Abstract P5-03-16: Changes in preferences for ovarian cancer prevention strategies during the COVID-19 pandemic: Results of a discrete choice experiment

Background: The COVID-19 pandemic influenced patient health care decisions, but there is little information about the pandemic’s impact on decisions about cancer risk reduction. This includes women at elevated risk of breast or ovarian cancer considering risk-reducing salpingo-oophorectomy (RRSO), risk-reducing salpingectomy (RRS), or other preventive measures. During the pandemic patients needed to balance their concerns about cancer risk reduction with their risks associated with elective health procedures, a risk which changed as vaccines became available. Methods: To address the impact of the COVID-19 pandemic on cancer prevention decision making, we recruited N=396 pre-menopausal women with a personal history of breast cancer or familial history suggestive of increased breast and/or ovarian cancer risk between 4/2019 and 3/2022. We conducted a discrete choice experiment in which patients were asked to choose between two scenarios that specified type of surgery (RRSO, RRS vs. non-surgical surveillance), age of menopause (natural versus immediate), quality of menopausal symptoms (mild, moderate, severe), and risk of ovarian cancer, heart disease, or osteoporosis. Risk of ovarian cancer for the scenarios provided varied in discrete intervals from 0% to 40%. We examined temporal trends during the pandemic using interactions with time coinciding approximately with the beginning of pandemic, peak vaccination period, and the Omicron wave. Results: We identified significant temporal interactions on a woman’s prevention decisions. In 2019, women at higher risk of ovarian cancer were more likely to choose prevention scenarios that favored lower ovarian cancer risk (odds ratio [OR] = 0.48; 95% CI = 0.37, 0.69 per 10% increase in ovarian cancer risk difference). This association decreased through the pre-vaccine period of 2020 by OR=2.61/month (95% CI = 1.21, 5.65). By June 2020, the effect of a 10% increase in ovarian cancer risk on intervention choice had attenuated substantially (OR=0.84, 95% CI 0.67, 1.00). By January 2022, the effect strengthened (OR= 0.69, 95% CI .49, .88), but had not reached pre-pandemic levels. Before 3/2020, natural age of menopause (versus immediate) had a strong impact on the choice of a scenario (OR=3.56, 95% CI 1.65-7.65). At the beginning of the pandemic, the effect was reduced by 0.47/month (95% CI 0.22-0.99). The rate of attenuation slowed over time, such that the effect of having a natural age of menopause on choice was OR= 1.56 (95% CI 0.65, 2.46) by January 2022. Tests for temporal interactions were statistically significant for both ovarian cancer risk and age of menopause. Conclusions: Our results suggest that over the course of the pandemic, women seemed more accepting of higher risks of ovarian cancer and immediate (post treatment) menopause when considering preventive options. There was an inverse U shape curve of the effect of ovarian cancer risk on choices over time (Figure A), but the strength of the relationship had not reached pre-pandemic levels by January 2022. This may reflect patient tolerance for side effects as the pandemic evolved. These results suggest that factors such as ovarian cancer risk and delay of menopause influenced personal prevention choices, but that these choices were influenced by events related to events that hallmarked the COVID-19 pandemic.

Citation Format: Brian Egleston, Mary Daly, Kaitlyn Lew, Lisa Bealin, Alexander Husband, Jill Stopfer, Pawel Przybysz, Olga Tchuvatkina, Yu-Ning Wong, Judy Garber, Timothy Rebbeck. Changes in preferences for ovarian cancer prevention strategies during the COVID-19 pandemic: Results of a discrete choice experiment. [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P5-03-16.

Inherited TP53 Variants and Risk of Prostate Cancer

BACKGROUND

Inherited germline TP53 pathogenic and likely pathogenic variants (gTP53) cause autosomal dominant multicancer predisposition including Li-Fraumeni syndrome (LFS). However, there is no known association of prostate cancer with gTP53.

OBJECTIVE

To determine whether gTP53 predisposes to prostate cancer.

DESIGN, SETTING, AND PARTICIPANTS

This multi-institutional retrospective study characterizes prostate cancer incidence in a cohort of LFS males and gTP53 prevalence in a prostate cancer cohort.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

We evaluated the spectrum of gTP53 variants and clinical features associated with prostate cancer.

RESULTS AND LIMITATIONS

We identified 31 prostate cancer cases among 163 adult LFS males, including 26 of 54 aged ≥50 yr. Among 117 LFS males without prostate cancer at the time of genetic testing, six were diagnosed with prostate cancer over a median (interquartile range [IQR]) of 3.0 (1.3-7.2) yr of follow-up, a 25-fold increased risk (95% confidence interval [CI] 9.2-55; p < 0.0001). We identified gTP53 in 38 of 6850 males (0.6%) in the prostate cancer cohort, a relative risk 9.1-fold higher than that of population controls (95% CI 6.2-14; p < 0.0001; gnomAD). We observed hotspots at the sites of attenuated variants not associated with classic LFS. Two-thirds of available gTP53 prostate tumors had somatic inactivation of the second TP53 allele. Among gTP53 prostate cancer cases in this study, the median age at diagnosis was 56 (IQR: 51-62) yr, 44% had Gleason ≥8 tumors, and 29% had advanced disease at diagnosis.

CONCLUSIONS

Complementary analyses of prostate cancer incidence in LFS males and gTP53 prevalence in prostate cancer cohorts suggest that gTP53 predisposes to aggressive prostate cancer. Prostate cancer should be considered as part of LFS screening protocols and TP53 considered in germline prostate cancer susceptibility testing.

PATIENT SUMMARY

Inherited pathogenic variants in the TP53 gene are likely to predispose men to aggressive prostate cancer.

Abstract PO-013: Comparison of novel healthcare delivery models on the uptake of genetic education and testing in families with a history of pancreatic cancer: The GENetic Education, Risk Assessment and TEsting (GENERATE) study

Background: Roughly 7–10% of patients with pancreatic ductal adenocarcinoma (PDAC) have a deleterious germline variant. Although identification of germline variants in family members has implications for cancer surveillance and can lead to early cancer detection and interception for PDAC, as well as other cancers, cascade genetic testing rates are low. The GENetic Education, Risk Assessment and TEsting (GENERATE) study evaluates novel methods of providing genetic education and testing for individuals at risk for hereditary PDAC. Methods: Eligible participants had: (1) a first- or second-degree relative with a diagnosis of PDAC and a known familial germline variant in APC, ATM, BRCA1, BRCA2, CDKN2A, EPCAM, MLH1, MSH2, MSH6, PALB2, PMS2, STK11, or TP53 (Known Familial Mutation (KFM)), (2) or were first-degree relatives of PDAC patients (no KFM). Participants were recruited through six academic centers, patient advocacy organizations and online outreach. Enrollment occurred through the study website (www.GENERATEstudy.org). All study participation, including genetic testing via a at home saliva sample kit, was done remotely. Participants were cluster randomized at the family level into one of two arms. Arm 1 (Doxy.me plus Color Genomics) included remote genetic education and testing through a video-based telemedicine platform (Doxy.me) and physician-mediated testing through Color Genomics. Arm 2 included remote genetic education and testing through Color Genomics only. Results: Between 5/8/2019–6/01/2021, 423 families were randomized, comprising 595 participants. Recruitment occurred through patient invitation via healthcare providers (n=128, 21.5%), family members (n=271, 45.5%), friends, advocacy groups, and online outreach (n=223, 37.5%). Participants were referred from the six GENERATE academic centers (n=270, 45.4%) and other institutions (n=325, 54.6%). Study participants were 52.5 years on average, primarily identified as White (n=577, 97%) and from the Northeast (n=184, 30.9%), Midwest (n=154, 25.9%), South (n=158, 26.6%) and West (n=99, 16.6%). Participants were randomized into each arm (n=296 Doxy.me plus Color Genomics; n=299 Color Genomics only). To date, 527 (88.6%) participants have ordered genetic testing. The uptake of genetic testing was 253/296 (85.5%) in the Doxy.me plus Color Genomics arm and 274/299 (91.6%) in the Color Genomics only arm (p=0.049, generalized mixed-effects model). A total of 82 PDAC associated pathogenic variants were identified. The most frequently detected variants were BRCA2 (n=32), ATM (n=25) and PALB2 (n=6). Additionally, 13 non-PDAC associated pathogenic variants and 20 low penetrance variants were detected. Conclusions: Remote methods of genetic education and testing are successful alternatives to traditional cascade testing, with genetic testing rates nearly 90%. Participant follow up will assess if satisfaction with decision making, cancer-risk distress, knowledge gained, family communication, and uptake of surveillance were impacted by the mode of delivery of pre-test genetic education.

Citation Format: Nicolette J. Rodriguez, Constance S. Furniss, Matthew B. Yurgelun, Chinedu Ukaegbu, Pamela E. Constantinou, Alison N. Schwartz, Jill Stopfer, Meghan Underhill-Blazey, Barbara Kenner, Scott Nelson, Sydney Okumura, Sherman Law, Alicia Y. Zhou, Tara B. Coffin, Hajime Uno, Allyson Ocean, Florencia McAllister, Andrew M. Lowy, Scott M. Lippman, Alison P. Klein, Lisa Madlensky, Gloria M. Petersen, Judy E. Garber, Michael G. Goggins, Anirban Maitra, Sapna Syngal. Comparison of novel healthcare delivery models on the uptake of genetic education and testing in families with a history of pancreatic cancer: The GENetic Education, Risk Assessment and TEsting (GENERATE) study [abstract]. In: Proceedings of the AACR Virtual Special Conference on Pancreatic Cancer; 2021 Sep 29-30. Philadelphia (PA): AACR; Cancer Res 2021;81(22 Suppl):Abstract nr PO-013.

Abstract OT-20-01: Genetic testing for all breast cancer patients (get facts)

Background: There is evidence that increases in germline cancer genetic testing result in higher rates of contralateral prophylactic mastectomy (CPM) in newly diagnosed breast cancer (BC) patients, even among those with negative results. Unlike carriers of BRCA pathogenic variants (PV), the risks of contralateral breast cancer (CBC) and benefits of CPM for women with PV in moderate penetrance genes are not well studied. There is a critical need to determine how to best counsel BC patients about their personal CBC risk and surgical decisions.

