High-risk breast clinic helps deliver specialized care

By Theresa Pablos, AuntMinnie staff writer

August 31, 2020 -- A breast clinic exclusively for high-risk patients successfully connected at-risk women with evidence-based care, including MRI, genetic counseling, and chemoprevention. Two specialists described the clinics' benefits -- and shortfalls -- in a study published on August 21 in JCO Oncology Practice.

One of the clinics' biggest successes was its MRI referral program. More than two-thirds of visitors to the nurse practitioner (NP)-led clinic underwent supplemental MRI screening. However, referrals to other evidence-based services were turned down more often than not.

"Our [clinic] provided quality care, with high rates of guideline-concordant recommendations observed," wrote the authors, Dr. Alison Laws and Dr. Therese Mulvey from Massachusetts General Hospital in Boston.

The team from Massachusetts General Hospital North Shore Cancer Center created the high-risk breast clinic (HRBC) after demand spiked when the state implemented breast cancer risk assessment during mammograms. The clinic uses a templated consultation model to provide consistent, evidence-based care to women with a high risk of breast cancer.

The part-time clinic is referral only and operates for a half-day, two days per week. Its only two staff members are a breast health coordinator and a nurse practitioner who is trained in risk assessment modeling and management of high-risk patients.

For the study, Laws and Mulvey evaluated the clinic's efficacy by retrospectively analyzing data from 318 patients with appointments between March 2018 and February 2019.

Patient utilization of evidence-based treatment recommendations
Treatment recommendation Eligibility criteria No. of eligible patients Patient utilization (%)
Annual mammography and annual breast MRI screening

• ≥ 20% lifetime breast cancer risk

• Personal history of atypia or lobular carcinoma in situ (LCIS)

284 65%
Referral for genetic counseling

• Strong family history

• ≥ 3%-5% likelihood of BRCA mutation on BRCAPRO model

• Ashkenazi Jewish heritage

159 21%
Referral for chemoprevention counseling • Age 35 or older with 5-year breast cancer risk of ≥ 1.7% on Gail model

• Personal history of atypia or LCIS

99 25%

Breast MRI was the most utilized treatment option, with 65% of eligible patients completing a supplemental MRI screening. MRI screening also identified 2 occult cancers out of the 184 patients screened.

However, patients utilized the other referred treatments much less often. Only 35% of eligible patients underwent genetic counseling, and 21% ultimately got tested. Similarly, only 25% of eligible patients received chemoprevention counseling, and just 9% followed through on treatment.

Although the use of some evidence-based treatment options appeared low, the percentages of patients who utilized preventive services were much higher than results found in other studies. For instance, one paper from April found fewer than 10% of high-risk women underwent MRI and only about 5% underwent genetic counseling.

Since the study years, the team at the Massachusetts General Hospital North Shore Cancer Center has also continued to improve the clinic's operations. The group has refined the genetic counseling referral pipeline, so eligible patients can get same-day counseling. In addition, intake forms screen out eligible patients who are unwilling to consider oncology services.

The clinic is also looking to conduct future efforts to raise awareness among primary care providers, who may not be sharing breast cancer risk scores with patients or referring patients to appropriate follow-up care. The hope is that ongoing efforts can help more high-risk women in the community obtain preventive treatment.

"Ongoing collaborative efforts are needed between breast imaging centers, PCPs, and the HRBC/breast cancer risk council to ensure high-risk women identified at time of screening mammogram are appropriately managed," the authors wrote.


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