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Krebs M, Haller F, Spörl S, Gerhard-Hartmann E, Utpatel K, Maurus K, Kunzmann V, Chatterjee M, Venkataramani V, Maatouk I, Bittrich M, Einwag T, Meidenbauer N, Tögel L, Hirsch D, Dietmaier W, Keil F, Scheiter A, Immel A, Heudobler D, Einhell S, Kaiser U, Sedlmeier AM, Maurer J, Schenkirsch G, Jordan F, Schmutz M, Dintner S, Rosenwald A, Hartmann A, Evert M, Märkl B, Bargou R, Mackensen A, Beckmann MW, Pukrop T, Herr W, Einsele H, Trepel M, Goebeler ME, Claus R, Kerscher A, Lüke F. The WERA cancer center matrix: Strategic management of patient access to precision oncology in a large and mostly rural area of Germany. Eur J Cancer 2024; 207:114144. [PMID: 38852290 DOI: 10.1016/j.ejca.2024.114144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 05/20/2024] [Accepted: 05/24/2024] [Indexed: 06/11/2024]
Abstract
PURPOSE Providing patient access to precision oncology (PO) is a major challenge of clinical oncologists. Here, we provide an easily transferable model from strategic management science to assess the outreach of a cancer center. METHODS As members of the German WERA alliance, the cancer centers in Würzburg, Erlangen, Regensburg and Augsburg merged care data regarding their geographical impact. Specifically, we examined the provenance of patients from WERA´s molecular tumor boards (MTBs) between 2020 and 2022 (n = 2243). As second dimension, we added the provenance of patients receiving general cancer care by WERA. Clustering our catchment area along these two dimensions set up a four-quadrant matrix consisting of postal code areas with referrals towards WERA. These areas were re-identified on a map of the Federal State of Bavaria. RESULTS The WERA matrix overlooked an active screening area of 821 postal code areas - representing about 50 % of Bavaria´s spatial expansion and more than six million inhabitants. The WERA matrix identified regions successfully connected to our outreach structures in terms of subsidiarity - with general cancer care mainly performed locally but PO performed in collaboration with WERA. We also detected postal code areas with a potential PO backlog - characterized by high levels of cancer care performed by WERA and low levels or no MTB representation. CONCLUSIONS The WERA matrix provided a transparent portfolio of postal code areas, which helped assessing the geographical impact of our PO program. We believe that its intuitive principle can easily be transferred to other cancer centers.
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Affiliation(s)
- Markus Krebs
- Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, 97080 Würzburg, Germany; Department of Urology and Pediatric Urology, University Hospital Würzburg, 97080 Würzburg, Germany.
| | - Florian Haller
- Institute of Pathology, Friedrich-Alexander University Erlangen-Nuremberg, University Hospital Erlangen, 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
| | - Silvia Spörl
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany; Department of Medicine V, Hematology and Oncology, University Hospital Erlangen, 91054 Erlangen, Germany
| | - Elena Gerhard-Hartmann
- Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, 97080 Würzburg, Germany; Institute of Pathology, University of Würzburg, 97080 Würzburg, Germany
| | - Kirsten Utpatel
- Institute of Pathology, University of Regensburg, 93053 Regensburg, Germany; Comprehensive Cancer Center Ostbayern, 93053 Regensburg, Germany
| | - Katja Maurus
- Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, 97080 Würzburg, Germany; Institute of Pathology, University of Würzburg, 97080 Würzburg, Germany
| | - Volker Kunzmann
- Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, 97080 Würzburg, Germany; Department of Internal Medicine II, University Hospital Würzburg, 97080 Würzburg, Germany
| | - Manik Chatterjee
- Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, 97080 Würzburg, Germany
| | - Vivek Venkataramani
- Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, 97080 Würzburg, Germany
| | - Imad Maatouk
- Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, 97080 Würzburg, Germany; Department of Internal Medicine II, University Hospital Würzburg, 97080 Würzburg, Germany
| | - Max Bittrich
- Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, 97080 Würzburg, Germany; Department of Internal Medicine II, University Hospital Würzburg, 97080 Würzburg, Germany
| | - Tatjana Einwag
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
| | - Norbert Meidenbauer
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany; Department of Medicine V, Hematology and Oncology, University Hospital Erlangen, 91054 Erlangen, Germany
| | - Lars Tögel
- Institute of Pathology, Friedrich-Alexander University Erlangen-Nuremberg, University Hospital Erlangen, 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
| | - Daniela Hirsch
- Institute of Pathology, University of Regensburg, 93053 Regensburg, Germany; Comprehensive Cancer Center Ostbayern, 93053 Regensburg, Germany
| | - Wolfgang Dietmaier
- Institute of Pathology, University of Regensburg, 93053 Regensburg, Germany; Comprehensive Cancer Center Ostbayern, 93053 Regensburg, Germany
| | - Felix Keil
- Institute of Pathology, University of Regensburg, 93053 Regensburg, Germany; Comprehensive Cancer Center Ostbayern, 93053 Regensburg, Germany
| | - Alexander Scheiter
- Institute of Pathology, University of Regensburg, 93053 Regensburg, Germany; Comprehensive Cancer Center Ostbayern, 93053 Regensburg, Germany
| | - Alexander Immel
- Comprehensive Cancer Center Ostbayern, 93053 Regensburg, Germany
| | - Daniel Heudobler
- Comprehensive Cancer Center Ostbayern, 93053 Regensburg, Germany; Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Sabine Einhell
- Comprehensive Cancer Center Ostbayern, 93053 Regensburg, Germany; Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Ulrich Kaiser
- Comprehensive Cancer Center Ostbayern, 93053 Regensburg, Germany; Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Anja M Sedlmeier
- Comprehensive Cancer Center Ostbayern, 93053 Regensburg, Germany; Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Julia Maurer
- Comprehensive Cancer Center Ostbayern, 93053 Regensburg, Germany
| | | | - Frank Jordan
- Comprehensive Cancer Center Augsburg, 86156 Augsburg, Germany; Department of Hematology and Clinical Oncology, Medical Faculty, University of Augsburg, 86156 Augsburg, Germany
| | - Maximilian Schmutz
- Comprehensive Cancer Center Augsburg, 86156 Augsburg, Germany; Department of Hematology and Clinical Oncology, Medical Faculty, University of Augsburg, 86156 Augsburg, Germany; Institute of Digital Medicine (IDM), Medical Faculty, University of Augsburg, 86156 Augsburg, Germany
| | - Sebastian Dintner
- Comprehensive Cancer Center Augsburg, 86156 Augsburg, Germany; Institute of Pathology and Molecular Diagnostics, Medical Faculty, University of Augsburg, 86156 Augsburg, Germany
| | - Andreas Rosenwald
- Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, 97080 Würzburg, Germany; Institute of Pathology, University of Würzburg, 97080 Würzburg, Germany
| | - Arndt Hartmann
- Institute of Pathology, Friedrich-Alexander University Erlangen-Nuremberg, University Hospital Erlangen, 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany
| | - Matthias Evert
- Institute of Pathology, University of Regensburg, 93053 Regensburg, Germany; Comprehensive Cancer Center Ostbayern, 93053 Regensburg, Germany
| | - Bruno Märkl
- Comprehensive Cancer Center Augsburg, 86156 Augsburg, Germany; Institute of Pathology and Molecular Diagnostics, Medical Faculty, University of Augsburg, 86156 Augsburg, Germany
| | - Ralf Bargou
- Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, 97080 Würzburg, Germany; Bavarian Cancer Research Center (BZKF), 91052 Erlangen, Germany
| | - Andreas Mackensen
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany; Department of Medicine V, Hematology and Oncology, University Hospital Erlangen, 91054 Erlangen, Germany; Bavarian Cancer Research Center (BZKF), 91052 Erlangen, Germany
| | - Matthias W Beckmann
- Comprehensive Cancer Center Erlangen-EMN, 91054 Erlangen, Germany; Bavarian Cancer Research Center (BZKF), 91052 Erlangen, Germany; Department of Gynecology and Obstetrics, University Hospital Erlangen, 91054 Erlangen, Germany
| | - Tobias Pukrop
- Comprehensive Cancer Center Ostbayern, 93053 Regensburg, Germany; Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, 93053 Regensburg, Germany; Bavarian Cancer Research Center (BZKF), 91052 Erlangen, Germany; Division of Personalized Tumor Therapy, Fraunhofer Institute for Toxicology and Experimental Medicine, 93053 Regensburg, Germany
| | - Wolfgang Herr
- Comprehensive Cancer Center Ostbayern, 93053 Regensburg, Germany; Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Hermann Einsele
- Department of Internal Medicine II, University Hospital Würzburg, 97080 Würzburg, Germany; Bavarian Cancer Research Center (BZKF), 91052 Erlangen, Germany
| | - Martin Trepel
- Comprehensive Cancer Center Augsburg, 86156 Augsburg, Germany; Department of Hematology and Clinical Oncology, Medical Faculty, University of Augsburg, 86156 Augsburg, Germany; Bavarian Cancer Research Center (BZKF), 91052 Erlangen, Germany
| | - Maria-Elisabeth Goebeler
- Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, 97080 Würzburg, Germany; Department of Internal Medicine II, University Hospital Würzburg, 97080 Würzburg, Germany
| | - Rainer Claus
- Comprehensive Cancer Center Augsburg, 86156 Augsburg, Germany; Department of Hematology and Clinical Oncology, Medical Faculty, University of Augsburg, 86156 Augsburg, Germany; Institute of Pathology and Molecular Diagnostics, Medical Faculty, University of Augsburg, 86156 Augsburg, Germany
| | - Alexander Kerscher
