arun
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - R Kukafka
- Columbia University Irving Medical Center, New York, NY, USA
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Stacey D, Lewis KB, Smith M, Carley M, Volk R, Douglas EE, Pacheco-Brousseau L, Finderup J, Gunderson J, Barry MJ, Bennett CL, Bravo P, Steffensen K, Gogovor A, Graham ID, Kelly SE, Légaré F, Sondergaard H, Thomson R, Trenaman L, Trevena L. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2024; 1:CD001431. [PMID: 38284415 PMCID: PMC10823577 DOI: 10.1002/14651858.cd001431.pub6] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2024]
Abstract
BACKGROUND Patient decision aids are interventions designed to support people making health decisions. At a minimum, patient decision aids make the decision explicit, provide evidence-based information about the options and associated benefits/harms, and help clarify personal values for features of options. This is an update of a Cochrane review that was first published in 2003 and last updated in 2017. OBJECTIVES To assess the effects of patient decision aids in adults considering treatment or screening decisions using an integrated knowledge translation approach. SEARCH METHODS We conducted the updated search for the period of 2015 (last search date) to March 2022 in CENTRAL, MEDLINE, Embase, PsycINFO, EBSCO, and grey literature. The cumulative search covers database origins to March 2022. SELECTION CRITERIA We included published randomized controlled trials comparing patient decision aids to usual care. Usual care was defined as general information, risk assessment, clinical practice guideline summaries for health consumers, placebo intervention (e.g. information on another topic), or no intervention. DATA COLLECTION AND ANALYSIS Two authors independently screened citations for inclusion, extracted intervention and outcome data, and assessed risk of bias using the Cochrane risk of bias tool. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made (informed values-based choice congruence) and the decision-making process, such as knowledge, accurate risk perceptions, feeling informed, clear values, participation in decision-making, and adverse events. Secondary outcomes were choice, confidence in decision-making, adherence to the chosen option, preference-linked health outcomes, and impact on the healthcare system (e.g. consultation length). We pooled results using mean differences (MDs) and risk ratios (RRs) with 95% confidence intervals (CIs), applying a random-effects model. We conducted a subgroup analysis of 105 studies that were included in the previous review version compared to those published since that update (n = 104 studies). We used Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to assess the certainty of the evidence. MAIN RESULTS This update added 104 new studies for a total of 209 studies involving 107,698 participants. The patient decision aids focused on 71 different decisions. The most common decisions were about cardiovascular treatments (n = 22 studies), cancer screening (n = 17 studies colorectal, 15 prostate, 12 breast), cancer treatments (e.g. 15 breast, 11 prostate), mental health treatments (n = 10 studies), and joint replacement surgery (n = 9 studies). When assessing risk of bias in the included studies, we rated two items as mostly unclear (selective reporting: 100 studies; blinding of participants/personnel: 161 studies), due to inadequate reporting. Of the 209 included studies, 34 had at least one item rated as high risk of bias. There was moderate-certainty evidence that patient decision aids probably increase the congruence between informed values and care choices compared to usual care (RR 1.75, 95% CI 1.44 to 2.13; 21 studies, 9377 participants). Regarding attributes related to the decision-making process and compared to usual care, there was high-certainty evidence that patient decision aids result in improved participants' knowledge (MD 11.90/100, 95% CI 10.60 to 13.19; 107 studies, 25,492 participants), accuracy of risk perceptions (RR 1.94, 95% CI 1.61 to 2.34; 25 studies, 7796 participants), and decreased decisional conflict related to feeling uninformed (MD -10.02, 95% CI -12.31 to -7.74; 58 studies, 12,104 participants), indecision about personal values (MD -7.86, 95% CI -9.69 to -6.02; 55 studies, 11,880 participants), and proportion of people who were passive in decision-making (clinician-controlled) (RR 0.72, 95% CI 0.59 to 0.88; 21 studies, 4348 participants). For adverse outcomes, there was high-certainty evidence that there was no difference in decision regret between the patient decision aid and usual care groups (MD -1.23, 95% CI -3.05 to 0.59; 22 studies, 3707 participants). Of note, there was no difference in the length of consultation when patient decision aids were used in preparation for the consultation (MD -2.97 minutes, 95% CI -7.84 to 1.90; 5 studies, 420 participants). When patient decision aids were used during the consultation with the clinician, the length of consultation was 1.5 minutes longer (MD 1.50 minutes, 95% CI 0.79 to 2.20; 8 studies, 2702 participants). We found the same direction of effect when we compared results for patient decision aid studies reported in the previous update compared to studies conducted since 2015. AUTHORS' CONCLUSIONS Compared to usual care, across a wide variety of decisions, patient decision aids probably helped more adults reach informed values-congruent choices. They led to large increases in knowledge, accurate risk perceptions, and an active role in decision-making. Our updated review also found that patient decision aids increased patients' feeling informed and clear about their personal values. There was no difference in decision regret between people using decision aids versus those receiving usual care. Further studies are needed to assess the impact of patient decision aids on adherence and downstream effects on cost and resource use.
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Affiliation(s)
- Dawn Stacey
- School of Nursing, University of Ottawa, Ottawa, Canada
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | | | - Meg Carley
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Robert Volk
- The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elisa E Douglas
- Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Jeanette Finderup
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Michael J Barry
- Informed Medical Decisions Program, Massachusetts General Hospital, Boston, MA, USA
| | - Carol L Bennett
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Paulina Bravo
- Education and Cancer Prevention, Fundación Arturo López Pérez, Santiago, Chile
| | - Karina Steffensen
- Center for Shared Decision Making, IRS - Lillebælt Hospital, Vejle, Denmark
| | - Amédé Gogovor
- VITAM - Centre de recherche en santé durable, Université Laval, Quebec, Canada
| | - Ian D Graham
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology, Public Health and Preventative Medicine, University of Ottawa, Ottawa, Canada
| | - Shannon E Kelly
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - France Légaré
- Centre de recherche sur les soins et les services de première ligne de l'Université Laval (CERSSPL-UL), Université Laval, Quebec, Canada
| | | | - Richard Thomson
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Logan Trenaman
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
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Kamil D, Wojcik KM, Smith L, Zhang J, Wilson OWA, Butera G, Jayasekera J. A Scoping Review of Personalized, Interactive, Web-Based Clinical Decision Tools Available for Breast Cancer Prevention and Screening in the United States. MDM Policy Pract 2024; 9:23814683241236511. [PMID: 38500600 PMCID: PMC10946080 DOI: 10.1177/23814683241236511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 02/04/2024] [Indexed: 03/20/2024] Open
Abstract
Introduction. Personalized web-based clinical decision tools for breast cancer prevention and screening could address knowledge gaps, enhance patient autonomy in shared decision-making, and promote equitable care. The purpose of this review was to present evidence on the availability, usability, feasibility, acceptability, quality, and uptake of breast cancer prevention and screening tools to support their integration into clinical care. Methods. We used the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews Checklist to conduct this review. We searched 6 databases to identify literature on the development, validation, usability, feasibility, acceptability testing, and uptake of the tools into practice settings. Quality assessment for each tool was conducted using the International Patient Decision Aid Standard instrument, with quality scores ranging from 0 to 63 (lowest-highest). Results. We identified 10 tools for breast cancer prevention and 9 tools for screening. The tools included individual (e.g., age), clinical (e.g., genomic risk factors), and health behavior (e.g., alcohol use) characteristics. Fourteen tools included race/ethnicity, but no tool incorporated contextual factors (e.g., insurance, access) associated with breast cancer. All tools were internally or externally validated. Six tools had undergone usability testing in samples including White (median, 71%; range, 9%-96%), insured (99%; 97%-100%) women, with college education or higher (60%; 27%-100%). All of the tools were developed and tested in academic settings. Seven (37%) tools showed potential evidence of uptake in clinical practice. The tools had an average quality assessment score of 21 (range, 9-39). Conclusions. There is limited evidence on testing and uptake of breast cancer prevention and screening tools in diverse clinical settings. The development, testing, and integration of tools in academic and nonacademic settings could potentially improve uptake and equitable access to these tools. Highlights There were 19 personalized, interactive, Web-based decision tools for breast cancer prevention and screening.Breast cancer outcomes were personalized based on individual clinical characteristics (e.g., age, medical history), genomic risk factors (e.g., BRCA1/2), race and ethnicity, and health behaviors (e.g., smoking). The tools did not include contextual factors (e.g., insurance status, access to screening facilities) that could potentially contribute to breast cancer outcomes.Validation, usability, acceptability, and feasibility testing were conducted mostly among White and/or insured patients with some college education (or higher) in academic settings. There was limited evidence on testing and uptake of the tools in nonacademic clinical settings.
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Affiliation(s)
- Dalya Kamil
- Health Equity and Decision Sciences Research Laboratory, Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Kaitlyn M. Wojcik
- Health Equity and Decision Sciences Research Laboratory, Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Laney Smith
- Frederick P. Whiddon College of Medicine, Mobile, AL, USA
| | | | - Oliver W. A. Wilson
- Health Equity and Decision Sciences Research Laboratory, Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
| | - Gisela Butera
- Office of Research Services, National Institutes of Health Library, Bethesda, MD, USA
| | - Jinani Jayasekera
- Health Equity and Decision Sciences Research Laboratory, Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
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Beauchesne R, Birch P, Elliott AM. Genetic counselling resources in non-english languages: A scoping review. PEC INNOVATION 2023; 2:100135. [PMID: 37214519 PMCID: PMC10194398 DOI: 10.1016/j.pecinn.2023.100135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 02/06/2023] [Accepted: 02/08/2023] [Indexed: 05/24/2023]
Abstract
Objective Genetic counselling is essential for individuals seeking genetic or genomic testing. Whereas innovative strategies for GC delivery are being explored to meet the growing demand on the clinical genetics workforce, it is essential to consider the unique needs of culturally and linguistically diverse populations. Methods We conducted a scoping review to examine the extent, range, and gaps in the body of non-English, patient-facing educational resources available for Limited English Proficient (LEP) patients accessing clinical genetics and genomics services. Results The literature search returned 246 unique resources, most available in several languages. Forty-six languages were represented, with Spanish, Russian, and French being the most common. Resources were in various formats and were of varying quality. Conclusions There is a lack of high-quality supplementary genetics education material available in languages other than English, which limits the quality-of-care that LEP families may receive compared to their English-speaking counterparts. Of equal concern is the difficulty in finding existing resources and in determining their quality. Innovation This research highlights the important need for genetics education material that is of good quality in languages other than English and the challenges associated with identifying this material. A central, curated repository, perhaps sponsored by a genetic counselling organization, would be of great benefit to help genetic counsellors meet the needs of their culturally and linguistically diverse patients.
