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Design and pilot implementation of the Achieving Cancer Equity through Identification, Testing, and Screening (ACE‐ITS) program in an urban underresourced population

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Cancer
Authors:
Chiranjeev Dash at Georgetown University
Chiranjeev Dash
Mary G. Mills
Mary G. Mills
Mary G. Mills
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Thelma D. Jones
Thelma D. Jones
Thelma D. Jones
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Ify A. Nwabukwu
Ify A. Nwabukwu
Ify A. Nwabukwu
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Abstract and Figures

Introduction The Achieving Cancer Equity through Identification, Testing, and Screening (ACE‐ITS) program is a community‐engaged framework to improve mammography maintenance and rates of genetic risk assessment, counseling, and testing using a multilevel approach that enhances patient navigation through mobile health and community education. Methods The ACE‐ITS program is based on the National Institute of Minority Health and Health Disparities research framework focused on the individual (genetic testing, screening navigation) and community (community‐based breast health education) levels and targeted to the biological‐ (genetic risk), behavioral‐ (mammography screening), sociocultural‐ (underserved Black and Hispanic women), and the health care system (patient navigation, automated text messages)–related domains. We further integrate the Practical Robust Implementation and Sustainability Model to describe our program implementation. Results In collaboration with genetic counselors and community partners, we created educational modules on mammography maintenance and genetic counseling/testing that have been incorporated into the navigator‐led community education sessions. We also implemented a universal genetic risk assessment tool and automated text message reminders for repeat mammograms into our mammography navigation workflow. Through the ACE‐ITS program implementation, we have collaboratively conducted 22 educational sessions and navigated 585 women to mammography screening over the 2020–2021 calendar years. From January to December 2021, we have also conducted genetic risk assessment on 292 women, of whom 7 have received genetic counseling/testing. Conclusions We describe a multilevel, community‐engaged quality improvement program designed to reduce screening‐related disparities in Black and Hispanic women in our catchment area.
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Received: 5 August 2022
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Revised: 5 January 2023
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Accepted: 6 January 2023
DOI: 10.1002/cncr.34691
SUPPLEMENT ARTICLE
Design and pilot implementation of the Achieving Cancer
Equity through Identification, Testing, and Screening
(ACE‐ITS) program in an urban underresourced population
Chiranjeev Dash MBBS, PhD, MPH
1
|Mary G. Mills MSN, FNP.‐BC
1
|
Thelma D. Jones AAS
2
|Ify A. Nwabukwu RN, BSN, CMF
3
|
Jacqueline Y. Beale MPA
4
|Rhonda N. Hamilton MPA
1
|
Alejandra Hurtado‐de‐Mendoza PhD
1
|Suzanne C. O’Neill PhD
1
1
Georgetown Lombardi Comprehensive
Cancer Center, Georgetown University
Medical Center, Washington, District of
Columbia, USA
2
Thelma D. Jones Breast Cancer Fund,
Washington, District of Columbia, USA
3
African Women’s Cancer Awareness
Association, Greenbelt, Maryland, USA
4
Cancer to Jasmine and Butterflies Consulting,
Glenn Dale, Maryland, USA
Correspondence
Chiranjeev Dash, 1000 New Jersey Ave SE,
Washington, DC 20003, USA.
Email: cd422@georgetown.edu
Funding information
Pfizer, Breast Health Equity Initiative;
National Cancer Institute, Grant/Award
Number: P30 CA051008
Abstract
Introduction: The Achieving Cancer Equity through Identification, Testing, and
Screening (ACE‐ITS) program is a community‐engaged framework to improve
mammography maintenance and rates of genetic risk assessment, counseling, and
testing using a multilevel approach that enhances patient navigation through mobile
health and community education.
