Breast Cancer Risk Reduction: A Patient-Doctor Intervention

Institution: University of California, San Francisco
Investigator(s): Celia Kaplan, Dr.P.H. -
Award Cycle: 2009 (Cycle 15) Grant #: 15OB-0158 Award: $740,685
Award Type: Translational Research Award
Research Priorities
Etiology and Prevention>Prevention and Risk Reduction: ending the danger of breast cancer

Initial Award Abstract (2009)

Despite advances in breast cancer research, many women remain unaware of their individual risk, and physicians have been unable to integrate risk assessment and discussion into their routine practices due largely to time constraints. The end result is that breast cancer risk assessment tools, as well as discussion and use of prevention and risk reduction therapies, have been greatly underutilized. Without timely assessments, breast cancer may be detected at a later stage, requiring more invasive treatments, or worse, detected too late for viable treatment.

During the last decade, health information technology (IT) tools have been shown to promote positive outcomes in patient health and care, providing women with the means to obtain assessments of breast cancer risk and critical breast information in an easy and convenient manner. The goal of this translational project is to evaluate a tablet PC-based breast cancer risk education (BCRE) bilingual English-Spanish intervention in a primary care setting. Two key outcomes will be evaluated: (1) women and physicians in the BCRE intervention group will indicate high rates of satisfaction with the format and content of the intervention, and (2) women in the BCRE intervention group, as compared to those in the control group, will report increased knowledge of risk reduction options, accurate perception of own risk, greater participation in patient-physician discussion of breast cancer risk and recommendations of risk reductions based on patient risk, and more up-to-date mammography screening.

More specifically, the bilingual intervention will utilize a computerized assessment module located in a primary care clinic. Patients will enter their health information into a tablet PC. From that information, a personalized patient feedback report and a referring physician report will be printed providing a breast cancer risk score and recommendations. It is expected that this information will promote discussion between patients and physicians about individualized breast cancer risk and recommendations. A parallel control module will be similar in time and attention requirements as the BCRE module and will include baseline questions and additional questions on cardiovascular history and lifestyle behaviors of smoking, diet, and exercise during the last month. A patient feedback report will be printed with appropriate recommendations about diet and exercise habits.

Advancing health information technology has great potential in the primary care setting. Primary care physicians play a crucial role in counseling women about their risk of developing breast cancer, referring women to screening, conducting clinical breast exams, promoting healthy lifestyles, discussing risk, and referring appropriate women to high-risk clinics and genetic testing. Our planned breast cancer risk education (BCRE) intervention has the potential to efficiently enhance the delivery of risk-specific breast cancer prevention and detection in the context of primary care, thus ultimately lowering breast cancer incidence, morbidity, and mortality.

Final Report (2015)

Despite new information on breast cancer risk and prevention, many women do not know their individual risk of developing breast cancer or what they can do to lower their risk. Health information technology provides a platform for timely and effective patient risk assessment and education, as well as physician information. The aim of this project was to increase patient knowledge and patient physician discussion of breast cancer risk and preventive practices through a tablet computer program in the outpatient clinic setting. In year one, the research team completed key research activities to lay the groundwork for the intervention (Aim 1). This included the organization and implementation of three expert panel discussions, conducting patient and physician semi-structured interviews to inform the content and design of the intervention materials, and developing the intervention risk assessment and feedback software program for a tablet computer.

In the second year of the project we piloted the intervention, developed data collection materials, and initiated full implementation of the randomized trial (Aim 2). During this phase of the project we addressed multiple issues regarding the latest technology available, computer programming, and IT logistics at the clinic sites. We also faced issues related to changes in the practice dynamics at the clinic sites which had adopted the electronic medical record. Based on the new clinic procedures, we made subsequent changes to our protocol to modify recruitment and data collection procedures. In month six of year two, research procedures were finalized. The randomized controlled trial was initiated in June 2011 at the two clinic sites.