- Comprehensive Cancer Center Mainfranken, University Hospital Würzburg, 97080 Würzburg, Germany
| | - Florian Lüke
- Comprehensive Cancer Center Ostbayern, 93053 Regensburg, Germany; Department of Internal Medicine III, Hematology and Oncology, University Hospital Regensburg, 93053 Regensburg, Germany; Division of Personalized Tumor Therapy, Fraunhofer Institute for Toxicology and Experimental Medicine, 93053 Regensburg, Germany
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Saylor KW, Fernandes EQ, Adams M, Paraghamian S, Shalowitz DI. Predictors of germline genetic testing referral and completion in ovarian cancer patients at a Comprehensive Cancer Center. Gynecol Oncol 2024; 186:53-60. [PMID: 38599112 PMCID: PMC11216855 DOI: 10.1016/j.ygyno.2024.03.028] [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: 02/02/2024] [Revised: 03/26/2024] [Accepted: 03/30/2024] [Indexed: 04/12/2024]
Abstract
OBJECTIVES To identify predictors of referral and completion of germline genetic testing among newly diagnosed ovarian cancer patients, with a focus on geographic social deprivation, oncologist-level practices, and time between diagnosis and completion of testing. METHODS Clinical and sociodemographic data were abstracted from medical records of patients newly diagnosed with ovarian cancer between 2014 and 2019 in the University of North Carolina Health System. Factors associated with referral for genetic counseling, completion of germline testing, and time between diagnosis and test results were identified using multivariable regression. RESULTS 307/459 (67%) patients were referred for genetic counseling and 285/459 (62%) completed testing. The predicted probability of test completion was 0.83 (95% CI: 0.77-0.88) for patients with a referral compared to 0.27 (95% CI: 0.18-0.35) for patients without a referral. The predicted probability of referral was 0.75 (95% CI: 0.69-0.82) for patients at the 25th percentile of ZIP code-level Social Deprivation Index (SDI) and 0.67 (0.60-0.74) for patients at the 75th percentile of SDI. Referral varied by oncologist, with predicted probabilities ranging from 0.47 (95% CI: 0.32-0.62) to 0.93 (95% CI: 0.85-1.00) across oncologists. The median time between diagnosis and test results was 137 days (IQR: 55-248 days). This interval decreased by a predicted 24.46 days per year (95% CI: 37.75-11.16). CONCLUSIONS We report relatively high germline testing and a promising trend in time from diagnosis to results, with variation by oncologist and patient factors. Automated referral, remote genetic counseling and sample collection, reduced out-of-pocket costs, and educational interventions should be explored.
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Affiliation(s)
- Katherine W Saylor
- Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA, United States of America.
| | - Elizabeth Q Fernandes
- University of North Carolina School of Medicine, Chapel Hill, NC, United States of America
| | - Michael Adams
- Division of Pediatric Genetics and Metabolism, University of North Carolina School of Medicine, Chapel Hill, PA, United States of America
| | - Sarah Paraghamian
- Department of Obstetrics and Gynecology, Tufts University School of Medicine, Boston, MA, United States of America
| | - David I Shalowitz
- West Michigan Cancer Center, Kalamazoo, MI, United States of America; Collaborative on Equity in Rural Cancer Care, Kalamazoo, MI, United States of America
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Riordan S, Richardson J, Zierhut H, Goodnight BL, Sieling FH, Black CM, Moore RA. Medicare beneficiary barriers to genetic counselor services: Implications for patient policy, decision-making, and care. J Genet Couns 2024; 33:262-268. [PMID: 37246362 DOI: 10.1002/jgc4.1729] [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: 04/20/2022] [Revised: 04/24/2023] [Accepted: 04/29/2023] [Indexed: 05/30/2023]
Abstract
If passed, the "Access to Genetic Counselor Services Act" will authorize genetic counselors to provide services under Medicare part B. We assert that Medicare policy should be updated through the enactment of this legislation to provide Medicare beneficiaries with direct access to genetic counselor services. In this article, we discuss the background, history, and some recent research relevant to patient access to genetic counselors to provide context and perspective regarding the rationale, justification, and potential results of the proposed legislation. We outline the potential impact of Medicare policy reform, including the effect on access to genetic counselors in high-demand areas or underserved communities. Although the proposed legislation pertains only to Medicare, we argue that private systems will also be impacted by passage as this may lead to an increase in hiring and retention of genetic counselors by health systems, thereby improving access to genetic counselors across the US.
