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Braithwaite D, Chicaiza A, Lopez K, Lin KW, Mishori R, Karanth SD, Anton S, Miller K, Schonberg MA, Schoenborn NL, O’Neill SC. Clinician and patient perspectives on screening mammography among women age 75 and older: A pilot study of a novel decision aid. PEC Innov 2023; 2:100132. [PMID: 37124453 PMCID: PMC10136373 DOI: 10.1016/j.pecinn.2023.100132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Objective Supporting patient-clinician communication is key to implementing tailored, risk-based screening for older adults. Objectives of this multiphase mixed methods study were to identify factors that primary care clinicians consider influential when making screening mammography recommendations for women ≥ 75 years, develop a patient decision aid that incorporates these factors, and gather feasibility and acceptability from the patients' perspective. Methods Clinicians from a Mid-Atlantic practice network completed online surveys. Women in the same network completed surveys before and after receiving a tailored booklet that included information about the benefits and harms of screening for women ≥ 75 years, a breast cancer risk-estimate, and a question prompt list to support patient-clinician communication. Results Clinicians (N = 21) were primarily women [57.1%] and practiced family medicine [81.0%]. They cited patients' age ≥ 75 years [95.4%], comorbidity [86.4%], functional status [77.3%], cancer family history [63.6%], U.S. Preventive Services Task Force guidelines [81.8%] and new research [77.3%] as factors influencing their recommendations. Fourteen women completed baseline surveys and received personalized decision aids (Mean age = 79.1 years). Eleven completed the post-intervention survey. All were satisfied with the booklet length, 81.8% found the booklet easy to understand and 72.7% helpful in decision-making Perceived lifetime breast cancer risk decreased significantly from pre- to post-intervention (p = 0.02). Conclusions Results suggest this decision aid, which incorporates key decisional factors from the clinician's perspective, is feasible and acceptable to patients. Innovation A tailored decision aid booklet is innovative as it provides information on personalized risk and potential benefits and harms to older women considering screening.
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Affiliation(s)
- Dejana Braithwaite
- University of Florida Health Cancer Center, Gainesville, FL, United States of America
- Corresponding author at: University of Florida Health Cancer Center, University of Florida, Clinical and Translational Research Building, 2004 Mowry Road, Gainesville, FL 32610, United States of America. (D. Braithwaite)
| | - Anthony Chicaiza
- Georgetown University Medical Center, Washington, DC, United States of America
| | - Katherine Lopez
- Georgetown University Medical Center, Washington, DC, United States of America
| | - Kenneth W. Lin
- Georgetown University Medical Center, Washington, DC, United States of America
| | - Ranit Mishori
- Georgetown University Medical Center, Washington, DC, United States of America
| | - Shama D. Karanth
- University of Florida Health Cancer Center, Gainesville, FL, United States of America
| | - Stephen Anton
- University of Florida Health Cancer Center, Gainesville, FL, United States of America
| | - Kristen Miller
- Georgetown University Medical Center, Washington, DC, United States of America
- National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, DC, United States of America
| | - Mara A. Schonberg
- Dana Farber Cancer Center, Harvard University, Boston, MA, United States of America
| | - Nancy L. Schoenborn
- Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Suzanne C. O’Neill
- Georgetown University Medical Center, Washington, DC, United States of America
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Dash C, Mills MG, Jones TD, Nwabukwu IA, Beale JY, Hamilton RN, Hurtado-de-Mendoza A, O’Neill SC. Design and pilot implementation of the Achieving Cancer Equity through Identification, Testing, and Screening (ACE-ITS) program in an urban underresourced population. Cancer 2023; 129:3141-3151. [PMID: 37691526 PMCID: PMC10502953 DOI: 10.1002/cncr.34691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 01/05/2023] [Accepted: 01/06/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION The Achieving Cancer Equity through Identification, Testing, and Screening (ACE-ITS) program is a community-engaged framework to improve mammography maintenance and rates of genetic risk assessment, counseling, and testing using a multilevel approach that enhances patient navigation through mobile health and community education. METHODS The ACE-ITS program is based on the National Institute of Minority Health and Health Disparities research framework focused on the individual (genetic testing, screening navigation) and community (community-based breast health education) levels and targeted to the biological- (genetic risk), behavioral- (mammography screening), sociocultural- (underserved Black and Hispanic women), and the health care system (patient navigation, automated text messages)-related domains. We further integrate the Practical Robust Implementation and Sustainability Model to describe our program implementation. RESULTS In collaboration with genetic counselors and community partners, we created educational modules on mammography maintenance and genetic counseling/testing that have been incorporated into the navigator-led community education sessions. We also implemented a universal genetic risk assessment tool and automated text message reminders for repeat mammograms into our mammography navigation workflow. Through the ACE-ITS program implementation, we have collaboratively conducted 22 educational sessions and navigated 585 women to mammography screening over the 2020-2021 calendar years. From January to December 2021, we have also conducted genetic risk assessment on 292 women, of whom 7 have received genetic counseling/testing. CONCLUSIONS We describe a multilevel, community-engaged quality improvement program designed to reduce screening-related disparities in Black and Hispanic women in our catchment area.
