ASCO Daily News - Dr. Larissa Korde Discusses the Implications of the New USPSTF Recommendations on Risk Assessment, Genetic Testing for BRCA Genes

Dr. Larissa Korde Discusses the Implications of the New USPSTF Recommendations on Risk Assessment, Genetic Testing for BRCA Genes

09/12/19 • 10 min

Welcome to the ASCO Daily News podcast. I'm Lauren Davis, and joining me today is Dr. Larissa Korde whose research interests focus on breast cancer treatment and prevention at the National Institutes of Health. Today we're talking about breast cancer screening as it relates to bracket gene mutations. Dr. Korde, welcome to the podcast.

Thank you for having me.

We're glad you're here. Although 12% of women in the United States will develop breast cancer sometime during their lives, approximately 72% of women who inherit the BRCA1 mutation and about 69% of women who inherit the BRCA2 mutation will develop breast cancer by the age of 80. Recently the US Preventive Services Task Force expanded the recommendation of patients who should be screened for the BRCA1 and BRCA2 genetic mutation, which is associated with multiple cancer types. How did this update come about?

The US Preventive Services Task Force last presented guidelines on this topic in 2013. The recent publication in the Journal of the American Medical Association is an update, and it reviews the evidence that has come about since 2013. It's important to note that these recommendations are not actually about who should be tested for BRCA1 or 2 mutations. What the recommendations address is really who should be screened and that screening would be evaluation of family history.

So the screening with family history is designed to identify which patients should be referred for further evaluation by a provider experience in genetic counseling and testing who can then make recommendations regarding actually having a gene test. The task force recommends that primary care providers assess women with a personal or family history of breast or ovarian cancer and ovarian includes fallopian tube and peritoneal cancers. And they also recommend that those who have an ancestry associated with a BRCA1 or 2 mutation should be assessed using a family history assessment tool.

There are a number of brief assessment tools that can be used in the clinic setting and are designed to assist providers in identifying which patients should be referred for genetic counseling and then if appropriate for genetic testing. Also the task force recommends against routine assessment and referral in patients that do not meet their set criteria.

The important update is that compared to the 2013 guideline, the population for whom risk assessment is deemed appropriate is broader, and specifically it's been expanded to include those women with a personal history of breast or ovarian cancer and those with a specific ancestry. The ancestry part of this was met to increase awareness of the strong association between BRCA1 and 2 mutations in Ashkenazi Jewish ancestry. Again, though, this is not a blanket recommendation that all women of Ashkenazi Jewish ancestry should be tested for BRCA1 and 2 mutations, just that the knowledge of ancestry should consider-- that should trigger additional evaluation.

There are certainly schools of thought that a more inclusive approach is needed. For example, there are folks who advocate for universal mutation testing in all women with breast cancer or all women with Ashkenazi Jewish descent while others favor a more targeted approach. These recommendations call for the more targeted and step-wise approach.

So the first step would be evaluation of personal and family history and ancestry followed by referral of patients that meet a certain threshold of risk. And then finally followed by testing if it's appropriate after counsel.

That's great. Sounds like it's a lot more about finding out who really needs to be tested and not so much about the test itself. So how can this update improve outcomes for patients?

Well, I think the basic goal here is that if we can do a better job at identifying who to screen for the BRCA1 and 2 mutation, then we can do a better job of offering appropriate interventions to those who take the test and test positive. And that can take many forms. The most obvious here is that those who have the highest likelihood of having the BRCA mutation will be referred for the appropriate counseling, and then they can make the decision with the advice of their providers about whether or not to undergo testing.

And, of course, there are also downstream effects. Once a patient is identified as having a BRCA mutation, she can be offered preventive interventions such as prophylactic mastectomy or [INAUDIBLE], and she can be offered more intensive cancer screening. It's important to note here that the recommendations were expanded to include women with a personal history of cancer because we know that these women are at risk for developing a second cancer. And that's important information, particularly for a patient whose original cancer was treated with curative intent.

Something that was outside of the scope of this guideline but which I think is becoming increas...

