Objectives: Genetics and genomics are playing an important role in cancer risk assessment. The Novant Health Cancer Risk Clinic was designed to assist patients and healthcare providers in addressing the complex issues of cancer risk related to genetic mutations and/or familial history of cancer.
Many factors are considered when determining an individual’s risk for cancer: family history, possibility of or known genetic mutation, exposure to known carcinogens, and lifestyle choices. Ten percent of all cancers are thought to have a genetic component. Few healthcare providers are equipped to manage the needs of cancer risk in patients with genetic mutations and/or familial history of cancer. The Cancer Risk Clinic is a specialized, multidisciplinary practice focusing on risk assessment, cancer prevention, early detection, and education. Its mission is to provide individuals who are at high risk of developing cancer with the tools needed to make informed health decisions. Four other cancer centers in the region offer high-risk clinics but primarily serve breast and colon patients utilizing physicians and genetic counselors. The Novant Health Cancer Risk Clinic is unique in offering ongoing, holistic multidisciplinary care to patients with a cancer risk related to any genetic mutation and/or familial history of cancer. To date, the genetic mutations seen in the Cancer Risk Clinic include APC, ATM, BARD1, BRCA1/2, BRIP1, CDH1, CHEK2, MSH6/MSH2 (Lynch syndrome), NBN, P10, PALPB2, MEN1, RAD50, SDHB, and TP53 (Li-Fraumeni syndrome).
Methods: At the first in-depth appointment, patients meet with a genetic counselor, oncologist, nurse practitioner, oncology nurse navigator, and wellness specialist for a clinical exam, review of imaging, review of personal and family history, review of risks associated with lifestyle, and follow-up recommendations for both screening and risk reduction by utilizing evidence-based National Comprehensive Cancer Network guidelines. High-risk breast cancer screening recommendations include annual breast magnetic resonance imaging (MRI) and mammogram. As a measure of compliance, we examined the number of patients who completed breast MRI during 2015 as part of their screening recommendation. Additionally, to measure patient satisfaction, patients are asked to complete a 12-item survey to assess the quality and value of their clinic visit.
Results: Of 131 patients reviewed, 74.4% completed MRI, with cost to patient reported as the major barrier to compliance. Since the beginning of the clinic in May 2013 through December 2015, 224 new patients visited the Cancer Risk Clinic, with 35 surveys returned. Ninety-five percent of patients returning surveys rated the Cancer Risk Clinic as excellent overall, and all would recommend the clinic. Sixty-seven percent of patients chose to continue follow-up screening and surveillance at the Cancer Risk Clinic.
Conclusions: Compliance in screening with breast MRI in high-risk patients is a challenge, with the primary barrier related to patient-incurred cost. Our institution is currently exploring ways to offer MRI at a lower cost to high-risk patients. Based on patient surveys, the Cancer Risk Clinic has been successful in helping patients navigate complex issues in cancer screening and surveillance.
Sources
American Nurses Association. Essentials of Genetic and Genomic Nursing: Competencies, Curricula Guidelines, and Outcome Indicators, 2nd Edition. Silver Spring, MD: American Nurses Association; 2009.
Oncology Nursing Society. Oncology Nursing: The Application of Cancer Genetics and Genomics Throughout the Oncology Care Continuum. www.ons.org/advocacy-policy/positions/education/genetics. 2015. Accessed September 17, 2015.
Ulrich B: Intensified surveillance for early detection of breast cancer in high-risk patients. Breast Care (Basel). 2015;10:13-20.