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Affiliation(s)
- Chiranjeev Dash
- Georgetown Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia
| | - Mary G. Mills
- Georgetown Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia
| | - Thelma D. Jones
- Thelma D. Jones Breast Cancer Fund, Washington, District of Columbia
| | - Ify A. Nwabukwu
- African Women’s Cancer Awareness Association, Greenbelt, Maryland
| | - Jacqueline Y. Beale
- Cancer to Jasmine and Butterflies Consulting, Glenn Dale, Maryland
- American Cancer Society, Cancer Action Network, Washington, District of Columbia
| | - Rhonda N. Hamilton
- Georgetown Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia
| | - Alejandra Hurtado-de-Mendoza
- Georgetown Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia
| | - Suzanne C. O’Neill
- Georgetown Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia
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Conley CC, Rodriguez J, O’Neill SC, Vadaparampil ST. Abstract P001: Frequency and covariates of chemoprevention use among women at high risk for breast cancer. Cancer Prev Res (Phila) 2023. [DOI: 10.1158/1940-6215.precprev22-p001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Abstract
Purpose: To assess patterns of self-reported use of chemopreventive medications (i.e., tamoxifen, raloxifene) among women with elevated risk for breast cancer. Methods: Women with elevated breast cancer risk (N=134; n=98 BRCA1/2 mutation carriers, n=36 with ≥1.67% 5-year breast cancer per the National Cancer Institute [NCI] Breast Cancer Risk Assessment Tool [BCRAT; https://bcrisktool.cancer.gov/]) were recruited by advertising on social media and through community organizations. Between August 2020 and January 2021, participants completed an online survey assessing demographic characteristics (race, ethnicity, education, employment, income, insurance, and usual healthcare setting), psychosocial characteristics (perceived breast cancer risk, self-efficacy), provider recommendation for breast cancer chemoprevention, and prior/current use of breast cancer chemoprevention. Descriptive statistics characterized the frequency of provider recommendation for and use of breast cancer chemoprevention. Multivariable logistic regression analysis examined demographic and psychosocial characteristics associated with use of breast cancer chemoprevention. Results: Participants were in middle adulthood (M=45) and mostly non-Hispanic White (90%), with ≥ Bachelor’s degree (69%), household income ≥ $50,000/year (67%), and private health insurance (69%). Most were employed outside the home (73%) and typically received medical care at a private doctor’s office (81%). Most (76%) had discussed their breast cancer risk with a healthcare provider. About one-third (33%) reported receiving a provider recommendation for tamoxifen or raloxifene, 16% had previously taken one of these medications, and 10% were currently taking one of these medications. This included 24% of participants with a BRCA1/2 mutation and 35% of participants with a 5-year breast cancer risk ≥1.67%; use of chemoprevention did not differ between these groups (p=0.22). Compared to participants with private health insurance, those who were publicly insured were more likely to have taken chemoprevention medications (OR=8.27, p=0.04, 95% C.I.=1.95-35.11). No other demographic or psychosocial characteristics were associated with chemoprevention use (all p’s≥0.09). Conclusions: Consistent with prior research, few women with elevated breast cancer risk reported currently or previously taking chemopreventive medications. Despite little data on the efficacy of chemoprevention for BRCA1/2 mutation carriers, self-reported use of chemoprevention did not differ based on BRCA1/2 mutation status. Insurance status emerged as a key predictor of chemoprevention use, indicating that cost and insurance coverage may be a barrier for some women and may need to be addressed in interventions aiming to increase use of chemoprevention. Given the homogenous convenience sample, results might not extend to the broader population and need to be replicated in larger, more diverse samples.