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Affiliation(s)
- Sara Riordan
- Unified Patient Network, Charlestown, Massachusetts, USA
| | - John Richardson
- National Society of Genetic Counselors, Washington, District of Columbia, USA
| | - Heather Zierhut
- Department of Genetics, Cell Biology, and Development, University of Minnesota, Minneapolis, Minnesota, USA
| | | | | | - Christopher M Black
- Center for Observational and Real-World Evidence (CORE), Merck & Co. Inc., Kenilworth, New Jersey, USA
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4
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Loeb S, Keith SW, Cheng HH, Leader AE, Gross L, Sanchez Nolasco T, Byrne N, Hartman R, Brown LH, Pieczonka CM, Gomella LG, Kelly WK, Lallas CD, Handley N, Mille PJ, Mark JR, Brown GA, Chopra S, McClellan A, Wise DR, Hollifield L, Giri VN. TARGET: A Randomized, Noninferiority Trial of a Pretest, Patient-Driven Genetic Education Webtool Versus Genetic Counseling for Prostate Cancer Germline Testing. JCO Precis Oncol 2024; 8:e2300552. [PMID: 38452310 PMCID: PMC10939575 DOI: 10.1200/po.23.00552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/22/2023] [Accepted: 12/12/2023] [Indexed: 03/09/2024] Open
Abstract
PURPOSE Germline genetic testing (GT) is important for prostate cancer (PCA) management, clinical trial eligibility, and hereditary cancer risk. However, GT is underutilized and there is a shortage of genetic counselors. To address these gaps, a patient-driven, pretest genetic education webtool was designed and studied compared with traditional genetic counseling (GC) to inform strategies for expanding access to genetic services. METHODS Technology-enhanced acceleration of germline evaluation for therapy (TARGET) was a multicenter, noninferiority, randomized trial (ClinicalTrials.gov identifier: NCT04447703) comparing a nine-module patient-driven genetic education webtool versus pretest GC. Participants completed surveys measuring decisional conflict, satisfaction, and attitudes toward GT at baseline, after pretest education/counseling, and after GT result disclosure. The primary end point was noninferiority in reducing decisional conflict between webtool and GC using the validated Decisional Conflict Scale. Mixed-effects regression modeling was used to compare decisional conflict between groups. Participants opting for GT received a 51-gene panel, with results delivered to participants and their providers. RESULTS The analytic data set includes primary outcome data from 315 participants (GC [n = 162] and webtool [n = 153]). Mean difference in decisional conflict score changes between groups was -0.04 (one-sided 95% CI, -∞ to 2.54; P = .01), suggesting the patient-driven webtool was noninferior to GC. Overall, 145 (89.5%) GC and 120 (78.4%) in the webtool arm underwent GT, with pathogenic variants in 15.8% (8.7% in PCA genes). Satisfaction did not differ significantly between arms; knowledge of cancer genetics was higher but attitudes toward GT were less favorable in the webtool arm. CONCLUSION The results of the TARGET study support the use of patient-driven digital webtools for expanding access to pretest genetic education for PCA GT. Further studies to optimize patient experience and evaluate them in diverse patient populations are warranted.
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Affiliation(s)
- Stacy Loeb
- Department of Urology, NYU Langone Health, New York, NY
- Department of Population Health, NYU Langone Health, New York, NY
- Perlmutter Cancer Center, NYU Langone Health, New York, NY
- Department of Surgery/Urology, Manhattan Veterans Affairs, New York, NY
| | - Scott W. Keith
- Division of Biostatistics and Bioinformatics, Department of Pharmacology, Physiology and Cancer Biology, Thomas Jefferson University, Philadelphia, PA
| | - Heather H. Cheng
- Division of Hematology and Oncology, Department of Medicine, University of Washington, Seattle, WA
- Fred Hutchinson Cancer Center, Seattle, WA
| | - Amy E. Leader
- Department of Medical Oncology, Thomas Jefferson University, Philadelphia, PA
| | - Laura Gross
- Yale Cancer Center, New Haven, CT
- Yale New Haven Health, New Haven, CT
| | - Tatiana Sanchez Nolasco
- Department of Urology, NYU Langone Health, New York, NY
- Department of Population Health, NYU Langone Health, New York, NY
- Department of Surgery/Urology, Manhattan Veterans Affairs, New York, NY
| | - Nataliya Byrne
- Department of Urology, NYU Langone Health, New York, NY
- Department of Population Health, NYU Langone Health, New York, NY
- Department of Surgery/Urology, Manhattan Veterans Affairs, New York, NY
| | - Rebecca Hartman
- Division of Biostatistics and Bioinformatics, Department of Pharmacology, Physiology and Cancer Biology, Thomas Jefferson University, Philadelphia, PA
| | | | | | - Leonard G. Gomella
- Department of Urology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | - William Kevin Kelly
- Department of Medical Oncology, Thomas Jefferson University, Philadelphia, PA
| | - Costas D. Lallas
- Department of Urology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | - Nathan Handley
- Department of Medical Oncology, Thomas Jefferson University, Philadelphia, PA
- Department of Integrative Medicine and Nutritional Sciences, Thomas Jefferson University, Philadelphia, PA
| | | | - James Ryan Mark
- Department of Urology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA
| | | | | | | | - David R. Wise
- Perlmutter Cancer Center, NYU Langone Health, New York, NY
| | | | - Veda N. Giri
- Yale Cancer Center, New Haven, CT
- Department of Medicine, Yale School of Medicine, New Haven, CT
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An J, McDougall J, Lin Y, Lu SE, Walters ST, Heidt E, Stroup A, Paddock L, Grumet S, Toppmeyer D, Kinney AY. Randomized trial promoting cancer genetic risk assessment when genetic counseling cost removed: 1-year follow-up. JNCI Cancer Spectr 2024; 8:pkae018. [PMID: 38490263 PMCID: PMC11006111 DOI: 10.1093/jncics/pkae018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 01/29/2024] [Accepted: 02/23/2024] [Indexed: 03/17/2024] Open
Abstract
PURPOSE Cancer genetic risk assessment (CGRA) is recommended for women with ovarian and high-risk breast cancer. However, the underutilization of CGRA has long been documented, and cost has been a major barrier. In this randomized controlled trial, a tailored counseling and navigation (TCN) intervention significantly improved CGRA uptake at 6-month follow-up, compared with targeted print (TP) and usual care (UC). We aimed to examine the effect of removing genetic counseling costs on CGRA uptake by 12 months. METHODS We recruited racially and geographically diverse women with breast and ovarian cancer from cancer registries in Colorado, New Jersey, and New Mexico. Participants assigned to TCN received telephone-based psychoeducation and navigation. After 6 months, the trial provided free genetic counseling to participants in all arms. RESULTS At 12 months, more women in TCN obtained CGRA (26.6%) than those in TP (11.0%; odds ratio [OR] = 2.77, 95% confidence interval [CI] = 1.56 to 4.89) and UC (12.2%; OR = 2.46, 95% CI = 1.41 to 4.29). There were no significant differences in CGRA uptake between TP and UC. The Kaplan-Meier curve shows that the divergence of cumulative incidence slopes (TCN vs UC, TCN vs TP) appears primarily within the initial 6 months. CONCLUSION TCN significantly increased CGRA uptake at the 12-month follow-up. Directly removing the costs of genetic counseling attenuated the effects of TCN, highlighting the critical enabling role played by cost coverage. Future policies and interventions should address multilevel cost-related barriers to expand patients' access to CGRA. TRIAL REGISTRATION This trial was registered with the NIH clinical trial registry, clinicaltrials.gov, NCT03326713. https://clinicaltrials.gov/ct2/show/NCT03326713.
