Validation Study on Risk-Reduction Activities after Exposure to a Personalized Breast Cancer Risk-Assessment Education Tool in High-Risk Women in the WISDOM Study

We performed a 318-participant validation study of an individualized risk assessment tool in women identified as having high- or highest-risk of breast cancer in the personalized arm of the Women Informed to Screen Depending on Measures of risk (WISDOM) trial. Per protocol, these women were educated about their risk and risk reducing options using the Breast Health Decisions (BHD) tool, which uses patient-friendly visuals and 8th grade reading level language to convey risk and prevention options. Prior to exposure to the educational tool, 4.7% of women were already taking endocrine risk reduction, 38.7% were reducing alcohol intake, and 62.6% were exercising. Three months after initial use of BHD, 8.4% of women who considered endocrine risk reduction, 33% of women who considered alcohol reduction, and 46% of women who considered exercise pursued the risk-reducing activities. Unlike lifestyle interventions which are under the control of the patient, additional barriers at the level of the healthcare provider may be impeding the targeted use of endocrine risk reduction medications in women with elevated breast cancer risk.

Telemental health policies for college students during COVID-19

Federal and institutional policy changes have accelerated the use of telemental health to care for college students distant from their mental health providers during the early part of the COVID-19 pandemic. Temporary measures have made telemental health more readily available, including relaxing of regulations related to interstate licensure, controlled substance prescribing, patient privacy, and reimbursement. Though early efforts are underway to sustain these changes during and in the wake of the pandemic, there are important areas in which federal and institutional policy are still lacking. Additional steps are needed to successfully implement and sustain telemental health for college students include ensuring student access to technology and Internet; proactive outreach to optimize the student's home environment, addressing concerns about safety and confidentiality; developing the means to track rapidly shifting telemental health policy changes; and developing centralized resources that enable remote providers to become familiar with involuntary commitment laws and emergency protocols.

Opportunities to use electronic health record audit logs to improve cancer care

The rapid adoption of electronic health records (EHRs) has created extensive repositories of digitized data that can be used to inform improvements in care delivery, processes, and patient outcomes. While the clinical data captured in EHRs are widely used for such efforts, EHRs also capture audit log data that reflect how users interact with the EHR to deliver care. Automatically collected audit log data provide a unique opportunity for new insights into EHR user behavior and decision‐making processes. Here, we provide an overview of audit log data and examples that could be used to improve oncology care and outcomes in four domains: diagnostic reasoning and consumption, care team collaboration and communication, patient outcomes and experience, and provider burnout/fatigue. This data source could identify gaps in performance and care, physician uptake of EHR features that enhance decision‐making, and integration of data trends for oncology. Ensuring researchers and oncologists are familiar with the data's potential and developing the data engineering capacity to utilize this rich data source, will expand the breadth of research to improve cancer care.

Pre-Appointment Nurse Navigation: Patient-Centered Findings From a Survey of Patients With Breast Cancer

BACKGROUND

Research indicates that nurse navigators can play key roles in promoting empowerment for patients with cancer through advocacy, educational support, resource navigation, and psychosocial care.

OBJECTIVES

This study attempted to elucidate the efficacy of nurse navigation in patient knowledge, care coordination, and well-being before a breast oncology appointment.

METHODS

Staff provided a nine-question survey to 50 newly referred patients before their initial appointment. After survey completion, patients had the option to participate in an open-ended interview about their experience.

FINDINGS

A greater proportion of patients with initial nurse navigation than those without felt informed before their appointment and thought that their care was effectively coordinated. Although some patients without nurse navigation experienced delays and confusion in scheduling their appointment, no patients with nurse navigators reported such issues.

