Impact of a Protocol Implementation on Identification and Referral of Women At-Risk for Hereditary Breast Cancer

Breast cancer is the foremost new cancer diagnosis and the second highest cause of cancer death in American women (American Cancer Society, 2019). Hereditary breast cancer is most commonly caused by a mutation within the breast cancer susceptibility genes, BRCA 1 or 2, which increases women’s risk for breast cancer by five to ten-fold the average population (Mayo Clinic, 2019). The U.S. Preventive Services Task Force has assigned a Grade B recommendation advising health care providers to use a risk assessment tool, such as the Breast Cancer Genetics Referral Screening Tool (B-RST™), to recognize and provide medical management recommendations for high-risk women (Nelson, Pappas, Cantor, Haney, & Holmes, 2019). Offering medical management options to this at-risk group can promote breast cancer prevention or early detection to positively affect health outcomes (ACOG, 2019; Kiely & Schwartz, 2014). The purpose of this evidence based practice (EBP) project was to determine if using the B-RST™ would aid in identifying women who are candidates for cancer genetic and/or High Risk Breast Clinic (HRBC) counseling, in comparison to the approach of reviewing cancer family history in the electronic medical record (EMR). The seven steps of the Iowa Model (Iowa Model Collaborative, 2017) guided this EBP protocol implementation. During a 12-week time period 994 women seen at a nine provider obstetrical and gynecological practice in a Midwestern state had a B-RST™ assessment performed during routine gynecological and new patient appointments. Data were collected by completing and recording the B-RST™ results in the EMR, reviewing populated reports, and performing chart audits. Additionally, chart audits established participation in scheduling and attending referral consultation appointments. Demographic information was obtained for the pre-protocol patient group (N = 880) along with genetics (N = 8) and HRBC (N = 6) referrals for the same 12-week time period one year prior. During this EBP project, a total of 994 participants had the B-RST™ assessment performed. Genetics referrals were provided to 32 (18.4%) of the 174 participants who qualified, with six (21.9%) of the appointments completed. From the 249 participants eligible for a HRBC consultation, 57 (22.9%) received referrals and eight (14.0%) participants had this performed. A Chi-square test for independence resulted in p values \u3e .05 for the variables of age, appointment type, insurance, race, and religion; thus determining the sampling was representative of the office population. Factorial ANOVA analyses were statistically significant for the effects of the health care providers using the B-RST™ to guide both HRBC (F(6, 1860), = 9.23, p \u3c.001) and genetics (F(6, 1860) = 6.46, p \u3c .001) referrals. It was determined that use of the B-RST™ was an effective method for identifying, and subsequently providing appropriate referrals, to women who are at-risk for hereditary breast cancer at an Ob/Gyn office setting. Future EBP projects and research should focus on methods to: (a) educate health care providers about hereditary breast cancer, its associated risks, and B-RST™ use to promote risk assessment utilization, (b) increase health care provider HRBC and genetics referral rates to provide identification and medical management for those at-risk, and (c) recognize and address patient-reported barriers to improve referral acceptance and participation rates