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Affiliation(s)
- Jinghua An
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | | | - Yong Lin
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
- Rutgers University School of Public Health, Piscataway, NJ, USA
| | - Shou-En Lu
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
- Rutgers University School of Public Health, Piscataway, NJ, USA
| | - Scott T Walters
- University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Emily Heidt
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Antoinette Stroup
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
- Rutgers University School of Public Health, Piscataway, NJ, USA
| | - Lisa Paddock
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
- Rutgers University School of Public Health, Piscataway, NJ, USA
| | - Sherry Grumet
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | | | - Anita Y Kinney
- Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
- Rutgers University School of Public Health, Piscataway, NJ, USA
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Syrnioti G, Eden CM, Johnson JA, Alston C, Syrnioti A, Newman LA. Social Determinants of Cancer Disparities. Ann Surg Oncol 2023; 30:8094-8104. [PMID: 37723358 DOI: 10.1245/s10434-023-14200-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 08/09/2023] [Indexed: 09/20/2023]
Abstract
Cancer is a major public health issue that is associated with significant morbidity and mortality across the globe. At its root, cancer represents a genetic aberration, but socioeconomic, environmental, and geographic factors contribute to different cancer outcomes for selected population subsets. The disparities in the delivery of healthcare affect all aspects of cancer management from early prevention to end-of-life care. In an effort to address the inequality in the delivery of healthcare among socioeconomically disadvantaged populations, the World Health Organization defined social determinants of health (SDOH) as conditions in which people are born, live, work, and age. These factors play a significant role in the disproportionate cancer burden among different population groups. SDOH are associated with disparities in risk factor burden, screening modalities, diagnostic testing, treatment options, and quality of life of patients with cancer. The purpose of this article is to describe a more holistic and integrated approach to patients with cancer and address the disparities that are derived from their socioeconomic background.
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Affiliation(s)
- Georgia Syrnioti
- Department of Surgery, New York Presbyterian, Weill Cornell Medicine, New York, NY, USA.
- Department of Surgery, One Brooklyn Health-Brookdale University Hospital and Medical Center, Brooklyn, NY, USA.
| | - Claire M Eden
- Department of Surgery New York Presbyterian Queens, Weill Cornell Medicine, Flushing, NY, USA
| | - Josh A Johnson
- Department of Surgery, New York Presbyterian, Weill Cornell Medicine, New York, NY, USA
| | - Chase Alston
- Department of Surgery, New York Presbyterian, Weill Cornell Medicine, New York, NY, USA
| | - Antonia Syrnioti
- Department of Pathology, School of Medicine, Aristotle University of Thessaloniki, Thessaloníki, Greece
| | - Lisa A Newman
- Department of Surgery, New York Presbyterian, Weill Cornell Medicine, New York, NY, USA
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Clark NM, Roberts EA, Fedorenko C, Sun Q, Dubard-Gault M, Handford C, Yung R, Cheng HH, Sham JG, Norquist BM, Flanagan MR. Genetic Testing Among Patients with High-Risk Breast, Ovarian, Pancreatic, and Prostate Cancers. Ann Surg Oncol 2023; 30:1312-1326. [PMID: 36335273 DOI: 10.1245/s10434-022-12755-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 10/04/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND The National Comprehensive Cancer Network recommends genetic testing in patients with potentially hereditary breast, ovarian, pancreatic, and prostate cancers (HBOPP). Knowledge of genetic mutations impacts decisions about screening and treatment. METHODS A retrospective cohort study of 28,586 HBOPP patients diagnosed from 2013 to 2019 was conducted using a linked administrative-cancer database in the Seattle-Puget Sound SEER area. Guideline-concordant testing (GCT) was assessed annually according to guideline updates. Frequency of testing according to patient/cancer characteristics was evaluated using chi-squared tests, and factors associated with receipt of genetic testing were identified using multivariable logistic regression. RESULTS Testing occurred in 17% of HBOPP patients, increasing from 9% in 2013 to 21% in 2019 (p < 0.001). Ovarian cancer had the highest testing (40%) and prostate cancer the lowest (4%). Age < 50, female sex, non-Hispanic White race, commercial insurance, urban location, family history of HBOPP, and triple negative breast cancer (TNBC) were associated with increased testing (all p < 0.05). GCT increased from 38% in 2013 to 44% in 2019, and was highest for early age at breast cancer diagnosis, TNBC, male breast cancer, and breast cancer with family history of HBOPP (all > 70% in 2019), and lowest for metastatic prostate cancer (6%). CONCLUSIONS The frequency of genetic testing for HBOPP cancer has increased over time. Though GCT is high for breast cancer, there are gaps in concordance among patients with other cancers. Increasing provider and patient education, genetic counseling, and insurance coverage for testing among HBOPP patients may improve guideline adherence.
