Integrating HBOC Screening into Public Health Practice Amber Roche, MPH Breast, Cervical, and Colon Health Program (BCCHP) Public Health – Seattle & King County

Healthy People 2020 Genomics Objective G-1: Increase the proportion of women with a family history of breast and/or ovarian cancer who receive genetic counseling Baseline: 23.3% Target: 25.6% (10% improvement) http://www.healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=15

Breast, Cervical, & Colon Health Program in WA Federal (CDC), state, and Komen funding Serves low-income clients without insurance, or with high deductibles Helps eligible clients get screened for breast, cervical, and colorectal cancers Connects clients with diagnostic services and treatment Pays for services Works to improve access/reduce barriers to care

BCCHP in Washington State

BCCHP Eligibility Breast screening & annual exam Cervical^ Colon 40-64, or 35-39, if being seen for breast symptoms, or 64+ if ineligible for Medicare   Priority for Mammography: Ages 50 or older, and last mammogram > 2 years Suspicious breast findings Strong family history or other high risk If last pap normal & > 3 years or co-testing (Pap normal and HPV negative) > 5 years: 40-64 35-39, if being seen for breast symptoms ^As per USPSTF 2012 Cervical Cancer Screening Guidelines. If not eligible for Pap Test, pelvic exam paid only if done as part of visit for breast screening/annual exam 50-64 or Under 50 if 1st degree relative (parent, sibling, child) was diagnosed prior to age 60 with colon cancer or pre-cancerous polyps At or below 250% of Federal Poverty Level (FPL)* Uninsured or Underinsured (deductible over $500) Washington State Residents *mammography and breast diagnostics available to clients at or below 300% FPL (Komen funding)

HBOC Screening Options BCCHP: Identify clients with family history of HBOC, and refer to genetic counseling Those diagnosed with breast cancer All enrolled clients Genetic counselors discuss contacting family members Beyond BCCHP: Providers ID women at risk, & make referrals. Use EMR capabilities?

Efforts So Far DOH revised questions about family history of breast/ovarian cancer on the BCCHP history & exam form Promoting: Cancer Family History Guide (developed by the Michigan Department of Community Health) Online Breast Cancer Genetics Referral Screening Tool (developed by Cecelia Bellcross, PhD, MS, CGC): http://www.brcagenscreen.org/

Challenges Data fields on forms vs. in data system Ability to run reports of clients with family history Limited time, not highest priority

Challenges Training clinic staff Possibility for inappropriate referrals Reality of EMRs Who to refer clients to? How to pay for genetic counseling and testing Will these be Essential Health Benefits?

Suggestions Pilot project Student labor! Involve patient navigators