Trial design: Newly diagnosed BC patients are randomized 1:1 to quantitative or standard post-genetic test cancer risk counseling methods by genetic counselors. Quantitative counseling includes personalized CBC risk estimates. For patients with a PV in a BC risk gene, CBC risk estimates are calculated via the “ASK2ME” decision tool (https://ask2me.org/). For those without a BC-associated PV, CBC risk estimates are calculated via a validated model “CBCRisk” (https://cbc-predictor-utd.shinyapps.io/CBCRisk/).Standard counseling does not typically include specific CBC risk estimates.Eligibility criteria: All patients over 18 with newly diagnosed invasive or in situ unilateral BC considering genetic testing at Dana-Farber/Brigham and Women’s Cancer Center are eligible. Exclusion criteria include a diagnosis of previous BC, metastatic or bilateral BC, hematologic malignancy, prior or active other malignancy, prior multi-gene panel testing, known medical or surgical contraindication to surgery and/or CPM.Specific aims: The primary aims are to 1) compare changes in patients’ personal CBC risk assessment before/after quantitative versus standard counseling; 2) determine changes in patients’ propensity to choose CPM before/after quantitative versus standard counseling. The secondary aims are to: 1) compare CPM rates; 2) determine concordance between patient and surgeon assessment of CBC risk; 3) evaluate patient genetic testing satisfaction via the Genetic Testing Satisfaction Survey administered post-counseling; 4) measure patient anxiety via the PROMIS Anxiety Survey administered pre- and post-counseling, at 6 months and 2 years; and 5) measure patient decisional regret for both undergoing genetic testing and their surgery choices at 6 months and 2 years; all by quantitative versus standard counseling arms.

Statistical methods: For aim 1, the difference between patients’ reported personal CBC risk and true risk before and after counseling will be determined. True risk will be based on the ASK2ME/CBCRisk estimates. We hypothesize that the difference between the true and estimated risk will be smaller post-counseling, and smaller in the quantitative counseling versus standard arm. Assuming an expected difference of 5% and expected standard deviation of 20%, 199 patients are needed for each arm to achieve 80% power and type I error of 5% (based on a two-sample t-test). For aim 2, to determine propensity to undergo CPM, patient responses will be assigned a numeric value: Very Unlikely (1), Somewhat unlikely (2), Unsure (3), Somewhat likely (4), Very likely (5). For each patient we will then calculate the difference in scores before/after counseling. Our hypothesis is that differences will be greater in the quantitative arm. Assuming an expected difference of 0.8 and expected standard deviation of 3, 175 patients are needed for each arm to achieve 80% power and type I error rate of 5% (based on a two-sample t-test).

Accrual: Recruitment began on June 8, 2020; there are currently 9 of the target 450 patients enrolled.

Funding Support: Sponsored Research Agreement with Myriad Laboratories, Inc. and a Brigham and Women’s Hospital Department of Surgery Robert T. Osteen Junior Fellowship Award.

PI: Anna Weiss, aweiss5@bwh.harvard.edu, @DrAnnaWeiss

Citation Format: Anna Weiss, Danielle Braun, Jill Stopfer, Daniel Desantis, Meaghan Dwan, Dillon Davis, Anjali Jha, Laura Dominici, Shoshana Rosenberg, Tari A. King, Elizabeth A Mittendorf, Mehra Golshan, Huma Q Rana, Judy E Garber. Genetic testing for all breast cancer patients (get facts) [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr OT-20-01.

Cancer Genetic Counseling-Current Practice and Future Challenges

Cancer genetic counseling practice is rapidly evolving, with services being provided in increasingly novel ways. Pretest counseling for cancer patients may be abbreviated from traditional models to cover the elements of informed consent in the broadest of strokes. Genetic testing may be ordered by a cancer genetics professional, oncology provider, or primary care provider. Increasingly, direct-to-consumer testing options are available and utilized by consumers anxious to take control of their genetic health. Finally, genetic information is being used to inform oncology care, from surgical decision-making to selection of chemotherapeutic agent. This review provides an overview of the current and evolving practice of cancer genetic counseling as well as opportunities and challenges for a wide variety of indications in both the adult and pediatric setting.

Development and testing of the KnowGene scale to assess general cancer genetic knowledge related to multigene panel testing

PURPOSE

To develop and evaluate a measure of cancer genetics knowledge relevant to multigene panel testing.

METHODS

The instrument was developed using systematic input from a national panel of genetics experts, acceptability evaluation by patient advocates, and cognitive testing. Twenty-four candidate items were completed by 591 breast or gynecological patients who had undergone genetic counseling and multigene panel testing in the past 18 months. A unidimensional item response theory model was fit with a mix of 2-parameter logistic nested response (2 plnrm) and 2-parameter logistic (2 pl) items.

RESULTS

Key domains addressing cancer genetics knowledge were found to be overlapping. Of the 24 candidate items, 8 items were removed due to poor discrimination or local dependence. The remaining 16 items had good fit (RMSEA = 0.045, CFI = 0.946) and discrimination parameters ranging from 0.49 to 1.60. The items specified as 2 plnrm distinguish between those answering incorrect versus don't know, with discrimination ranging from 0.51 to 1.02. Information curves were highest among those with lower knowledge.

CONCLUSION

KnowGene is a rigorously developed and effective measure of knowledge after cancer genetic counseling and multigene panel testing.

PRACTICE IMPLICATIONS

Measuring knowledge in a systematic way will inform practice and research initiatives in cancer genetics.

Abstract P3-03-01: Clinical utility of finding pathogenic mutations beyond BRCA1/2 in breast cancer patients

Background

The clinical utility of germline genetic testing for BRCA1 and BRCA2 has long been established. However, management recommendations for pathogenic variants in other genes, typically included in multigene panels, have only recently been included in consensus guidelines for HBOC. The clinician actions implemented for findings in these genes, and patient follow-up, are not yet well studied. We report interim results from a multi-site study of clinical actions undertaken in patients presenting with HBOC and carrying a pathogenic germline mutation in cancer risk genes other than BRCA1/2.

Methods

We retrospectively examined a cohort of patients with a personal history of HBOC who had been referred for hereditary cancer multigene testing from three major academic medical centers. For patients with pathogenic findings in a non-BRCA1/2 cancer risk gene, ordering clinicians completed a short case report form describing the clinical actions taken in response to the genetic test result, and patient follow-up. Some patients were lost to follow-up and answers of “unknown” were permitted. Genes with positive findings included CHEK2, PALB2, ATM, MUTYH, RAD51C, TP53, MSH6, RAD50, APC, BARD1, BRIP1, MSH2, NF1, NBN, PMS2, and PTEN. Case report forms were available for 77 patients as of our cut off date, and these data were de-identified and summarized for this interim report. Additional cases continue to accrue in this ongoing study.

Results

In 57% (44/77) of cases, clinicians reported that counseling and/or clinical management recommendations were changed in response to the genetic test findings. Management changes included modification of imaging surveillance (38%), considered or recommended surgical prophylaxis (12%), modified surgical plan for an existing malignancy (5%), and for one patient each: inclusion in a research trial for PARP inhibitors, modification of colonoscopy schedule, and screening for cancers other than existing malignancy. Clinicians indicated that genetic test results changed management in 48% of patients, did not change management in 29%, and had unknown impact for 23%.

Clinicians also reported that counseling and/or management for the patients' family members was changed in 67% (52/77) of cases, including family variant testing. 27% (21/77) of the patient families had cascade genetic testing, and one or more new carriers were identified in 47% (10) of the tested families. In 58% of cases, the impact of management recommendations on family members was unknown as of the case report date.

Conclusions

Pathogenic variants in non-BRCA genes are present in about 3-11% of patients with a history of HBOC. This study suggests that genetic test results in cancer genes beyond BRCA1/2 changed clinical management for a majority of patients and their family members, led to identification of new carriers, and directly impacted treatment decisions. In almost half of these patients, genetic test results impacted their health outcome, including those reported to be disease free after undergoing interventional or prophylactic surgery informed by their genetic variant. More research is needed to improve the implementation of genetic testing based management recommendations for patients and their family members.

Citation Format: Esplin ED, Michalski S, Yang S, Hampel H, Jeter J, Sweet K, Pilarski R, Pearlman R, Shane K, Brock P, Westman J, Chittenden A, Stopfer J, Schneider K, Sacca R, Stickevers S, Kipnis L, Koeller D, Gaonkar S, Sotelo J, Vaccari E, Cochrane S, Champine M, Espinel W, Lincoln SE, Nussbaum RL. Clinical utility of finding pathogenic mutations beyond BRCA1/2 in breast cancer patients [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-03-01.

Proceedings of the 8th Annual Conference on the Science of Dissemination and Implementation : Washington, DC, USA. 14-15 December 2015

A1 Introduction to the 8^th Annual Conference on the Science of Dissemination and Implementation: Optimizing Personal and Population Health

David Chambers, Lisa Simpson

D1 Discussion forum: Population health D&I research

Felicia Hill-Briggs

D2 Discussion forum: Global health D&I research

Gila Neta, Cynthia Vinson

D3 Discussion forum: Precision medicine and D&I research

David Chambers

S1 Predictors of community therapists’ use of therapy techniques in a large public mental health system

Rinad Beidas, Steven Marcus, Gregory Aarons, Kimberly Hoagwood, Sonja Schoenwald, Arthur Evans, Matthew Hurford, Ronnie Rubin, Trevor Hadley, Frances Barg, Lucia Walsh, Danielle Adams, David Mandell

S2 Implementing brief cognitive behavioral therapy (CBT) in primary care: Clinicians' experiences from the field

Lindsey Martin, Joseph Mignogna, Juliette Mott, Natalie Hundt, Michael Kauth, Mark Kunik, Aanand Naik, Jeffrey Cully

S3 Clinician competence: Natural variation, factors affecting, and effect on patient outcomes

Alan McGuire, Dominique White, Tom Bartholomew, John McGrew, Lauren Luther, Angie Rollins, Michelle Salyers

S4 Exploring the multifaceted nature of sustainability in community-based prevention: A mixed-method approach

Brittany Cooper, Angie Funaiole

S5 Theory informed behavioral health integration in primary care: Mixed methods evaluation of the implementation of routine depression and alcohol screening and assessment

Julie Richards, Amy Lee, Gwen Lapham, Ryan Caldeiro, Paula Lozano, Tory Gildred, Carol Achtmeyer, Evette Ludman, Megan Addis, Larry Marx, Katharine Bradley

S6 Enhancing the evidence for specialty mental health probation through a hybrid efficacy and implementation study

Tonya VanDeinse, Amy Blank Wilson, Burgin Stacey, Byron Powell, Alicia Bunger, Gary Cuddeback

S7 Personalizing evidence-based child mental health care within a fiscally mandated policy reform

Miya Barnett, Nicole Stadnick, Lauren Brookman-Frazee, Anna Lau

S8 Leveraging an existing resource for technical assistance: Community-based supervisors in public mental health

Shannon Dorsey, Michael Pullmann

S9 SBIRT implementation for adolescents in urban federally qualified health centers: Implementation outcomes

Shannon Mitchell, Robert Schwartz, Arethusa Kirk, Kristi Dusek, Marla Oros, Colleen Hosler, Jan Gryczynski, Carolina Barbosa, Laura Dunlap, David Lounsbury, Kevin O'Grady, Barry Brown

S10 PANEL: Tailoring Implementation Strategies to Context - Expert recommendations for tailoring strategies to context

Laura Damschroder, Thomas Waltz, Byron Powell

S11 PANEL: Tailoring Implementation Strategies to Context - Extreme facilitation: Helping challenged healthcare settings implement complex programs

Mona Ritchie

S12 PANEL: Tailoring Implementation Strategies to Context - Using menu-based choice tasks to obtain expert recommendations for implementing three high-priority practices in the VA