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Affiliation(s)
- Nina M Clark
- Department of Surgery, University of Washington, Seattle, USA
| | - Emma A Roberts
- University of Washington School of Medicine, Seattle, USA
| | - Catherine Fedorenko
- Hutchinson Institute for Cancer Outcomes Research Fred Hutchinson Cancer Center, Seattle, USA
| | - Qin Sun
- Hutchinson Institute for Cancer Outcomes Research Fred Hutchinson Cancer Center, Seattle, USA
| | - Marianne Dubard-Gault
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, USA.,Fred Hutchinson Cancer Center, Seattle, USA
| | | | - Rachel Yung
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, USA.,Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, USA
| | - Heather H Cheng
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, USA.,Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, USA
| | - Jonathan G Sham
- Department of Surgery, University of Washington, Seattle, USA.,Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, USA
| | - Barbara M Norquist
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Washington, Seattle, USA
| | - Meghan R Flanagan
- Department of Surgery, University of Washington, Seattle, USA. .,Division of Public Health Sciences, Fred Hutchinson Cancer Center, Seattle, USA.
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8
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Hughes BN, Jorgensen KA, Cummings S, Morah D, Krause K, Rauh-Hain JA, Herzog TJ. Systematic mapping review of guidelines for BRCA1/2 genetic testing globally: investigating geographic and regional disparities in health equity for women and families at risk for hereditary ovarian cancer. Int J Gynecol Cancer 2023; 33:250-256. [PMID: 36368709 DOI: 10.1136/ijgc-2022-003913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Identification of persons at risk for hereditary syndromes through genetic testing prior to cancer diagnosis may proactively reduce the cancer burden morbidity and mortality. Using a framework of health equity, this study characterizes the global landscape of publication and reference to BRCA1/2 genetic testing guidelines (GTG). METHODS This study used a systematic literature search supplemented by an International Gynecologic Cancer Society (IGCS) informal survey and cross referenced with Myriad Genetics records, to identify published GTG, their country of origin, and countries referencing them. RESULTS Of 1011 identified publications, 166 met the inclusion criteria, from which 46 unique guidelines were identified, published by 18 countries and two regions (Europe and the UK). Authorship from the USA accounted for 63% of publications on GTG. Systematic mapping reviews revealed 34 countries with published and/or referenced guidelines, the IGCS survey revealed 22 additional countries, and coordination with Myriad Genetics revealed additional information for two countries and primary information for one country. Of the 57 countries evaluated, 33% published their own guidelines and reference guidelines from another country/region, 5% published their own guidelines without referencing another country/region, and 61% only referenced a guideline from another country/region. No data were available for 138 of 195 countries, disproportionately from Africa, the Middle East, Eastern Europe, and Southeast Asia. CONCLUSIONS Global geographic disparities in the publication and referencing of GTG exist, with a large emphasis on North American and European guidelines in the published literature. These disparities highlight a need for uniform BRCA GTG to improve global health equity.
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Affiliation(s)
| | - Kirsten A Jorgensen
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center Division of Surgery, Houston, Texas, USA
| | | | | | - Kate Krause
- The University of Texas MD Anderson Cancer Center Research Medical Library, Houston, Texas, USA
| | - Jose Alejandro Rauh-Hain
- The University of Texas MD Anderson Cancer Center Department of Gynecologic Oncology and Reproductive Medicine, Houston, Texas, USA
| | - Thomas J Herzog
- University of Cincinnati Cancer Center, Cincinnati, Ohio, USA
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9
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Higgs E, Wain KE, Wynn J, Cho MT, Higgins S, Blaisdell D, Dugan D, Valek S, Cohen S. Measuring quality and value in genetic counseling: The current landscape and future directions. J Genet Couns 2022; 32:315-324. [PMID: 36385723 DOI: 10.1002/jgc4.1657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 10/27/2022] [Accepted: 10/28/2022] [Indexed: 11/18/2022]
Abstract
Genetic counselors strive to provide high-quality genetic services. To do so, it is essential to define quality in genetic counseling and identify opportunities for improvement. This Professional Issues article provides an overview of the evaluation of healthcare quality in genetic counseling. The National Society of Genetic Counselors' Research, Quality, and Outcomes Committee partnered with Discern Health, a value-based healthcare policy consulting firm, to develop a care continuum model of genetic counseling. Using the proposed model, currently available quality measures relevant to genetic counseling in the US healthcare system were assessed, allowing for the identification of gaps and priority areas for further development. A total of 560 quality measures were identified that can be applied to various aspects of the care continuum model across a range of clinical specialty areas in genetic counseling, although few measures were specific to genetic counseling or genetic conditions. Areas where quality measures were lacking included: attitudes toward genetic testing, family communication, stigma, and issues of justice, equity, diversity, and inclusion. We discuss these findings and other strategies for an evidence-based approach to quality in genetic counseling. Strategic directions for the genetic counseling profession should include a consolidated approach to research on quality and value of genetic counseling, development of quality metrics and patient-experience measures, and engagement with other improvement activities. These strategies will allow for benchmarking, performance improvement, and future implementation in accountability programs which will strengthen genetic counseling as a profession that provides evidence-based high-quality care to all patients.
