Nurse-led High Risk Referral Protocol Improves Risk Communications During Mammography Appointments

Nurse-led High Risk Referral Protocol Improves Risk Communications During Mammography Appointments

A nurse-led high-risk referral protocol when mammography was performed was attributed to the increase in breast MRIs, consultations, genetic testing, and other types of testing, according to findings published in the Clinical Journal of Oncology Nursing.

“In this project, the role of the [advanced practice provider] was being a patient advocate,” said Ashley B. Johnson, DNP, APRN, FNP-C, an ambulatory nurse practitioner associate in the Division of Surgical Oncology and Endocrine Surgery at Vanderbilt-Ingram Cancer Center in Nashville, Tennessee, in an interview with Oncology Nursing News. “It was also being somebody who was very informed about high-risk screening options. And then through that, that improves the discussion with the woman.”

During postintervention, 14 patients underwent high-risk consultations, allowing them to receive education and management in alignment with NCCN guidelines. Eight women who received referrals underwent (n = 3) or scheduled (n = 5) breast MRIs.

“The strategy that was most effective [in increasing MRI rates] was having a face-to-face clinic appointment,” Johnson said. “…It was that face-to-face clinic appointment, where each nurse practitioner really went over, what is your risk? Your options can include different breast imaging services, genetic counseling, genetic testing. I think for most women, it was just no one had ever explained it to them before. They had no idea that they were eligible for those services.”

Notably, patient satisfactory scores improved by 4.6% overall and attainment of 100% patient satisfaction with care, according to surveys completed by patients within 1 month of their appointment.

“So, I think in other centers, if you can implement a screening tool like this, whether it's with a mammogram appointment or maybe it's during the woman's annual well woman exam with her GYN, or even just an annual wellness visit, there's different intervals that a person seeks care,” said Johnson, who was one of the researchers on the project. “And if you can engage the patient at that time with such a screening tool, they would then be identified [as] high risk, and it could lead to all these other outcomes. So, I think just implementing [high risk screening protocols] at different intervals throughout healthcare would improve quality across the board.”

Additionally, 4 of the 8 women for whom genetic counseling was ordered completed counseling, and the remaining women scheduled counseling beyond the project timeline. Researchers noted that all 4 women who were suggested genetic testing per the consultation received it within the project timeline.

Breast cancer was diagnosed in 1 participant of the high-risk clinic consultation suggesting earlier cancer detection.

Johnson noted that APPs advocating for patients may be one of the major factors behind this project’s success.

“I think it's just being an advocate for each patient you see and being a good listener. I think that's absolutely key, is engaging each person where they're at, talking to them about what are their goals for their care, and then letting them know what types of screening services they're eligible for.”

Screening and diagnostic mammograms were performed on 7191 women, of whom 150 (2%) were considered to be at high risk for breast cancer according to the Breast Cancer Risk Assessment Tool (BCRAT). Of the 150 women considered to be at high risk, 46 (31%) were eligible for referral to the high-risk clinic, for which attending providers were notified by electronic messaging. Furthermore, 33 providers placed referrals and 14 women completed the high-risk breast cancer clinic consultation.

Patient eligibility included women aged older than 35, self-referred or referred by their provider at Vanderbilt University Medical Center, and having a lifetime risk of breast cancer greater than 20% per the BCRAT.

Patient satisfaction was measured by the Vanderbilt University Medical Center Patient Experience: Outpatient Services Survey, which was sent via text or email. Responses were rated on a scale of very poor to very good, which were then converted into a 100-point system, with 100 noting the highest satisfaction score.

Multiple barriers impede the identification of woman at high risk for breast cancer including healthcare providers failing to recognize woman at increased risk for breast cancer, low acceptance of genetic counseling and testing, and high cost of breast MRIs and genetic testing.

“Women are not identified at being at high risk for breast cancer,” Johnson said. “In many, many cases, a woman has no idea that maybe her family history or personal history, or just different characteristics that she has would put her at high risk. So that's the first barrier, is actually identifying what is your individualized risk for breast cancer.”

Johnson also commented on the financial barrier around breast cancer screening. “Often a woman may know her family history or she knows she's at higher risk, but maybe the big barrier for her is cost,” she said. “While some screenings are well covered by insurance, not everybody can access great quality care. So access and cost are tremendous barriers”

Sometimes another person’s experience with cancer may influence a woman’s decision to undergo screening, Johnson said.

“Sometimes it's fear,” Johnson added. “People maybe—if they've seen a loved one go through cancer—they're just scared. So they are hesitant to come in because they've seen how it played out with their loved one.”

Reference

Johnson AB, Beck ML, Jackson HJ. The Impact of a Nurse-Led High-Risk Referral Protocol Implemented in a Comprehensive Breast Center. Clin J Oncol Nurs. 2024;28(4):366-371. doi:10.1188/24.CJON.366-371