Thomas Waltz

S13 PANEL: The Use of Technology to Improve Efficient Monitoring of Implementation of Evidence-based Programs - Siri, rate my therapist: Using technology to automate fidelity ratings of motivational interviewing

David Atkins, Zac E. Imel, Bo Xiao, Doğan Can, Panayiotis Georgiou, Shrikanth Narayanan

S14 PANEL: The Use of Technology to Improve Efficient Monitoring of Implementation of Evidence-based Programs - Identifying indicators of implementation quality for computer-based ratings

Cady Berkel, Carlos Gallo, Irwin Sandler, C. Hendricks Brown, Sharlene Wolchik, Anne Marie Mauricio

S15 PANEL: The Use of Technology to Improve Efficient Monitoring of Implementation of Evidence-based Programs - Improving implementation of behavioral interventions by monitoring emotion in spoken speech

Carlos Gallo, C. Hendricks Brown, Sanjay Mehrotra

S16 Scorecards and dashboards to assure data quality of health management information system (HMIS) using R

Dharmendra Chandurkar, Siddhartha Bora, Arup Das, Anand Tripathi, Niranjan Saggurti, Anita Raj

S17 A big data approach for discovering and implementing patient safety insights

Eric Hughes, Brian Jacobs, Eric Kirkendall

S18 Improving the efficacy of a depression registry for use in a collaborative care model

Danielle Loeb, Katy Trinkley, Michael Yang, Andrew Sprowell, Donald Nease

S19 Measurement feedback systems as a strategy to support implementation of measurement-based care in behavioral health

Aaron Lyon, Cara Lewis, Meredith Boyd, Abigail Melvin, Semret Nicodimos, Freda Liu, Nathanial Jungbluth

S20 PANEL: Implementation Science and Learning Health Systems: Intersections and Commonalities - Common loop assay: Methods of supporting learning collaboratives

Allen Flynn

S21 PANEL: Implementation Science and Learning Health Systems: Intersections and Commonalities - Innovating audit and feedback using message tailoring models for learning health systems

Zach Landis-Lewis

S22 PANEL: Implementation Science and Learning Health Systems: Intersections and Commonalities - Implementation science and learning health systems: Connecting the dots

Anne Sales

S23 Facilitation activities of Critical Access Hospitals during TeamSTEPPS implementation

Jure Baloh, Marcia Ward, Xi Zhu

S24 Organizational and social context of federally qualified health centers and variation in maternal depression outcomes

Ian Bennett, Jurgen Unutzer, Johnny Mao, Enola Proctor, Mindy Vredevoogd, Ya-Fen Chan, Nathaniel Williams, Phillip Green

S25 Decision support to enhance treatment of hospitalized smokers: A randomized trial

Steven Bernstein, June-Marie Rosner, Michelle DeWitt, Jeanette Tetrault, James Dziura, Allen Hsiao, Scott Sussman, Patrick O’Connor, Benjamin Toll

S26 PANEL: Developing Sustainable Strategies for the Implementation of Patient-Centered Care across Diverse US Healthcare Systems - A patient-centered approach to successful community transition after catastrophic injury

Michael Jones, Julie Gassaway

S27 PANEL: Developing Sustainable Strategies for the Implementation of Patient-Centered Care across Diverse US Healthcare Systems - Conducting PCOR to integrate mental health and cancer screening services in primary care

Jonathan Tobin

S28 PANEL: Developing Sustainable Strategies for the Implementation of Patient-Centered Care across Diverse US Healthcare Systems - A comparative effectiveness trial of optimal patient-centered care for US trauma care systems

Douglas Zatzick

S29 Preferences for in-person communication among patients in a multi-center randomized study of in-person versus telephone communication of genetic test results for cancer susceptibility

Angela R Bradbury, Linda Patrick-Miller, Brian Egleston, Olufunmilayo I Olopade, Michael J Hall, Mary B Daly, Linda Fleisher, Generosa Grana, Pamela Ganschow, Dominique Fetzer, Amanda Brandt, Dana Farengo-Clark, Andrea Forman, Rikki S Gaber, Cassandra Gulden, Janice Horte, Jessica Long, Rachelle Lorenz Chambers, Terra Lucas, Shreshtha Madaan, Kristin Mattie, Danielle McKenna, Susan Montgomery, Sarah Nielsen, Jacquelyn Powers, Kim Rainey, Christina Rybak, Michelle Savage, Christina Seelaus, Jessica Stoll, Jill Stopfer, Shirley Yao and Susan Domchek

S30 Working towards de-implementation: A mixed methods study in breast cancer surveillance care

Erin Hahn, Corrine Munoz-Plaza, Jianjin Wang, Jazmine Garcia Delgadillo, Brian Mittman Michael Gould

S31Integrating evidence-based practices for increasing cancer screenings in safety-net primary care systems: A multiple case study using the consolidated framework for implementation research

Shuting (Lily) Liang, Michelle C. Kegler, Megan Cotter, Emily Phillips, April Hermstad, Rentonia Morton, Derrick Beasley, Jeremy Martinez, Kara Riehman

S32 Observations from implementing an mHealth intervention in an FQHC

David Gustafson, Lisa Marsch, Louise Mares, Andrew Quanbeck, Fiona McTavish, Helene McDowell, Randall Brown, Chantelle Thomas, Joseph Glass, Joseph Isham, Dhavan Shah

S33 A multicomponent intervention to improve primary care provider adherence to chronic opioid therapy guidelines and reduce opioid misuse: A cluster randomized controlled trial protocol

Jane Liebschutz, Karen Lasser

S34 Implementing collaborative care for substance use disorders in primary care: Preliminary findings from the summit study

Katherine Watkins, Allison Ober, Sarah Hunter, Karen Lamp, Brett Ewing

S35 Sustaining a task-shifting strategy for blood pressure control in Ghana: A stakeholder analysis

Juliet Iwelunmor, Joyce Gyamfi, Sarah Blackstone, Nana Kofi Quakyi, Jacob Plange-Rhule, Gbenga Ogedegbe

S36 Contextual adaptation of the consolidated framework for implementation research (CFIR) in a tobacco cessation study in Vietnam

Pritika Kumar, Nancy Van Devanter, Nam Nguyen, Linh Nguyen, Trang Nguyen, Nguyet Phuong, Donna Shelley

S37 Evidence check: A knowledge brokering approach to systematic reviews for policy

Sian Rudge

S38 Using Evidence Synthesis to Strengthen Complex Health Systems in Low- and Middle-Income Countries

Etienne Langlois

S39 Does it matter: timeliness or accuracy of results? The choice of rapid reviews or systematic reviews to inform decision-making

Andrea Tricco

S40 Evaluation of the veterans choice program using lean six sigma at a VA medical center to identify benefits and overcome obstacles

Sherry Ball, Anne Lambert-Kerzner, Christine Sulc, Carol Simmons, Jeneen Shell-Boyd, Taryn Oestreich, Ashley O'Connor, Emily Neely, Marina McCreight, Amy Labebue, Doreen DiFiore, Diana Brostow, P. Michael Ho, David Aron

S41 The influence of local context on multi-stakeholder alliance quality improvement activities: A multiple case study

Jillian Harvey, Megan McHugh, Dennis Scanlon

S42 Increasing physical activity in early care and education: Sustainability via active garden education (SAGE)

Rebecca Lee, Erica Soltero, Nathan Parker, Lorna McNeill, Tracey Ledoux

S43 Marking a decade of policy implementation: The successes and continuing challenges of a provincial school food and nutrition policy in Canada

Jessie-Lee McIsaac, Kate MacLeod, Nicole Ata, Sherry Jarvis, Sara Kirk

S44 Use of research evidence among state legislators who prioritize mental health and substance abuse issues

Jonathan Purtle, Elizabeth Dodson, Ross Brownson

S45 PANEL: Effectiveness-Implementation Hybrid Designs: Clarifications, Refinements, and Additional Guidance Based on a Systematic Review and Reports from the Field - Hybrid type 1 designs

Brian Mittman, Geoffrey Curran

S46 PANEL: Effectiveness-Implementation Hybrid Designs: Clarifications, Refinements, and Additional Guidance Based on a Systematic Review and Reports from the Field - Hybrid type 2 designs

Geoffrey Curran

S47 PANEL: Effectiveness-Implementation Hybrid Designs: Clarifications, Refinements, and Additional Guidance Based on a Systematic Review and Reports from the Field - Hybrid type 3 designs

Jeffrey Pyne

S48 Linking team level implementation leadership and implementation climate to individual level attitudes, behaviors, and implementation outcomes

Gregory Aarons, Mark Ehrhart, Elisa Torres

S49 Pinpointing the specific elements of local context that matter most to implementation outcomes: Findings from qualitative comparative analysis in the RE-inspire study of VA acute stroke care

Edward Miech

S50 The GO score: A new context-sensitive instrument to measure group organization level for providing and improving care

Edward Miech

S51 A research network approach for boosting implementation and improvement

Kathleen Stevens, I.S.R.N. Steering Council

S52 PANEL: Qualitative methods in D&I Research: Value, rigor and challenge - The value of qualitative methods in implementation research

Alison Hamilton

S53 PANEL: Qualitative methods in D&I Research: Value, rigor and challenge - Learning evaluation: The role of qualitative methods in dissemination and implementation research

Deborah Cohen

S54 PANEL: Qualitative methods in D&I Research: Value, rigor and challenge - Qualitative methods in D&I research

Deborah Padgett

S55 PANEL: Maps & models: The promise of network science for clinical D&I - Hospital network of sharing patients with acute and chronic diseases in California

Alexandra Morshed

S56 PANEL: Maps & models: The promise of network science for clinical D&I - The use of social network analysis to identify dissemination targets and enhance D&I research study recruitment for pre-exposure prophylaxis for HIV (PrEP) among men who have sex with men

Rupa Patel

S57 PANEL: Maps & models: The promise of network science for clinical D&I - Network and organizational factors related to the adoption of patient navigation services among rural breast cancer care providers

Beth Prusaczyk

S58 A theory of de-implementation based on the theory of healthcare professionals’ behavior and intention (THPBI) and the becker model of unlearning

David C. Aron, Divya Gupta, Sherry Ball

S59 Observation of registered dietitian nutritionist-patient encounters by dietetic interns highlights low awareness and implementation of evidence-based nutrition practice guidelines

Rosa Hand, Jenica Abram, Taylor Wolfram

S60 Program sustainability action planning: Building capacity for program sustainability using the program sustainability assessment tool

Molly Hastings, Sarah Moreland-Russell

S61 A review of D&I study designs in published study protocols

Rachel Tabak, Alex Ramsey, Ana Baumann, Emily Kryzer, Katherine Montgomery, Ericka Lewis, Margaret Padek, Byron Powell, Ross Brownson

S62 PANEL: Geographic variation in the implementation of public health services: Economic, organizational, and network determinants - Model simulation techniques to estimate the cost of implementing foundational public health services

Cezar Brian Mamaril, Glen Mays, Keith Branham, Lava Timsina

S63 PANEL: Geographic variation in the implementation of public health services: Economic, organizational, and network determinants - Inter-organizational network effects on the implementation of public health services

Glen Mays, Rachel Hogg

S64 PANEL: Building capacity for implementation and dissemination of the communities that care prevention system at scale to promote evidence-based practices in behavioral health - Implementation fidelity, coalition functioning, and community prevention system transformation using communities that care

Abigail Fagan, Valerie Shapiro, Eric Brown

S65 PANEL: Building capacity for implementation and dissemination of the communities that care prevention system at scale to promote evidence-based practices in behavioral health - Expanding capacity for implementation of communities that care at scale using a web-based, video-assisted training system

Kevin Haggerty, David Hawkins

S66 PANEL: Building capacity for implementation and dissemination of the communities that care prevention system at scale to promote evidence-based practices in behavioral health - Effects of communities that care on reducing youth behavioral health problems

Sabrina Oesterle, David Hawkins, Richard Catalano

S68 When interventions end: the dynamics of intervention de-adoption and replacement

Virginia McKay, M. Margaret Dolcini, Lee Hoffer

S69 Results from next-d: can a disease specific health plan reduce incident diabetes development among a national sample of working-age adults with pre-diabetes?