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Affiliation(s)
- Rhea Beauchesne
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Patricia Birch
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - GenCOUNSEL Study
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alison M. Elliott
- Department of Medical Genetics, University of British Columbia, Vancouver, British Columbia, Canada
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
- Women's Health Research Institute, Vancouver, British Columbia, Canada
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Walsh JME, Karliner L, Smith A, Leykin Y, Gregorich SE, Livaudais-Toman J, Velazquez AI, Lowenstein M, Kaplan CP. LungCARE: Encouraging Shared Decision-Making in Lung Cancer Screening-a Randomized Trial. J Gen Intern Med 2023; 38:3115-3122. [PMID: 37653203 PMCID: PMC10651593 DOI: 10.1007/s11606-023-08189-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 03/23/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Lung cancer screening (LCS) is recommended for individuals at high risk due to age and smoking history after a shared decision-making conversation. However, little is known about best strategies for incorporating shared decision-making, especially in a busy primary care setting. OBJECTIVE To develop a novel tool, Lung Cancer Assessment of Risk and Education (LungCARE) to guide LCS decisions among eligible primary care patients. DESIGN Pilot cluster randomized controlled trial of LungCARE versus usual care. PARTICIPANTS Patients of providers in a university primary care clinic, who met criteria for LCS. INTERVENTION Providers were randomized to LungCARE intervention or control. LungCARE participants completed a computer tablet-based video assessment of lung cancer educational needs in the waiting room prior to a primary care visit. Patient and provider both received a summary handout of patient concerns and responses. MAIN MEASURES All eligible patients completed baseline interviews by telephone. One week after the index visit, participants completed a follow-up telephone survey that assessed patient-physician discussion of LCS, referral to and scheduling of LCS, as well as LCS knowledge and acceptability of LungCARE. Two months after index visit, we reviewed patients' electronic health records (EHRs) for evidence of a shared decision-making conversation and referral to and receipt of LCS. KEY RESULTS A total of 66 participants completed baseline and follow-up visits (34: LungCARE; 32: usual care). Mean age was 65.9 (± 6.0). Based on EHR review, compared to usual care, LungCARE participants were more likely to have discussed LCS with their physicians (56% vs 25%; p = 0.04) and to be referred to LCS (44% vs 13%; p < 0.02). Intervention participants were also more likely to complete LCS (32% vs 13%; p < 0.01) and had higher knowledge scores (mean score 6.5 (± 1.7) vs 5.5 (± 1.4; p < 0.01). CONCLUSIONS LungCARE increased discussion, referral, and completion of LCS and improved LCS knowledge. CLINICAL TRIAL REGISTRATION NCT03862001.
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Affiliation(s)
- Judith M E Walsh
- Department of Medicine, Division of General Internal Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA.
- Multi-Ethnic Health Equity Research Center, UCSF, San Francisco, CA, USA.
- Helen Diller Family Comprehensive Cancer Center, UCSF, San Francisco, CA, USA.
| | - Leah Karliner
- Department of Medicine, Division of General Internal Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
- Multi-Ethnic Health Equity Research Center, UCSF, San Francisco, CA, USA
| | - Ashley Smith
- Department of Medicine, Division of General Internal Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | - Yan Leykin
- Department of Psychology, Palo Alto University, Palo Alto, CA, USA
| | - Steven E Gregorich
- Department of Medicine, Division of General Internal Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
- Multi-Ethnic Health Equity Research Center, UCSF, San Francisco, CA, USA
| | - Jennifer Livaudais-Toman
- Department of Medicine, Division of General Internal Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
| | - Ana I Velazquez
- Multi-Ethnic Health Equity Research Center, UCSF, San Francisco, CA, USA
- Helen Diller Family Comprehensive Cancer Center, UCSF, San Francisco, CA, USA
- Department of Medicine, Division of Hematology/Oncology, UCSF, San Francisco, CA, USA
| | - Margaret Lowenstein
- Division of General Internal Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, Philadelphia, PA, USA
| | - Celia P Kaplan
- Department of Medicine, Division of General Internal Medicine, University of California, San Francisco (UCSF), San Francisco, CA, USA
- Multi-Ethnic Health Equity Research Center, UCSF, San Francisco, CA, USA
- Helen Diller Family Comprehensive Cancer Center, UCSF, San Francisco, CA, USA
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Usher-Smith JA, Hindmarch S, French DP, Tischkowitz M, Moorthie S, Walter FM, Dennison RA, Stutzin Donoso F, Archer S, Taylor L, Emery J, Morris S, Easton DF, Antoniou AC. Proactive breast cancer risk assessment in primary care: a review based on the principles of screening. Br J Cancer 2023; 128:1636-1646. [PMID: 36737659 PMCID: PMC9897164 DOI: 10.1038/s41416-023-02145-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 01/05/2023] [Accepted: 01/06/2023] [Indexed: 02/05/2023] Open
Abstract
In the UK, the National Institute for Health and Care Excellence (NICE) recommends that women at moderate or high risk of breast cancer be offered risk-reducing medication and enhanced breast screening/surveillance. In June 2022, NICE withdrew a statement recommending assessment of risk in primary care only when women present with concerns. This shift to the proactive assessment of risk substantially changes the role of primary care, in effect paving the way for a primary care-based screening programme to identify those at moderate or high risk of breast cancer. In this article, we review the literature surrounding proactive breast cancer risk assessment within primary care against the consolidated framework for screening. We find that risk assessment for women under 50 years currently satisfies many of the standard principles for screening. Most notably, there are large numbers of women at moderate or high risk currently unidentified, risk models exist that can identify those women with reasonable accuracy, and management options offer the opportunity to reduce breast cancer incidence and mortality in that group. However, there remain a number of uncertainties and research gaps, particularly around the programme/system requirements, that need to be addressed before these benefits can be realised.
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Affiliation(s)
- Juliet A. Usher-Smith
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Sarah Hindmarch
- grid.5379.80000000121662407Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - David P. French
- grid.5379.80000000121662407Manchester Centre for Health Psychology, Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Marc Tischkowitz
- grid.5335.00000000121885934Department of Medical Genetics, National Institute for Health Research Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Sowmiya Moorthie
- grid.5335.00000000121885934PHG Foundation, University of Cambridge, Cambridge, UK
| | - Fiona M. Walter
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK ,grid.4868.20000 0001 2171 1133Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Rebecca A. Dennison
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Francisca Stutzin Donoso
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Stephanie Archer
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK ,grid.5335.00000000121885934Department of Psychology, University of Cambridge, Cambridge, UK
| | - Lily Taylor
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jon Emery
- grid.1008.90000 0001 2179 088XCentre for Cancer Research and Department of General Practice, University of Melbourne, Melbourne, VIC Australia
| | - Stephen Morris
- grid.5335.00000000121885934The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Douglas F. Easton
- grid.5335.00000000121885934Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Antonis C. Antoniou
- grid.5335.00000000121885934Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Beidler LB, Kressin NR, Wormwood JB, Battaglia TA, Slanetz PJ, Gunn CM. Perceptions of Breast Cancer Risks Among Women Receiving Mammograph Screening. JAMA Netw Open 2023; 6:e2252209. [PMID: 36689223 PMCID: PMC9871800 DOI: 10.1001/jamanetworkopen.2022.52209] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 12/02/2022] [Indexed: 01/24/2023] Open
Abstract
Importance Breast density is an independent risk factor for breast cancer. Despite the proliferation of mandated written notifications about breast density following mammography, there is little understanding of how women perceive the relative breast cancer risk associated with breast density. Objective To assess women's perception of breast density compared with other breast cancer risks and explore their understanding of risk reduction. Design, Setting, and Participants This mixed-methods qualitative study used telephone surveys and semistructured interviews to investigate perceptions about breast cancer risk among a nationally representative, population-based sample of women. Eligible study participants were aged 40 to 76 years, reported having recently undergone mammography, had no history of prior breast cancer, and had heard of breast density. Survey participants who had been informed of their personal breast density were invited for a qualitative interview. Survey administration spanned July 1, 2019, to April 30, 2020, with 2306 women completing the survey. Qualitative interviews were conducted from February 1 to May 30, 2020. Main Outcomes and Measures Respondents compared the breast cancer risk associated with breast density with 5 other risk factors. Participants qualitatively described what they thought contributed to breast cancer risk and ways to reduce risk. Results Of the 2306 women who completed the survey, 1858 (166 [9%] Asian, 503 [27%] Black, 268 [14%] Hispanic, 792 [43%] White, and 128 [7%] other race or ethnicity; 358 [19%] aged 40-49 years, 906 [49%] aged 50-64 years, and 594 [32%] aged ≥65 years) completed the revised risk perception questions and were included in the analysis. Half of respondents thought breast density to be a greater risk than not having children (957 [52%]), having more than 1 alcoholic drink per day (975 [53%]), or having a prior breast biopsy (867 [48%]). Most respondents felt breast density was a lesser risk than having a first-degree relative with breast cancer (1706 [93%]) or being overweight or obese (1188 [65%]). Of the 61 women who were interviewed, 6 (10%) described breast density as contributing to breast cancer risk, and 43 (70%) emphasized family history as a breast cancer risk factor. Of the interviewed women, 17 (28%) stated they did not know whether it was possible to reduce their breast cancer risk. Conclusions and Relevance In this qualitative study of women of breast cancer screening age, family history was perceived as the primary breast cancer risk factor. Most interviewees did not identify breast density as a risk factor and did not feel confident about actions to mitigate breast cancer risk. Comprehensive education about breast cancer risks and prevention strategies is needed.
