High-Risk Benign Breast Disease and the Need for Navigation

Background: The National Accreditation Program for Breast Centers (NAPBC)/American College of Surgeons is dedicated to promoting improved treatment outcomes for breast disease. NAPBC Standard 2.19: Evaluation and Management of Non-Malignant Breast Disease and NAPBC Standard 2.16: Genetic Evaluation and Management describe adherence to national guidelines for management and treatment of the patient with high familial or hereditary breast cancer syndromes and of nonmalignant breast conditions, including assessments for genetic risk.

For our NAPBC 2018 survey, a deficiency was identified regarding management and treatment of high-risk benign (HRB) breast patients. A plan was devised to assign a navigator to identify these patients at the time of a biopsy-proven HRB diagnosis to assess for adherence to National Comprehensive Cancer Network (NCCN) and NAPBC treatment guidelines.^1,2

Objectives: Ensure that all HRB patients are evaluated, educated, and managed in adherence to NAPBC Standard 2.19, Standard 2.16, and the NCCN Guidelines for Breast Cancer Risk Reduction.^1,2

Methods: Evaluate baseline number of HRB patients 2017-2018 for disposition and adherence to NAPBC guidelines 2.16 and 2.19. Identify a task force to identify program processes, tools, and implementation.

• Task force developed: Breast Fellowship–trained surgeon, respiratory therapist navigator, medical oncologist
• Process designed for HRB patient tracking
• Navigation: Measure and track HRB patients for surgical intervention, genetic evaluation, chemoprevention according to NAPBC and NCCN guidelines
• Report to breast program leadership results/submit findings to NAPBC surveyor

Results: Baseline: Sampling of 2017-2018 patients

• 30 patients identified with biopsy-proven high-risk benign disease
• 10 patients were identified with atypical lobular hyperplasia (ALH), atypical ductal hyperplasia (ADH), and lobular carcinoma in situ (LCIS)
• 2 patients were subsequently referred for genetic evaluation, or chemoprevention

No documentation was vailable regarding 28 of the 30 patients who were evaluated regarding genetic evaluations (ie, Tyer-Cuzick testing³)

20% of Patients Met NAPBC and NCCN Guidelines

HRB navigation program implementation, April 2019/April-December 2019:

• 60 patients diagnosed with HRB disease (6 patient providers declined navigation)
• 54 patients navigated biopsy-proven HRB disease
• 40 patients monitored for, education provided, genetic evaluation, surgery options
• 10 patients were identified with ALH, ADH, LCIS
• 19 patients identified for medical oncology follow-up

Of the HRB population in 2019, 90% navigated per documentation received genetic, surgical, and preventive options for HRB disease in accordance to NAPBC and NCCN guidelines.

Conclusions: It is well documented that navigation plays a key role in the management and treatment of breast cancer patients. When navigation is used in the setting of HRB breast disease, patient management improves. The HRB patients who once missed genetic evaluations and chemoprevention are now being navigated and educated to ensure they have treatment that adheres to national guidelines.

References

1. American College of Surgeons. National Accreditation Program for Breast Centers Standards Manual. 2018 Edition. https://accreditation.facs.org/ac creditationdocuments/NAPBC/Portal%20Resources/2018NAPBCStan dardsManual.pdf.
2. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). Breast Cancer Risk Reduction. Version 1.2020. www.nccn.org/professionals/physician_gls/pdf/breast_risk.pdf.
3. Tyer J, Cuzick PJ. IBIS Breast Cancer Risk Evaluation tool. www.ems-trials.org/riskevaluator.