Tannaz Moin, Jinnan Li, O. Kenrik Duru, Susan Ettner, Norman Turk, Charles Chan, Abigail Keckhafer, Robert Luchs, Sam Ho, Carol Mangione

S70 Implementing smoking cessation interventions in primary care settings (STOP): using the interactive systems framework

Peter Selby, Laurie Zawertailo, Nadia Minian, Dolly Balliunas, Rosa Dragonetti, Sarwar Hussain, Julia Lecce

S71 Testing the Getting To Outcomes implementation support intervention in prevention-oriented, community-based settings

Matthew Chinman, Joie Acosta, Patricia Ebener, Patrick S Malone, Mary Slaughter

S72 Examining the reach of a multi-component farmers’ market implementation approach among low-income consumers in an urban context

Darcy Freedman, Susan Flocke, Eunlye Lee, Kristen Matlack, Erika Trapl, Punam Ohri-Vachaspati, Morgan Taggart, Elaine Borawski

S73 Increasing implementation of evidence-based health promotion practices at large workplaces: The CEOs Challenge

Amanda Parrish, Jeffrey Harris, Marlana Kohn, Kristen Hammerback, Becca McMillan, Peggy Hannon

S74 A qualitative assessment of barriers to nutrition promotion and obesity prevention in childcare

Taren Swindle, Geoffrey Curran, Leanne Whiteside-Mansell, Wendy Ward

S75 Documenting institutionalization of a health communication intervention in African American churches

Cheryl Holt, Sheri Lou Santos, Erin Tagai, Mary Ann Scheirer, Roxanne Carter, Janice Bowie, Muhiuddin Haider, Jimmie Slade, Min Qi Wang

S76 Reduction in hospital utilization by underserved patients through use of a community-medical home

Andrew Masica, Gerald Ogola, Candice Berryman, Kathleen Richter

S77 Sustainability of evidence-based lay health advisor programs in African American communities: A mixed methods investigation of the National Witness Project

Rachel Shelton, Lina Jandorf, Deborah Erwin

S78 Predicting the long-term uninsured population and analyzing their gaps in physical access to healthcare in South Carolina

Khoa Truong

S79 Using an evidence-based parenting intervention in churches to prevent behavioral problems among Filipino youth: A randomized pilot study

Joyce R. Javier, Dean Coffey, Sheree M. Schrager, Lawrence Palinkas, Jeanne Miranda

S80 Sustainability of elementary school-based health centers in three health-disparate southern communities

Veda Johnson, Valerie Hutcherson, Ruth Ellis

S81 Childhood obesity prevention partnership in Louisville: creative opportunities to engage families in a multifaceted approach to obesity prevention

Anna Kharmats, Sandra Marshall-King, Monica LaPradd, Fannie Fonseca-Becker

S82 Improvements in cervical cancer prevention found after implementation of evidence-based Latina prevention care management program

Deanna Kepka, Julia Bodson, Echo Warner, Brynn Fowler

S83 The OneFlorida data trust: Achieving health equity through research & training capacity building

Elizabeth Shenkman, William Hogan, Folakami Odedina, Jessica De Leon, Monica Hooper, Olveen Carrasquillo, Renee Reams, Myra Hurt, Steven Smith, Jose Szapocznik, David Nelson, Prabir Mandal

S84 Disseminating and sustaining medical-legal partnerships: Shared value and social return on investment

James Teufel

Abstract P2-09-01: Patient reported outcomes of multiplex breast cancer susceptibility testing utilizing a tiered-binned counseling and informed consent model in BRCA1/2 negative patients

Background:The risks, benefits and utilities of multiplex panels for breast cancer susceptibility are unknown and new counseling and informed consent models are needed. We sought to obtain patient reported outcomes of multiplex testing in BRCA1/2 negative patients utilizing a novel, previously piloted tiered-binned counseling model for multiplex testing. Methods:BRCA1/2 negative participants completed pre(V1) and post-test counseling(V2) and surveys evaluating cognitive, affective and behavioral responses to a 25-gene multiplex testing panel. We used linear regressions with estimation by GEE where appropriate. Results:376 patients have been approached. To date, 124 participants(33%) have consented to the study, 21(6%) declined and 231(61%) are considering. Of 95 who have completed pre-test counseling(V1), 88(93%) elected to proceed with 25-gene panel testing and (81%) were classified as making an informed choice after tiered-binned counseling. 6/53(11%) participants received a positive result, including 1 mutation in MSH2 and 5 in moderate penetrance genes (2 ATM, 1 BARD1, 1 CHEK2, 1 PALB2). 22/53(42%) participants received a variant of unknown significance(VUS). General anxiety and perceived utility decreased significantly with pre-test counseling and after results (Table 1). Knowledge increased with pre-test counseling; cancer worry increased after receipt of multiplex results. Higher cancer worry was associated only with lower income (2.6 points/income category, p&lt;0.01). Those with a VUS had greater decreases in perceived utility compared to negative (p=0.01) or positive (p=0.003) results. To date, there are no other significant differences in knowledge, distress or uncertainty by test result. Medical management recommendations for the proband changed in 3/6 with a positive result. Cascade testing in the family was discussed as an option in 3/6 with a positive result. Conclusions:Many BRCA1/2-negative patients proceed with 25-gene cancer susceptibility testing if offered and most make informed choices utilizing a tiered-binned genetic counseling model. The tiered-binned counseling model is associated with increased knowledge, decreases in general anxiety and uncertainty after pre-test counseling and disclosure of results, but an increase in cancer worry after result disclosure. The clinical utility, long-term outcomes and differences in patient reported outcomes by test result remain unknown.

Table 1 Baseline, Mean(SD)After V1, Mean(SD)After V2, Mean(SD) N=75ˆ;N=49ˆˆN=75ˆ;N=49ˆˆN=49ˆˆGeneral Anxiety (range 0-21)6.4(3.9)*;6.9(3.9)**6.0(4.3)*;6.6(4.2)**5.8(4.5)**General Depression (range 0-212.8(2.9);3.1(3.2)3.0(3.5);3.1(3.6)3.0(3.7)State Anxiety (range 20-80)35.5(11.2);36.6(11.9)35.5(11.8);36.8(11.9)36.1(12.2)Cancer Worry (range 0-75)18.2(13.5);20.1(13.8)**16.7(12.5);17.2(11.9)**21.0(13.9)**Knowledge (range 17-82)65.7(5.0)**;66.5(5.0)**68.0(5.7)**;68.4(5.6)**67.3(4.9)**Uncertainty (range 0-15)5.8(3.9);6.2(4.3)5.6(3.7);5.4(3.2)5.6(3.5)Perceived Utility (range 24-120)75.2(14.0)*;75.9(14.0)**73.0(14.1)*;74.1(13.4)**68.4(16.9)***p≤0.05 **p≤0.01. ˆcompleted V1. ˆˆcompleted V1 & V2. To date, 53 have received results and 49 have completed post-disclosure surveys.

Citation Format: Bradbury AR, Patrick-Miller L, Egleston BE, Maxwell KN, Brandt A, Brower J, DiGiovanni L, Long JM, Powers J, Stopfer J, Nathanson KL, Domchek SM. Patient reported outcomes of multiplex breast cancer susceptibility testing utilizing a tiered-binned counseling and informed consent model in BRCA1/2 negative patients. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-09-01.

Utilizing Remote Real-Time Videoconferencing to Expand Access to Cancer Genetic Services in Community Practices: A Multicenter Feasibility Study

BACKGROUND

Videoconferencing has been used to expand medical services to low-access populations and could increase access to genetic services at community sites where in-person visits with genetic providers are not available.

OBJECTIVE

To evaluate the feasibility of, patient feedback of, and cognitive and affective responses to remote two-way videoconferencing (RVC) telegenetic services at multiple sociodemographically diverse community practices without access to genetic providers.

METHODS

Patients at 3 community sites in 2 US states outside the host center completed RVC pretest (visit 1, V1) and post-test (visit 2, V2) genetic counseling for cancer susceptibility. Surveys evaluated patient experiences, knowledge, satisfaction with telegenetic and cancer genetics services, anxiety, depression, and cancer worry.

RESULTS

A total of 82 out of 100 (82.0%) approached patients consented to RVC services. A total of 61 out of 82 patients (74%) completed pretest counseling and 41 out of 61 (67%) proceeded with testing and post-test counseling. A total of 4 out of 41 (10%) mutation carriers were identified: BRCA2, MSH2, and PMS2. Patients reported many advantages (eg, lower travel burden and convenience) and few disadvantages to RVC telegenetic services. Most patients reported feeling comfortable with the video camera--post-V1: 52/57 (91%); post-V2: 39/41 (95%)--and that their privacy was respected--post-V1: 56/57 (98%); post-V2: 40/41 (98%); however, some reported concerns that RVC might increase the risk of a confidentiality breach of their health information--post-V1: 14/57 (25%); post-V2: 12/41 (29%). While the majority of patients reported having no trouble seeing or hearing the genetic counselor--post-V1: 47/57 (82%); post-V2: 39/41 (95%)--51 out of 98 (52%) patients reported technical difficulties. Nonetheless, all patients reported being satisfied with genetic services. Compared to baseline, knowledge increased significantly after pretest counseling (+1.11 mean score, P=.005); satisfaction with telegenetic (+1.74 mean score, P=.02) and genetic services (+2.22 mean score, P=.001) increased after post-test counseling. General anxiety and depression decreased after pretest (-0.97 mean anxiety score, P=.003; -0.37 mean depression score, P=.046) and post-test counseling (-1.13 mean anxiety score, P=.003; -0.75 mean depression score, P=.01); state anxiety and cancer-specific worry did not significantly increase.