Citation Format: Claire C. Conley, Jennifer Rodriguez, Suzanne C. O’Neill, Susan T. Vadaparampil. Frequency and covariates of chemoprevention use among women at high risk for breast cancer. [abstract]. In: Proceedings of the AACR Special Conference: Precision Prevention, Early Detection, and Interception of Cancer; 2022 Nov 17-19; Austin, TX. Philadelphia (PA): AACR; Can Prev Res 2023;16(1 Suppl): Abstract nr P001.
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McDonnell GA, Peshkin BN, DeMarco TA, Peterson SK, Arun BK, Miesfeldt S, O’Neill SC, Schneider K, Garber J, Isaacs C, Luta G, Tercyak KP. Long-Term Adaptation Among Adolescent and Young Adult Children to Familial Cancer Risk. Pediatrics 2022; 150:e2022056339. [PMID: 35859209 PMCID: PMC10646493 DOI: 10.1542/peds.2022-056339] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/01/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND It is important to examine adolescent and young adult (AYA) children's long-term psychosocial and behavioral adaptation to disclosure of maternal BRCA-positive carrier status (BRCA+) to inform approaches for familial cancer risk communication, education, and counseling. METHODS Mothers underwent BRCA genetic testing 1 to 5 years earlier. Group differences in AYAs' self-reported outcomes were analyzed by maternal health and carrier status, and child age and sex. RESULTS A total of N = 272 AYAs were enrolled: 76.1% of their mothers were breast or ovarian cancer survivors and 17.3% were BRCA+. AYAs' cancer risk behavior (tobacco and alcohol use, physical activity) and psychologic distress levels did not vary by maternal status. In bivariate analyses, AYAs of cancer-surviving mothers believed themselves to be at greater risk for, and were more knowledgeable about, cancer than AYAs of mothers without cancer. AYAs of BRCA+ mothers were more concerned about cancer, held stronger beliefs about genetic risk, and placed a higher value on learning about genetics. In adjusted models, maternal cancer history (not BRCA+) remained associated with AYAs' greater perceptions of cancer risk (P = .002), and knowledge about cancer (P = .03) and its causes (P = .002). CONCLUSIONS Disclosing maternal BRCA+ status did not influence children's lifestyle behavior or adversely affect quality of life long term. AYAs of BRCA+ mothers were more aware of and interested in genetic risk information. Such families may benefit from support to promote open communication about genetic testing choices.