Methods: The ACE‐ITS program is based on the National Institute of Minority
Health and Health Disparities research framework focused on the individual (ge-
netic testing, screening navigation) and community (community‐based breast health
education) levels and targeted to the biological‐(genetic risk), behavioral‐
(mammography screening), sociocultural‐(underserved Black and Hispanic women),
and the health care system (patient navigation, automated text messages)–related
domains. We further integrate the Practical Robust Implementation and Sustain-
ability Model to describe our program implementation.
Results: In collaboration with genetic counselors and community partners, we
created educational modules on mammography maintenance and genetic coun-
seling/testing that have been incorporated into the navigator‐led community edu-
cation sessions. We also implemented a universal genetic risk assessment tool and
automated text message reminders for repeat mammograms into our mammog-
raphy navigation workflow. Through the ACE‐ITS program implementation, we have
collaboratively conducted 22 educational sessions and navigated 585 women to
mammography screening over the 2020–2021 calendar years. From January to
December 2021, we have also conducted genetic risk assessment on 292 women, of
whom 7 have received genetic counseling/testing.
Support for this supplement has been provided by Pfizer Inc. through a Breast Health Equity initiative with the American Cancer Society.
The findings and conclusions in this Supplement are those of the authors and do not necessarily reflect the official position of the sponsor, the American Cancer Society, John Wiley & Sons, Inc.,
or the opinions of the journal editors.
Cancer. 2023;129(S19):3141–3151. wileyonlinelibrary.com/journal/cncr © 2023 American Cancer Society.
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... The pandemic confirmed the importance of organized screening programs for cancer of the breast, colon-rectum, and cervix [18][19][20][21][22]. Reduced screening was associated with a lower number of diagnoses and operations, as well as with the diagnosis of cancer at more advanced stages. Reduced adherence to screening programs included all levels of the population, and it was more evident for people with lower educational attainment, those with a lower family income, and immigrants from low-income countries [23][24][25]. Timely treatment may have been less accessible to vulnerable patient populations. ...
Education and Information to Improve Adherence to Screening for Breast, Colorectal, and Cervical Cancer—Lessons Learned during the COVID-19 Pandemic
Article
Full-text available
  • Aug 2024
Simple Summary Screening for breast, colorectal, and cervical cancer is correlated with diagnosis at an earlier stage, less extensive surgery, and reduced mortality and fewer complications. Adherence rates to cancer screening are lower for individuals with low socio-economic conditions and educational attainment. These social disparities are only partially reduced by free screening through national initiatives. Education and information and appropriate expenditure for preventive care have the potentials to increase adherence to screening for colorectal, breast, and cervical cancer with the possibility of reduced cancer mortality. The findings of our study highlight the importance of the implementation of nationally organized screening programs for several other types of cancers that are often detected after the occurrence of symptoms. Nationally organized screening programs for several types of cancers, like esophageal, gastric, and pancreatic cancer, in regions with a high prevalence may increase the possibility of diagnosis at earlier stages and improved early and late results. Abstract The objective of this study was to determine the correlation between adherence to cancer screening programs and earlier diagnosis of the 14 most common types of cancers in the adult population, before and during the COVID-19 pandemic. National data concerning number of admissions and operations in Italy for adult patients admitted with oncologic problems during the COVID-19 pandemic (2020 to 2022) and in the pre-pandemic period (2015 to 2019) were analyzed. We selected 14 types of cancer that present the most common indications for surgery in Italy. This study included 1,365,000 adult patients who had surgery for the 14 most common types of cancer in the period 2015–2022, and interviews concerning adherence rates to screening for breast, colorectal, and cervical cancer were conducted for 133,455 individuals. A higher decrease in the number of operations for the 14 types of cancer (−45%) was registered during the first three acute phases of the pandemic, and it was more evident for screenable cancers like breast, colorectal, and cervical cancer (p < 0.001). During the first year of the COVID-19 pandemic, the number of screened individuals for breast, colorectal, and cervical cancer decreased by 33.8% (from 7,507,893 to 4,969,000) and the number of diagnoses and operations for these three types of cancer decreased by 10.5% (from 107,656 to 96,405). The increase and return to normality of the number of screened individuals in the last year of the pandemic (2022) and in the first post-pandemic year (2023) was associated with a return to the pre-pandemic levels of diagnoses and operations. The adherence rates were lower for individuals living in rural areas, with low socio-economic status, and unmarried persons; however, the most statistically significant factor for reduced adherence was a lower level of educational attainment. Free screening through nationally organized programs reduced social disparities. There were no significant differences between the pre-pandemic and pandemic periods for several types of cancers (stomach, esophagus, pancreas, liver) that are diagnosed for the occurrence of symptoms and for which nationally organized programs might increase the possibility of earlier diagnosis and improved clinical outcomes. Education, information, and appropriate expenditure for preventive care have the potential to reduce cancer mortality. Nationally organized screening programs for several types of cancers, which are often detected for the occurrence of symptoms, may increase the possibility of diagnosis at earlier stages.