CONCLUSIONS

Remote videoconferencing telegenetic services are feasible, identify genetic carriers in community practices, and are associated with high patient satisfaction and favorable cognitive and affective outcomes, suggesting an innovative delivery model for further study to improve access to genetic providers and services. Potential barriers to dissemination include technology costs, unclear billing and reimbursement, and state requirements for provider licensure.

Abstract P4-12-10: Uptake and outcomes of multiplex testing for breast cancer susceptibility

Background: New counseling models for multiplex genetic testing for breast cancer susceptibility are needed. Further, the risks, benefits and utilities of multiplex genetic panels are unknown.

Purpose: To obtain stakeholder feedback on an innovative tiered-binned model for pretest counseling and informed consent for multiplex testing and to evaluate the uptake of, cognitive and affective responses to and perceived utility of panel testing.

Methods: Patients previously BRCA1/2- or BRCA1/2 untested completed in-person pre-test (V1) and post-test counseling (V2) and surveys regarding the novel counseling model and evaluating cognitive and affective responses to, and perceived utility of the 26 gene Myriad MyRisk panel for cancer susceptibility.

Results: 49 patients (62% of eligible) enrolled and completed V1. 38% of decliners were not interested in panel testing. BRCA1/2- were more likely to proceed with MyRisk (89%) than BRCA1/2 untested (48%, p&lt;0.01). Although not statistically significant, those who declined panel testing after V1 had higher anxiety, depression and cancer worry, but no difference in knowledge. They also had lower perceived utility (p=0.005). Most patients would not change anything about their V1 (86%) or V2 (91%) counseling. Surveys suggest that patients value the engagement, personalization, organization and visual aids of the novel counseling model. Potential refinements include enhancing assessments of informational overload, confusion and psychosocial needs, particularly with uncertain results. As shown in Table 1, event anxiety, depression, uncertainty and cancer worry did not change, while general anxiety decreased. Knowledge increased and perceived utility and satisfaction decreased significantly. Exploratory analyses by results to date (positive = 5; VUS = 9; negative =22), suggest no difference in uncertainty by test result. Patients with a positive result might experience greater event anxiety and have less decline in perceived utility (p=0.02) than those with a negative or VUS result.

Table 1 BaselinePost V1Post V2 Mean (SD)Mean (SD)Mean (SD)General Anxiety6.8 (3.9)*6.1 (4.0)*  7.2 (3.5)*6.1 (3.6)*5.8 (4.2)*General Depression2.6 (3.0)2.3 (2.6)  2.6 (2.9)2.3 (2.6)2.9 (3.6)Event Anxiety37.1 (9.6)37.7 (9.5)  37.0 (8.9)37.3 (8.5)37.3 (9.4)Cancer Worry18.3 (15.7)16.9 (14.1)  18.4 (15.4)15.7 (14.1)6.6 (14.7)Knowledge (K) Total61.8 (6.1)**63.9 (6.4)**  62.1 (6.7)**64.1 (6.8)**66.3 (6.9)**K-Inheritance29.5 (3.2)30.0 (3.2)  29.7 (3.5)29.8 (3.3)30.3 (3.7)K-Benefits12.0 (1.4)12.3 (1.8)  12.0 (1.4)12.4 (1.7)12.4 (1.9)K-Limitations20.3 (3.2)**21.6 (2.8)**  20.4 (3.4)**21.9 (3.0)**23.6 (2.6)**Satisfaction 42.8 (3.8)   42.9 (3.6)*41.4 (2.6)*Uncertainty7.5 (4.3)6.9 (4.6)  7.7 (4.0)6.5 (4.5)6.7 (4.6)Perceived Utility 37.2 (7.9)   37.7 (7.0)*33.8 (8.6)**p,0.05, **p&lt;0.001

Conclusion: With a tiered-binned counseling model, patients experience increased knowledge. Uptake of panel testing varies by prior testing and potentially by patient affective factors. Most patients do not experience negative psychological responses, although this may vary by test result. Declines in satisfaction and perceived utility may also vary by test result and may reflect the current unclear utility and uncertainty of multiplex testing.

Citation Format: Angela R Bradbury, Linda Patrick-Miller, Brian L Egleston, Amanda Brandt, Jessica Long, Jacquelyn Powers, Jill Stopfer, Laura DiGiovanni, Jamie Brower, Susan M Domchek. Uptake and outcomes of multiplex testing for breast cancer susceptibility [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P4-12-10.

Abstract P1-11-02: Telemedicine: Expanding access to cancer genetic services to underserved populations

Background: Given the increasing demand for genetic services and limited genetic workforce, many patients do not receive recommended pre- and post-test genetic counseling. Telemedicine has been used to expand specialized medical services to low access populations. The feasibility and outcomes of telemedicine in clinical genetics are not well described.

Methods: Patients at 3 community sites without genetic counseling services received real-time pre-test (V1) and post-test (V2) counseling for cancer susceptibility with a genetic counselor (GC) at a center of expertise via community sites’ and host institution’s computers equipped with web cameras and videoconferencing software. Mixed-methods surveys assessed patient knowledge, satisfaction, psychosocial responses and experiences at baseline (BL), post-V1 and post-V2. We used paired T-tests to assess change between time points and linear regressions.

Results: Of 100 patients approached, 83% consented to telegenetic services. To date, 57 have completed BL and V1, and 70% proceeded with genetic testing, 31 patients have received results, including 3 carriers (BRCA2, MSH2, PMS2). Patient characteristics did not differ between those who agreed to and declined telegenetics. 4% of sessions were aborted due to technology failures. 30% experienced disconnections but were completed. Nearly all (94%) were satisfied with their telegenetic experience. Knowledge and satisfaction with telegenetic services significantly increased and general anxiety and depression significantly decreased. Event related (state) anxiety did not change significantly.

Table 1.OutcomeBL Mean (sd)Post-V1 Mean(sd)Post-V2 Mean(sd)pKnowledge (6-28)20.9(2.8)22.0 (3.0) 0.007 20.8 (3.3)21.8(3.2)21.5(3.1)NSSGeneral Anxiety (0-21)7.4(4.1)6.6(4.1) 0,02 6.6 ((4.0)5.7 (3.8)5.7 (3.5)0.06Genarla Depression(0-21)3.9 (3.9)3.5 (3.4) 0,05 3.6 (3.7)3.4(3.5)2.9 (3.5)0.07State Anxiety(20-80)36.0(15.2)35.7(13.7) NSS 34.6(15.0)34.5(13.1)32.1(12.5)NSSSatisfaction with Genetic Services 39.5(3.(    39.8(4.0)42.2(3.6)0.002Satisfaction with Telemedicine 51.3(5.6)    51.5(5.7)53.0(5.3)0.008     

Patients reported several advantages to telegenetics (e.g. decreased travel burden) and few disadvantages (e.g. audio challenges and technical glitches).Conclusions: Telemedicine delivery of cancer genetic services is feasible, identifies genetic mutation carriers, increases knowledge, decreases anxiety and depression and is associated with high satisfaction, suggesting an innovative model for delivery of genetic services for patients and community practices without access to local genetic providers.

Citation Format: Linda Patrick-Miller, Diana Harris, Evelyn Stevens, Brian Egleston, Linda Fleisher, Rebbeca Mueller, Amanda Brandt, Jill Stopfer, Susan Domchek, Angela Bradbury. Telemedicine: Expanding access to cancer genetic services to underserved populations [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-11-02.

Development of a tiered and binned genetic counseling model for informed consent in the era of multiplex testing for cancer susceptibility

PURPOSE

Multiplex genetic testing, including both moderate- and high-penetrance genes for cancer susceptibility, is associated with greater uncertainty than traditional testing, presenting challenges to informed consent and genetic counseling. We sought to develop a new model for informed consent and genetic counseling for four ongoing studies.

METHODS

Drawing from professional guidelines, literature, conceptual frameworks, and clinical experience, a multidisciplinary group developed a tiered-binned genetic counseling approach proposed to facilitate informed consent and improve outcomes of cancer susceptibility multiplex testing.

RESULTS

In this model, tier 1 "indispensable" information is presented to all patients. More specific tier 2 information is provided to support variable informational needs among diverse patient populations. Clinically relevant information is "binned" into groups to minimize information overload, support informed decision making, and facilitate adaptive responses to testing. Seven essential elements of informed consent are provided to address the unique limitations, risks, and uncertainties of multiplex testing.

CONCLUSION

A tiered-binned model for informed consent and genetic counseling has the potential to address the challenges of multiplex testing for cancer susceptibility and to support informed decision making and adaptive responses to testing. Future prospective studies including patient-reported outcomes are needed to inform how to best incorporate multiplex testing for cancer susceptibility into clinical practice.Genet Med 17 6, 485-492.

The mutational spectrum of breast and ovarian tumors from BRCA1 and BRCA2 mutation carriers

1510

Background: Individuals who carry one mutated copy of the BRCA1 or BRCA2 genes have elevated lifetime risks of breast and ovarian cancer. A number of studies have investigated the somatic mutational spectra of breast and ovarian tumors; however, BRCA1/2mutated tumors are underrepresented. Methods: Sixty-eight formalin-fixed paraffin embedded samples from BRCA1/2patients have been identified. Massively parallel sequencing using 48 gene capture is in process, whole exome sequencing of tumor and matched germline DNA is planned. Data are analyzed using a custom bioinformatics pipeline. Results: In analysis of data from the first 26 breast (4 BRCA1, 6 BRCA2) and ovarian (8 BRCA1, 8 BRCA2) tumors, the majority (23/26, 88%) had 0-2 variants in 48 cancer genes. Known deleterious TP53 mutations were the only variants identified in 2/4 BRCA1 and 2/6 BRCA2 breast tumors. Of those remaining, 2 BRCA1 and 1 BRCA2 breast tumors had no identified deleterious mutations. Two BRCA2 breast tumors with no TP53 mutations had known deleterious mutations in a single gene each - FGFR2 and PI3KCA. One BRCA2 breast tumor with no TP53 mutation had a variant of uncertain significance in FLT3. Finally, one BRCA2 breast tumor had a very high mutational rate, with one deleterious TP53 mutation and 7 other small deletion and single nucleotide variants. For the ovarian tumors, 15/16 BRCA1 and BRCA2 tumors had known deleterious TP53 mutations; the ovarian tumor with no TP53 mutation had no other variants. TP53 mutations were the sole identified mutations in 8 ovarian tumors. One ovarian tumor carried a known JAK3 activating mutation and 4 ovarian tumors carried one variant of uncertain significance in a single gene - SMO, PDGFRA, GNA11 and NRAS. Finally, two ovarian tumors were found to have high mutational rates. Conclusions: Using a targeted resequencing panel, we confirmed the high rate of TP53 mutations in BRCA1/2 breast tumors and observed a higher than expected rate in BRCA1/2 ovarian tumors. Importantly, we have identified mutations in other known driver genes using FFPE samples, allowing generalizability to other sites. These analyses may uncover novel mutations that could be exploited in the development of targeted therapeutic agents for BRCA1/2 carriers.

