Abstract B84: Practical risk assessment: Identifying women at risk for hereditary cancer in a low-income cancer clinic
Authors: Biltibo Eden , Lammers Philip E. , Thomas Kimberley , Rao Smita , Ashworth Renee , Wiesner Georgia L. 
Published: March 2017

Abstract
Introduction: The identification of breast and ovarian patients for genetic counseling and genetic testing is of paramount importance in order to offer tailored treatments to patients and their family members at high risk. Current guidelines for genetic counseling referrals require physicians to devote an inordinate amount of time to investigate patient family histories and risk factors. We devised a hereditary risk assessment strategy utilizing a previously described 10-item Family Cancer Risk Assessment (RISK) tool1 to accurately and quickly identify appropriate patients for genetic counseling referrals in an unobtrusive manner in a busy low-income oncology clinic.
Methods: All women with a history of breast or ovarian cancer at the Robert Hardy Cancer Clinic at Nashville General Hospital at Meharry Medical College were approached for inclusion in this study. Exclusions included severe illness and previous genetic testing. Survey questions included family history of breast or ovarian cancer, ethnic background, and age at diagnosis, among others. Points were conferred as described previously1 and a score greater than or equal to six entailed an automatic referral to the Vanderbilt Hereditary Cancer Program (VHCP). Referred patients had an initial telephone appointment to construct a pedigree then followed by a face to face genetic counseling appointment and genetic testing if advised by the counselor. Sociodemographic data, cancer stage and cancer treatment data were collected using a RedCap database2 sponsored by Vanderbilt. The study was approved by the IRB of each institution.
Results: 79 women were approached over a ten-month period. 73 (92%) of the women agreed to take the RISK survey. One patient had ovarian cancer and the others had a personal history of breast cancer. The average age of the women in the study was 56 (range 34-75). 48% of patients were African-American, 37% Caucasian, and 8% Hispanic. 83% of patients had Tennessee Medicaid as their sole insurance coverage. 79% of the 38 patients who completed questions regarding finances indicated their annual household income was less than $15,000. 14% of patients were diagnosed with triple negative breast cancer (TNBC) before the age of 60 and 35% were diagnosed with non-TNBC before age 50. 41 (56%) women scored six or greater on the RISK tool, and all of these women were referred to the VHCP. To date, 18 women have completed the genetics telephone interview with pedigree construction and 23 are awaiting telephone appointments. Of these 18 women, 17 (94%) met current NCCN guidelines3 for hereditary cancer screening based on pedigree analysis, age of diagnosis, and histology of the malignancy. 10 of the 18 patients were offered genetic testing, one patient declined the test after counseling. The other 8 women either failed (n=4) or are awaiting an appointment (n=4). No deleterious mutations were found in those tested and 4 variants of unknown significance (VUS) were found in 3 individual patients.
Conclusions: A hereditary risk assessment strategy utilizing a 10-item RISK tool is an effective means for physicians practicing in a low-income, predominantly African-American clinic to easily identify appropriate patients with history of breast cancer for genetic counseling referral. Further, the extremely high participation rate of this patient population may indicate a high level of interest in genetic screening. Importantly, a number of patients did not follow through and attend the genetic counseling appointments; we are studying the reasons behind this lack of follow-through. Overall, this strategy could be easily implemented in other busy low-income clinics to screen patients for risk of hereditary cancer.
1 Joseph G. et al. 2012 Public Health Genomics. 2 Harris et al. 2009. J Biomed Inform. 3 National Comprehensive Cancer Network: Genetic/High-risk Breast_Ovarian (Version 2.2016).
This study was funded by GreaterGood.org and by the Robert Wood Johnson Foundation.
Citation Format: Eden Biltibo, Philip E. Lammers, Kimberley Thomas, Smita Rao, Renee Ashworth, Georgia L. Wiesner. Practical risk assessment: Identifying women at risk for hereditary cancer in a low-income cancer clinic. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr B84.