Chair, Cancer Program, The Outer Banks Hospital, Nags Head, North Carolina.
Director, Risk-Reduction Clinic, The Center for Healthy Living, The Outer Banks Hospital, Nags Head, North Carolina.
N C Med J. 2022 May-Jun;83(3):221-228. doi: 10.18043/ncm.83.3.221.
The average lifetime risk of breast cancer for an American woman is 12.5%, but individual risks vary significantly. Risk modeling is a standard of care for breast cancer screening and prevention with recommended tools to stratify individual risks based on age, family history, breast density, and a host of other known risk factors. Because of a lack of resources rurally, we have not consistently met this standard of care within all of North Carolina. We implemented a quality improvement project to assess the risk for breast cancer by gathering data on community risks. We implemented an evidence-based tool (Tyrer-Cuzick) for quantifying risk within a mostly rural population of Eastern North Carolina and developed customized services for women meeting elevated-risk definition. These services included additional imaging for elevated-risk women and a risk-reduction program. We also assessed genetic risks for hereditary breast and ovarian cancer in our at-risk population using National Comprehensive Cancer Network (NCCN) guidelines based on family history and added local genetics extenders to help test more women. We analyzed data regularly using Plan-Do-Study-Act methods to improve outcomes over 1 year. We screened a population of 4500 women at a community hospital over a 1-year period for their individual lifetime cancer risk and genetic risk. Breast cancer risk was quantitated at the time of mammography, and women were stratified into 3 groups for risk management. Within our screening population, 6.3% of women were at high risk (defined by a lifetime breast cancer risk greater than or equal to 20%) and another 8.1% were above-average risk (defined by a lifetime breast cancer risk of 15%-20%). These women (14.4%) could potentially benefit from additional risk-management strategies. Additionally, 20% of all unaffected women within a typical screening population of Eastern North Carolina met NCCN guidelines for hereditary breast cancer and ovarian cancer testing independent of their cancer risk score. Using a model of targeted intervention within a population with elevated risks can be helpful in improving outcomes. This population within Eastern North Carolina is mostly rural and represents a potentially biased population, as it involves older women undergoing annual mammography. It may not be broadly applicable to the entire population based on age, geography, and other risks. This model for improving cancer risk assessment and testing at a small community hospital in Eastern North Carolina was successful and addressed a community need. We discovered a high rate of increased-risk women who can benefit from individualized risk management, and a higher percentage of women who potentially benefit from genetic testing. These higher cumulative risks may in part explain some of the disparities seen for breast-cancer-specific outcomes in some parts of the state.
美国女性一生中患乳腺癌的平均风险为 12.5%，但个体风险差异很大。风险建模是乳腺癌筛查和预防的标准护理方法，建议使用推荐工具根据年龄、家族史、乳房密度和许多其他已知风险因素对个体风险进行分层。由于农村地区资源匮乏，我们在北卡罗来纳州的所有地区都没有始终达到这一护理标准。我们实施了一项质量改进项目，通过收集社区风险数据来评估乳腺癌风险。我们在北卡罗来纳州东部的一个主要农村人口中实施了一种基于证据的工具（Tyrer-Cuzick）来量化风险，并为符合高风险定义的女性制定了定制化服务。这些服务包括对高风险女性进行额外的影像学检查和开展降低风险计划。我们还根据家族史，使用国家综合癌症网络 (NCCN) 指南，对我们的高危人群进行遗传性乳腺癌和卵巢癌的遗传风险评估，并增加了当地的遗传扩展，以帮助更多的女性进行检测。我们使用“计划-执行-研究-行动”方法定期分析数据，以在 1 年内改善结果。我们在一家社区医院对 4500 名女性进行了为期 1 年的个人终生癌症风险和遗传风险筛查。在进行乳房 X 光检查时，我们对乳腺癌风险进行量化，并将女性分为 3 组进行风险管理。在我们的筛查人群中，6.3%的女性处于高风险（定义为终生乳腺癌风险大于或等于 20%），另有 8.1%的女性处于高风险（定义为终生乳腺癌风险为 15%-20%）。这些女性（14.4%）可能受益于额外的风险管理策略。此外，在北卡罗来纳州东部典型的筛查人群中，20%的所有未受影响的女性都符合 NCCN 遗传性乳腺癌和卵巢癌检测指南，无论其癌症风险评分如何。在风险较高的人群中使用有针对性的干预模式可以帮助改善结果。北卡罗来纳州东部的这一人群主要是农村地区，代表了一个潜在的有偏见的人群，因为它涉及到每年接受乳房 X 光检查的老年女性。根据年龄、地理位置和其他风险因素，它可能不适用于整个人群。这种在北卡罗来纳州东部的小型社区医院改善癌症风险评估和检测的模式是成功的，并满足了社区的需求。我们发现了许多处于高风险的女性，她们可以从个性化的风险管理中受益，还有更多的女性可能受益于基因检测。这些更高的累积风险可能部分解释了该州某些地区乳腺癌特定结局方面存在的一些差异。