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Affiliation(s)
- Laura B. Beidler
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Nancy R. Kressin
- Section of General Internal Medicine, Boston University Chobanian and Avedesian School of Medicine, Boston, Massachusetts
| | | | - Tracy A. Battaglia
- Section of General Internal Medicine, Boston University Chobanian and Avedesian School of Medicine, Boston, Massachusetts
| | - Priscilla J. Slanetz
- Department of Radiology, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Christine M. Gunn
- Dartmouth Cancer Center, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
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Crew KD, Bhatkhande G, Silverman T, Amenta J, Jones T, McGuinness JE, Mata J, Guzman A, He T, Dimond J, Tsai WY, Kukafka R. Patient and Provider Web-Based Decision Support for Breast Cancer Chemoprevention: A Randomized Controlled Trial. Cancer Prev Res (Phila) 2022; 15:689-700. [PMID: 35679576 PMCID: PMC9532364 DOI: 10.1158/1940-6207.capr-22-0013] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 05/09/2022] [Accepted: 06/06/2022] [Indexed: 11/16/2022]
Abstract
Significant underutilization of breast cancer chemoprevention remains, despite guidelines stating that physicians should recommend chemoprevention with antiestrogen therapy to high-risk women. We randomized women, ages 35 to 75 years, who met high-risk criteria for breast cancer, without a personal history of breast cancer or prior chemoprevention use, to standard educational materials alone or combined with a web-based decision aid. All healthcare providers, including primary care providers and breast specialists, were given access to a web-based decision support tool. The primary endpoint was chemoprevention uptake at 6 months. Secondary outcomes included decision antecedents (perceived breast cancer risk/worry, chemoprevention knowledge, self-efficacy) and decision quality (decision conflict, chemoprevention informed choice) based upon patient surveys administered at baseline, 1 and 6 months after randomization. Among 282 evaluable high-risk women enrolled from November 2016 to March 2020, mean age was 57 years (SD, 9.9) and mean 5-year invasive breast cancer risk was 2.98% (SD, 1.42). There was no significant difference in chemoprevention uptake at 6 months between the intervention and control groups (2.1% vs. 3.5%). Comparing the intervention and control arms at 1 month, there were significant differences among high-risk women in accurate breast cancer risk perceptions (56% vs. 39%, P = 0.017), adequate chemoprevention knowledge (49% vs. 27%, P < 0.001), mean decision conflict (34.0 vs. 47.0, P < 0.001), and informed choice (41% vs. 23%, P = 0.003). These differences were no longer significant at 6 months. Although our decision support tools did not result in a significant increase in chemoprevention uptake, we did observe improvements in decision antecedents and decision quality measures. PREVENTION RELEVANCE In this randomized controlled trial of decision support for 300 high-risk women and 50 healthcare providers, we did not observe a significant increase in chemoprevention uptake, which remained low at under 5%. However, these decision support tools may increase knowledge and informed choice about breast cancer chemoprevention.
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Affiliation(s)
- Katherine D. Crew
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY
- Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
| | - Gauri Bhatkhande
- Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY
| | - Thomas Silverman
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY
| | - Jacquelyn Amenta
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY
| | - Tarsha Jones
- Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, FL
| | - Julia E. McGuinness
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
| | - Jennie Mata
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
| | - Ashlee Guzman
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
| | - Ting He
- Department of Biomedical Informatics and Data Sciences, Johns Hopkins University, Baltimore, MD
| | | | - Wei-Yann Tsai
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
- Department of Biostatistics, Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY
| | - Rita Kukafka
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY
- Department of Biomedical Informatics, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY
- Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University Irving Medical Center, New York, NY
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9
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Nadler MB, Corrado AM, Desveaux L, Neil-Sztramko SE, Wilson BE, Desnoyers A, Amir E, Ivers N. Determinants of guideline-concordant breast cancer screening by family physicians for women aged 40-49 years: a qualitative analysis. CMAJ Open 2022; 10:E900-E910. [PMID: 36257683 PMCID: PMC9616605 DOI: 10.9778/cmajo.20210266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Although the current Canadian Task Force on Preventive Health Care guideline recommends that physicians should inform women aged 40-49 years of the potential benefits and harms of screening mammography to support individualized decisions, previous reports of variation in clinical practice at the physician level suggest a lack of guideline-concordant care. We explored determinants (barriers and facilitators) of guideline-concordant care by family physicians regarding screening mammography in this age group. METHODS We conducted qualitative semi-structured interviews by phone with family physicians in the Greater Toronto Area from January to November 2020. We structured interviews using the Theoretical Domains Framework to explore determinants (barriers and facilitators) of 5 physician screening behaviours, namely risk assessment, discussion regarding benefits and harms, decision or referral for mammography, referral for genetic counselling and referral to high-risk screening programs. Two independent researchers iteratively analyzed interview transcripts and deductively coded for each behaviour by domain to identify key behavioural determinants until saturation was reached. RESULTS We interviewed 18 physicians (mean age 48 yr, 72% self-identified as women). Risk assessment was influenced by physicians' knowledge of risk factors, skills to synthesize risk and beliefs about utility. Physicians had beliefs in their capabilities to have informed patient-centred discussions, but insufficient knowledge regarding the harms of screening. The decision or referral for mammography was affected by emotions related to past patient outcomes, social influences of patients and radiology departments, and knowledge and beliefs about consequences (benefits and harms of screening). Referrals for genetic counselling and to high-risk screening programs were facilitated by their availability and by the knowledge and skills to complete forms. Lack of knowledge regarding which patients qualify and beliefs about consequences were barriers to referral. INTERPRETATION Insufficient knowledge and skills for performance of risk assessment, combined with a tendency to overestimate benefits of screening relative to harms affected provision of guideline-concordant care. These may be effective targets for future interventions to improve guideline-concordant care.
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Affiliation(s)
- Michelle B Nadler
- Division of Medical Oncology & Hematology, Department of Medicine (Nadler, Wilson, Desnoyers, Amir), Princess Margaret Cancer Centre; Department of Medicine (Nadler, Wilson, Desnoyers, Amir), University of Toronto; The Peter Gilgan Centre for Women's Cancers (Corrado, Ivers), Women's College Hospital; Institute for Better Health (Desveaux), Trillium Health Partners; Institute of Health Policy, Management and Evaluation (Desveaux, Amir, Ivers), Dalla Lana School of Public Health, University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Desveaux), Toronto, Ont.; Department of Health Research Methods, Evidence & Impact, Faculty of Health Sciences (Neil-Sztramko), McMaster University, Hamilton Ont.; University of New South Wales (Wilson, Ivers), Sydney, Australia; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont.
| | - Ann Marie Corrado
- Division of Medical Oncology & Hematology, Department of Medicine (Nadler, Wilson, Desnoyers, Amir), Princess Margaret Cancer Centre; Department of Medicine (Nadler, Wilson, Desnoyers, Amir), University of Toronto; The Peter Gilgan Centre for Women's Cancers (Corrado, Ivers), Women's College Hospital; Institute for Better Health (Desveaux), Trillium Health Partners; Institute of Health Policy, Management and Evaluation (Desveaux, Amir, Ivers), Dalla Lana School of Public Health, University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Desveaux), Toronto, Ont.; Department of Health Research Methods, Evidence & Impact, Faculty of Health Sciences (Neil-Sztramko), McMaster University, Hamilton Ont.; University of New South Wales (Wilson, Ivers), Sydney, Australia; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
| | - Laura Desveaux
- Division of Medical Oncology & Hematology, Department of Medicine (Nadler, Wilson, Desnoyers, Amir), Princess Margaret Cancer Centre; Department of Medicine (Nadler, Wilson, Desnoyers, Amir), University of Toronto; The Peter Gilgan Centre for Women's Cancers (Corrado, Ivers), Women's College Hospital; Institute for Better Health (Desveaux), Trillium Health Partners; Institute of Health Policy, Management and Evaluation (Desveaux, Amir, Ivers), Dalla Lana School of Public Health, University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Desveaux), Toronto, Ont.; Department of Health Research Methods, Evidence & Impact, Faculty of Health Sciences (Neil-Sztramko), McMaster University, Hamilton Ont.; University of New South Wales (Wilson, Ivers), Sydney, Australia; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
| | - Sarah E Neil-Sztramko
- Division of Medical Oncology & Hematology, Department of Medicine (Nadler, Wilson, Desnoyers, Amir), Princess Margaret Cancer Centre; Department of Medicine (Nadler, Wilson, Desnoyers, Amir), University of Toronto; The Peter Gilgan Centre for Women's Cancers (Corrado, Ivers), Women's College Hospital; Institute for Better Health (Desveaux), Trillium Health Partners; Institute of Health Policy, Management and Evaluation (Desveaux, Amir, Ivers), Dalla Lana School of Public Health, University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Desveaux), Toronto, Ont.; Department of Health Research Methods, Evidence & Impact, Faculty of Health Sciences (Neil-Sztramko), McMaster University, Hamilton Ont.; University of New South Wales (Wilson, Ivers), Sydney, Australia; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
| | - Brooke E Wilson
- Division of Medical Oncology & Hematology, Department of Medicine (Nadler, Wilson, Desnoyers, Amir), Princess Margaret Cancer Centre; Department of Medicine (Nadler, Wilson, Desnoyers, Amir), University of Toronto; The Peter Gilgan Centre for Women's Cancers (Corrado, Ivers), Women's College Hospital; Institute for Better Health (Desveaux), Trillium Health Partners; Institute of Health Policy, Management and Evaluation (Desveaux, Amir, Ivers), Dalla Lana School of Public Health, University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Desveaux), Toronto, Ont.; Department of Health Research Methods, Evidence & Impact, Faculty of Health Sciences (Neil-Sztramko), McMaster University, Hamilton Ont.; University of New South Wales (Wilson, Ivers), Sydney, Australia; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
| | - Alexandra Desnoyers
- Division of Medical Oncology & Hematology, Department of Medicine (Nadler, Wilson, Desnoyers, Amir), Princess Margaret Cancer Centre; Department of Medicine (Nadler, Wilson, Desnoyers, Amir), University of Toronto; The Peter Gilgan Centre for Women's Cancers (Corrado, Ivers), Women's College Hospital; Institute for Better Health (Desveaux), Trillium Health Partners; Institute of Health Policy, Management and Evaluation (Desveaux, Amir, Ivers), Dalla Lana School of Public Health, University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Desveaux), Toronto, Ont.; Department of Health Research Methods, Evidence & Impact, Faculty of Health Sciences (Neil-Sztramko), McMaster University, Hamilton Ont.; University of New South Wales (Wilson, Ivers), Sydney, Australia; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
| | - Eitan Amir
- Division of Medical Oncology & Hematology, Department of Medicine (Nadler, Wilson, Desnoyers, Amir), Princess Margaret Cancer Centre; Department of Medicine (Nadler, Wilson, Desnoyers, Amir), University of Toronto; The Peter Gilgan Centre for Women's Cancers (Corrado, Ivers), Women's College Hospital; Institute for Better Health (Desveaux), Trillium Health Partners; Institute of Health Policy, Management and Evaluation (Desveaux, Amir, Ivers), Dalla Lana School of Public Health, University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Desveaux), Toronto, Ont.; Department of Health Research Methods, Evidence & Impact, Faculty of Health Sciences (Neil-Sztramko), McMaster University, Hamilton Ont.; University of New South Wales (Wilson, Ivers), Sydney, Australia; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
| | - Noah Ivers
- Division of Medical Oncology & Hematology, Department of Medicine (Nadler, Wilson, Desnoyers, Amir), Princess Margaret Cancer Centre; Department of Medicine (Nadler, Wilson, Desnoyers, Amir), University of Toronto; The Peter Gilgan Centre for Women's Cancers (Corrado, Ivers), Women's College Hospital; Institute for Better Health (Desveaux), Trillium Health Partners; Institute of Health Policy, Management and Evaluation (Desveaux, Amir, Ivers), Dalla Lana School of Public Health, University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Desveaux), Toronto, Ont.; Department of Health Research Methods, Evidence & Impact, Faculty of Health Sciences (Neil-Sztramko), McMaster University, Hamilton Ont.; University of New South Wales (Wilson, Ivers), Sydney, Australia; Department of Family and Community Medicine (Ivers), University of Toronto, Toronto, Ont
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10
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Chou AF, Duncan AR, Hallford G, Kelley DM, Dean LW. Barriers and strategies to integrate medical genetics and primary care in underserved populations: a scoping review. J Community Genet 2021; 12:291-309. [PMID: 33523369 PMCID: PMC7849219 DOI: 10.1007/s12687-021-00508-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 01/18/2021] [Indexed: 01/18/2023] Open
Abstract
Despite clinical and technological advances, serious gaps remain in delivering genetic services due to disparities in workforce distribution and lack of coverage for genetic testing and counseling. Genetic services delivery, particularly in medically underserved populations, may rely heavily on primary care providers (PCPs). This study aims to identify barriers to integrating genetic services and primary care, and strategies to support integration, by conducting a scoping review. Literature synthesis found barriers most frequently cited by PCPs including insufficient knowledge about genetics and risk assessment, lack of access to geneticists, and insufficient time to address these challenges. Telegenetics, patient-centered care, and learning communities are strategies to overcome these barriers. Telegenetics supplements face-to-face clinics by providing remote access to genetic services. It may also be used for physician consultations and education. Patient-centered care allows providers, families, and patients to coordinate services and resources. Access to expert information provides a critical resource for PCPs. Learning communities may represent a mechanism that facilitates information exchange and knowledge sharing among different providers. As PCPs often play a crucial role caring for patients with genetic disorders in underserved areas, barriers to primary care-medical genetics integration must be addressed to improve access. Strategies, such as telegenetics, promotion of evidence-based guidelines, point-of-care risk assessment tools, tailored education in genetics-related topics, and other system-level strategies, will facilitate better genetics and primary care integration, which in turn, may improve genetic service delivery to patients residing in underserved communities.