In the third year of the project, we concluded the implementation of the intervention, initiated patient chart reviews and physician follow-up survey. Patient recruitment and data collection ended in July 2012. Preliminary analyses of baseline data were initiated in year three.

In the fourth year of the project, we completed patient chart reviews and physician interviews. We analyzed all main study outcomes and prepared two manuscripts for publication in peer-reviewed journals; both have been published. We also initiated Aim 3, the generation and distribution of risk reports to physicians for high-risk women in the comparison group. We identified 94 high-risk patients in the comparison group who completed baseline and follow-up surveys and sent patient risk reports to their physicians.

In the fifth and final year of the project we completed Aim 3 and conducted six-month chart reviews for 91 high-risk women in the comparison group whose physicians had received risk reports, to determine documentation of: high-risk status, genetic counseling/testing, chemoprevention, mammography, exercise, weight/diet and alcohol intake. In addition, we submitted a third manuscript to be considered for publication and a fourth manuscript is in preparation for submission in 2015.

The mean age of our sample was 56 years (SD=9) and 25% of women were identified as high-risk by family history, Gail, or Breast Cancer Surveillance Consortium risk models. Results from our study indicate that at baseline, when we compared high and average risk women irrespective of study group, more average risk than high-risk women had correct risk perception of breast cancer risk (72% vs. 18%) and 25% of both average and high risk women reported being very concerned about breast cancer. Average risk women with correct risk perception were less likely to be concerned about breast cancer (OR=0.3; 95%CI=0.2-0.4). High risk women with correct risk perception were more likely to be concerned about breast cancer (OR=5.1, 95%CI=2.7-9.6). When we examined intervention effects comparing intervention and control groups at follow-up, we found that BreastCARE increased discussions at follow-up of family cancer history (OR=1.54, 95% CI=1.25-1.91), personal breast cancer risk (OR=4.15, 3.02-5.70), high-risk clinics (OR=3.84, 2.13-6.95), and genetic counseling/testing (OR=2.22, 1.34-3.68). These intervention effects were stronger among high-risk women. There were no differences in correct risk perception or concern about breast cancer at follow-up, but intervention patients had greater breast cancer knowledge ([OR]=1.62;95% [CI]=1.19-2.23) The intervention also increased discussions of regular exercise (OR=1.94, 1.50-2.51) and weight (OR=1.56, 1.23-1.96), while there was no effect of the intervention on discussion of alcohol. Overall, patients and physicians were satisfied with the intervention. The majority of patients reported liking the computer survey “a lot” (70%), felt that completing the computer survey was “very easy” (84%) and that the survey questions were “very easy to understand” (82%). The majority of participants also reported liking the breast cancer risk reports “a lot” (61%). Patients preferred completing the survey on a computer (59%) and in the waiting room before a doctor’s visit (50%). Most women preferred to receive the breast care risk reports before a doctor’s visit (72%).

Perceived versus objective breast cancer risk in diverse women.
Periodical:Journal of Women's Health
Index Medicus: J Womens Health
Authors: Fehniger J, Livaudais-Toman J, Karliner L, Kerlikowske K, Tice JA, Quinn J,, et al.
Yr: 2014 Vol: 23 Nbr: 5 Abs: Pg:420-427

A randomized, controlled trial to increase discussion of breast cancer in primary care.
Periodical:Cancer Epidemiology Biomarkers and Prevention
Index Medicus: Cancer Epidemiol Biomarkers Prev
Authors: Kaplan CP, Livaudais-Toman J, Tice JA, Kerlikowske K, Gregorich SE, et al.
Yr: 2014 Vol: 23 Nbr: 7 Abs: Pg:1245-1253

Validation of an Efficient Screening Tool to Identify Low-Income Women at High Risk for Hereditary Breast Cancer DOI:10.1159/000452095
Periodical:Public Health Genomics
Index Medicus: Public Health Genomics
Authors: Stewart S.L., Kaplan C.P., Lee R., Joseph G., Karliner L., Livaudais-Toman, J., Pasick R.J
Yr: 2016 Vol: Nbr: Abs: Pg: