Search

PURPOSE: Tumor genomic testing (TGT) has become increasingly adopted as part of standard cancer care for many cancers. Despite national guidelines around patient education before TGT, available evidence suggests that most patients' understanding of genomics remains limited, particularly lower-income and minority patients, and most patients are not informed regarding potential incidental germline findings. METHODS: To investigate and address limitations in patient understanding of TGT results, a Plan-Do-Study-Act (PDSA) approach is being used to assess needs, identify opportunities for improvement, and implement approaches to optimize patient education. We reviewed published guidelines related to pre-TGT provider-patient education and to identify key points (Plan). A provider quality improvement survey was completed (Do), which highlighted inconsistency in pre-TGT discussion practice across providers and minimal discussion with patients regarding the possibility of incidental germline findings. RESULTS: Patient focus groups and interviews (N = 12 patients) were completed with coding of each transcript (Study), which revealed themes including trouble differentiating TGT from other forms of testing, yet understanding that results could tailor therapy. The integration of data across this initial PDSA cycle identified consistent themes and opportunities, which were incorporated into a patient-directed, concise animated video for pre-TGT education (Act), which will form the foundation of a subsequent PDSA cycle. The video addresses how TGT may/may not inform treatment, the process for TGT using existing tissue or liquid biopsy, insurance coverage, and the potential need for germline genetics follow-up because of incidental findings. CONCLUSION: This PDSA cycle reveals key gaps and opportunities for improvement in patient education before TGT.

Purpose Breast cancer is the most common female cancer in Africa and leading cause of death resulting from cancer; however, many countries lack early detection services. In Malawi, women are frequently diagnosed with large tumors after long symptomatic periods. Little is known about local cancer knowledge. Methods We administered a cross-sectional survey with a discrete choice experiment to a random sample in urban and rural areas of Lilongwe district. Bivariable and multivariable analyses determined factors associated with knowledge. Preference utilities for early detection interventions were estimated using a hierarchical Bayesian model in Sawtooth software. Results Of 213 women recruited, fewer than half were aware of breast cancer. In multivariable analysis, electricity at home and knowing someone with cancer increased the odds of awareness. Women were more knowledgeable about symptoms than treatment or risk factors; more than 60% erroneously believed local misconceptions. Seventeen percent were aware of breast self-examination, and 20% were aware of clinical breast examination (CBE); few reported either behavior. Common barriers included not knowing where to access CBE and transportation difficulties. Discrete choice experiment results indicated the detection strategy (breast health awareness, CBE, or both) was the most important attribute of an intervention, followed by the encounter setting and travel time. Conclusion Addressing misconceptions in health messages and engaging survivors to promote early detection may help improve breast cancer knowledge in Malawi. Program designs accounting for women’s preferences should provide breast health education and CBEs in convenient settings to address transportation barriers, particularly for women with low socioeconomic position.

Abstract 2 Background: Breast cancer mortality is high in sub-Saharan Africa (SSA) partly due to limited breast cancer awareness and challenges in early detection. We trained laywomen to promote breast cancer awareness and perform screening - clinical breast exam (CBE) - in urban clinics. This is the first breast cancer screening study in Malawi, and the first study in SSA to assess CBE delivered by laywomen with other health services. Methods: Four laywomen were trained to deliver breast cancer educational talks and conduct CBE. After training, screening was implemented in diverse urban health clinics. Women eligible to undergo CBE were ≥30 years, with no prior breast cancer or breast surgery, and clinic attendance for reasons other than a breast concern. Women with abnormal CBE were referred to a study surgeon. All palpable masses confirmed by surgeon exam were pathologically sampled. Patients with abnormal screening CBE but normal surgeon exam underwent breast ultrasound confirmation. Additionally, 50 randomly selected women with normal screening CBE underwent breast ultrasound, and 45 different women with normal CBE were randomly assigned to surgeon exam. Results: 175 educational talks were delivered to 4,295 people across 5 clinics. Among 1,220 eligible women, 1,000 (82%) agreed to CBE. Lack of time (68%) was the most common reason for refusal. CBE agreement varied across clinics from 71% to 86% (p=0.001). Women who attended the talk were more likely to accept CBE than women who did not (83% vs 77%, p=0.012). Among 1,000 women screened, 7% had abnormal CBE. All 50 women with normal CBE randomized to ultrasound had normal findings. Of 45 women with normal CBE randomized to surgeon exam, 43 had normal surgeon exams and 2 had axillary lymphadenopathy not detected by screening CBE. Sixty of 67 women (90%) with abnormal CBE attended the referral visit. Of these, 29 (48%) had concordant abnormal surgeon exam, and 15 were recommended to have pathologic sampling. Fourteen women had nipple discharge or breast pain identified by both CBE and surgeon exam, which did not require further work-up after surgeon review. Thirty-one women (52%) had discordant normal surgeon exam, all of whom had normal breast ultrasounds. Compared to surgeon exam, sensitivity for CBE by laywomen was 94% (CI 79-99%), specificity 58% (CI 46-70%), positive predictive value 48% (CI 35-62%), and negative predictive value 96% (CI 85-100%). Of 15 women who underwent pathologic sampling, 2 had cytologic dysplasia and are awaiting surgical excision, 7 had fibroadenomas, 2 normal tissue, 1 galactocele, 1 abscess, 1 lymph node with Kaposi sarcoma, and 1 tumoral calcinosis. Conclusions: Uptake of CBE screening in Lilongwe clinics was high. CBE by laywomen compared favorably with surgeon exam, and follow-up was good. Our intervention can serve as a model for wider implementation. Performance in rural areas, effects on breast cancer stage distribution and mortality, and cost-effectiveness require further evaluation. AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST: No COIs from the authors.

9534 Background: Risk perceptions (RP) play an important role in decision making in localized BC. Little is known about RP in the context of adjuvant (adj) therapy decisions. We examined the accuracy of estimate of absolute benefit of adj therapy among patients (pts) with localized BC and sought to identify determinants of accurate RP. Methods: A cross-sectional survey was conducted in localized (Stage I-III) BC pts within 3 months after surgery at 4 U.S. cancer centers. Pts completed the Decision Quality Instrument, which includes items on BC knowledge, numerical estimates of benefit of adj therapy, and communication with providers. We analyzed pts with Stage I/II and calculated objective estimates of benefit of adj therapy using Adjuvant! Online. Based on published data, an estimate that was +/- 5% of the calculated risk was considered correct. We used multivariable (MV) regression to identify determinants of accuracy including tumor stage, age, adj treatment, education, total knowledge score, and decision involvement. Results: 192/249 (77.1%) pts completed the survey; analyses were limited to 166 pts stage I/II with complete risk estimate data. Mean age was 56.4 years (SD 12.1), 83% of respondents were white, and 58.5% were college graduates. 56.3% had stage I and 43.7% had stage II disease. Most (95.6%) had some type of adj therapy, either endocrine therapy only (43.2%), chemotherapy only (15.3%), or both (32%). On average, pts estimated the absolute benefit of adj therapy to be 31.8% (SD24.9), and this varied by stage (28.4 and 35.9 for stage I and II, p=0.06). The overall estimate for this sample from Adjuvant! Online was 11.8% (SD 7.67) and this varied by stage (8.6/16.0 for stage I/II respectively, p