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Affiliation(s)
- Ann F Chou
- Department of Family and Preventive Medicine, College of Medicine, The University of Oklahoma Health Sciences Center (OUHSC), 900 NE 10th St., Oklahoma City, OK, 73151, USA.
| | | | - Gene Hallford
- Department of Pediatrics, College of Medicine, OUHSC, Oklahoma City, OK, USA
| | - David M Kelley
- Department of Family and Preventive Medicine, College of Medicine, The University of Oklahoma Health Sciences Center (OUHSC), 900 NE 10th St., Oklahoma City, OK, 73151, USA
| | - Lori Williamson Dean
- Department of Genetic Counseling, College of Health Professions, The University of Arkansas for Medical Sciences, Little Rock, AR, USA
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11
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Kaplan CP, Karliner L, Lee A, Livaudais-Toman J, Tice JA, Ozanne E. Acceptability of an mHealth breast cancer risk-reduction intervention promoting risk assessment, education, and discussion of risk in the primary care setting. Mhealth 2021; 7:54. [PMID: 34805385 PMCID: PMC8572750 DOI: 10.21037/mhealth-20-82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 12/21/2020] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Breast cancer risk assessment tools and risk reduction strategies have advanced significantly over the past few decades but are underutilized in practice, due in part to limited acceptability by patients and physicians. We implemented a tablet-based Breast Cancer Risk Education Intervention (BreastCARE) tailored towards increasing patients' knowledge about their individual risk of developing breast cancer, increasing patient-physician discussion of breast cancer risk reduction practices, and increasing participation in recommended screening. METHODS We surveyed patients and physicians who received the BreastCARE intervention and analyzed their satisfaction and acceptability of the intervention. We compared patient satisfaction measures by race/ethnicity and used multivariable logistic regression models to examine the effect of race/ethnicity on measures of patient satisfaction with the tablet-based risk assessment and with the breast cancer risk report. We also compared measures of physician satisfaction by resident vs. attending/NP status. Finally, we identified patients' and physicians' suggestions for implementation. RESULTS Overall, both patients and physicians were highly satisfied with BreastCARE, with some variation by patient race/ethnicity and breast cancer risk status. The risk assessment tool and accompanying risk report helped transmit complex information in an efficient way. CONCLUSIONS Patient self-administered risk assessment with a health education component at the point of care is acceptable for both patients and physicians, and represents a novel approach to facilitating health promotion. This risk assessment tool should be made routine in primary care accompanied by results that are easy for the patient to understand and actionable for the clinician.
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Affiliation(s)
- Celia P. Kaplan
- Division of General Internal Medicine, University of California, San Francisco, CA, USA
- Multiethnic Health Equity Research Center, University of California, San Francisco, CA, USA
| | - Leah Karliner
- Division of General Internal Medicine, University of California, San Francisco, CA, USA
- Multiethnic Health Equity Research Center, University of California, San Francisco, CA, USA
| | - Andrew Lee
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA, USA
| | | | - Jeffrey A. Tice
- Division of General Internal Medicine, University of California, San Francisco, CA, USA
| | - Elissa Ozanne
- Population Health Science, University of Utah School of Medicine, Salt Lake City, UT, USA
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12
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A Pre-Test-Post-Test Trial of a Breast Cancer Risk Report for Women in Their 40s. Am J Prev Med 2020; 59:343-354. [PMID: 32828322 DOI: 10.1016/j.amepre.2020.04.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 03/31/2020] [Accepted: 04/05/2020] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Guidelines recommend individualized breast cancer screening and prevention interventions for women in their 40s. Yet, few primary care clinicians assess breast cancer risk. STUDY DESIGN Pretest-Posttest trial. SETTING/PARTICIPANTS Women aged 40-49 years were recruited from one large Boston-based academic primary care practice between July 2017 and April 2019. INTERVENTION Participants completed a pretest, received a personalized breast cancer risk report, saw their primary care clinician, and completed a posttest. MAIN OUTCOME MEASURES Using mixed effects models, changes in screening intentions (0-100 scale [0=will not screen to 100=will screen]), mammography knowledge, decisional conflict, and receipt of screening were examined. Analyses were conducted from June 2019 to February 2020. RESULTS Patient (n=337) mean age was 44.1 (SD=2.9) years, 61.4% were non-Hispanic white, and 76.6% were college graduates; 306 (90.5%) completed follow-up (203 with 5-year breast cancer risk <1.1%). Screening intentions declined from pre- to post-visit (79.3 to 68.0, p<0.0001), especially for women with 5-year risk <1.1% (77.2 to 63.3, p<0.0001), but still favored screening. In the 2 years prior, 37.6% had screening mammography compared with 41.8% over a mean 16 months follow-up (p=0.17). Mammography knowledge increased and decisional conflict declined. Eleven (3.3%) women met criteria for breast cancer prevention medications (ten discussed medications with their clinicians), 22 (6.5%) for MRI (19 discussed MRI with their clinician), and 67 (19.8%) for genetic counseling (47 discussed with the clinician). CONCLUSIONS Receipt of a personalized breast cancer report was associated with women in their 40s making more-informed and less-conflicted mammography screening decisions and with high-risk women discussing breast cancer prevention interventions with clinicians. TRIAL REGISTRATION This study is registered at www.clinicaltrials.govNCT03180086.
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13
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Laws A, Mulvey TM. 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. JCO Oncol Pract 2020; 17:e217-e225. [PMID: 32822256 DOI: 10.1200/op.20.00256] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Alison Laws
- Department of Surgical Oncology, Massachusetts General Hospital, Boston, MA
| | - Therese M Mulvey
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA
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14
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Gunn C, Maschke A, Bickmore T, Kennedy M, Hopkins MF, Fishman MDC, Paasche-Orlow MK, Warner ET. Acceptability of an Interactive Computer-Animated Agent to Promote Patient-Provider Communication About Breast Density: a Mixed Method Pilot Study. J Gen Intern Med 2020; 35:1069-1077. [PMID: 31919723 PMCID: PMC7174461 DOI: 10.1007/s11606-019-05622-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 12/13/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Half of women undergoing mammography have dense breasts. Mandatory dense breast notification and educational materials have been shown to confuse women, rather than empower them. OBJECTIVE This study used a mixed method, multi-stakeholder approach to assess acceptability of an interactive, computer-animated agent that provided breast density information to women and changes in knowledge, satisfaction, and informational needs. DESIGN A pre-post survey and qualitative focus groups assessed the acceptability of the computer-animated agent among women. An anonymous, online survey measuring acceptability was delivered to a multi-stakeholder group. PARTICIPANTS English-speaking, mammography-eligible women ages 40-74 were invited and 44 women participated in one of nine focus groups. In addition, 14 stakeholders representing primary care, radiology, patient advocates, public health practitioners, and researchers completed the online survey. INTERVENTIONS A prototype of a computer-animated agent was delivered to women in a group setting; stakeholders viewed the prototype independently. MAIN MEASURES Data collected included open-ended qualitative questions that guided discussion about the content and form of the computer-animated agent. Structured surveys included domains related to knowledge, acceptability, and satisfaction. Stakeholder acceptability was measured with a series of statements about aspects of the intervention and delivery approach and are reported as the proportion of respondents who endorsed each statement. KEY RESULTS Six of 12 knowledge items demonstrated improvement post-intervention, satisfaction with the agent was high (81%), but the number of unanswered questions did not improve (67% vs. 54%, p = 0.37). Understanding of the distinction between connective and fatty tissue in the breast did not increase (30% vs. 26%, p = 0.48). Results of the multi-stakeholder survey suggest broad acceptability of the approach and agent. CONCLUSIONS Findings highlight the benefits of a brief interactive educational exposure as well as misperceptions that persisted. Results demonstrate the need for an evidence-based, accessible intervention that is easy to understand for patients.