Elevated risk thresholds predict endocrine risk-reducing medication use in the Athena screening registry

Risk-reducing endocrine therapy use, though the benefit is validated, is extremely low. The FDA has approved tamoxifen and raloxifene for a 5-year Breast Cancer Risk Assessment Tool (BCRAT) risk ≥ 1.67%. We examined the threshold at which high-risk women are likely to be using endocrine risk-reducing therapies among Athena Breast Health Network participants from 2011-2018. We identified high-risk women by a 5-year BCRAT risk ≥ 1.67% and those in the top 10% and 2.5% risk thresholds by age. We estimated the odds ratio (OR) of current medication use based on these thresholds using logistic regression. One thousand two hundred and one (1.2%) of 104,223 total participants used medication. Of the 33,082 participants with 5-year BCRAT risk ≥ 1.67%, 772 (2.3%) used medication. Of 2445 in the top 2.5% threshold, 209 (8.6%) used medication. Participants whose 5-year risk exceeded 1.67% were more likely to use medication than those whose risk was below this threshold, OR 3.94 (95% CI = 3.50-4.43). The top 2.5% was most strongly associated with medication usage, OR 9.50 (8.13-11.09) compared to the bottom 97.5%. Women exceeding a 5-year BCRAT ≥ 1.67% had modest medication use. We demonstrate that women in the top 2.5% have higher odds of medication use than those in the bottom 97.5% and compared to a risk of 1.67%. The top 2.5% threshold would more effectively target medication use and is being tested prospectively in a randomized control clinical trial.

Development and pilot of an online, personalized risk assessment tool for a breast cancer precision medicine trial

Breast cancer risk reduction has been validated by large-scale clinical trials, but uptake remains low. A risk communication tool could provide personalized risk-reduction information for high-risk women. A low-literacy-friendly, visual, and personalized tool was designed as part of the Women Informed to Screen Depending On Measures of risk (WISDOM) study. The tool integrates genetic, polygenic, and lifestyle factors, and quantifies the risk-reduction from undertaking medication and lifestyle interventions. The development and design process utilized feedback from clinicians, decision-making scientists, software engineers, and patient advocates. We piloted the tool with 17 study participants, collecting quantitative and qualitative feedback. Overall, participants felt they better understood their personalized breast cancer risk, were motivated to reduce their risk, and considered lifestyle interventions. The tool will be used to evaluate whether risk-based screening leads to more informed decisions and higher uptake of risk-reduction interventions among those most likely to benefit.

Abstract P4-15-02: Lessons learned: Implementing the WISDOM study using private payors to cover study services and generate evidence

Background: Generating real world evidence in support of value-based healthcare solutions has traditionally been difficult due to the nature of funding and reimbursement mechanisms. Pragmatic, comparative effectiveness studies need additional funding to cover study costs, and systems are not in place to incorporate evidence generation into improving health outcomes. In 2005, the Centers for Medicare and Medicaid Services (CMS) identified the need to broaden access to innovative therapies and practices, and implemented a Coverage with Evidence Development (CED) model. This model has not been adapted by private payers.

Methods: The WISDOM (Women Informed to Screen Depending on Measures of risk) Study in collaboration with the Patient-Centered Outcomes Research Institute (PCORI), addressed this challenge by co-developing a private payer coverage with evidence progression (CEP) model, based upon Medicare’s CED policy. Since the study began in 2016, numerous payers cover the WISDOM Study using CEP, including private, Medi-Cal, and self-insured employer groups, across six states (California, Illinois, Iowa, New Jersey, North Dakota and South Dakota). The payers helped cover study services used for risk assessment and high-risk counseling in the WISDOM Study.

Results: The first barrier was the payer’s fiscal concerns over adopting CEP, which was overcome by establishing the case for evidence generation as a route to better outcomes, cost savings and overall healthcare value. The second barrier was that health insurance companies may only control benefits for a fraction of their members. To overcome this barrier, WISDOM Study Investigators extended CEP to self-insured employers, who have been enthusiastic proponents in covering and recruiting participants. In implementing CEP, a third significant barrier was billing for individual services on a national scale. In response, WISDOM investigators established a scalable and replicable billing infrastructure for pre-approving and submitting claims for study services.

Discussion: The WISDOM Study is a pragmatic, comparative effectiveness trial that provides a framework for future research studies to adopt and build upon. For CEP to be scalable, an established simple mechanism is essential. For every limitation, we have identified important lessons that have been learned during the study’s implementation to address what started as insurmountable barriers and ended as a critical demonstration of feasibility.

