Alexandra M. Hernandez, MSN, APRN, FNP-C
In accordance with the American Most cancers Society, “In the USA, 1 in 2 males and 1 in 3 girls shall be recognized with most cancers of their lifetime.”1 Most people can have a member of the family affected by most cancers, if they don’t obtain a prognosis themselves. Thus, there’s an elevated want inside communities for people to have entry to well being care groups that may permit them to change into proactive of their care. On the College of Miami-Sylvester Complete Most cancers Middle in Florida, we consider that by serving to sufferers perceive their danger for most cancers—together with their attainable inherited genetic danger— and specializing in their screening and prevention, we will help people change into engaged of their well being and wellness. To that finish, in 2023, our establishment launched a brand new program that focuses on high-risk prevention and wellness for people who could also be in danger for growing most cancers of their lifetime. This system’s initiative goals to determine these at elevated danger for most cancers by way of evaluation and testing after which formulate a personalised evidence-based most cancers surveillance or screening plan.
A affected person’s genetic danger is evaluated by way of germline testing.2 The frequency of germline testing continues to extend all through the oncology care continuum due to the event and enlargement of testing tips. Due to the significance genetics have in most cancers care, there’s a nice want for knowledgeable genetic professionals to offer counseling and proposals to sufferers and households. Earlier than any germline testing, sufferers are evaluated by a genetic skilled. Their private medical historical past and complete household historical past with a 3-generation pedigree are obtained, adopted by pretest counseling for complete schooling and planning. Historically, genetic danger assessments have been carried out by licensed genetic counselors, however because the demand for genetic danger evaluation will increase, the restricted provide of genetic counselors affords the chance for different skilled assist to be thought-about. The variety of genetic counselors just isn’t anticipated to stabilize till someday between 2024 and 2026, in response to a workforce research commissioned by the Genetic Counselor Workforce Working Group.2 To sort out the elevated want for most cancers danger evaluation and genetic testing, the College of Miami Sylvester Complete Most cancers Middle bridged the hole between genetic counselors and superior observe registered nurses (APRNs) with genetic coaching and useful resource assist. The coaching interval consists of visits with genetic counselors to make sure that APRNs perceive methods to compose a 3-generational pedigree. It’s the particulars of the pedigree and private medical historical past that, if not accomplished precisely, could cause pertinent info to be omitted when contemplating the kind of genetic testing to be carried out. If inaccurate, there could be a chance for genes related to household historical past to be missed in testing.
After genetic analysis, if there’s a risk for an inherited danger of most cancers, it is very important calculate the affected person’s individualized danger, particularly if their testing comes out unfavourable. For instance, per SEER (Surveillance, Epidemiology, and Finish Outcomes) registry knowledge, the overall inhabitants danger for breast most cancers in girls is 12% to 13%.3 This knowledge doesn’t think about different danger components. Danger components for breast most cancers embrace intercourse, age, inherited genetic change predisposing to most cancers, household historical past of breast or ovarian most cancers, private historical past of breast most cancers, racial/ethnic group, dense breast tissue, nonproliferative lesions of the breast, proliferative lesions of the breast with or with out atypia or lobular or ductal carcinoma in situ, early menses (youthful than 12 years), late menopause (older than 55 years), radiation remedy to the chest as an adolescent or younger grownup, historical past of hormone substitute remedy (HRT), and present or previous publicity to estrogen or progesterone hormone brokers.4 These components are used to calculate a personalised danger evaluation for breast most cancers and to determine if there’s an elevated danger. If a affected person is discovered to have elevated danger, evidence-based suggestions for enhanced screening or chemoprevention are established as a part of the affected person’s plan of care. Completely different danger fashions might be applied to evaluate a affected person’s danger of growing breast most cancers. Examples of generally used danger fashions embrace the Gail mannequin, the