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Affiliation(s)
- Christine Gunn
- Department of Medicine, Section of General Internal Medicine, Women's Health Unit, Boston University School of Medicine, 801 Massachusetts Avenue, First Floor, Boston, MA, 02118, USA.
| | - Ariel Maschke
- Department of Medicine, Section of General Internal Medicine, Women's Health Unit, Boston University School of Medicine, 801 Massachusetts Avenue, First Floor, Boston, MA, 02118, USA
| | - Timothy Bickmore
- Khoury College of Computer Sciences, Northeastern University, Boston, USA
| | | | | | - Michael D C Fishman
- Department of Radiology, Boston Medical Center, Section of Breast Imaging, Boston University School of Medicine, Boston, USA
| | - Michael K Paasche-Orlow
- Department of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston University School of Medicine, Boston, USA
| | - Erica T Warner
- Department of Medicine, Massachusetts General Hospital, Boston, USA
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Ozanne E, Karliner LS, Tice JA, Haas JS, Livaudais-Toman J, Pasick RJ, Kaplan CP. An Intervention Tool to Increase Patient-Physician Discussion of Lifestyle Risk Factors for Breast Cancer. J Womens Health (Larchmt) 2019; 28:1468-1475. [PMID: 30222505 PMCID: PMC7207052 DOI: 10.1089/jwh.2018.7026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background: Risk assessment and discussion of lifestyle in primary care are crucial elements of breast cancer prevention and risk reduction. Our objective was to evaluate the impact of a breast cancer risk assessment and education tool on patient-physician discussion of behaviors and breast cancer risk. Materials and Methods: We conducted a randomized controlled trial with an ethnically and linguistically diverse sample of women, ages 40-74, from two primary care practices. Intervention participants completed a tablet computer-based Breast Cancer Risk Assessment and Education (BreastCARE) intervention in the waiting room before a scheduled visit. Both patients and physicians received an individualized risk report to discuss during the visit. Control patients underwent usual care. Telephone surveys assessed patient-physician discussion of weight, exercise, and alcohol use 1 week following the visit. Results: Among the 1235 participants, 27.7% (161/580) intervention and 22.3% (146/655) usual-care patients were high risk for breast cancer. Adjusting for clustering by physician, the intervention increased discussions of regular exercise (odds ratios [OR] = 1.94, 1.50-2.51) and weight (OR = 1.56, 1.23-1.96). There was no effect of the intervention on discussion of alcohol. Women with some college education were more likely to discuss their weight than those with high school education or less (OR = 1.75, 1.03-2.96). Similarly, non-English speakers were more likely to discuss their weight compared with English speakers (OR = 2.33, 1.04-5.22). Conclusions: BreastCARE is a feasible risk assessment tool that can successfully promote discussions about modifiable breast cancer risk factors between patients and primary care physicians.
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Affiliation(s)
- Elissa Ozanne
- Division of Health System Innovation and Research, Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
| | - Leah S. Karliner
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, California
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California
- Multi-Ethnic Health Equity Research Center, University of California San Francisco, San Francisco, California
| | - Jeffrey A. Tice
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Jennifer S. Haas
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jennifer Livaudais-Toman
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Rena J. Pasick
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, California
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California
| | - Celia P. Kaplan
- Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, California
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California
- Multi-Ethnic Health Equity Research Center, University of California San Francisco, San Francisco, California
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Haas JS, Giess CS, Harris KA, Ansolabehere J, Kaplan CP. Randomized Trial of Personalized Breast Density and Breast Cancer Risk Notification. J Gen Intern Med 2019; 34:591-597. [PMID: 30091121 PMCID: PMC6445917 DOI: 10.1007/s11606-018-4622-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 06/15/2018] [Accepted: 07/27/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Despite widespread implementation of mammographic breast density (MBD) notification laws, the impact of these laws on knowledge of MBD and knowledge of breast cancer risk is limited by the lack of tools to promote informed decision-making in practice. OBJECTIVE To develop and evaluate whether brief, personalized informational videos following a normal mammogram in addition to a legislatively required letter about MBD result can improve knowledge of MBD and breast cancer risk compared to standard care (i.e., legislatively required letter about MBD included with the mammogram result). DESIGN/PARTICIPANTS Prospective randomized controlled trial of English-speaking women, age 40-74 years, without prior history of breast cancer, receiving a screening mammogram with a normal or benign finding (intervention group n = 235, control group n = 224). INTERVENTION brief (3-5 min) video, personalized to a woman's MBD result and breast cancer risk. MAIN MEASURES Primary outcomes were a woman's knowledge of her MBD and risk of breast cancer. Secondary outcomes included whether a woman reported that she discussed the results of her mammogram with her primary care provider (PCP). KEY RESULTS Relative to women in the control arm, women in the intervention arm had greater improvement in their knowledge of both their personal MBD (intervention pre/post 39.2%/ 77.5%; control pre/post 36.2%/ 37.5%; odds ratio (OR) 5.34 for change for intervention vs. control, 95% confidence interval (CI) 3.87-7.36; p < 0.001) and risk of breast cancer (intervention pre/post: 66.8%/74.0%; control pre/post 67.9%/ 65.2%; OR 1.42, 95% confidence interval (CI) 1.09-1.84; p = 0.01). Women in the intervention group were more likely than those in the control group to report discussing the results of their mammogram with their PCP (p = 0.05). CONCLUSIONS Brief, personalized videos following mammography can improve knowledge of MBD and personal risk of breast cancer compared to a legislatively mandated informational letter. Trial Registration Clinicaltrials.gov (NCT02986360).
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Affiliation(s)
- Jennifer S Haas
- Division of General Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
| | - Catherine S Giess
- Department of Radiology, Division of Breast Imaging, Brigham and Women's Hospital, Boston, MA, USA
| | - Kimberly A Harris
- Division of General Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Julia Ansolabehere
- Division of General Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Celia P Kaplan
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
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Pilot study of decision support tools on breast cancer chemoprevention for high-risk women and healthcare providers in the primary care setting. BMC Med Inform Decis Mak 2018; 18:134. [PMID: 30558581 PMCID: PMC6296071 DOI: 10.1186/s12911-018-0716-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 12/03/2018] [Indexed: 02/08/2023] Open
Abstract
Background Breast cancer chemoprevention can reduce breast cancer incidence in high-risk women; however, chemoprevention is underutilized in the primary care setting. We conducted a pilot study of decision support tools among high-risk women and their primary care providers (PCPs). Methods The intervention included a decision aid (DA) for high-risk women, RealRisks, and a provider-centered tool, Breast Cancer Risk Navigation (BNAV). Patients completed validated surveys at baseline, after RealRisks and after their PCP clinical encounter or at 6-months. Referral for high-risk consultation and chemoprevention uptake were assessed via the electronic health record. The primary endpoint was accuracy of breast cancer risk perception at 6-months. Results Among 40 evaluable high-risk women, median age was 64.5 years and median 5-year breast cancer risk was 2.19%. After exposure to RealRisks, patients demonstrated an improvement in accurate breast cancer risk perceptions (p = 0.02), an increase in chemoprevention knowledge (p < 0.01), and 24% expressed interest in taking chemoprevention. Three women had a high-risk referral, and no one initiated chemoprevention. Decisional conflict significantly increased from after exposure to RealRisks to after their clinical encounter or at 6-months (p < 0.01). Accurate breast cancer risk perceptions improved and was sustained at 6-months or after clinical encounters. We discuss the side effect profile of chemoprevention and the care pathway when RealRisks was introduced to understand why patients experienced increased decision conflict. Conclusion Future interventions should carefully link the use of a DA more proximally to the clinical encounter, investigate timed measurements of decision conflict and improve risk communication, shared decision making, and chemoprevention education for PCPs. Additional work remains to better understand the impact of decision aids targeting both patients and providers. Trial registration ClinicalTrials.gov Identifier: NCT02954900 November 4, 2016 Retrospectively registered.
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18
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van Erkelens A, Sie AS, Spanier MBW, van Kouwen M, Visser A, Prins JB, Hoogerbrugge N. An online self-test added to colorectal cancer screening can increase the effectiveness of familial cancer risk assessment without increasing distress. Colorectal Dis 2018; 20:897-904. [PMID: 29956442 DOI: 10.1111/codi.14319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 05/28/2018] [Indexed: 02/08/2023]
Abstract
AIM Most people who are at increased familial colorectal cancer (FCRC) risk are not identified, despite the need for enhanced surveillance colonoscopy for effective CRC prevention. An online self-test may enhance this identification. We assessed whether taking an online self-test to identify increased FCRC risk increases anxiety, distress or CRC risk perception in population-based CRC screening. METHOD After the precolonoscopy consultation, patients who had a positive immunohistochemical occult faecal blood test (iFOBT+) in population-based CRC screening were invited by email to take an online self-test at home which returned details of family history. Anxiety (STAI-DY), distress (HADS) and CRC risk perception were assessed immediately before and after taking the online self-test and 2 weeks later. RESULTS Of 250 participants invited, 177 (71%) completed the online self-test and psychological questionnaires and 153 (61%) completed questionnaires 2 weeks later. The median age was 65 years (range 61-75). The FCRC risk was increased in 17 participants (9.6%). Of these, 12 (6.8%) had a highly increased FCRC risk and may benefit from germline genetic testing for Lynch syndrome. In 7 of 17 participants (40%) the self-test obtained novel information on family history. Anxiety and distress levels were, and remained, below a clinically relevant level. Perception of CRC risk remained unchanged. Most participants (83%) would recommend the online self-test to others. CONCLUSION Of those with a iFOBT+, 9.6% had a previously unidentified increasedFCRC risk and require an enhanced surveillance colonoscopy instead of iFOBT. As screening for this risk did not increase anxiety or distress, and was highly acceptable, we recommend adding the online self-test to population-based CRC screening.
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Affiliation(s)
- A van Erkelens
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A S Sie
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - M B W Spanier
- Department of Gastroenterology and Hepatology, Rijnstate Hospital, Arnhem, The Netherlands
| | - M van Kouwen
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A Visser
- Department of Medical Psychology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J B Prins
- Department of Medical Psychology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - N Hoogerbrugge
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
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E Anderson E, Tejada S, B Warnecke R, Hoskins K. Views of Low-Income Women of Color at Increased Risk for Breast Cancer. Narrat Inq Bioeth 2018; 8:53-66. [PMID: 29657180 DOI: 10.1353/nib.2018.0023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Individual risk assessment (IRA) for breast cancer may increase adherence to risk-appropriate screening and prevention measures. However, knowledge gaps exist regarding how best to communicate IRA results and support women at increased risk in future health care decisions, in part because patients conceptualize and make meaning of risk differently from the medical community. Better understanding the views of low-income women of color identified as being at increased risk for breast cancer can inform efforts to conduct IRA in an ethical and respectful manner. We conducted in-depth interviews with 13 low-income African American and Latina women who receive care at a federally qualified health center (FQHC) and had recently learned of their increased risk for breast cancer. These interviews explored their experience of the IRA process, their interpretation of what being at increased risk means, and their reactions to provider recommendations. Eight key themes were identified. We conclude with recommendations for the implementation of IRA for breast cancer in underserved primary care settings.
