Advancing health equity: A qualitative study assessing barriers and facilitators of implementing hereditary breast and ovarian cancer risk screening tools in community-based organizations

Genetic counseling and testing (GCT) inform cancer management for persons at risk for hereditary breast and ovarian cancer (HBOC). Community-based organizations (CBOs) may play a role in identifying at-risk Latinx individuals to connect them to GCT but data are lacking. Two academic centers and their four CBO partners planned to implement a validated questionnaire for HBOC risk screening ("HBOC risk screening tool"). This study aimed to assess CBO's preferences for HBOC risk screening tools, as well as the barriers and facilitators anticipated for future implementation. Pre-implementation focus groups were conducted with CBO's staff. Discussions centered on current practices to identify and refer at-risk patients. During the discussion, staff were asked to select one out of five validated HBOC risk screening tools to implement and to discuss anticipated barriers/facilitators for implementation. The four focus groups were coded and qualitative analyzed following the Consolidated Framework for Implementation Research (CFIR) and Health Equity domains. All CBOs chose the Family History Screen 7 (FHS-7). Participants (N = 35) highlighted how the FHS-7 was easy to adapt to better fit the target population and changing guidelines. They had positive attitudes toward implementing the screening tool, stressed how the culture of the organization positioned them to reach the target population, and noted barriers in different CFIR domains (e.g., low knowledge about HBOC and GCT referrals; scarce available resources). Participants pointed to barriers related to health equity domains including limited access to GCT and follow-up care for uninsured and underinsured populations, challenges obtaining accurate family history, and immigration-related barriers. CBOs highlighted the importance of partnering with other stakeholders to overcome barriers. Findings emphasize the need to develop multi-level implementation strategies to overcome barriers and leverage facilitators. This study can inform the development of implementation toolkits for CBOs to implement HBOC screening tools to advance health equity.

Abstract P6-12-07: Prevalence of propionibacterium acnes and bartonella henselae DNA in patients with inflammatory breast cancer (IBC)

Introduction:

Inflammatory breast cancer (IBC) is a very aggressive variant of breast cancer with a poor prognosis.. Mouse Mammary Tumor-associated Virus (MMTV) and other infectious agents have been considered as possible etiological agents of IBC particularly related to the initial description of higher incidence in women living in rural areas in North Africa. The etiological role of bacteria in this disease has never been explored in spite of the evidence that chronic infections with certain bacteria can facilitate tumors development. We retrospectively evaluated tissue samples from patients with recurrent IBC to identify potential bacterial agents that could play a role in the development and progression of the disease.

Methods:

DNA was isolated from formalin-fixed paraffin embedded samples of 24 Inflammatory Breast Cancer (IBC) patients whose specimen had been submitted for genomic analysis using next-genomic sequencing (Foundation One™). An additional 3 non-IBC patients (lymph node, lung metastatic lesions) were included in the study. Unselected DNA libraries from these samples were pooled and sequenced on a HiSeq-2000 sequencer. Comparing the sequence data to a reference of 5,569 bacterial and viral genomic sequences identified the presence of Propionibacterium acnes, Ralstonia pickettii and Methylobacterium consequently, we enriched the DNA libraries for the presence of these species as well as bacterial rRNA genes using hybrid capture with synthesized oligonucleotide baits and sequenced the enriched libraries.

Results:

Twenty three IBC patients and 3 non-IBC breast cancer patients were included in the study. Tissue specimens included, 14 chest wall and skin;6 breast, 2 lymph nodes; 1 liver, 1 lung, 1 pleural fluid, 1 brain. In 16 out of the 23 IBC (70%) of specimens we detected bacteria DNA. Propionibacterium acnes were detected in 12 cases. Bartonella henselae was detected in 1 out of the 23 IBC specimens. Furthermore, additional detected species included Ralstonia pickettii (3 cases) and Pseudomonas aeruginosa (2). No bacteria were detected in samples from non-IBC breast cancer patients.

Conclusions:

In this study, we identified Propionibacterium acnes and Bartonella henselae in samples from IBC patients. The anaerobic Gram-positive bacterium P. acnes is ubiquitously found in sebaceous follicles of the human skin. Recent reports showed that P. acnes was present in a high number of cancerous prostate tissue samples. It has been suggested that P. acnes may be a contributing factor to the initiation or progression of prostate cancer. Bartonella is a Gram-negative bacteria usually associated with cat-scratch disease, urban trench fever, bacillary angiomatosis-peliosis and endocarditis. Some reports that have showed some similarities between cat scratch disease and inflammatory breast cancer. Our results suggested that P. acnes or Bartonella henselae infections might contribute to the clinical and pathological characteristics of IBC, associated with rapid spread of the breast tumor cells through the lymphatic system.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-12-07.

Abstract P3-10-03: Bartonella henselae Infection Detected in Patients with Inflammatory Breast Cancer

Inflammatory breast cancer (IBC) is a very aggressive type of advanced breast cancer with a poor prognosis. Clinical symptoms involve a rapid onset of changes in the skin overlying the breast, including edema, redness and swelling including a wrinkled and orange peel appearance in the skin. This particular presentation is due to the invasion of the skin dermal lymphatics by breast cancer cells that obstructed the lymph channels producing the characteristic skin changes that mimic an inflammatory process. Mouse Mammary Tumor-associated Virus (MMTV) and other infectious agents have been consider as possible etiological agents of IBC particularly related to the initial description of higher incidence in women living in rural areas in North Africa. Although, the etiopathological role of bacteria in this disease has never been explored in spite of the evidence that chronic infections with certain bacteria can facilitate tumors development.

Several bacterial infections promote cell proliferation and could increase the rate of cell transformation. Bartonella spp. is an emerging pathogen that can cause conditions which are characterized by the development of proliferative lesions. Bartonella might cause vasculoproliferative disorders by triggering the proliferation of endothelial cells and inducing the secretion of proliferative cytokines from infected host cells. It cause persistent infection of erythrocytes and endothelial cells in their mammalian hosts and their transmission occur mainly by blood-sucking arthropods. Bartonella are Gram-negative bacteria usually associated with cat-scratch disease, urban trench fever, bacillary angiomatosis-peliosis and endocarditis. Some reports have showed some similarities between cat scratch disease and inflammatory breast cancer (Povoski et al., Breast J 9: 497–500, 2003).

Methods and Results: In the present work, we report the identification of Bartonella henselae in the pleural effusions of two patients with IBC. These patients had both estrogen-receptor negative (ER−) and progesterone-receptor negative (PR−) disease and have failed a number of previous chemotherapy regimens. Furthermore, they had metastatic disease to the pleura, skin, lymph nodes and lung. Cells from the pleural fluids of these patients stained positive for Bartonella sp. using the Warthin-Starry staining kit. Moreover, we used PCR and sequencing of the 16S–23S intergenic spacer (ITS) region to identify the etiological agent as Bartonella henselae. By immunofluorescence using an antibody that specifically recognized Bartonella henselae, the bacteria were found in the nucleus of IBC tumor cells confirming the infection and their intracellular localization.

Conclusions: These results suggested that bacteria infections such as the one produced by Bartonella henselae might contribute to the clinical and pathological characteristics of IBC, associated with rapid spread of the breast tumor cells through the lymphatic system. The infection and activation of endothelial lymphatics by Bartonella might contribute to the highly metastatic process observed in IBC patients. An acute inflammatory reaction triggered by the Bartonella infected endothelium may be crucial for initiating the chronic inflammation in IBC patients and the rapid spread of tumor cells.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P3-10-03.