Biallelic deleterious BRCA1 mutations in a woman with early-onset ovarian cancer

BRCA1 and BRCA2 are the most important breast and ovarian cancer susceptibility genes. Biallelic mutations in BRCA2 can lead to Fanconi anemia and predisposition to cancers, whereas biallelic BRCA1 mutations have not been confirmed, presumably because one wild-type BRCA1 allele is required during embryogenesis. This study describes an individual who was diagnosed with ovarian carcinoma at age 28 and found to have one allele with a deleterious mutation in BRCA1, c.2457delC (p.Asp821Ilefs*25), and a second allele with a variant of unknown significance in BRCA1, c.5207T>C (p.Val1736Ala). Medical records revealed short stature, microcephaly, developmental delay, and significant toxicity from chemotherapy. BRCA1 p.Val1736Ala cosegregated with cancer in multiple families, associated tumors showed loss of wild-type BRCA1, and BRCA1 p.Val1736Ala showed reduced DNA damage localization. These findings represent the first validated example of biallelic deleterious human BRCA1 mutations and have implications for the interpretation of genetic test results.

SIGNIFICANCE

Accurate assessment of genetic testing data for BRCA1 mutations is essential for clinical monitoring and treatment strategies. Here, we report the fi rst validated example of an individual with biallelic BRCA1 mutations, early-onset ovarian cancer, and clinically significant hypersensitivity to chemotherapy.

Sensitivity of clinical BRCA1 testing compared with linkage analysis

1506

Background: Specific clinical interventions in BRCA mutation carriers reduces the risk of breast and ovarian cancers and may improve survival; thus,identification of mutation carriers is important. The sensitivity of current BRCA mutation testing is unclear as a “gold standard” test is lacking. We assessed the BRCA1 mutation detection rate with current comprehensive clinical testing using linkage analysis as the comparator. Methods: 26 families with linkage analyses results available were included in this analysis. BRCAPRO, BOADICEA, and other risk estimation models were applied. Maximum-likelihood linkage analyses were performed to compute two-point and multipoint LOD scores using previously described BRCA1 –linked genetic markers; scores were classified as linked, not linked, or suggestive. At least one individual from each family underwent comprehensive testing. Results: Of 26 families analyzed, 9 demonstrated linkage and 4 demonstrated suggestive linkage to BRCA1. Of these 13 families, 12 were found to have BRCA1 mutations: a detection rate of 92.3%. In 3 of these 12 families, genetic mutation testing performed prior to large genomic rearrangement (LGR) testing was negative, demonstrating an improved detection rate with LGR testing which in this series was 23%. The 12 families with higher LOD scores and positive mutation testing had high mean prior probabilities by all models. Families which were not linked and who tested negative for mutations had lower mean prior probabilities. In one family, disease demonstrated linkage with a two-point LOD score of 1.59 and multipoint LOD of 0.85 and all risk estimation models yielded high prior probabilities. Despite this, mutation testing was negative by full sequencing and MLPA analysis. Conclusions: When evaluated in a sample of families from high-risk clinics, current comprehensive testing compares well to linkage data. The inclusion of LGR testing has improved the mutation detection capability of clinical testing; however, some mutations may still be missed. Negative mutation testing results should be interpreted in the context of family history and prior probability during counseling. Despite recent advances, further improvements in genetic testing are warranted.

Bridging the gap with an ileocolonic graft after extensive colorectal resections

BACKGROUND

Ileocecal interposition (ICI) for first-line reconstruction after low anterior colorectal resection was introduced by von Flüe and Harder in 1994 (Dis Colon Rectum 37:1160-1162, 1994). We report our experience using this technique to bridge colonic gaps after significant loss of bowel length.

PATIENTS AND METHODS

Between 1999 and 2009 the left-sided colon was too short for traditional isoperistaltic reconstruction in six patients treated in our hospital. Reasons for extensive bowel loss were a deficient (n = 3) or torn (n = 1) marginal artery with ischemia or repeat colorectal resections (n = 2). An ICI was done to bridge the gap and enable restoration of intestinal continuity.

RESULTS

No patient died. Whenever performing a coloanal anastomosis (4/6) a loop ileostomy was raised. One patient with colonic diversion experienced graft-related complications: ischemic colitis of the interposed colonic segment, anastomotic stenosis, and a presacral sinus were observed and managed nonoperatively. Subsequent closure of the stoma was possible in all cases. A median Vaizey incontinence score of 9 (range: 4-14) was recorded in the patient with coloanal anastomosis. The average number of bowel movements per day was 1.5 (range: 0.5-6).

CONCLUSIONS

When the descending colon does not reach the rectal stump or anal canal in reoperative cases or after vascular complication, ICI is a useful salvage procedure resulting in good bowel function.

Evaluation of physician knowledge and referral practices for colorectal cancer (CRC) genetic risk assessment: The experience at the Hospital of University of Pennsylvania (HUP)

379

Background: 3-5% of CRCs are due to inherited genetic mutations. We surveyed knowledge and practices of academic physicians for identification and care of individuals at risk for inherited CRC.

Methods: 264 physicians (oncologists (ON), gastroenterologists (GA), surgeons, internists, gynecologists, and radiation oncologists) at HUP were invited to participate in a web-based 9-min survey. The ability to obtain appropriate medical history and to make referral to genetic services was evaluated. Knowledge of hereditary CRC syndromes was examined both pre and post viewing of an educational web-page on inherited CRCs. Mantel-Haenszel, Fisher exact, and McNemar statistical tests were applied.

Results: Response rate was 33.3%; and of those, 97.4% accessed the educational webpage. In the cohort, 98.9 % obtained a medical history very frequently (VF), 88.6% obtained cancer history in 1st and 45.5% in the 2nd degree relatives VF, and 63.9% asked about the relatives' age at time of cancer diagnosis VF. Of those most likely to care for patients with CRC, the GA more frequently asked about relatives' age at cancer diagnosis (p=0.014) and family history of polyps (p< 0.001) than ON. GA were more likely than ON to refer patients for genetic counseling (73.9% vs. 36.8%, p=0.008). GA had superior knowledge of the availability of genetic testing for Lynch syndrome (LS) (95.6% GA vs. 63.2% ON, p=0.005) and for familial adenomatous polyposis (FAP) (100.0% GA vs. 65.8% ON, p<0.001). For the entire cohort, the educational intervention raised awareness of genetic testing for LS (64.5% pre vs. 94.7% post, p<0.001), FAP (69.7% pre vs. 97.4% post, p<0.001), and Peutz-Jeghers Syndrome (31.6% pre vs. 84.2% post, p<0.001); and it significantly improved recognition of LS family pedigrees and selection of appropriate surveillance.

Conclusions: Of the respondents, GA are more likely to obtain a detailed family history, utilize genetic services, and have a greater awareness of the availability of genetic testing, than ON. A simple educational intervention improves physician knowledge on inherited CRC risk recognition and surveillance recommendations.

No significant financial relationships to disclose.

The relative contribution of point mutations and genomic rearrangements in BRCA1 and BRCA2 in high-risk breast cancer families

The demand for BRCA1 and BRCA2 mutation screening is increasing as their identification will affect medical management. However, both the contribution of different mutation types in BRCA1 and BRCA2 and whom should be offered testing for large genomic rearrangements have not been well established in the U.S. high-risk population. We define the prevalence and spectrum of point mutations and genomic rearrangements in BRCA genes in a large U.S. high-risk clinic population of both non-Ashkenazi and Ashkenazi Jewish descent, using a sample set representative of the U.S. genetic testing population. Two hundred fifty-one probands ascertained through the University of Pennsylvania high-risk clinic, all with commercial testing for BRCA1 and BRCA2, with an estimated prevalence of BRCA mutation >or=10% using the Myriad II model and a DNA sample available, were studied. Individuals without deleterious point mutations were screened for genomic rearrangements in BRCA1 and BRCA2. In the 136 non-Ashkenazi Jewish probands, 36 (26%) BRCA point mutations and 8 (6%) genomic rearrangements (7 in BRCA1 and 1 in BRCA2) were identified. Forty-seven of the 115 (40%) Ashkenazi Jewish probands had point mutations; no genomic rearrangements were identified in the group without mutations. In the non-Ashkenazi Jewish probands, genomic rearrangements constituted 18% of all identified BRCA mutations; estimated mutation prevalence (Myriad II model) was not predictive of their presence. Whereas these findings should be confirmed in larger sample sets, our data suggest that genomic rearrangement testing be considered in all non-Ashkenazi Jewish women with an estimated mutation prevalence >or=10%.

BRCA1 and BRCA2 risk perceptions among African American women at increased risk for hereditary breast-ovarian cancer

OBJECTIVES

To describe BRCA1 or BRCA2 (BRCA1/2) risk perceptions among African American women at increased risk for hereditary breast-ovarian cancer and to identify factors having independent associations with these perceptions.

METHODS

Risk perceptions were evaluated by self-report during a structured telephone interview among African American women (n = 162) at increased risk for hereditary cancer who were recruited from oncology clinics, general medical practices, and community oncology resources.

RESULTS

The majority of women (75%) believed that it was likely that they had a BRCA1/2 mutation. Women ages 50 and younger and those with greater cancer-specific worry were most likely to believe that they had a BRCA1/2 mutation.

CONCLUSIONS

Although BRCA1/2 risk perceptions may be consistent with objective risk levels among African American women, discussion about the basis of risk perceptions may enhance provision of genetic counseling and testing in this population.

Retention of African American women in cancer genetics research

Although retention is a critical component of longitudinal cancer genetics research, limited empirical data are available on predictors of study retention among populations that are difficult to enroll. We evaluated predictors of retention in cancer genetics research among African American women at increased risk for having a BRCA1 and BRCA2 (BRCA1/2) mutation. Participants were African American women (n = 192) at increased risk for hereditary breast-ovarian cancer who were enrolled in a longitudinal genetic counseling research study. Retention was evaluated separately for the 1- and 6-month follow-ups and in terms of overall retention (e.g., completion of both telephone interviews). Seventy-three percent of women and 65% of women were retained at the 1- and 6-month follow-ups respectively; in terms of overall retention, 60% of women were retained in both follow-up telephone interviews. Predictors of retention at 1-month included being employed (OR = 2.47, 95% CI = 1.24, 4.93, P = 0.01) whereas predictors of overall retention included having a personal history of breast and/or ovarian cancer (OR = 2.06, 95% CI = 1.07, 3.95, P = 0.03) and having completed genetic counseling (OR = 2.63, 95% CI = 1.39, 4.98, P = 0.003). These data suggest that once enrolled in genetic counseling research, the majority of African American women will continue to participate, especially if concrete clinical services are provided.

Breast cancer screening behaviors among African American women with a strong family history of breast cancer

BACKGROUND

Despite the importance of breast cancer screening to reduce morbidity and mortality, limited information is available on screening practices among African American women with a family history that is suggestive of hereditary breast cancer.

