Impact of rurality on screening and prevention strategies for patients with hereditary breast and ovarian cancer syndrome.

Abstract

e22662 Background: Patients with hereditary breast and ovarian cancer syndrome (HBOC) with a germline pathogenic variant in BRCA1/2 are at a high lifetime risk of breast and ovarian cancer. Existing cancer surveillance and prevention strategies improve survival or detect cancer at an earlier stage in this population. Despite this, barriers to uptake exist. Rurality is a known barrier to healthcare access but its impact on adherence to guideline-based cancer surveillance and prevention among women with HBOC remains poorly understood. Methods: We enumerated a cohort of patients with pathogenic BRCA1 / 2 variants residing in Vermont or northern New York who were seen by the Cancer Genetics Program at the University of Vermont Cancer Center. Cancer surveillance and prevention methods analyzed included adherence to guideline-based mammography, breast MRI and bilateral salpingo-oophorectomy (BSO). Rates of risk-reducing mastectomy (RRM) were also determined. Compliance with breast cancer surveillance imaging among patients who had not undergone RRM was defined as annual screening breast MRI for patients >25 years old and mammogram for patients >30 years old with a 3-month grace period. Adherence to BSO was determined based on gene-specific age recommendations from the NCCN guidelines . We classified rurality status by converting residential ZIP codes into Rural-Urban Commuting Area (RUCA) codes, with RUCA>7 comprising the most rural patients. We compared adherence proportions for the screening/prevention strategies adjusted for participation in longitudinal follow-up via stratified analysis. Results: We enrolled 285 natal females with HBOC, of whom 120 (43%) had previously undergone RRM. Annual mammogram and screening breast MRI were recommended for 98 (34%) and 110 (39%) of enrolled patients, respectively. Mean age was 49.7 years (SD 15.1), and 90 (32%) patients resided in a small town/rural setting. For eligible patients, adherence was 54% for mammography 43% for breast MRI. Uptake of chemoprevention was 2.5%. Compared with metropolitan/micropolitan patients, small town/rural patients were less likely to adhere to screening mammography (RR adj = 0.63, 95% CI: 0.41, 0.97) and somewhat less likely to adhere to screening breast MRI (RR adj 0.73, 95% CI 0.45, 1.2). Rates of RRM and BSO were similar by rurality. Conclusions: In a cohort of BRCA1/2 carriers, adherence to screening mammogram and breast MRI was lower for rural patients compared with non-rural patients. Adherence rates to screening mammogram and breast MRI overall were suboptimal but comparable to previously reported rates in HBOC patients. Uptake of chemoprevention was lower than expected. Rates of BSO and RRM were similar to previously published results. Research resources should be invested to identify and ameliorate other barriers to uptake of cancer prevention and surveillance strategies in the HBOC population.