Worldwide Breast Most cancers Intervention Examine (IBIS)/ Tyrer-Cuzick (model 8) mannequin, and the CanRisk Software (The Breast and Ovarian Evaluation of Illness Incidence and Provider Estimation Algorithm [BOADICEA v5]).4 These danger fashions will help calculate 5-year danger (Gail mannequin), 10-year danger (IBIS/Tyrer-Cuzick), or lifetime danger (IBIS/ Tyrer-Cuzick/Gail/CanRisk). If a affected person’s 5-year danger is larger than or equal to 1.7%, a dialog about risk-reducing brokers could also be warranted, however per Nationwide Complete Most cancers Community tips, precautions ought to solely be advisable when a affected person has not less than a 5-year danger of three% per the Gail mannequin or a 10-year danger of 5% in response to the IBIS/Tyrer-Cuzick mannequin.4 These danger fashions will also be used for consideration of enhanced screening if lifetime danger is larger than 20%. The improved screening suggestions for these people embrace scientific breast exams each 6 to 12 months as a substitute of the annual advice, and annual screening mammogram with tomosynthesis and annual breast MRI, with each beginning at age 40, or 10 years previous to the earliest breast most cancers prognosis (whichever is first) however not below age 30 with mammogram and never below age 25 with MRI.5 These customized danger assessments will not be restricted to breast most cancers however will also be applied for different cancers reminiscent of colorectal, ovarian, and kidney cancers along with different danger fashions.6-11
Though a proper evaluation of our institutional program has but to be performed, the early proof has been promising. To this point we have now noticed a lower in genetic counselor wait instances from 74 to 34 days. Moreover, our information point out that, as a staff, the licensed genetic counselors and high-risk APRNs have elevated the variety of sufferers who undergo counseling. The affected person quantity elevated from 496 sufferers with genetic counselors alone in 2022 to 807 with each genetic counselors and APRNs in 2023. Equally, the entire variety of affected person encounters elevated from 643 in 2022 to 1199 in 2023, suggesting vital enchancment to well being care entry. Via complete private and familial most cancers historical past, genetic testing, most cancers danger evaluation, and implementation of most cancers prevention plans, Sylvester’s Excessive-Danger Prevention and Wellness Program is striving for proactive versus reactive care.
Alexandra M. Hernandez, MSN, APRN, FNP-C, is a nurse practitioner within the Excessive-Danger Prevention and Wellness Program on the College of Miami-Sylvester Complete Most cancers Middle in Florida.
References
1. All about most cancers. American Most cancers Society. Accessed June 22, 2023. https://bit.ly/3NLeO3o
2. Hoskovec JM, Bennett RL, Carey ME, et al. Projecting the availability and demand for licensed genetic counselors: a workforce research. J Genet Couns. 2018;27(1):16-20. doi:10.1007/ s10897-017-0158-8
3. Most cancers stat information: feminine breast most cancers. Nationwide Most cancers Institute. Accessed July 7, 2023. https://bit.ly/44rnDq4
4. NCCN. Medical Follow Tips in Oncology. Breast most cancers danger discount, model 1.2023. Accessed June 22, 2023. https://www.nccn.org/professionals/physician_gls/pdf/ breast_risk.pdf
5. NCCN. Medical Follow Tips in Oncology. Breast most cancers screening and prognosis, model 1.2023. Accessed June 20, 2023. https://www.nccn.org/professionals/physician_ gls/pdf/breast-screening.pdf
6. Lee A, Yang X, Tyrer J, et al. Complete epithelial tubo-ovarian most cancers danger prediction mannequin incorporating genetic and epidemiological danger components. J Med Genet. 2022;59(7):632- 643. doi:10.1136/jmedgenet-2021-107904
7. Fitzgerald RC, Antoniou AC, Fruk L, Rosenfeld N. The way forward for early most cancers detection. Nat Med. 2022;28(4):666-677. doi:10.1038/s41591-022-01746-x
8. McGeoch L, Saunders CL, Griffin SJ, et al. Danger prediction fashions for colorectal most cancers incorporating widespread genetic variants: a scientific assessment. Most cancers Epidemiol Biomarkers Prev. 2019;28(10):1580-1593. doi:10.1158/1055-9965.EPI-19-0059
9. Harrison H, Thompson RE, Lin Z, et al. Danger prediction fashions for kidney most cancers: a scientific assessment. Eur Urol Focus. 2021;7(6):1380-1390. doi:10.1016/j.euf.2020.06.024
10. Tyrer J, Duffy SW, Cuzick J. A breast most cancers prediction mannequin incorporating familial and private danger components. Stat Med. 2004;23(7):1111-1130. doi:10.1002/sim.1668
11. Lee A, Mavaddat N, Wilcox AN, et al. BOADICEA: a complete breast most cancers danger prediction mannequin incorporating genetic and nongenetic danger components. Genet Med. 2019;21(8):1708-1718. doi:10.1038/s41436-018-0406-9