OBJECTIVES

To describe adherence to breast cancer screening recommendations among African American women with a family history that is suggestive of hereditary disease.

METHODS

Participants were unaffected African American women (n=65) who had a family history of cancer that was suggestive of hereditary breast cancer. Breast cancer screening practices were evaluated by self-report. The study was conducted at the University of Pennsylvania in Philadelphia, PA. Women were recruited to participate in the study from February 2003-December 2005.

RESULTS

Most women were adherent to recommendations for mammography (75%) and CBE (93%). A sizeable minority of women (41%) also performed excessive BSE. Being older than age 50 was associated significantly with mammography adherence (FET<0.05). Employment had a significant independent association with BSE; unemployed women were most likely to perform excessive BSE (OR=3.28, 95% CI: 1.05, 10.21, p<0.05).

CONCLUSIONS

The results of this study suggest a complex pattern of breast cancer screening practices among African American women at increased risk for hereditary breast cancer.

Racial differences in the use of BRCA1/2 testing among women with a family history of breast or ovarian cancer

CONTEXT

Given the current context of racial disparities in health and health care and the historical context of eugenics, racial disparities in the use of genetic susceptibility testing have been widely anticipated. However, to our knowledge there are no published studies examining the magnitude and determinants of racial differences in the use of genetic susceptibility testing.

OBJECTIVES

To investigate the relationship between race and the use of BRCA1/2 counseling among women with a family history of breast or ovarian cancer and to determine the contribution of socioeconomic characteristics, cancer risk perception and worry, attitudes about genetic testing, and interactions with primary care physicians to racial differences in utilization.

DESIGN, SETTING, AND PARTICIPANTS

Case-control study (December 1999-August 2003) of 408 women with a family history of breast or ovarian cancer, of whom 217 underwent genetic counseling for BRCA1/2 testing (cases) and 191 women did not (controls). Participants received primary care within a large health system in greater Philadelphia, Pa.

MAIN OUTCOME MEASURES

Probability of carrying a BRCA1/2 mutation, socioeconomic characteristics, perception of breast and ovarian cancer risk, worry about breast and ovarian cancer, attitudes about BRCA1/2 testing, and primary care physician discussion of BRCA1/2 testing were measured prior to undergoing BRCA1/2 counseling for cases and at the time of enrollment for controls.

RESULTS

African American women with a family history of breast or ovarian cancer were significantly less likely to undergo genetic counseling for BRCA1/2 testing than were white women with a family history of breast or ovarian cancer (odds ratio, 0.22; 95% confidence interval, 0.12-0.40). This association persisted after adjustment for probability of BRCA1/2 mutation, socioeconomic characteristics, breast and ovarian cancer risk perception and worry, attitudes about the risks and benefits of BRCA1/2 testing, and primary care physician discussion of BRCA1/2 testing (adjusted odds ratio for African American vs white, 0.28; 95% confidence interval, 0.09-0.89).

CONCLUSIONS

Racial disparities in the use of BRCA1/2 counseling are large and do not appear to be explained by differences in risk factors for carrying a BRCA1/2 mutation, socioeconomic factors, risk perception, attitudes, or primary care physician recommendations. The benefit of predictive genetic testing will not be fully realized unless these disparities can be addressed.

Patients’ Resistance to Risk Information in Genetic Counseling for BRCA1/2

BACKGROUND

Risk information from health care providers is relevant to and used in nearly all medical decisions. Patients often misunderstand their risks, yet little is known about the risk perception that patients derive from risk communications with health care providers. This study examines patients' risk perceptions following communication with health care providers during genetic counseling about the risks of breast cancer and BRCA1/2 mutations.

METHODS

A prospective, longitudinal study was conducted from October 2002 to February 2004 of women who received genetic counseling. The women completed a survey before their counseling and a telephone interview in the week after the counseling. Main outcome measures included change from precounseling in risk perception and accuracy of postcounseling risk perception (relative to actual risk information communicated).

RESULTS

A total of 108 women agreed to participate in the study. The women's postcounseling risk perceptions were significantly lower than their precounseling risk perceptions (breast cancer: 17%, P<.001; mutation: 13%, P<.001) but were significantly higher than the actual risk information communicated (breast cancer: 19%, P<.001; mutation: 24%, P<.001). Accuracy of breast cancer risk perception but not mutation risk perception was associated with precounseling worry (P = .04), even after adjusting for trait anxiety (P = .01).

CONCLUSIONS

This research demonstrates patients' resistance to risk information. Inappropriately high risk perception derived from a risk communication with a health care provider can lead patients to make different, and potentially worse, medical decisions than they would with an accurate risk perception and to be unnecessarily distressed about their risk.

Knowledge, Attitudes, and Utilization of BRCA1/2 Testing among Women with Early-Onset Breast Cancer

A total of 2,400 questionnaires were mailed to members of two mid-Atlantic breast cancer awareness/support groups to investigate the association between attitudes, knowledge, and use of BRCA1/2 testing among women with early-onset breast cancer. Of the 493 (21%) questionnaires returned, 406 respondents had a diagnosis of breast cancer, of whom 248 were diagnosed prior to age 50 and included in the analyses. Eighty-three percent (206/248) of these women had heard of BRCA1/2 testing and 12.5% (31/248) had undergone BRCA1/2 testing. Among women who had heard of BRCA1/2 testing, women who had been tested were younger (p = 0.03), more likely to have a college education (p = 0.03), more likely to have a family member who had undergone BRCA1/2 testing (p = 0.005), and had greater knowledge, more positive attitudes, and fewer negative attitudes about BRCA1/2 testing (p = 0.02, p = 0.004, and p = 0.004, respectively). In this sample, knowledge regarding BRCA1/2 testing is high, but uptake of genetic testing is low. Lack of information regarding how genetic testing might alter health-care decisions and fear about the genetic testing procedure, its costs, and possible false-positive results are associated with low uptake of genetic testing. Further education regarding these specific points may enhance the use of genetic testing.

Genetic cancer risk assessment and counseling: recommendations of the national society of genetic counselors

These cancer genetic counseling recommendations describe the medical, psychosocial, and ethical ramifications of identifying at-risk individuals through cancer risk assessment with or without genetic testing. They were developed by members of the Practice Issues Subcommittee of the National Society of Genetic Counselors Cancer Genetic Counseling Special Interest Group. The information contained in this document is derived from extensive review of the current literature on cancer genetic risk assessment and counseling as well as the personal expertise of genetic counselors specializing in cancer genetics. The recommendations are intended to provide information about the process of genetic counseling and risk assessment for hereditary cancer disorders rather than specific information about individual syndromes. Key components include the intake (medical and family histories), psychosocial assessment (assessment of risk perception), cancer risk assessment (determination and communication of risk), molecular testing for hereditary cancer syndromes (regulations, informed consent, and counseling process), and follow-up considerations. These recommendations should not be construed as dictating an exclusive course of management, nor does use of such recommendations guarantee a particular outcome. These recommendations do not displace a health care provider's professional judgment based on the clinical circumstances of a client.

What does my doctor think? Preferences for knowing the doctor's opinion among women considering clinical testing for BRCA1/2 mutations

The traditional emphasis on nondirectiveness in genetic counseling has become increasingly controversial with the rapid expansion of genetic testing in clinical medicine. This study was done to determine whether women considering clinical testing for BRCA1/2 mutations want to know their health care providers' opinions about whether or not they should undergo testing. Participating in the study was a retrospective cohort of 335 women who participated in a university-based clinic offering breast cancer risk assessment, genetic counseling, and BRCA1/2 testing between January, 1996, and April, 1998. A total of 242 women (77%) wanted to know if the doctors at the Breast and Ovarian Cancer Risk Evaluation Program (BCREP) thought they should be tested, 28 women (9%) were unsure, and 46 women (14%) did not want a BCREP doctor's opinion on testing. A total of 158 women (49%) wanted to know if their primary doctor thought they should be tested, 31 women (10%) were unsure, and 130 women (41%) did not want to know. Desire to know the opinion of the BCREP doctors was inversely associated with having undergone BRCA1/2 testing (RR 0.83, 95% CI 0.73-0.95) and having a breast cancer diagnosis (RR 0.86, 95% CI 0.75-0.99). Desire to know their primary doctor's opinion was inversely associated with having undergone BRCA1/2 testing (RR 0.72, 95% CI 0.56-0.92). Our study suggests that over three-quarters of women who considered clinical testing for BRCA1/2 mutations wanted to know the opinions of the cancer genetics doctors and almost half wanted to know their primary doctor's opinion about whether or not they should undergo testing. These results support the use of models of genetic counseling that allow for sharing the health care providers' opinions when desired by the patient.

Early use of clinical BRCA1/2 testing: associations with race and breast cancer risk

When BRCA1/2 testing became commercially available in 1996, many U.S. experts voiced concern about the potential for indiscriminate use of testing among low-risk women. Supporting this concern, several early surveys of interest in genetic testing suggested that genetic testing for cancer susceptibility might appeal most to individuals at low risk of carrying a mutation. To identify factors associated with early use of clinical BRCA1/2 testing, a case-control study was conducted at a large academic health system in the metropolitan Philadelphia region. A total of 167 women underwent genetic counseling for clinical BRCA1/2 testing between 1996 and 1997 (cases) compared with 138 women who were seen in faculty general internal medicine practices over the same period (controls). In this study we measured the risk factors for breast cancer, the risk factors for carrying a BRCA1/2 mutation, and sociodemographic characteristics. Use of BRCA1/2 counseling between 1996 and 1997 was positively associated with family but no personal history of breast cancer (odds ratio (OR), 22.4; 95% confidence interval (CI), 9.3-54.3); family and personal history of breast cancer (OR, 150.3; 95% CI, 24.1-939.6); being Caucasian and non-Jewish (OR, 4.1; 95% CI, 1.3-13.5); being Caucasian and Jewish (OR, 8.8; 95% CI, 2.2-35.5); and being married (OR, 3.2; 95% CI, 1.6-6.3). Use of BRCA1/2 counseling was inversely associated with increasing age (OR, 0.07; 95% CI, 0.02-0.28 for >60 compared to <50). As suggested by the association with family history, use of counseling was associated with having a higher predicted risk of breast cancer and a higher predicted risk of carrying a BRCA1 mutation (P < 0.0001). Women who sought clinical BRCA1/2 testing in the year after it became commercially available were not the "worried well," but women at significantly increased risk of carrying a mutation. However, even after adjusting for breast cancer risk, there was a substantial racial disparity in use of BRCA1/2 testing. These findings suggest that ensuring equal access to testing for high-risk individuals irrespective of race may be as important for the future of predictive genetic testing as restricting the use of testing among low-risk individuals.