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... We will be drawing on the Achieving Cancer Equity through Identification, Testing, and Screening (ACE-ITS) program developed at the Georgetown Lombardi Comprehensive Cancer Center in Washington, DC, which was designed to serve an urban underresourced population. 23 The ACE-ITS program centers on three interrelated activities. First, women from the target community who are overdue for screening are identified through record reviews and community outreach. ...
Reducing Breast Cancer Disparities with Precision Public Health
Article
Full-text available
  • Aug 2024
While Black and White women are diagnosed with breast cancer (BC) at similar rates, Black women die from BC at a 40% higher rate. This disparity is even more pronounced for younger Black women, who die from BC at nearly twice the rate as younger White women. Black-White differences in BC mortality are largely attributable to health care and tumor biology factors. Black women face greater barriers to accessing BC screening and are twice as likely to be diagnosed with the aggressive triple-negative breast cancer (TNBC) subtype. Delaware leads the US for the incidence of late-stage BC diagnosed among younger women and TNBC. This commentary begins with a discussion of precision public health, an emerging framework that builds on and complements recent advances in precision medicine. Next, a new precision public health initiative designed to reduce BC disparities in Delaware by targeting local hotspots with prevention interventions is presented. Finally, next steps are considered for implementation, evaluation, and new research activities.
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Pilot study of a culturally sensitive intervention to promote genetic counseling for breast cancer risk
Article
Full-text available
  • Jun 2022
  • BMC HEALTH SERV RES
Background Despite the benefits of genetic counseling and testing, uptake of cancer genetic services is generally low and Black/African American (Black) women are substantially less likely to receive genetic services than non-Hispanic White women. Our team developed a culturally sensitive, narrative decision aid video to promote uptake of genetic counseling among Black women at risk for a hereditary breast cancer syndrome that can be incorporated in conjunction with population-based cancer risk assessment in a clinical setting. We report here a pilot study to demonstrate changes in intention to access genetic counseling and intervention satisfaction. Methods Black women who were personally unaffected by breast cancer and were recommended for genetic counseling based on family history screening in a mammography center were recruited at the time of the mammogram. A prospective, pre-post survey study design, guided by theoretical constructs, was used to evaluate baseline and immediate post-intervention psychosocial factors, including intention to participate in genetic counseling and intervention satisfaction. Results Pilot recruitment goals were met (n = 30). Pre-intervention, 50% of participants indicated that they were extremely likely to make a genetic counseling appointment, compared with 70% post-intervention (p = 0.05). After watching the intervention, 50% of participants indicated that the video changed their mind regarding genetic counseling. Conclusions This study demonstrated cultural satisfaction with a decision aid intervention designed to motivate Black women with hereditary breast cancer risk to attend a genetic counseling appointment. Our study showed that intention may be a specific and key construct to target in interventions designed to support decision-making about genetic services. Study results informed the design of a subsequent large scale, randomized implementation study. Trial registration Trial registration: Clinicaltrials.govNCT04082117. Registered September 9, 2019. Retrospectively registered.