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Affiliation(s)
- Glynnis A. McDonnell
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - Beth N. Peshkin
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | | | | | | | | | - Suzanne C. O’Neill
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | | | - Judy Garber
- Dana-Farber Cancer Institute, Boston, MA, USA
| | - Claudine Isaacs
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - George Luta
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - Kenneth P. Tercyak
- Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
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Wernli KJ, Knerr S, Li T, Leppig K, Ehrlich K, Farrell D, Gao H, Bowles EJA, Graham AL, Luta G, Jayasekera J, Mandelblatt JS, Schwartz MD, O’Neill SC. Effect of Personalized Breast Cancer Risk Tool on Chemoprevention and Breast Imaging: ENGAGED-2 Trial. JNCI Cancer Spectr 2021; 5:pkaa114. [PMID: 33554037 PMCID: PMC7853161 DOI: 10.1093/jncics/pkaa114] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 10/14/2020] [Accepted: 11/09/2020] [Indexed: 12/12/2022] Open
Abstract
Background Limited evidence exists about how to communicate breast density-informed breast cancer risk to women at elevated risk to motivate cancer prevention. Methods We conducted a randomized controlled trial evaluating a web-based intervention incorporating personalized breast cancer risk, information on chemoprevention, and values clarification on chemoprevention uptake vs active control. Eligible women aged 40-69 years with normal mammograms and elevated 5-year breast cancer risk were recruited from Kaiser Permanente Washington from February 2017 to May 2018. Chemoprevention uptake was measured as any prescription for raloxifene or tamoxifen within 12 months from baseline in electronic health record pharmacy data. Secondary outcomes included breast magnetic resonance imaging (MRI), mammography use, self-reported distress, and communication with providers. We calculated unadjusted odds ratios (ORs) using logistic regression models and mean differences using analysis of covariance models with 95% confidence intervals (CIs) with generalized estimating equations. Results We randomly assigned 995 women to the intervention arm (n = 492) or control arm (n = 503). The intervention (vs control) had no effect on chemoprevention uptake (OR = 1.04, 95% CI = 0.07 to 16.62). The intervention increased breast MRI use (OR = 5.65, 95% CI = 1.61 to 19.74) while maintaining annual mammography (OR = 0.98, 95% CI = 0.75 to 1.28). Women in the intervention (vs control) arm had 5.67-times higher odds of having discussed chemoprevention or breast MRI with provider by 6 weeks (OR = 5.67, 95% CI = 2.47 to 13.03) and 2.36-times higher odds by 12 months (OR = 2.36, 95% CI = 1.65 to 3.37). No measurable differences in distress were detected. Conclusions A web-based, patient-level intervention activated women at elevated 5-year breast cancer risk to engage in clinical discussions about chemoprevention, but uptake remained low.
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Affiliation(s)
- Karen J Wernli
- Correspondence to: Karen J. Wernli, PhD, Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101, USA (e-mail: )
| | - Sarah Knerr
- Department of Health Services, University of Washington, Seattle, WA, USA
| | - Tengfei Li
- Department of Biostatistics, Bioinformatics, and Biomathematics, Georgetown University, Washington, DC, USA
| | | | - Kelly Ehrlich
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | | | - Hongyuan Gao
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Erin J A Bowles
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Amanda L Graham
- Truth Initiative, Washington, DC, USA,Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - George Luta
- Department of Biostatistics, Bioinformatics, and Biomathematics, Georgetown University, Washington, DC, USA
| | - Jinani Jayasekera
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Jeanne S Mandelblatt
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Marc D Schwartz
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Suzanne C O’Neill
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
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Wernli KJ, Bowles EA, Knerr S, Leppig KA, Ehrlich K, Gao H, Schwartz MD, O’Neill SC. Characteristics Associated with Participation in ENGAGED 2 - A Web-based Breast Cancer Risk Communication and Decision Support Trial. Perm J 2020; 24:1-4. [PMID: 33482952 PMCID: PMC7849258 DOI: 10.7812/tpp/19.205] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 10/14/2020] [Accepted: 03/01/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE We evaluated demographic and clinical characteristics associated with participation in a clinical trial testing the efficacy of an online tool to support breast cancer risk communication and decision support for risk mitigation to determine the generalizability of trial results. METHODS Eligible women were members of Kaiser Permanente Washington aged 40-69 years with a recent normal screening mammogram, heterogeneously or extremely dense breasts and a calculated risk of > 1.67% based on the Breast Cancer Surveillance Consortium 5-year breast cancer risk model. Trial outcomes were chemoprevention and breast magnetic resonance imaging by 12-months post-baseline. Women were recruited via mail with phone follow-up using plain language materials notifying them of their density status and higher than average breast cancer risk. Multivariable logistic regression calculated independent odds ratios (ORs) for associations between demographic and clinical characteristics with trial participation. RESULTS Of 2,569 eligible women contacted, 995 (38.7%) participated. Women with some college (OR = 1.99, 95% confidence interval [CI] 1.34-2.96) or college degree (OR = 3.35, 95% CI 2.29-4.90) were more likely to participate than high school-educated women. Race/ethnicity also was associated with participation (African-American OR = 0.50, 95% CI 0.29-0.87; Asian OR = 0.22, 95% CI 0.12-0.41). Multivariate adjusted ORs for family history of breast/ovarian cancer were not associated with trial participation. DISCUSSION Use of plain language and potential access to a website providing personal breast cancer risk information and education were insufficient in achieving representative participation in a breast cancer prevention trial. Additional methods of targeting and tailoring, potentially facilitated by clinical and community outreach, are needed to facilitate equitable engagement for all women.