Application of breast cancer risk prediction models in clinical practice

Breast cancer risk assessment provides an estimation of disease risk that can be used to guide management for women at all levels of risk. In addition, the likelihood that breast cancer risk is due to specific genetic susceptibility (such as BRCA1 or BRCA2 mutations) can be determined. Recent developments have reinforced the clinical importance of breast cancer risk assessment. Tamoxifen chemoprevention as well as prevention studies such as the Study of Tamoxifen and Raloxifene are available to women at increased risk of developing breast cancer. In addition, specific management strategies are now defined for BRCA1 and BRCA2 mutation carriers. Risk may be assessed as the likelihood of developing breast cancer (using risk assessment models) or as the likelihood of detecting a BRCA1 or BRCA2 mutation (using prior probability models). Each of the models has advantages and disadvantages, and all need to be interpreted in context. We review available risk assessment tools and discuss their application. As illustrated by clinical examples, optimal counseling may require the use of several models, as well as clinical judgment, to provide the most accurate and useful information to women and their families.

BRCA1 and BRCA2 mutation frequency in women evaluated in a breast cancer risk evaluation clinic

PURPOSE

To determine the prevalence of BRCA1 and BRCA2 mutations in families identified in a breast cancer risk evaluation clinic.

PATIENTS AND METHODS

One hundred sixty-four families seeking breast cancer risk evaluation were screened for coding region mutations in BRCA1 and BRCA2 by conformation-sensitive gel electrophoresis and DNA sequencing.

RESULTS

Mutations were identified in 37 families (22.6%); 28 (17.1%) had BRCA1 mutations and nine (5.5%) had BRCA2 mutations. The Ashkenazi Jewish founder mutations 185delAG and 5382insC (BRCA1) were found in 10 families (6.1%). However, 6174delT (BRCA2) was found in only one family (0.6%) despite estimates of equal frequency in the Ashkenazi population. In contrast to other series, the average age of breast cancer diagnosis was earlier in BRCA2 mutation carriers (32.1 years) than in women with BRCA1 mutations (37.6 years, P =.028). BRCA1 mutations were detected in 20 (45.5%) of 44 families with ovarian cancer and 12 (75%) of 16 families with both breast and ovarian cancer in a single individual. Significantly fewer BRCA2 mutations (two [4.5%] of 44) were detected in families with ovarian cancer (P =.01). Eight families had male breast cancer; one had a BRCA1 mutation and three had BRCA2 mutations.

CONCLUSION

BRCA1 mutations were three times more prevalent than BRCA2 mutations. Breast cancer diagnosis before 50 years of age, ovarian cancer, breast and ovarian cancer in a single individual, and male breast cancer were all significantly more common in families with BRCA1 and BRCA2 mutations, but none of these factors distinguished between BRCA1 and BRCA2 mutations. Evidence for reduced breast cancer penetrance associated with the BRCA2 mutation 6174delT was noted.

BRCA1 and BRCA2 mutation frequency in women evaluated in a breast cancer risk evaluation clinic

PURPOSE

To determine the prevalence of BRCA1 and BRCA2 mutations in families identified in a breast cancer risk evaluation clinic.

PATIENTS AND METHODS

One hundred sixty-four families seeking breast cancer risk evaluation were screened for coding region mutations in BRCA1 and BRCA2 by conformation-sensitive gel electrophoresis and DNA sequencing.

RESULTS

Mutations were identified in 37 families (22.6%); 28 (17.1%) had BRCA1 mutations and nine (5.5%) had BRCA2 mutations. The Ashkenazi Jewish founder mutations 185delAG and 5382insC (BRCA1) were found in 10 families (6.1%). However, 6174delT (BRCA2) was found in only one family (0.6%) despite estimates of equal frequency in the Ashkenazi population. In contrast to other series, the average age of breast cancer diagnosis was earlier in BRCA2 mutation carriers (32.1 years) than in women with BRCA1 mutations (37.6 years, P =.028). BRCA1 mutations were detected in 20 (45.5%) of 44 families with ovarian cancer and 12 (75%) of 16 families with both breast and ovarian cancer in a single individual. Significantly fewer BRCA2 mutations (two [4.5%] of 44) were detected in families with ovarian cancer (P =.01). Eight families had male breast cancer; one had a BRCA1 mutation and three had BRCA2 mutations.

CONCLUSION

BRCA1 mutations were three times more prevalent than BRCA2 mutations. Breast cancer diagnosis before 50 years of age, ovarian cancer, breast and ovarian cancer in a single individual, and male breast cancer were all significantly more common in families with BRCA1 and BRCA2 mutations, but none of these factors distinguished between BRCA1 and BRCA2 mutations. Evidence for reduced breast cancer penetrance associated with the BRCA2 mutation 6174delT was noted.

Factors associated with decisions about clinical BRCA1/2 testing

Testing for mutations in BRCA1 and BRCA2 can provide important information about breast and ovarian cancer risk to a small but identifiable subgroup of women. Women who test positive for a BRCA1/2 mutation can pursue more aggressive cancer surveillance and prevention regimens. Among families with known mutations, women who test negative may avoid unnecessary interventions. Currently, little is known about the factors associated with the use of clinical BRCA1/2 testing. The objective of this study was to determine the factors associated with decisions about clinical BRCA1/2 testing among women undergoing clinical BRCA1/2 counseling through a retrospective cohort study of women who participated in a university-based clinic offering breast cancer risk assessment, genetic counseling, and BRCA1/2 testing between January 1996 and April 1998. From the 251 eligible women who responded to a follow-up survey, 125 (50%) had undergone or were undergoing BRCA1/2 testing, 86 (34%) had decided not to undergo testing, and 40 (16%) were undecided about testing. After multivariate adjustment, we found that women who chose to undergo BRCA1/2 testing were more likely to have a known familial mutation [odds ratio (OR), 7.46; 95% confidence interval (CI), 0.97-62.16], more likely to be Ashkenazi Jewish (OR, 6.37; 95% CI, 2.68-15.12), more likely to want cancer risk information for family members (OR, 1.93; 95% CI, 0.99-4.14), more likely to want information about ovarian cancer risk (OR, 1.69; 95% CI, 1.18-3.69), and less likely to be concerned about insurance or job discrimination (OR, 0.45; 95% CI, 0.21-0.94). These associations were also found in the subgroup of women with a predicted probability of a BRCA1 mutation of 25%. Our study suggests that approximately half of eligible women choose to undergo clinical BRCA1/2 testing after participating in counseling. Women who have the highest risk of carrying a mutation, and thus the greatest probability of gaining some useful information from the test results, are most likely to undergo testing. Women who undergo testing are also more interested in ovarian cancer risk information and less concerned about job and insurance discrimination.

Anticipated versus actual emotional reactions to disclosure of results of genetic tests for cancer susceptibility: findings from p53 and BRCA1 testing programs

PURPOSE

We examined the ability of individuals undergoing genetic testing for cancer susceptibility in two structured research protocols to accurately anticipate emotional reactions to disclosure of their test result. We explored whether accuracy of emotional anticipation was associated with postdisclosure psychologic adjustment.

METHODS

Data from 65 individuals were analyzed; 24 members of Li-Fraumeni cancer syndrome families were tested for p53 mutations (all 24 were unaffected), and 41 subjects with hereditary breast-ovarian cancer susceptibility were tested for BRCA1 mutations (34 were unaffected and seven were affected). Subjects were from families in which a germline mutation had been previously identified. At the pretest session, subjects rated the extent to which they anticipated feeling each of six emotional states (relief, happiness, sadness, guilt, anger, and worry) after disclosure that they did or did not carry the familial mutation. After receiving their test result, they rated their feelings on the same scale of emotions for the appropriate condition. Extent of accuracy and association with psychologic distress at 6 months, as assessed with standardized measures, were evaluated.

RESULTS

Overall, mean levels of emotional reactions after receiving test results were not different from those anticipated before result disclosure. However, affected BRCA1 carriers experienced higher levels of anger and worry than they had anticipated. Underestimation of subsequent distress emotions related to test result was associated with a significant increase in general psychologic distress at 6 months.

CONCLUSION

Unaffected individuals in cancer-predisposition testing programs are generally accurate in anticipating emotional reactions to test results. However, cancer patients may underestimate their distress after disclosure of positive results and could benefit from intervention strategies.

Establishing a cancer risk evaluation program

PURPOSE

Presymptomatic genetic testing for cancer susceptibility is a new practice arena that raises many complex issues. This article presents one model of a cancer risk evaluation program that specifically addresses the unique issues associated with genetic testing for cancer risk.

DESCRIPTION OF PROGRAM

The Cancer Risk Evaluation Program is designed to care for any individual concerned about his or her risk for cancer, offering predisposition genetic testing if appropriate. The program includes clinical and psychosocial assessment, education, cancer risk analysis, and genetic counseling; it offers long-term screening and surveillance and provides a forum for ongoing genetic and clinical research.

RESULTS

Program evaluations from participants have shown that the program is successfully meeting the needs of the participants. This program also ensures that the University of Pennsylvania Cancer Center is delivering cancer genetic services consistent with the existing position statements on genetic testing for cancer susceptibility, which have included guidelines and indications for predisposition genetic testing and informed consent.

CLINICAL IMPLICATIONS

Researchers anticipate a substantial demand for predisposition genetic testing for cancer susceptibility. However, not all individuals interested in testing are eligible or willing to undergo direct gene analysis because of the potential risks. Therefore, clinical programs must address the complex issues surrounding presymptomatic genetic testing and incorporate cancer risk assessment strategies. Additionally, healthcare providers in this new practice arena should be fully informed and current in the state of the knowledge regarding cancer risk assessment; predisposition genetic testing; and the ethical, legal, and social issues pertaining to cancer risk assessment and management.

BRCA1 mutations in women attending clinics that evaluate the risk of breast cancer

BACKGROUND

To define the incidence of BRCA1 mutations among patients seen in clinics that evaluate the risk of breast cancer, we analyzed DNA samples from women seen in this setting and constructed probability tables to provide estimates of the likelihood of finding a BRCA1 mutation in individual families.

METHODS

Clinical information, family histories, and blood for DNA analysis were obtained from 263 women with breast cancer. Conformation-sensitive gel electrophoresis and DNA sequencing were used to identify BRCA1 mutations.

RESULTS

BRCA1 mutations were identified in 16 percent of women with a family history of breast cancer. Only 7 percent of women from families with a history of breast cancer but not ovarian cancer had BRCA1 mutations. The rates were higher among women from families with a history of both breast and ovarian cancer. Among family members, an average age of less than 55 years at the diagnosis of breast cancer, the presence of ovarian cancer, the presence of breast and ovarian cancer in the same woman, and Ashkenazi Jewish ancestry were all associated with an increased risk of detecting a BRCA1 mutation. No association was found between the presence of bilateral breast cancer or the number of breast cancers in a family and the detection of a BRCA1 mutation, or between the position of the mutation in the BRCA1 gene and the presence of ovarian cancer in a family.

CONCLUSIONS

Among women with breast cancer and a family history of the disease, the percentage with BRCA1 coding-region mutations is less than the 45 percent predicted by genetic-linkage analysis. These results suggest that even in a referral clinic specializing in screening women from high-risk families, the majority of tests for BRCA1 mutations will be negative and therefore uninformative.