W ORKGROUP D ISCUSSION Provider Ad Hoc Workgroup, Advisory Committee on Breast Cancer in Young Women December 13, 2012.

WORKGROUP DISCUSSION

Provider Ad Hoc Workgroup,

Advisory Committee on Breast Cancer in Young Women

December 13, 2012

MEMBERS

Generosa Grana* Brandon Hayes–Lattin* Renee Nicholas Wendy Susswein* Karen Kelly Thomas* Laura Tillman JoAnne Zujewski

CHARGE Gather initial background information and to

advise the Committee regarding behavior change of providers as relates to:

1. Enhancing provider knowledge regarding breast cancer in young women

Assessing gaps, guidelines, and issues messaging regarding breast cancer in young women.

2. Improving skills of providers regarding delivery of care to young women at risk (average risk and high risk) of– and/or facing breast cancer (e.g., Survivors).

“Providers” to be defined.

PATIENT POPULATIONS

Women of Reproductive Age (up to 45 years) PreDiagnosis

Average Risk High Risk (including risk for relapse or second

primary) PostDiagnosis

PROVIDERS

PreDiagnosis and Early Diagnosis (Primary Care) Primary Care Physicians

General Practice Family Practice Internal Medicine Obstetrics/Gynecology

Primary Care Nurse Practitioners/Physician Assistants

High School and College School Nurses

PROVIDERS

Post–Diagnosis Oncologists

Medical Oncology Surgical Oncology Radiation Oncology

Oncology Nursing Primary Care Providers (including transitions)

PROFESSIONAL SOCIETIES AND NETWORKS(POTENTIAL PARTNERS TO REACH PROVIDERS)

American College Health Association (ACHA) American Academy of Family Practice (AAFP) American College of Physicians (ACP) American Congress of Obstetricians and

Gynecologists (ACOG) American Academy of Nurse Practitioners

(AANP) American Academy of Physician Assistants

(AAPA)

PROFESSIONAL SOCIETIES AND NETWORKS

American Society of Clinical Oncology (ASCO) American College of Surgeons (ACoS) American Society for Radiation Oncology

(ASTRO) Oncology Nursing Society (ONS) National Comprehensive Cancer Network

(NCCN)

ASSESSMENT OF FACTORS FOR BEHAVIOR CHANGEBRANDON HAYESLATTIN

Knowledge Training, Continuing Education

Resources Guidelines, Materials

Skills Communication

Access Utilization/Opportunities for Engagement

Accountability Quality Assurance

KNOWLEDGE / GUIDELINES

AVAILABLE GUIDELINES

Screening ACOG ACP AAFP ASCO ACoS NCCN

Practice ACHA AAFP ACOG ACP ASCO ACoS ASTRO NCCN ONS

OPPORTUNITIES FOR ENGAGEMENT

Sexually active women Pregnant women During Breastfeeding Taking a Family history Assessing chronic medical conditions

(high blood pressure, diabetes, hyperlipidemia)

NCCN CLINICAL PRACTICE GUIDELINE: PRE–DIAGNOSIS

Breast Cancer Screening and Diagnosis Normal Risk, Modified Gail Model Increased Risk Positive Physical Findings

Palpable Mass Age >29 Palpable Mass Age <30

Breast Cancer Risk Reduction Familial Risk Assessment Risk Reduction Therapy

DISCUSSION QUESTIONS FOR GROUP

How can we better assess the knowledge base of providers?

How can we assure appropriate resources are developed and used? How can we integrate with quality assessment/improvement efforts?

How can we better assess provider skills in resource utilization and communication?

How can we improve patient access and utilization?

HEALTHCARE PROVIDERSCURRENT STATUS

Genetic Counseling Services

Variation in:• Referral for genetic consultation• Appropriateness of referrals• Communication of risk information

Work done by CDC researchers: • DOCstyles 2007 National Survey (Bellcross et al)• Vignette based survey instrument (Trivers et al)

HEALTHCARE PROVIDERSCURRENT STATUS

Bellcross et al. Am J Prev Med 2011 Determine, among U.S. primary care physicians, the level

of awareness and utilization of BRCA testing and the 2005 us preventive services task force recommendations.