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Cancer statistics, 2022
Article
Full-text available
Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths in the United States and compiles the most recent data on population‐based cancer occurrence and outcomes. Incidence data (through 2018) were collected by the Surveillance, Epidemiology, and End Results program; the National Program of Cancer Registries; and the North American Association of Central Cancer Registries. Mortality data (through 2019) were collected by the National Center for Health Statistics. In 2022, 1,918,030 new cancer cases and 609,360 cancer deaths are projected to occur in the United States, including approximately 350 deaths per day from lung cancer, the leading cause of cancer death. Incidence during 2014 through 2018 continued a slow increase for female breast cancer (by 0.5% annually) and remained stable for prostate cancer, despite a 4% to 6% annual increase for advanced disease since 2011. Consequently, the proportion of prostate cancer diagnosed at a distant stage increased from 3.9% to 8.2% over the past decade. In contrast, lung cancer incidence continued to decline steeply for advanced disease while rates for localized‐stage increased suddenly by 4.5% annually, contributing to gains both in the proportion of localized‐stage diagnoses (from 17% in 2004 to 28% in 2018) and 3‐year relative survival (from 21% to 31%). Mortality patterns reflect incidence trends, with declines accelerating for lung cancer, slowing for breast cancer, and stabilizing for prostate cancer. In summary, progress has stagnated for breast and prostate cancers but strengthened for lung cancer, coinciding with changes in medical practice related to cancer screening and/or treatment. More targeted cancer control interventions and investment in improved early detection and treatment would facilitate reductions in cancer mortality.
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Association of Population Screening for Breast Cancer Risk With Use of Mammography Among Women in Medically Underserved Racial and Ethnic Minority Groups
Article
Full-text available
  • Sep 2021
Importance Black women bear a disproportionate burden of breast cancer mortality in the US, in part due to inequities in the use of mammography. Population screening for breast cancer risk in primary care is a promising strategy for mitigating breast cancer disparities, but it is unknown whether this strategy would be associated with increased mammography rates in underserved women of racial and ethnic minority groups. Objective To examine whether providing individualized breast cancer risk estimates is associated with an increase in the rate of screening mammography. Design, Setting, and Participants A cohort study was conducted in women receiving individualized risk estimates as part of routine primary health care at federally qualified health centers in medically underserved communities in Chicago, Illinois. The study was conducted from November 5, 2013, to December 19, 2014, with data acquisition completed on March 5, 2017; data analysis was performed from December 30, 2020, to February 2, 2021. A total of 347 women aged 25 to 69 years without a personal history of breast cancer presenting for an annual visit with their primary care clinician were enrolled. Exposures Breast cancer risk estimates were obtained with validated risk assessment tools as a standard component of the clinic check-in process. One of 4 women at average risk and all women at high risk were invited to participate in the study. Main Outcomes and Measures The primary outcome was the mammography rate during 18 months of usual care compared with the rate during 18 months after implementation of risk assessment. Results Of the 347 women enrolled, 188 were age-eligible for mammography and were included in the analysis (mean [SD] age, 50.8 [7.04] years); 70 women (37.2%) were Hispanic, 114 (60.6%) were non-Hispanic African American, and 4 (2.1%) were from other racial and ethnic groups (4 non-Hispanic White women). Ninety-eight women (52.1%) had an average risk of developing breast cancer and 90 (47.9%) were at high risk. Overall, there was a nonsignificant increase in the mammography rate, from 38.8% during usual care to 48.9% following implementation of risk assessment (odds ratio, 1.37; 95% CI, 0.92-2.03). In preplanned subgroup analysis, the mammography rate among women at high risk was significantly higher after vs before risk assessment (51.1% vs 36.6%; odds ratio, 1.88; 95% CI, 1.10-3.23). Conclusions and Relevance In this study, providing individualized breast cancer risk estimates as a component of primary health care in federally qualified health centers was associated with increased use of mammography among women of racial and ethnic minority groups who were at high risk. Implementation of this approach in underserved communities could promote equity in the use of mammography and reduce racial disparities in breast cancer mortality. This strategy warrants further investigation.