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Affiliation(s)
- Emily Higgs
- Cardiovascular Genetics Program, University of California San Francisco California USA
| | | | - Julia Wynn
- Department of Pediatrics Columbia University Irving Medical Center New York New York USA
| | - Megan T. Cho
- Center for Precision Health Research, National Human Genome Research Institute, National Institutes of Health Bethesda Maryland USA
| | | | - David Blaisdell
- Discern Health, Part of Real Chemistry San Francisco California USA
| | - Donna Dugan
- Discern Health, Part of Real Chemistry San Francisco California USA
| | - Sara Valek
- Discern Health, Part of Real Chemistry San Francisco California USA
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10
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Identification of Disparities in Personalized Cancer Care-A Joint Approach of the German WERA Consortium. Cancers (Basel) 2022; 14:cancers14205040. [PMID: 36291825 PMCID: PMC9600149 DOI: 10.3390/cancers14205040] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 10/04/2022] [Accepted: 10/12/2022] [Indexed: 12/02/2022] Open
Abstract
Simple Summary In Molecular Tumor Boards (MTBs), clinicians and researchers discuss the biology of tumor samples from individual patients to find suitable therapies. MTBs have therefore become key elements of precision oncology programs. Patients living in urban areas with specialized medical centers can easily access MTBs. Dedicated efforts are necessary to also grant equal access for patients from rural areas. To address this challenge, the four German cancer centers in Würzburg, Erlangen, Regensburg and Augsburg collectively measured the regional efficacy of their MTBs. By jointly analyzing the residences of all MTB patients, we uncovered regional differences in our mostly rural catchment area. Mapping and further understanding these local differences—especially the underrepresented white spots—will help resolving inequalities in patient access to precision oncology. Our study represents a hands-on approach to assessing the regional efficacy of a precision oncology program. Moreover, this approach is transferable to other regions and clinical applications. Abstract (1) Background: molecular tumor boards (MTBs) are crucial instruments for discussing and allocating targeted therapies to suitable cancer patients based on genetic findings. Currently, limited evidence is available regarding the regional impact and the outreach component of MTBs; (2) Methods: we analyzed MTB patient data from four neighboring Bavarian tertiary care oncology centers in Würzburg, Erlangen, Regensburg, and Augsburg, together constituting the WERA Alliance. Absolute patient numbers and regional distribution across the WERA-wide catchment area were weighted with local population densities; (3) Results: the highest MTB patient numbers were found close to the four cancer centers. However, peaks in absolute patient numbers were also detected in more distant and rural areas. Moreover, weighting absolute numbers with local population density allowed for identifying so-called white spots—regions within our catchment that were relatively underrepresented in WERA MTBs; (4) Conclusions: investigating patient data from four neighboring cancer centers, we comprehensively assessed the regional impact of our MTBs. The results confirmed the success of existing collaborative structures with our regional partners. Additionally, our results help identifying potential white spots in providing precision oncology and help establishing a joint WERA-wide outreach strategy.
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11
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Stakeholders Perceptions of Barriers to Precision Medicine Adoption in the United States. J Pers Med 2022; 12:jpm12071025. [PMID: 35887521 PMCID: PMC9316935 DOI: 10.3390/jpm12071025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/13/2022] [Accepted: 06/16/2022] [Indexed: 11/17/2022] Open
Abstract
Despite evidence that precision medicine (PM) results in improved patient care, the broad adoption and implementation has been challenging across the United States (US). To better understand the perceived barriers associated with PM adoption, a quantitative survey was conducted across five stakeholders including medical oncologists, surgeons, lab directors, payers, and patients. The results of the survey reveal that stakeholders are often not aligned on the perceived challenges with PM awareness, education and reimbursement, with there being stark contrast in viewpoints particularly between clinicians, payers, and patients. The output of this study aims to help raise the awareness that misalignment on the challenges to PM adoption is contributing to broader lack of implementation that ultimately impacts patients. With better understanding of stakeholder viewpoints, we can help alleviate the challenges by focusing on multi-disciplinary education and awareness to ultimately improve patient outcomes.