Web based survey “DocStyles 2007” – CDC licensed data Random sample of 3115 physicians. Response rate 48% Asked about actually ordering at least 1 test – did not ask

about referral for genetic counseling / testing, provision of counseling or “implementation of management recommendations”

Potential use of DocStyles for assessment of chemoprevention & screening recommendation use???

HEALTHCARE PROVIDERSCURRENT STATUS

Trivers et al. Cancer 2011, Annals of Internal Medicine 2012

Vignettebased survey instrument

High risk women – 41% of physicians referred for counseling, testing and ovarian screening

Average risk women – 22% of women still referred for genetic counseling

HEALTHCARE PROVIDERSCURRENT STATUS

Chemoprevention

NHIS 2000 data >10million women aged 3579 risk eligible for

tamoxifen

>2million White women risk / benefit analysis positive

Actual use: 2000 – 0.2% 2005 – 0.08%

CURRENT STATEPATIENTS

Uptake rates for breast cancer genetic testing.

Olaya et al. Am Journal of Surgery, 2009. Half of patients referred for genetic testing

do not undergo testing. Unrelated to insurance coverage for testing. Affected by weather previously diagnosed

or not and by educational level. Need for counseling instruments to improve

testing rates.

POTENTIAL OPPORTUNITIES TO IMPACT HEALTHCARE PROVIDERS

I. Training of students, residents & other healthcare providers (NP, PA)

Modules to be used in training – genetics, communication skills, clinical skills

II. Training of Practicing Clinicians Initial practice Certification Process Maintenance of Certification Ongoing CME

III. Role of EMR

ONGOING WORKHEALTHCARE PROVIDERS

CDC Office of Public Health Genomics & National

Cancer Education & Early Detection Program 2003 – Michigan & Oregon pilot programs 2011 – Michigan, Oregon & Georgia programs

Focus: Education (patient & provider), surveillance and policy

Body Talk Decision support tool – aimed at providers &

patients

ONGOING WORKHEALTHCARE PROVIDERS

NIH eDoctoring Program (Dr. Michael Wilkes) Interactive online educational tool Topics – ethics, genetics, clinical

management, epidemiology, communication skills

Potential users – students (medical & nursing), residents, primary care providers

Potential use by credentialing bodies for certification and licensure (ex., California – palliative care and end of life)

ONGOING WORKHEALTHCARE PROVIDERS

Agency for Healthcare Research & Quality Resources (AHRQ)

Effective Healthcare Program – Create educational material for patients & healthcare providers.

The ACTION Network (Accelerating Change and Transformation in Organizations and Networks) Test and disseminate defined strategies.

SUMMARY

Guidelines have been developed to guide healthcare providers on issues related to genetic testing, risk assessment and chemoprevention strategies for young women at risk for breast cancer.

Significant gaps exist and additional research is needed to assess current level of knowledge of primary care providers and to fill in the gaps left by the above referenced studies.

Information thus learned could then be used to develop

focused strategies to target healthcare providers.

SUGGESTIONS TO COMMITTEE

1. Conduct assessment of current level of knowledge and practice of primary care providers around topic of breast cancer in young women

• Work with primary care societies (Medical and Nursing) to develop and disseminate survey instrument.

• Use eDoctoring tool to assess both knowledge and practice and impact of education.

• Assess use of tools available to CDC DocStyles Ongoing genomics initiatives

SUGGESTIONS TO COMMITTEE

2. Foster development of educational tools targeted to education of healthcare providers at various points of training:

• Assess potential use of certification and recertification requirements.

• Assess and expand tools such as eDoctoring to both study the needs of providers and to meet those needs.

SUGGESTIONS TO COMMITTEE

3. Continued study of Body Talk as a tool focused on both patients and healthcare providers:

• Potential use of AHRQ Action Network to study its effectiveness in both target groups.

• Search for effective dissemination strategies – potential use of AHRQ Effective Healthcare Program.

SUGGESTIONS TO COMMITTEE

4. Potential collaboration between CDC and AHRQ on EMR build out and evaluation.

5. Collaborate with other initiatives addressing Healthcare providers and topic of Breast Cancer in Young Women.