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Development of a culturally sensitive narrative intervention to promote genetic counseling among African American women at risk for hereditary breast cancer
Article
Full-text available
BACKGROUND African American women with hereditary breast cancer risk are less likely to undergo genetic counseling and testing compared with non‐Hispanic White women. Inequities in the use of precision cancer care are likely to exacerbate racial disparities in cancer outcomes. A culturally sensitive multimedia narrative intervention was developed to motivate African American women at risk for hereditary breast cancer to engage in genetic counseling. METHODS Development of the intervention was grounded in the Integrative Model of Behavioral Prediction using a phenomenological, deductive approach and employed multiple qualitative methods for data collection, including 1‐on‐1 interviews and story circles with members of the target audience to identify salient themes and lived experiences. Focus group testing was then conducted with members of the group of focus, primary care providers, and community stakeholders. RESULTS Six themes that mapped to the theoretical model were identified. Lived experiences were abstracted from story circle data to create a narrative storyline. Educational content and motivational messaging derived from the 6 themes were embedded into the script. Focus group testing with stakeholder groups was used to refine the intervention. Testing of the final multimedia narrative with focus groups indicated that the intervention was culturally sensitive and authentic, and the messaging was effective. CONCLUSIONS Multiple qualitative data collection methods and a robust theoretical framework of health behavior were key elements for this study to develop a culturally sensitive, narrative intervention that reflects lived experiences and motivates underserved African American women with hereditary breast cancer risk to engage in genetic counseling. This strategy can be applied to mitigate racial inequities in the use of other genomic approaches for personalizing cancer care.
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Culturally Targeted Video Improves Psychosocial Outcomes in Latina Women at Risk of Hereditary Breast and Ovarian Cancer
Article
Full-text available
Latina women at risk of hereditary breast and ovarian cancer (HBOC) have lower awareness, knowledge, and use of genetic counseling and testing services (GCT) than non-Latina Whites. Few interventions have been developed to reduce these disparities among at-risk Latinas. This pilot study assessed the impact of a culturally targeted narrative video developed by our team. The study included 40 Latina immigrants living in the United States who were at risk of HBOC, including affected and unaffected women. We assessed pre-post differences in psychosocial outcomes. Participants were 47.35 years old on average (SD = 9.48). Most (70%) were unaffected with cancer, had an annual income of $40,000 or less (65%), an education of High School or less (62.5%), and were uninsured (77.5%). The video significantly enhanced knowledge (p < 0.001), positive attitudes (p < 0.05), anticipatory positive emotions (p < 0.05), and intentions to participate in counseling (p < 0.001). Importantly, the video also significantly reduced negative attitudes (p < 0.05), and attitudinal ambivalence (p < 0.001). The culturally targeted video shows preliminary evidence in improving psychosocial outcomes related to GCT uptake in Latinas at risk for HBOC. This intervention is a promising easily-disseminable strategy to address disparities in GCT utilization.