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Hoskins KF, Tejeda S, Vijayasiri G, Chukwudozie IB, Remo MH, Shah HA, Abraham IE, Balay LE, Maga TK, Searles ER, Korah VJ, Biggers A, Stolley MR, Warnecke RB. A feasibility study of breast cancer genetic risk assessment in a federally qualified health center. Cancer 2018; 124:3733-3741. [PMID: 30320429 PMCID: PMC6214782 DOI: 10.1002/cncr.31635] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 05/21/2018] [Accepted: 05/24/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND The US Preventive Services Task Force (USPSTF) endorses routine screening for genetic risk of breast and/or ovarian cancer as a component of primary health care. Implementation of this recommendation may prove challenging, especially in clinics serving disadvantaged communities. METHODS The authors tested the feasibility of implementing the USPSTF mandate at a federally qualified health center (FQHC) to identify women who were eligible for genetic counseling (GC). A 12-month usual-care phase was followed by a 12-month intervention phase, during which time cancer genetic risk assessment (CGRA) was systematically performed for all women aged 25 to 69 years who presented for an annual examination. Women who were eligible for GC were recruited to participate in the study. RESULTS After initiating CGRA, 112 women who were eligible for GC consented to study participation, and 56% of them received a referral for GC from their primary care physician. A subgroup of 50 participants were seen by the same primary care physician during both the usual-care and intervention phases. None of these patients was referred for GC during usual care, compared with 64% after the initiation of CGRA (P < .001). Only 16% of referred participants attended a GC session. CONCLUSIONS Implementing USPSTF recommendations for CGRA as a standard component of primary health care in FQHCs is feasible and improves referral of minority women for GC, but more work is needed to understand the beliefs and barriers that prevent many underserved women from accessing cancer genetic services.
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Affiliation(s)
- Kent F Hoskins
- Section of Hematology and Oncology, Department of Medicine, University of Illinois at Chicago College of Medicine, Chicago, Illinois
- Institute for Health Research and Policy, School of Public Health, University of Illinois at Chicago, Chicago, Illinois
| | - Silvia Tejeda
- Institute for Health Research and Policy, School of Public Health, University of Illinois at Chicago, Chicago, Illinois
| | - Ganga Vijayasiri
- Institute for Health Research and Policy, School of Public Health, University of Illinois at Chicago, Chicago, Illinois
| | - Ifeanyi Beverly Chukwudozie
- Institute for Health Research and Policy, School of Public Health, University of Illinois at Chicago, Chicago, Illinois
| | - Mylene H Remo
- Section of Hematology and Oncology, Department of Medicine, University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Hiral A Shah
- Section of Hematology and Oncology, Department of Medicine, University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Ivy E Abraham
- Section of Hematology and Oncology, Department of Medicine, University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Lara E Balay
- Section of Hematology and Oncology, Department of Medicine, University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Tara K Maga
- Section of Hematology and Oncology, Department of Medicine, University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | | | | | - Alana Biggers
- Section of General Internal Medicine, University of Illinois at Chicago College of Medicine, Chicago, Illinois
| | - Melinda R Stolley
- Institute for Health Research and Policy, School of Public Health, University of Illinois at Chicago, Chicago, Illinois
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Richard B Warnecke
- Institute for Health Research and Policy, School of Public Health, University of Illinois at Chicago, Chicago, Illinois
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21
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Moore SE, Ulbrich HH, Hepburn K, Holaday B, Mayo R, Sharp J, Pruitt RH. Behavioral Economics: A New Lens for Understanding Genomic Decision Making. J Nurs Scholarsh 2018; 50:241-248. [PMID: 29689133 DOI: 10.1111/jnu.12379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 10/16/2017] [Accepted: 12/05/2017] [Indexed: 12/24/2022]
Abstract
PURPOSE This article seeks to take the next step in examining the insights that nurses and other healthcare providers can derive from applying behavioral economic concepts to support genomic decision making. As genomic science continues to permeate clinical practice, nurses must continue to adapt practice to meet new challenges. Decisions associated with genomics are often not simple and dichotomous in nature. They can be complex and challenging for all involved. DESIGN This article offers an introduction to behavioral economics as a possible tool to help support patients', families', and caregivers' decision making related to genomics. METHODS Using current writings from nursing, ethics, behavioral economic, and other healthcare scholars, we review key concepts of behavioral economics and discuss their relevance to supporting genomic decision making. FINDINGS Behavioral economic concepts-particularly relativity, deliberation, and choice architecture-are specifically examined as new ways to view the complexities of genomic decision making. Each concept is explored through patient decision making and clinical practice examples. This article also discusses next steps and practice implications for further development of the behavioral economic lens in nursing. CONCLUSIONS Behavioral economics provides valuable insight into the unique nature of genetic decision-making practices. CLINICAL RELEVANCE Nurses are often a source of information and support for patients during clinical decision making. This article seeks to offer behavioral economic concepts as a framework for understanding and examining the unique nature of genomic decision making. As genetic and genomic testing become more common in practice, it will continue to grow in importance for nurses to be able to support the autonomous decision making of patients, their families, and caregivers.
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Affiliation(s)
- Scott Emory Moore
- Alpha Mu, Gamma Mu, Mu Rho, Phi Gamma, Post-Doctoral Fellow, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, USA
| | - Holley H Ulbrich
- Alumni Distinguished Professor Emerita of Economics, Clemson University, Clemson, SC, USA
| | - Kenneth Hepburn
- Professor, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, USA
| | - Bonnie Holaday
- Gamma Mu, Professor Emerita of Nursing, Clemson University, Clemson, SC, USA
| | - Rachel Mayo
- Professor, Department of Public Health, Clemson University, Clemson, SC, USA
| | - Julia Sharp
- Associate Professor, Department of Statistics, Colorado State University, Fort Collins, CO, USA
| | - Rosanne H Pruitt
- Gamma Mu, Professor, School of Nursing, Clemson University, Clemson, SC, USA
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Stenehjem DD, Au T, Sainski AM, Bauer H, Brown K, Lancaster J, Stevens V, Brixner DI. Impact of a genetic counseling requirement prior to genetic testing. BMC Health Serv Res 2018. [PMID: 29514700 PMCID: PMC5842549 DOI: 10.1186/s12913-018-2957-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background Genetic counseling by a Genetic Counselor (GC) is a requirement prior to genetic testing for cancer susceptibility genes (GC-mandate policy) for some insurers. This study evaluated the impact of this policy from the patient perspective. Methods Surveys were sent to individuals for whom their insurer ordered genetic testing for the cancer susceptibility genes BCRA1 and BRCA2 over a 1 year time period that spanned the introduction of a GC-mandate policy. Responses were assessed by time period (before/after policy introduction) and genetic test completion. Results The surveys were completed by 1247/4950 (25.7%) eligible individuals. After policy introduction, there was no change in the proportion of respondents who completed genetic testing (p = 0.13) or had a mutation (p = 0.55). Overall decisional conflict (uncertainty or feeling uninformed) around genetic testing did not change after policy introduction (p = 0.16), but was significantly higher among respondents who did not complete genetic testing (p < 0.01). Although a larger proportion of respondents saw a GC after policy introduction (p < 0.01), fewer did so to better understand their test results (p < 0.01). The proportion of respondents who did not see a GC due to insurance issues/requirements and time restraints was higher among those tested after policy introduction or who did not complete genetic testing (p < 0.01). In multivariate analysis, respondents with a household income of $25,000 or greater were 3-times more likely to complete testing. Conclusions A GC-mandate policy did not improve decisional conflict or increase the number of deleterious mutations identified and low-income respondents were less likely to complete testing. On the contrary, insurance requirements and time constraints may be preventing individuals at risk from receiving appropriate testing. Electronic supplementary material The online version of this article (10.1186/s12913-018-2957-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David D Stenehjem
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, USA. .,Huntsman Cancer Institute, Salt Lake City, UT, USA. .,Department of Pharmacy Practice and Pharmaceutical Sciences, University of Minnesota, College of Pharmacy, 1110 Kirby Drive, 232 Life Science, Duluth, MN, 55812, USA.
| | - Trang Au
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, USA.,Huntsman Cancer Institute, Salt Lake City, UT, USA
| | - Amy M Sainski
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
| | - Hillevi Bauer
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
| | - Krystal Brown
- Myriad Genetic Laboratories, Inc, Salt Lake City, UT, USA
| | | | - Vanessa Stevens
- Department of Internal Medicine, Division of Epidemiology University of Utah, Salt Lake City, UT, USA
| | - Diana I Brixner
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, USA.,Personalized Health Care Program, University of Utah, Salt Lake City, UT, USA
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Crew KD, Albain KS, Hershman DL, Unger JM, Lo SS. How do we increase uptake of tamoxifen and other anti-estrogens for breast cancer prevention? NPJ Breast Cancer 2017. [PMID: 28649660 PMCID: PMC5460136 DOI: 10.1038/s41523-017-0021-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Several randomized controlled trials of anti-estrogens, such as tamoxifen and aromatase inhibitors, have demonstrated up to a 50–65% decrease in breast cancerincidence among high-risk women. Approximately 15% of women, age 35–79 years, in the U.S. meet criteria for breast cancer preventive therapies, but uptake of these medications remain low. Explanations for this low uptake includelack of awareness of breast cancer risk status, insufficient knowledge about breast cancer preventive therapies among patients and physicians, and toxicity concerns. Increasing acceptance of pharmacologic breast cancer prevention will require effective communication of breast cancer risk, accurate representation about the potential benefits and side effects of anti-estrogens, targeting-specific high-risk populations most likely to benefit from preventive therapy, and minimizing the side effects of current anti-estrogens with novel administration and dosing options. One strategy to improve the uptake of chemoprevention strategies is to consider lessons learned from the use of drugs to prevent other chronic conditions, such as cardiovascular disease. Enhancing uptake and adherence to anti-estrogens for primary prevention holds promise for significantly reducing breast cancer incidence, however, this will require a significant change in our current clinical practice and stronger advocacy and awareness at the national level.