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Affiliation(s)
- Karen J Wernli
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Erin A Bowles
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | | | | | - Kelly Ehrlich
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Hongyuan Gao
- Kaiser Permanente Washington Health Research Institute, Seattle, WA
| | - Marc D Schwartz
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
| | - Suzanne C O’Neill
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC
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Tercyak KP, Bronheim SM, Kahn N, Robertson HA, Anthony BJ, Mays D, O’Neill SC, Peterson SK, Miesfeldt S, Peshkin BN, DeMarco TA. Cancer genetic health communication in families tested for hereditary breast/ovarian cancer risk: a qualitative investigation of impact on children's genetic health literacy and psychosocial adjustment. Transl Behav Med 2019; 9:493-503. [PMID: 31094441 PMCID: PMC6520800 DOI: 10.1093/tbm/ibz012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Children's literacy about the genetics of late-onset hereditary breast/ovarian cancer (HBOC) often develops through conversations with parents about BRCA gene testing and adults' cancer diagnoses. These conversations may promote early understanding of HBOC, but the long-term impact on children's psychosocial adjustment remains unclear. We investigated cancer genetic health communication in BRCA-tested families to consider benefits, risks, and moderating influences on children's understanding and well-being. Adolescent and young adult children (ages 12-24) of mothers who underwent BRCA testing 1+ years previously completed qualitative interviews that were transcribed, coded (intercoder K ≥ .70), and content-analyzed (N = 34). Children readily recalled conversations about BRCA testing and HBOC (100%) that they considered important (94%), but implications for children were ambiguous and obfuscated their concerns. Psychosocial impacts were muted, multifaceted, and displayed a range of favorable (82%), neutral (71%), and unfavorable (59%) response-frequently co-occurring within the same child over different aspects (e.g., medical, concern for self and others). Children verbalized active (50%) and avoidant (38%) coping strategies: about 1:5 endorsed transient thoughts about vulnerability to HBOC, 1:3 had not further considered it, and all reported specific actions they had or would undertake to remain healthy (e.g., diet/exercise). A majority (94%) of children had or would consider genetic testing for themselves, usually later in life (59%). Long-term outcomes highlighted benefits (awareness of HBOC, psychological hardiness, healthier lifestyle behaviors), as well as some psychosocial concerns that could be managed through interventions promoting genetic health literacy.