Thank you for having me.

That's great. Sounds like it's a lot more about finding out who really needs to be tested and not so much about the test itself. So how can this update improve outcomes for patients?

Something that was outside of the scope of this guideline but which I think is becoming increas...

Previous Episode

Dr. Linda Bosserman Highlights Key Presentations from ASCO's Oncology Practice Conference

Welcome to the ASCO Daily News podcast. I'm Lauren Davis, and joining me today is Dr. Linda Bosserman, assistant clinical professor at City of Hope in Southern California where she is a breast cancer specialist who does research and projects in value-based care for the organization. Dr. Bosserman is also editor in chief of the Journal of Oncology Practice who served as chair for the third annual Oncology Practice Conference that just concluded last week. Dr. Bosserman, welcome to the podcast.

Thank you so much for having me.

We're glad you're here. So you've just returned from the conference. How was this year's event compared with previous years?

Well, the feedback was that this was the most successful oncology practice meeting that we've had. I have to really give credit to my planning committee including the co-chair of Barry Rousseau and the imminent Robin Zahn, who is the chair of last year's conference, and all three of us have been on the planning committee with many really amazing national specialists to put this together.

The focus this year was really on issues of administration and practice that would help people within community practice or academics in improving quality and care delivery.

What were some of the key themes and presentations of this year's conference?

So we divided the conference into five major topics. The first was practical solutions for something we all deal with every day-- physician compensation and succession planning. There were incredible talks led by Barry Rousseau and Tracy Weisberg, but with Lance [INAUDIBLE] from Stratify Health Consultants, Dean Gest, Mia Long, experienced oncologists with Texas Oncology from Minnesota Oncology with a lot of succession planning wisdom and Brad Sommer from West Clinic who really talked about very different models of hospital-based and private-based compensation and succession planning. That was very successful and helpful the people.

The second major topic was implementing a medically integrated pharmacy. So that was led by Steve Giamatto and Paul Fossberg from Minnesota Oncology and from New England Cancer Specialists and really had specials from Ray Bailey from Florida Cancer Specialists, Stacy McCullough Pharm D from Tennessee Oncology and Ira Ciccone from New York Chemo ONC Albany Med Center.
I had to laugh because our private practice in 2008 put this in and really helped spur some of the work that went on later at US oncology when we join them and now at City of Hope, a very large multi-specialty, multi-site academic network. And, in fact, this topic was so important there were subsequent key presentations at the oncology quality meeting, which followed the next two days after the business conference so highly recommend those talks.
The third talk was really uncharted waters, how to leverage your practice data, led again by Dr. Zahn and Harvey Bickoff and included Kathleen Beekham from IHA, hematology oncology, talked about practice net and the benchmarking data, Kimberly Woofter, who is really from [INAUDIBLE] and Christian [INAUDIBLE] who is with UnitedHealthcare and a former ASCO administrator.

Another key topic on how to use data both for your internal processes, improving care delivery, and quality as well as to negotiate high-quality care with payers and employers. Our fourth topic was really about value-based contracting, which is the theme of all of our current lives, really led by again Barry Rosseau and Robert Baird of Dayton Physicians and, of course, Barry from Center for Cancer and Blood Disorders.

Steve Grubbs from ASCO talked about the PCOP model and fundamental components of contracting. Julie Royalty from Humana spoke, and Terrell Jordan from regional Cancer Care Associates in New Jersey spoke. Lot of wisdom in how we're all navigating this value-based contracting transition as we move from volume-base to value-based contracting and care delivery.

And then this is really tied together in our keynote presentation from Laura Simon and Olivia Ross, both from the Pacific Business Group on Health who really talked about the employer review and that the majority of private care is covered by employers. They're seeing 10% to 12% of their costs for 1% to 2% of their employees depending on the age of the population.

They want rapid access to very precise personalized cancer care, the state of the art, but they want it cost effectively and they want integration between the centers that do specialty surgery and transplant and [INAUDIBLE] with local physicians that can provide that hands on local care to the patient and their family in the community. So those topics really tied together as the key issues that are affecting practices today regardless of the setting that you're in.

