Public reporting of outcomes

At the Cancer Centers of Sharp HealthCare, we are committed to sharing the outcomes of our efforts to continuously evaluate and improve the quality of care we provide. Through feedback from our patients, our physicians and comparison to national cancer benchmarks and publications, we continuously identify and act upon opportunities for improvement.

Quality Study 2019

Impact of Cancer Genetics on Breast Cancer Patient Care Decisions

Problem: In review of registry data, it was identified that a population of breast cancer patients treated at Sharp HealthCare incurred multiple primary diagnoses, and failed to receive genetic counseling at the time of their first cancer diagnosis. Genetic counselors attending Sharp tumor boards also identified that not all high-risk breast cancer patients were routinely referred to the cancer genetics program for risk assessment for treatment decisions.

Rationale: The use of cancer genetics in care decisions for breast cancer patients at high risk for a breast cancer-associated genetic mutation has become increasingly important over the last several years. Not all care providers or administrative team members are familiar with national recommended guidelines and the impact of genetic risk assessment on care decisions; therefore, a gap in consistent patient care management exists. This study will demonstrate a gap in referrals for genetics counseling and testing in patients who are at high risk for breast cancer-associated genetic mutations. 

Team members: Dr. Christina Casteel; Jonathan Molina, CTR; Summer Ayers, CTR; Gina Passmore; Kristin Kalla, LCGC; Nancy Harris; Christy Wenger

Benchmark: 2019 NCCN Guidelines for Genetic Risk Assessment and Breast Cancer Treatment.

Method: Breast cancer patients diagnosed between 2011 and 2017 with the following inclusion criteria:

• Patients with a breast cancer diagnosis at age 50 or younger

• Patients with a triple negative breast cancer diagnosis at age 60 or younger

• Patients diagnosed and treated at Sharp for their first course of treatment (analytic cases 00 to 22)

• Does not include LCIS, lymphoma and phyllodes

Exclusions:

• Cases where HER2 status was unknown for patients 50-60 years

• Class of case 00 (diagnosed but no treatment at a Sharp facility)

Data sources: Sharp Cancer Registry, Sharp Cancer Genetics Program reports, private practice reports

Analysis: 

• Number of patients eligible for genetic testing was 1253/5,084 (25%) over the study period

• Number of patients referred for genetic counseling/testing to the Sharp Cancer Genetics Program steadily increased from 2011 (14%) to 2017 (63%)

• 2017 showed a dramatic increase in the number of high-risk patients referred for genetic counseling

Contributing factors:

• Increase in tumor board support by genetic counselors cultivating input on cases presented, relationship building with providers and potential "curbside consults" for provider questions

• Accelerated frequency and complexity of NCCN Guidelines updates for breast/ovarian cancer risk assessment, challenging providers to keep current with changes

• Increased awareness of shifts in genetic testing from single/duo mutations to panel testing for breast cancer risk. A 2017 INCP quality study revealed that 50% of pathogenic mutations identified in high-risk breast patients were not BRCA1 or 2.

• Institution of Sharp Rees-Stealy Breast Clinic, October 2016, improved genetic referral process

• Although there was a steady improvement in genetic referrals, 37% of high-risk breast cancer patients were not referred, presenting further opportunity for care improvement

Proposed recommendations:

1. Develop education for oncologists and surgeons regarding the current national guidelines for genetic testing in breast cancer patients.

2. Consider further study of cancer registry data to determine how many breast cancer patients at Sharp HealthCare at high risk for a breast cancer-associated genetic mutation went on to develop second cancers, and the associated cost of those cancers.

3. Share study results with medical group and health plan audiences to increase awareness of pathogenic genetic mutations on care management decisions, cost of care and patient quality of life.