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Affiliation(s)
- Kenneth P Tercyak
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
- Center for Child and Human Development, Georgetown University Medical Center, Washington, DC, USA
| | - Suzanne M Bronheim
- Center for Child and Human Development, Georgetown University Medical Center, Washington, DC, USA
| | - Nicole Kahn
- Center for Child and Human Development, Georgetown University Medical Center, Washington, DC, USA
| | - Hillary A Robertson
- Department of Psychiatry, Georgetown University Medical Center, Washington, DC, USA
| | - Bruno J Anthony
- Center for Child and Human Development, Georgetown University Medical Center, Washington, DC, USA
| | - Darren Mays
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Suzanne C O’Neill
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Susan K Peterson
- Department of Behavioral Science, MD Anderson Cancer Center, Houston, TX, USA
| | - Susan Miesfeldt
- Scarborough Campus, Maine Medical Center Cancer Institute, Scarborough, ME, USA
| | - Beth N Peshkin
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
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O’Neill SC, Taylor KL, Clapp J, Jayasekera J, Isaacs C, Graham D, Goldberg SL, Mandelblatt J. Multilevel Influences on Patient-Oncologist Communication about Genomic Test Results: Oncologist Perspectives. J Health Commun 2018; 23:679-686. [PMID: 30130477 PMCID: PMC6310162 DOI: 10.1080/10810730.2018.1506836] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
Thousands of women with early-stage breast cancer receive gene-expression profile (GEP) tests to guide chemotherapy decisions. However, many patients report a poor understanding of how their test results inform treatment decision-making. We applied models of patient-centered communication and informed decision-making to assess which variables oncologists' perceive as most influential to effective communication with their patients about GEP results and intervention modalities and approaches that could support more effective conversations about treatment decisions in routine clinical care. Medical oncologists who were part of a practice group in the mid-Atlantic US completed an online, cross-sectional survey in 2016. These data were merged with de-identified electronic patient and practice data. Of the 83 oncologists contacted, 29 completed the survey (35% response rate, representing 52% of the test-eligible patients in the practice network). There were no significant differences between survey responders and nonresponders. Oncologists reported patient-related variables as most influential, including performance status (65.5%), pretesting preferences for chemotherapy (55.2%), and comprehension of complex test results (55.2%). Oncologists endorsed their experience with testing (58.6%) and their own confidence in using the test results (48.3%) as influential as well. They indicated that a clinical decision support tool incorporating patient comorbidities, age, and potential benefits from chemotherapy would support their own practice and that they could share these results and other means of communication support using print materials (79.3%) with their patients in clinic (72.4%). These preferred intervention characteristics could be integrated into routine care, ultimately facilitating more effective communication about genomic testing (such as GEP) and its role in treatment selection.
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Affiliation(s)
- Suzanne C. O’Neill
- Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - Kathryn L. Taylor
- Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - Jonathan Clapp
- Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - Jinani Jayasekera
- Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - Claudine Isaacs
- Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC, USA
| | - Deena Graham
- John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | | | - Jeanne Mandelblatt
- Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC, USA
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Chandler Y, Schechter CB, Jayasekera J, Near A, O’Neill SC, Isaacs C, Phelps CE, Ray GT, Lieu TA, Ramsey S, Mandelblatt JS. Cost Effectiveness of Gene Expression Profile Testing in Community Practice. J Clin Oncol 2018; 36:554-562. [PMID: 29309250 PMCID: PMC5815401 DOI: 10.1200/jco.2017.74.5034] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Purpose Gene expression profile (GEP) testing can support chemotherapy decision making for patients with early-stage, estrogen receptor-positive, human epidermal growth factor 2-negative breast cancers. This study evaluated the cost effectiveness of one GEP test, Onco type DX (Genomic Health, Redwood City, CA), in community practice with test-eligible patients age 40 to 79 years. Methods A simulation model compared 25-year societal incremental costs and quality-adjusted life-years (QALYs) of community Onco type DX use from 2005 to 2012 versus usual care in the pretesting era (2000 to 2004). Inputs included Onco type DX and chemotherapy data from an integrated health care system and national and published data on Onco type DX accuracy, chemotherapy effectiveness, utilities, survival and recurrence, and Medicare and patient costs. Sensitivity analyses varied individual parameters; results were also estimated for ideal conditions (ie, 100% testing and adherence to test-suggested treatment, perfect test accuracy, considering test effects on reassurance or worry, and lowest costs). Results Twenty-four percent of test-eligible patients had Onco type DX testing. Testing was higher in younger patients and patients with stage I disease ( v stage IIA), and 75.3% and 10.2% of patients with high and low recurrence risk scores received chemotherapy, respectively. The cost-effectiveness ratio for testing ( v usual care) was $188,125 per QALY. Considering test effects on worry versus reassurance decreased the cost-effectiveness ratio to $58,431 per QALY. With perfect test accuracy, the cost-effectiveness ratio was $28,947 per QALY, and under ideal conditions, it was $39,496 per QALY. Conclusion GEP testing is likely to have a high cost-effectiveness ratio on the basis of community practice patterns. However, realistic variations in assumptions about key variables could result in GEP testing having cost-effectiveness ratios in the range of other accepted interventions. The differences in cost-effectiveness ratios on the basis of community versus ideal conditions underscore the importance of considering real-world implementation when assessing the new technology.