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Breast cancer statistics, 2019
Article
Full-text available
This article is the American Cancer Society’s biennial update on female breast cancer statistics in the United States, including data on incidence, mortality, survival, and screening. Over the most recent 5‐year period (2012‐2016), the breast cancer incidence rate increased slightly by 0.3% per year, largely because of rising rates of local stage and hormone receptor‐positive disease. In contrast, the breast cancer death rate continues to decline, dropping 40% from 1989 to 2017 and translating to 375,900 breast cancer deaths averted. Notably, the pace of the decline has slowed from an annual decrease of 1.9% during 1998 through 2011 to 1.3% during 2011 through 2017, largely driven by the trend in white women. Consequently, the black–white disparity in breast cancer mortality has remained stable since 2011 after widening over the past 3 decades. Nevertheless, the death rate remains 40% higher in blacks (28.4 vs 20.3 deaths per 100,000) despite a lower incidence rate (126.7 vs 130.8); this disparity is magnified among black women aged <50 years, who have a death rate double that of whites. In the most recent 5‐year period (2013‐2017), the death rate declined in Hispanics (2.1% per year), blacks (1.5%), whites (1.0%), and Asians/Pacific Islanders (0.8%) but was stable in American Indians/Alaska Natives. However, by state, breast cancer mortality rates are no longer declining in Nebraska overall; in Colorado and Wisconsin in black women; and in Nebraska, Texas, and Virginia in white women. Breast cancer was the leading cause of cancer death in women (surpassing lung cancer) in four Southern and two Midwestern states among blacks and in Utah among whites during 2016‐2017. Declines in breast cancer mortality could be accelerated by expanding access to high‐quality prevention, early detection, and treatment services to all women.
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A culturally targeted video to promote genetic counseling in a community sample of at-risk US Latina women: The role of the concrete mindset
Article
Latina women, who are at increased risk of hereditary breast and ovarian cancer (HBOC), have lower use of genetic counseling and testing (GCT) than non-Hispanic White women. In a recent study, culturally targeted video improved psychosocial outcomes related to GCT. Additional analyses examine whether the culturally targeted video improved positive reactions in women who focus on difficulties (concrete mindset) versus women who focus on the final goals (abstract mindset). Participants (N = 32) completed surveys before and immediately after watching the video. The surveys measured attitudes, emotions, and women's mindset. Before watching the video, women with a concrete mindset reported more negative attitudes and negative emotions about GCT than women with an abstract mindset. After watching the video, women with a concrete mindset reported negative attitudes and feelings at levels comparable to those of women with an abstract mindset, reflecting a reduction in their negative attitudes and emotions. The sample size limits the power to find statistically significant differences. Results support the relevance of considering the audience's mindset in the development and testing of public health messages to promote the use of GCT.
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COVID-19 impact on screening test volume through the National Breast and Cervical Cancer early detection program, January-June 2020, in the United States
Article
  • Oct 2021
  • PREV MED
Women from racial and ethnic minority groups face a disproportionate burden of cervical and breast cancers in the United States. The Coronavirus Disease 2019 (COVID-19) pandemic might exacerbate these disparities as supply and demand for screening services are reduced. The National Breast and Cervical Cancer Early Detection Program (NBCCEDP) provides cancer screening services to women with low income and inadequate health insurance. We examined COVID-19's impact on NBCCEDP screening services during January-June 2020. We found the total number of NBCCEDP-funded breast and cervical cancer screening tests declined by 87% and 84%, respectively, during April 2020 compared with the previous 5-year averages for that month. The extent of declines varied by geography, race/ethnicity, and rurality. In April 2020, screening test volume declined most severely in Health and Human Services Region 2 - New York (96% for breast, 95% for cervical cancer screening) compared to the previous 5-year averages. The greatest declines were among American Indian/Alaskan Native women for breast cancer screening (98%) and Asian Pacific Islander women for cervical cancer screening (92%). Test volume began to recover in May and, by June 2020, NBCCEDP breast and cervical cancer screening test volume was 39% and 40% below the 5-year average for that month, respectively. However, breast cancer screening remained over 50% below the 5-year average among women in rural areas. NBCCEDP programs reported assisting health care providers resume screening.