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12
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Best S, Vidic N, An K, Collins F, White SM. A systematic review of geographical inequities for accessing clinical genomic and genetic services for non-cancer related rare disease. Eur J Hum Genet 2022; 30:645-652. [PMID: 35046503 DOI: 10.1038/s41431-021-01022-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 11/28/2021] [Accepted: 12/02/2021] [Indexed: 11/09/2022] Open
Abstract
Place plays a significant role in our health. As genetic/genomic services evolve and are increasingly seen as mainstream, especially within the field of rare disease, it is important to ensure that where one lives does not impede access to genetic/genomic services. Our aim was to identify barriers and enablers of geographical equity in accessing clinical genomic or genetic services. We undertook a systematic review searching for articles relating to geographical access to genetic/genomic services for rare disease. Searching the databases Medline, EMBASE and PubMed returned 1803 papers. Screening led to the inclusion of 20 articles for data extraction. Using inductive thematic analysis, we identified four themes (i) Current service model design, (ii) Logistical issues facing clinicians and communities, (iii) Workforce capacity and capability and iv) Rural culture and consumer beliefs. Several themes were common to both rural and urban communities. However, many themes were exacerbated for rural populations due to a lack of clinician access to/relationships with genetic specialist staff, the need to provide more generalist services and a lack of genetic/genomic knowledge and skill. Additional barriers included long standing systemic service designs that are not fit for purpose due to historically ad hoc approaches to delivery of care. There were calls for needs assessments to clarify community needs. Enablers of geographically equitable care included the uptake of new innovative models of care and a call to raise both community and clinician knowledge and awareness to demystify the clinical offer from genetics/genomics services.
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Affiliation(s)
- Stephanie Best
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia. .,Australian Genomics, Murdoch Children's Research Institute, Melbourne, VIC, Australia.
| | - Nada Vidic
- Australian Genomics, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, NSW, Australia
| | - Kim An
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Felicity Collins
- Clinical Genetics Service, Institute of Precision Medicine and Bioinformatics, Royal Prince Alfred Hospital, Sydney, NSW, Australia.,Divisions of Genomic Medicine, Paediatrics and Child Health, University of Sydney, Sydney, NSW, Australia
| | - Susan M White
- Australian Genomics, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia.,Victorian Clinical Genetics Services, Melbourne, VIC, Australia
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13
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Abstract
The accelerating integration of telehealth technologies in neurology practice has transformed traditional interactions between neurologists and patients, allied clinicians and society. Despite the immense promise of these technologies to improve systems of neurological care, the infusion of telehealth technologies into neurology practice introduces a host of unique ethical challenges. Proactive consideration of the ethical dimensions of teleneurology and of the impact of these innovations on the field of neurology more generally can help to ensure responsible development and deployment across stages of implementation. Toward these ends, this article explores key ethical dimensions of teleneurology practice and policy, presents a normative framework for their consideration, and calls attention to underexplored questions ripe for further study at this evolving nexus of teleneurology and neuroethics. To promote successful and ethically resilient development of teleneurology across diverse contexts, clinicians, organizational leaders, and information technology specialists should work closely with neuroethicists with the common goal of identifying and rigorously assessing the trajectories and potential limits of teleneurology systems.
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Affiliation(s)
- Michael J Young
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
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14
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Martinez-Cannon BA, Barragan-Carrillo R, Villarreal-Garza C. Young Women with Breast Cancer in Resource-Limited Settings: What We Know and What We Need to Do Better. BREAST CANCER (DOVE MEDICAL PRESS) 2021; 13:641-650. [PMID: 34880675 PMCID: PMC8648095 DOI: 10.2147/bctt.s303047] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 11/23/2021] [Indexed: 06/13/2023]
Abstract
Young women with breast cancer (YWBC) account for a variable proportion of patients diagnosed with breast cancer around the globe, with a higher prevalence in resource-limited settings than in high-income countries. This group represents a unique population that warrants special attention due to specific biological considerations and age-specific supportive care issues. This review aims to explore existing knowledge regarding YWBC's needs, particularly in resource-restricted settings. To date, scarce information regarding the care of YWBC in resource-constrained countries is available, with most reports describing suboptimal care in terms of survivorship needs. Health care providers should implement actions to improve endocrine treatment adherence, referrals for fertility counseling and preservation, contraceptive use compliance, timely body image and sexual function interventions, comprehensive genetic risk assessments, and early quality of life and psychosocial health interventions. While high costs act as a barrier for optimal care in resource-limited settings, improving patient education represents a promising and cost-effective solution to improve patient care. Future research on developing tailored educational resources for YWBC in resource-limited settings should be considered a priority.
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Affiliation(s)
- Bertha Alejandra Martinez-Cannon
- Hematology-Oncology Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
- Joven & Fuerte: Programa para la Atencion e Investigacion de Mujeres Jovenes con Cancer de Mama en Mexico, Mexico City, Mexico
| | - Regina Barragan-Carrillo
- Hematology-Oncology Department, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico City, Mexico
- Joven & Fuerte: Programa para la Atencion e Investigacion de Mujeres Jovenes con Cancer de Mama en Mexico, Mexico City, Mexico
| | - Cynthia Villarreal-Garza
- Joven & Fuerte: Programa para la Atencion e Investigacion de Mujeres Jovenes con Cancer de Mama en Mexico, Mexico City, Mexico
- Breast Cancer Center, Hospital Zambrano Hellion TecSalud, Tecnologico de Monterrey, San Pedro Garza Garcia, Nuevo Leon, Mexico
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