That's interesting. A lot of fascinating topics that really do affect everyone within a practice. So I'm curious, what are some of the challenge...

Next Episode

Dr. Ethan Basch Highlights Key Presentations from the ASCO Quality Care Symposium

Welcome to the ASCO Daily News podcast. I'm Lauren Davis. And joining me today is Dr. Ethan Basch. He holds several professional titles at the University of North Carolina at Chapel Hill, including Distinguished Professor of Oncology and Director of the Cancer Outcomes Research Program. Dr. Basch is a member of ASCO's board of directors and recently served as the program chair of the ASCO Quality Cancer Symposium. Dr. Basch, welcome to the podcast.

Thanks so much. Nice to be here.

We're glad you're here. So you've just returned from the conference. How was this year's event compared with previous years?

This year's event was a great success. Similar to prior years, the conference focused on quality of care delivery. But increasingly, we have seen a move towards research and practical presentations around value-based care and alternative payment models. I would say that what was particularly successful this year was the bringing together quality activities in the community with academic research that is being conducted by health services research.

Increasingly, we've been seeing that community-based quality initiatives are beginning to use more rigorous scientific methods and similarly that academic research is becoming more practical and community-based. And this conference really shows the marriage of the two at this moment in oncology.

That's great. So which presentations or abstracts did you find the most compelling or practice-changing?

There were so many terrific abstracts this year, we had a very difficult time choosing the oral abstracts for the meeting. And we had more than 500 submissions of scientific abstracts for the meeting. I thought I would go over three of the abstracts that I found particularly exciting and that I think reflected some of the overall themes of the meeting.

The first was from Kerin Adelson, who's a medical oncologist and a quality officer at Yale Cancer Center. And Yale is one of the participating sites in the Oncology Care Model, which is the Medicare Innovation Center's demonstration project for an alternative payment model in oncology. And they've been participating over the past several years implementing a number of value-based care initiatives to try and reduce costs and improve quality.

This has included broadening their care coordination and navigation services, providing an alternative pathway to the ER to an acute care center, providing access to providers 24/7 with access to the electronic health record, and several other patient-oriented initiatives.

And over time, they've looked at the impact of these initiatives on their total cost of care. And they've broken it down into different categories. And at the meeting this year, Dr. Adelson presented what's happened specifically to the cost of emergency room and hospital utilization, as well as pharmaceuticals.

And what they found at Yale is that as they progressively implemented these value-based programs, they also progressively decreased the amount of emergency room and hospital utilization quite substantially and significantly, yielding a decrease in cost.
However, simultaneously, the cost of drugs increased as we all in oncology are acutely aware of. In fact, the cost of pharmaceuticals went up by about 9% per year. So while they very substantially drove down the costs of emergency room visits and hospitalization, they were barely able to keep up with the rising costs of pharmaceuticals.

The second abstract, I think, of particular interest also relates to the cost of drugs. This was a presentation by Bernardo Goulart from Scott Ramsey's group at Fred Hutch Cancer Research Center in Seattle. They are particularly interested in the relationships between the costs of drugs and adherence and other outcomes.
Now, previously, there have been several studies published by investigators like Stacy Dusetzina at Vanderbilt showing that as the incremental out-of-pocket costs of drugs goes up that adherence with drugs goes down, i.e. the more that people have to pay out of pocket, the less they take their drugs. And drugs that this has been particularly shown for are oral tyrosine kinase ACE inhibitors. And this has been looked at in a number of different diseases.
In this particular study, Dr. Goulart and colleagues looked at the relationship between higher patient out-of-pocket TKI costs and both adherence to drugs, but also overall survival. And consistent with prior studies, they found that greater out-of-pocket costs were again associated with lower adherence. But in this case, they added on the overall survival metric and found that in fact, higher out-of-pocket costs were associated with worse survival.

This is important information as we as a country think about how out-of-pocket costs are structured within benefits programs, t...