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Affiliation(s)
- Katherine D Crew
- Columbia University Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY USA
| | - Kathy S Albain
- Loyola University Chicago Stritch School of Medicine, Cardinal Bernardin Cancer Center, Maywood, IL USA
| | - Dawn L Hershman
- Columbia University Medical Center, Herbert Irving Comprehensive Cancer Center, New York, NY USA
| | - Joseph M Unger
- SWOG Statistical Center, Fred Hutchinson Cancer Research Center, Seattle, WA USA
| | - Shelly S Lo
- Loyola University Chicago Stritch School of Medicine, Cardinal Bernardin Cancer Center, Maywood, IL USA
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Stacey D, Légaré F, Lewis K, Barry MJ, Bennett CL, Eden KB, Holmes‐Rovner M, Llewellyn‐Thomas H, Lyddiatt A, Thomson R, Trevena L. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2017; 4:CD001431. [PMID: 28402085 PMCID: PMC6478132 DOI: 10.1002/14651858.cd001431.pub5] [Citation(s) in RCA: 1186] [Impact Index Per Article: 169.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Decision aids are interventions that support patients by making their decisions explicit, providing information about options and associated benefits/harms, and helping clarify congruence between decisions and personal values. OBJECTIVES To assess the effects of decision aids in people facing treatment or screening decisions. SEARCH METHODS Updated search (2012 to April 2015) in CENTRAL; MEDLINE; Embase; PsycINFO; and grey literature; includes CINAHL to September 2008. SELECTION CRITERIA We included published randomized controlled trials comparing decision aids to usual care and/or alternative interventions. For this update, we excluded studies comparing detailed versus simple decision aids. DATA COLLECTION AND ANALYSIS Two reviewers independently screened citations for inclusion, extracted data, and assessed risk of bias. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made and the decision-making process.Secondary outcomes were behavioural, health, and health system effects.We pooled results using mean differences (MDs) and risk ratios (RRs), applying a random-effects model. We conducted a subgroup analysis of studies that used the patient decision aid to prepare for the consultation and of those that used it in the consultation. We used GRADE to assess the strength of the evidence. MAIN RESULTS We included 105 studies involving 31,043 participants. This update added 18 studies and removed 28 previously included studies comparing detailed versus simple decision aids. During the 'Risk of bias' assessment, we rated two items (selective reporting and blinding of participants/personnel) as mostly unclear due to inadequate reporting. Twelve of 105 studies were at high risk of bias.With regard to the attributes of the choice made, decision aids increased participants' knowledge (MD 13.27/100; 95% confidence interval (CI) 11.32 to 15.23; 52 studies; N = 13,316; high-quality evidence), accuracy of risk perceptions (RR 2.10; 95% CI 1.66 to 2.66; 17 studies; N = 5096; moderate-quality evidence), and congruency between informed values and care choices (RR 2.06; 95% CI 1.46 to 2.91; 10 studies; N = 4626; low-quality evidence) compared to usual care.Regarding attributes related to the decision-making process and compared to usual care, decision aids decreased decisional conflict related to feeling uninformed (MD -9.28/100; 95% CI -12.20 to -6.36; 27 studies; N = 5707; high-quality evidence), indecision about personal values (MD -8.81/100; 95% CI -11.99 to -5.63; 23 studies; N = 5068; high-quality evidence), and the proportion of people who were passive in decision making (RR 0.68; 95% CI 0.55 to 0.83; 16 studies; N = 3180; moderate-quality evidence).Decision aids reduced the proportion of undecided participants and appeared to have a positive effect on patient-clinician communication. Moreover, those exposed to a decision aid were either equally or more satisfied with their decision, the decision-making process, and/or the preparation for decision making compared to usual care.Decision aids also reduced the number of people choosing major elective invasive surgery in favour of more conservative options (RR 0.86; 95% CI 0.75 to 1.00; 18 studies; N = 3844), but this reduction reached statistical significance only after removing the study on prophylactic mastectomy for breast cancer gene carriers (RR 0.84; 95% CI 0.73 to 0.97; 17 studies; N = 3108). Compared to usual care, decision aids reduced the number of people choosing prostate-specific antigen screening (RR 0.88; 95% CI 0.80 to 0.98; 10 studies; N = 3996) and increased those choosing to start new medications for diabetes (RR 1.65; 95% CI 1.06 to 2.56; 4 studies; N = 447). For other testing and screening choices, mostly there were no differences between decision aids and usual care.The median effect of decision aids on length of consultation was 2.6 minutes longer (24 versus 21; 7.5% increase). The costs of the decision aid group were lower in two studies and similar to usual care in four studies. People receiving decision aids do not appear to differ from those receiving usual care in terms of anxiety, general health outcomes, and condition-specific health outcomes. Studies did not report adverse events associated with the use of decision aids.In subgroup analysis, we compared results for decision aids used in preparation for the consultation versus during the consultation, finding similar improvements in pooled analysis for knowledge and accurate risk perception. For other outcomes, we could not conduct formal subgroup analyses because there were too few studies in each subgroup. AUTHORS' CONCLUSIONS Compared to usual care across a wide variety of decision contexts, people exposed to decision aids feel more knowledgeable, better informed, and clearer about their values, and they probably have a more active role in decision making and more accurate risk perceptions. There is growing evidence that decision aids may improve values-congruent choices. There are no adverse effects on health outcomes or satisfaction. New for this updated is evidence indicating improved knowledge and accurate risk perceptions when decision aids are used either within or in preparation for the consultation. Further research is needed on the effects on adherence with the chosen option, cost-effectiveness, and use with lower literacy populations.
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Affiliation(s)
- Dawn Stacey
- University of OttawaSchool of Nursing451 Smyth RoadOttawaONCanada
- Ottawa Hospital Research InstituteCentre for Practice Changing Research501 Smyth RdOttawaONCanadaK1H 8L6
| | - France Légaré
- CHU de Québec Research Center, Université LavalPopulation Health and Optimal Health Practices Research Axis10 Rue de l'Espinay, D6‐727Québec CityQCCanadaG1L 3L5
| | - Krystina Lewis
- University of OttawaSchool of Nursing451 Smyth RoadOttawaONCanada
| | | | - Carol L Bennett
- Ottawa Hospital Research InstituteClinical Epidemiology ProgramAdministrative Services Building, Room 2‐0131053 Carling AvenueOttawaONCanadaK1Y 4E9
| | - Karen B Eden
- Oregon Health Sciences UniversityDepartment of Medical Informatics and Clinical EpidemiologyBICC 5353181 S.W. Sam Jackson Park RoadPortlandOregonUSA97239‐3098
| | - Margaret Holmes‐Rovner
- Michigan State University College of Human MedicineCenter for Ethics and Humanities in the Life SciencesEast Fee Road956 Fee Road Rm C203East LansingMichiganUSA48824‐1316
| | - Hilary Llewellyn‐Thomas
- Dartmouth CollegeThe Dartmouth Center for Health Policy & Clinical Practice, The Geisel School of Medicine at DartmouthHanoverNew HampshireUSA03755
| | - Anne Lyddiatt
- No affiliation28 Greenwood RoadIngersollONCanadaN5C 3N1
| | - Richard Thomson
- Newcastle UniversityInstitute of Health and SocietyBaddiley‐Clark BuildingRichardson RoadNewcastle upon TyneUKNE2 4AX
| | - Lyndal Trevena
- The University of SydneyRoom 322Edward Ford Building (A27)SydneyNSWAustralia2006
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Skandarajah AR, Thomas S, Shackleton K, Chin-Lenn L, Lindeman GJ, Mann GB. Patient and medical barriers preclude uptake of tamoxifen preventative therapy in women with a strong family history. Breast 2017; 32:93-97. [DOI: 10.1016/j.breast.2017.01.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Revised: 01/08/2017] [Accepted: 01/09/2017] [Indexed: 01/26/2023] Open
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Haas JS, Baer HJ, Eibensteiner K, Klinger EV, St Hubert S, Getty G, Brawarsky P, Orav EJ, Onega T, Tosteson ANA, Bates DW, Colditz G. A Cluster Randomized Trial of a Personalized Multi-Condition Risk Assessment in Primary Care. Am J Prev Med 2017; 52:100-105. [PMID: 27639785 PMCID: PMC5167657 DOI: 10.1016/j.amepre.2016.07.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 06/17/2016] [Accepted: 07/15/2016] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Personal risk for multiple conditions should be assessed in primary care. This study evaluated whether collection of risk factors to generate electronic health record (EHR)-linked health risk appraisal (HRA) for coronary heart disease, diabetes, breast cancer, and colorectal cancer was associated with improved patient-provider communication, risk assessment, and plans for breast cancer screening. METHODS This pragmatic trial recruited adults with upcoming visits to 11 primary care practices during 2013-2014 (N=3,703). Pre-visit, intervention patients completed a risk factor and perception assessment and received an HRA; coded risk factor data were sent to the EHR. Post-visit, intervention patients reported risk perception. Pre-visit, control patients only completed the risk perception assessment; post-visit they also completed the risk factor assessment and received the HRA. No data were sent to the EHR for controls. Accuracy/improvement of self-perceived risk was assessed by comparing self-perceived to calculated risk. RESULTS The intervention was associated with improvement of patient-provider communication of changes to improve health (78.5% vs 74.1%, AOR=1.67, 99% CI=1.07, 2.60). There was a similar trend for discussion of risk (54.1% vs 45.5%, AOR=1.34, 95% CI=0.97, 1.85). The intervention was associated with greater improvement in accuracy of self-perceived risk for diabetes (16.0% vs 12.6%, p=0.006) and colorectal cancer (27.9% vs 17.2%, p<0.001) with a similar trend for coronary heart disease and breast cancer. There were no changes in plans for breast cancer screening. CONCLUSIONS Patient-reported risk factors and EHR-linked multi-condition HRAs in primary care can modestly improve communication and promote accuracy of self-perceived risk.