Conclusion: These obstacles may inform subsequent implementations of coverage for evidence generation purposes as a means to promote value-based improvements in care.

Citation Format: Yash S Huilgol, Kenneth Wimmer, Erick Lin, Marcus Thygeson, Allison S Fiscalini, Karyn DiGiorgio, David Kraus, Lisa M Latts, Laura Tauber, Trent T Haywood, Athena Breast Health Network Investigators and Advocate Partners, Laura J Esserman. Lessons learned: Implementing the WISDOM study using private payors to cover study services and generate evidence [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P4-15-02.

Abstract P5-08-01: Breast cancer risk thresholds as a predictor of chemoprevention uptake in the Athena Breast Health Network

Background: Large-scale chemoprevention trials validated endocrine risk reduction strategies to lower breast cancer risk. We sought to understand the risk at which women are likely to adopt chemoprevention. A 5-year Gail risk of 1.67% or above is considered elevated risk, and the FDA indication for prescribing chemoprevention. We examined chemoprevention use in the Athena Breast Health Network (Athena), which includes approximately 100,000 women who are screened by mammography at Sanford Health, UC Davis, UC Irvine, UC Los Angeles, UC San Diego, and UC San Francisco.

Methods: We calculated the Gail risk score for women who had completed an Athena online intake survey distributed before being seen at screening centers; this survey included questions about chemoprevention usage. First, we analyzed 16,518 surveys of 9,318 unique women without breast cancer or DCIS who received breast cancer screening at UCSF from 2011- 2018 and who consented to research. These women also self-reported use of chemoprevention. We stratified Gail risk scores by a threshold of 1.67%, and by percentiles to identify those women in the top 2.5% by age. We compared current chemoprevention use in these different breast cancer risk strata, and factors associated with its use. An analysis including all 100,000 women in the Athena Network will be presented at SABCS.

Results: Overall, at UCSF, 48 of 9,318 women (0.51%) reported current chemoprevention use. The 5-year Gail risk was greater than 1.66% in 3,675 of 9,318 women (39%), of whom 205 (2.2%) were in the top 2.5% of risk by age. Chemoprevention use was reported by 13 of 205 (6.3%) women in the top 2.5% of risk by age (mean Gail risk 5.6%), as compared to 41 of 3,675 (1.1%) who were at Gail above 1.66% (mean Gail = 3.9%). Women in the top 2.5% and those with Gail risk >1.66% were significantly more likely to be using chemoprevention p< 0.01 for each respectively). Chemoprevention uptake was correlated with the joint effect of the top 2.5% of risk by age and increasing Gail score (OR = 10.25; P = 0.009). Preliminary results were consistent among the 100,000 women in the Athena registry (analysis ongoing). In addition, chemoprevention use was more likely in older women (OR = 1.10; P < 0.01, for every year of age) and in those women with Ashkenazi ancestry on both sides of the family compared to none (OR = 2.32; P = 0.02). Race and education were not associated with use of chemoprevention.

Discussion: Women with higher Gail scores in the top 2.5% of risk by age are positively associated with current chemoprevention use (6.34%). Importantly, this analysis presents a risk-stratified, population-level risk reduction strategy, using the top 2.5% risk threshold by age. It provides an opportunity to specifically target chemoprevention to women at highest need to reduce their breast cancer risk. In the WISDOM Study (NCT02620852), we are prospectively testing active outreach based on breast cancer risk in the top 2.5% of risk by age, and have developed a breast health decisions aid to standardize communication of risk-reducing options.

Citation Format: Yash S Huilgol, Holly Keane, Yiwey Shieh, Jeffrey Tice, Elad Ziv, Lisa Madlensky, Leah Sabacan, Irene Acerbi, Mandy Che, Allison Stover Fiscalini, Hoda Anton-Culver, Alexander D Borowsky, Sharon Hunt, Arash Naeim, Barbara Parker, Laura J van 't Veer, Athena Breast Health Network Investigators and Advocate Partners and Laura J Esserman. Breast cancer risk thresholds as a predictor of chemoprevention uptake in the Athena Breast Health Network [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P5-08-01.