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Implementation of an integrated framework for a breast cancer screening and navigation program for women from underresourced communities
Article
  • May 2020
Background: Trends in breast cancer mortality in the United States are decreasing, but racial disparities persist. Using an implementation science framework to inform evidence-based breast cancer screening and navigation within federally qualified health centers (FQHCs) with community stakeholders can mitigate barriers to screening. Methods: Using an integrated theoretical framework of the Practical, Robust Implementation and Sustainability Model and the Social Ecological Model, the University of Illinois Cancer Center and Mile Square Health Centers (MSHC) FQHC developed a breast cancer screening and navigation program, known as the Mile Square Accessible Mammogram Outreach and Engagement (Mi-MAMO) program, to tackle breast cancer disparities in Chicago among underresourced communities. To increase access to screening, patient navigators conducted community outreach activities. Partnerships were forged with community-based organizations, health care systems, and insurers. Outcomes were monitored with standardized performance measures. Results: Between January and December 2017, 103 women received a screening mammogram at MSHC. To increase screening rates, Mi-MAMO was started in August 2017. Between January and December 2018, the number of women who received a screening mammogram increased to 567. From August 2017 to December 2018, 779 women received navigation to screening and/or diagnostic services through the Mi-MAMO program. The majority of women were uninsured (63.9%), and 95.5% were racial/ethnic minorities. Twenty-four percent (n = 185) completed diagnostic services, and 10 women received positive breast cancer diagnoses (mean age, 49.7 years); all successfully navigated to treatment. The Mi-MAMO program is ongoing. Conclusions: Deploying an integrated framework for patient navigation programs can increase breast cancer screening utilization and awareness among underresourced populations at higher risk for breast cancer.
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Risk Assessment, Genetic Counseling, and Genetic Testing for BRCA -Related Cancer: US Preventive Services Task Force Recommendation Statement
Article
  • Aug 2019
Importance Potentially harmful mutations of the breast cancer susceptibility 1 and 2 genes (BRCA1/2) are associated with increased risk for breast, ovarian, fallopian tube, and peritoneal cancer. For women in the United States, breast cancer is the most common cancer after nonmelanoma skin cancer and the second leading cause of cancer death. In the general population, BRCA1/2 mutations occur in an estimated 1 in 300 to 500 women and account for 5% to 10% of breast cancer cases and 15% of ovarian cancer cases. Objective To update the 2013 US Preventive Services Task Force (USPSTF) recommendation on risk assessment, genetic counseling, and genetic testing for BRCA-related cancer. Evidence Review The USPSTF reviewed the evidence on risk assessment, genetic counseling, and genetic testing for potentially harmful BRCA1/2 mutations in asymptomatic women who have never been diagnosed with BRCA-related cancer, as well as those with a previous diagnosis of breast, ovarian, tubal, or peritoneal cancer who have completed treatment and are considered cancer free. In addition, the USPSTF reviewed interventions to reduce the risk for breast, ovarian, tubal, or peritoneal cancer in women with potentially harmful BRCA1/2 mutations, including intensive cancer screening, medications, and risk-reducing surgery. Findings For women whose family or personal history is associated with an increased risk for harmful mutations in the BRCA1/2 genes, or who have an ancestry associated with BRCA1/2 gene mutations, there is adequate evidence that the benefits of risk assessment, genetic counseling, genetic testing, and interventions are moderate. For women whose personal or family history or ancestry is not associated with an increased risk for harmful mutations in the BRCA1/2 genes, there is adequate evidence that the benefits of risk assessment, genetic counseling, genetic testing, and interventions are small to none. Regardless of family or personal history, the USPSTF found adequate evidence that the overall harms of risk assessment, genetic counseling, genetic testing, and interventions are small to moderate. Conclusions and Recommendation The USPSTF recommends that primary care clinicians assess women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or who have an ancestry associated with BRCA1/2 gene mutations with an appropriate brief familial risk assessment tool. Women with a positive result on the risk assessment tool should receive genetic counseling and, if indicated after counseling, genetic testing. (B recommendation) The USPSTF recommends against routine risk assessment, genetic counseling, or genetic testing for women whose personal or family history or ancestry is not associated with potentially harmful BRCA1/2 gene mutations. (D recommendation)
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