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Affiliation(s)
- Jennifer S Haas
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts; Department of Medicine, Harvard University Medical School, Boston, Massachusetts; Department of Social and Behavioral Sciences, Harvard University School of Public Health, Boston, Massachusetts.
| | - Heather J Baer
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts; Department of Medicine, Harvard University Medical School, Boston, Massachusetts; Department of Epidemiology, Harvard University School of Public Health, Boston, Massachusetts
| | - Katyuska Eibensteiner
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - Elissa V Klinger
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stella St Hubert
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - George Getty
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - Phyllis Brawarsky
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - E John Orav
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts; Department of Medicine, Harvard University Medical School, Boston, Massachusetts; Department of Biostatistics, Harvard University School of Public Health, Boston, Massachusetts
| | - Tracy Onega
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, New Hampshire
| | - Anna N A Tosteson
- Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth and Norris Cotton Cancer Center, Lebanon, New Hampshire
| | - David W Bates
- Division of General Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts; Department of Medicine, Harvard University Medical School, Boston, Massachusetts; Department of Health Policy and Management, Harvard University School of Public Health, Boston, Massachusetts
| | - Graham Colditz
- Institute for Public Health, Washington University School of Medicine, St. Louis, Missouri
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Stewart SL, Kaplan CP, Lee R, Joseph G, Karliner L, Livaudais-Toman J, Pasick RJ. Validation of an Efficient Screening Tool to Identify Low-Income Women at High Risk for Hereditary Breast Cancer. Public Health Genomics 2016; 19:342-351. [PMID: 27788513 DOI: 10.1159/000452095] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 09/28/2016] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND/AIMS We compared the 6-Point Scale, a screening tool to identify low-income women for referral to genetic counseling, with genetic counselors' (GCs') recommendation and the Referral Screening Tool (RST). METHODS RST and 6-Point Scale scores were computed for 2 samples: (1) S1, public hospital mammography clinic patients in 2006-2010 (n = 744), classified by GCs as high risk (meriting referral to counseling) or not high risk, and (2) S2, primary care patients enrolled in an education intervention study in 2011-2012 (n = 1,425). Sensitivity, specificity, and area under the ROC curve (AUROC) were computed for the 6-Point Scale score versus GC and RST classification as high risk. RESULTS The 6-Point Scale had low sensitivity (0.27, 95% confidence interval [CI] 0.21-0.34) but high specificity (0.97, 95% CI 0.95-0.99) and AUROC (0.85, 95% CI 0.81-0.90) versus GC classification, and high sensitivity (S1: 0.90, 95% CI 0.79-1.00; S2: 0.94, 95% CI 0.87-0.97), specificity (S1: 0.95, 95% CI 0.93-0.97; S2: 0.94, 95% CI 0.93-0.96), and AUROC (S1: 0.98, 95% CI 0.96-0.99; S2: 0.98, 95% CI 0.98-0.99) versus the RST. CONCLUSION The 6-Point Scale compared favorably with the RST, a validated instrument, and is potentially useful as a simple tool for administration in a safety net setting, requiring minimal time investment by primary care physicians and their staff and no financial investment in tablet computers or software.
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Affiliation(s)
- Susan L Stewart
- University of California, Davis Division of Biostatistics, Sacramento, CA, USA
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Henrich VC, Orlando LA. Family health history: an essential starting point for personalized risk assessment and disease prevention. Per Med 2016; 13:499-510. [DOI: 10.2217/pme-2016-0007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Family health history (FHH) information is well established as a basis for assessing a patient's personal disease risk, but is underutilized for diagnosis and making medical recommendations. Epidemiological and genetic information have heightened the value of FHH to an individual's health. This has motivated the development of new FHH collection tools and strategies for family members, but will require greater awareness and knowledge by both patients and practitioners. FHH will be increasingly important as genomic data become a mainstay of medical diagnostics, since in many cases, a medically important FHH results from lineage-specific genetic variants. The impact of complementary FHH and genomic information will drive the pursuit of personalized and precise targeting of treatments and interventions aimed at maintaining patient health.
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Affiliation(s)
- Vincent C Henrich
- Center for Biotechnology, Genomics, & Health Research, University of North Carolina at Greensboro, Greensboro, NC 27402-21670, USA
| | - Lori A Orlando
- Department of Medicine, Center for Personalized & Precision Medicine, Duke University, Durham, NC 27705, USA
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Furberg RD, Ortiz AM, Zulkiewicz BA, Hudson JP, Taylor OM, Lewis MA. Supporting Tablet Configuration, Tracking, and Infection Control Practices in Digital Health Interventions: Study Protocol. JMIR Res Protoc 2016; 5:e136. [PMID: 27350013 PMCID: PMC4940603 DOI: 10.2196/resprot.5400] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 02/26/2016] [Accepted: 03/31/2016] [Indexed: 11/13/2022] Open
Abstract
Background Tablet-based health care interventions have the potential to encourage patient care in a timelier manner, allow physicians convenient access to patient records, and provide an improved method for patient education. However, along with the continued adoption of tablet technologies, there is a concomitant need to develop protocols focusing on the configuration, management, and maintenance of these devices within the health care setting to support the conduct of clinical research. Objective Develop three protocols to support tablet configuration, tablet management, and tablet maintenance. Methods The Configurator software, Tile technology, and current infection control recommendations were employed to develop three distinct protocols for tablet-based digital health interventions. Configurator is a mobile device management software specifically for iPhone operating system (iOS) devices. The capabilities and current applications of Configurator were reviewed and used to develop the protocol to support device configuration. Tile is a tracking tag associated with a free mobile app available for iOS and Android devices. The features associated with Tile were evaluated and used to develop the Tile protocol to support tablet management. Furthermore, current recommendations on preventing health care–related infections were reviewed to develop the infection control protocol to support tablet maintenance. Results This article provides three protocols: the Configurator protocol, the Tile protocol, and the infection control protocol. Conclusions These protocols can help to ensure consistent implementation of tablet-based interventions, enhance fidelity when employing tablets for research purposes, and serve as a guide for tablet deployments within clinical settings.
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Randall TC, Armstrong K. Health Care Disparities in Hereditary Ovarian Cancer: Are We Reaching the Underserved Population? Curr Treat Options Oncol 2016; 17:39. [DOI: 10.1007/s11864-016-0417-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Crew KD. Addressing barriers to uptake of breast cancer chemoprevention for patients and providers. Am Soc Clin Oncol Educ Book 2016:e50-8. [PMID: 25993215 DOI: 10.14694/edbook_am.2015.35.e50] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Breast cancer is the most common malignancy among women in the United States, and the primary prevention of this disease is a major public health issue. Because there are relatively few modifiable breast cancer risk factors, pharmacologic interventions with antiestrogens have the potential to significantly affect the primary prevention setting. Breast cancer chemoprevention with selective estrogen receptor modulators (SERMs) tamoxifen and raloxifene, and with aromatase inhibitors (AIs) exemestane and anastrozole, is underutilized despite several randomized controlled trials demonstrating up to a 50% to 65% relative risk reduction in breast cancer incidence among women at high risk. An estimated 10 million women in the United States meet high-risk criteria for breast cancer and are potentially eligible for chemoprevention, but less than 5% of women at high risk who are offered antiestrogens for primary prevention agree to take it. Reasons for low chemoprevention uptake include lack of routine breast cancer risk assessment in primary care, inadequate time for counseling, insufficient knowledge about antiestrogens among patients and providers, and concerns about side effects. Interventions designed to increase chemoprevention uptake, such as decision aids and incorporating breast cancer risk assessment into clinical practice, have met with limited success. Clinicians can help women make informed decisions about chemoprevention by effectively communicating breast cancer risk and enhancing knowledge about the risks and benefits of antiestrogens. Widespread adoption of chemoprevention will require a major paradigm shift in clinical practice for primary care providers (PCPs). However, enhancing uptake and adherence to breast cancer chemoprevention holds promise for reducing the public health burden of this disease.
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Affiliation(s)
- Katherine D Crew
- From the Department of Medicine, College of Physicians and Surgeons, Department of Epidemiology, Mailman School of Public Health, and Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY
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Livaudais-Toman J, Karliner LS, Tice JA, Kerlikowske K, Gregorich S, Pérez-Stable EJ, Pasick RJ, Chen A, Quinn J, Kaplan CP. Impact of a primary care based intervention on breast cancer knowledge, risk perception and concern: A randomized, controlled trial. Breast 2015; 24:758-66. [PMID: 26476466 PMCID: PMC4698352 DOI: 10.1016/j.breast.2015.09.009] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 09/06/2015] [Accepted: 09/22/2015] [Indexed: 01/25/2023] Open
Abstract
PURPOSE To estimate the effects of a tablet-based, breast cancer risk education intervention for use in primary care settings (BreastCARE) on patients' breast cancer knowledge, risk perception and concern. METHODS From June 2011-August 2012, we enrolled women from two clinics, aged 40-74 years with no personal breast cancer history, and randomized them to the BreastCARE intervention group or to the control group. All patients completed a baseline telephone survey and risk assessment (via telephone for controls, via tablet computer in clinic waiting room prior to visit for intervention). All women were categorized as high or average risk based on the Referral Screening Tool, the Gail model or the Breast Cancer Surveillance Consortium model. Intervention patients and their physicians received an individualized risk report to discuss during the visit. All women completed a follow-up telephone survey 1-2 weeks after risk assessment. Post-test comparisons estimated differences at follow-up in breast cancer knowledge, risk perception and concern. RESULTS 580 intervention and 655 control women completed follow-up interviews. Mean age was 56 years (SD = 9). At follow-up, 73% of controls and 71% of intervention women correctly perceived their breast cancer risk and 22% of controls and 24% of intervention women were very concerned about breast cancer. Intervention patients had greater knowledge (≥75% correct answers) of breast cancer risk factors at follow-up (24% vs. 16%; p = 0.002). In multivariable analysis, there were no differences in correct risk perception or concern, but intervention patients had greater knowledge ([OR] = 1.62; 95% [CI] = 1.19-2.23). CONCLUSIONS A simple, practical intervention involving physicians at the point of care can improve knowledge of breast cancer without increasing concern. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT01830933.
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Affiliation(s)
- Jennifer Livaudais-Toman
- Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA; Medical Effectiveness Research Center for Diverse Populations, Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA.
| | - Leah S Karliner
- Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA; Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA; Medical Effectiveness Research Center for Diverse Populations, Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Jeffrey A Tice
- Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA; Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
| | - Karla Kerlikowske
- Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA; Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA; General Internal Medicine Section, Department of Veterans Affairs, San Francisco, CA, USA
| | - Steven Gregorich
- Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA; Medical Effectiveness Research Center for Diverse Populations, Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Eliseo J Pérez-Stable
- Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA; Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA; Medical Effectiveness Research Center for Diverse Populations, Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Rena J Pasick
- Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA; Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
| | - Alice Chen
- Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA; Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
| | - Jessica Quinn
- Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Celia P Kaplan
- Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA; Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA; Medical Effectiveness Research Center for Diverse Populations, Department of Medicine, Division of General Internal Medicine, University of California San Francisco, San Francisco, CA, USA
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