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Affiliation(s)
- Young Chandler
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Clyde B. Schechter
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jinani Jayasekera
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Aimee Near
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Suzanne C. O’Neill
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Claudine Isaacs
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Charles E. Phelps
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - G. Thomas Ray
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Tracy A. Lieu
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Scott Ramsey
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Jeanne S. Mandelblatt
- Young Chandler, Jinani Jayasekera, Aimee Near, Suzanne C. O’Neill, Claudine Isaacs, and Jeanne S. Mandelblatt, Georgetown University Medical Center, Lombardi Comprehensive Cancer Center, Washington, DC; Clyde B. Schechter, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx; Charles E. Phelps, University of Rochester, Rochester, NY; G. Thomas Ray and Tracy A. Lieu, Kaiser Permanente Northern California, Oakland, CA; and Scott Ramsey, Fred Hutchinson Cancer Research Center, Seattle, WA
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10
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O’Neill SC, Isaacs C, Lynce F, Graham DMA, Chao C, Sheppard VB, Zhou Y, Liu C, Selvam N, Schwartz MD, Potosky AL. Endocrine therapy initiation, discontinuation and adherence and breast imaging among 21-gene recurrence score assay-eligible women under age 65. Breast Cancer Res 2017; 19:45. [PMID: 28359319 PMCID: PMC5374604 DOI: 10.1186/s13058-017-0837-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 03/15/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Aside from chemotherapy utilization, limited data are available on the relationship between gene expression profiling (GEP) testing and breast cancer care. We assessed the relationship between GEP testing and additional variables and the outcomes of endocrine therapy initiation, discontinuation and adherence, and breast imaging exams in women under age 65 years. METHODS Data from five state cancer registries were linked with claims data and GEP results. We assessed variables associated with survivorship care outcomes in an incident cohort of 5014 commercially insured women under age 65 years, newly diagnosed with stage I or II hormone-receptor-positive, human epidermal growth factor receptor 2 (HER2) non-positive breast cancer from 2006 to 2010. RESULTS Among tested women, those with high Oncotype DX® Breast Recurrence Score® (RS) were significantly less likely to initiate endocrine therapy than women with low RS tumors (OR 0.40 (95% CI 0.20 to 0.81); P = 0.01). Among all test-eligible women, receipt of Oncotype DX testing was associated with a greater likelihood of endocrine therapy initiation (OR 2.48 (95% CI 2.03 to 3.04); P <0.0001). The odds of initiation were also significantly higher for tested vs. untested women among women who did not initiate chemotherapy within six months of diagnosis (OR 3.25 (95% CI 2.53 to 4.16)), with no effect in women who received chemotherapy. Discontinuation and adherence and breast imaging exams were unrelated to tested status or RS. CONCLUSIONS Lower endocrine therapy initiation rates among women with high RS tumors and among untested women not receiving chemotherapy are concerning, given its established efficacy. Additional research is needed to suggest mechanisms to close this gap.
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Affiliation(s)
- Suzanne C. O’Neill
- Georgetown Lombardi Comprehensive Cancer Center, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007 USA
| | - Claudine Isaacs
- Georgetown Lombardi Comprehensive Cancer Center, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007 USA
| | - Filipa Lynce
- Georgetown Lombardi Comprehensive Cancer Center, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007 USA
| | | | | | | | - Yingjun Zhou
- Georgetown Lombardi Comprehensive Cancer Center, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007 USA
| | | | | | - Marc D. Schwartz
- Georgetown Lombardi Comprehensive Cancer Center, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007 USA
| | - Arnold L. Potosky
- Georgetown Lombardi Comprehensive Cancer Center, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007 USA
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