Breast cancer screening in an era of personalized regimens: A conceptual model and National Cancer Institute initiative for risk‐based and preference‐based approaches at a population level

Abstract

Breast cancer screening holds a prominent place in public health, health care delivery, policy, and women’s health care decisions. Several factors are driving shifts in how population-based breast cancer screening is approached, including advanced imaging technologies, health system performance measures, health care reform, concern for “overdiagnosis,” and improved understanding of risk. Maximizing benefits while minimizing the harms of screening requires moving from a “1-size-fits-all” guideline paradigm to more personalized strategies. A refined conceptual model for breast cancer screening is needed to align women’s risks and preferences with screening regimens. A conceptual model of personalized breast cancer screening is presented herein that emphasizes key domains and transitions throughout the screening process, as well as multilevel perspectives. The key domains of screening awareness, detection, diagnosis, and treatment and survivorship are conceptualized to function at the level of the patient, provider, facility, health care system, and population/policy arena. Personalized breast cancer screening can be assessed across these domains with both process and outcome measures. Identifying, evaluating, and monitoring process measures in screening is a focus of a National Cancer Institute initiative entitled PROSPR (Population-based Research Optimizing Screening through Personalized Regimens), which will provide generalizable evidence for a risk-based model of breast cancer screening, The model presented builds on prior breast cancer screening models and may serve to identify new measures to optimize benefits-to-harms tradeoffs in population-based screening, which is a timely goal in the era of health care reform.

Provider Attitudes and Screening Practices Following Changes in Breast and Cervical Cancer Screening Guidelines

“…18 More information about PROSPR, the participating sites, and publications to date can be found on the PROSPR website (http:// healthcaredelivery.cancer.gov/prospr/). For BWH, DH and PENN, we included providers who had ordered or were expected to order at least five mammograms among those recorded in the existing PROSPR consortium database.…”

Inadequate Systems to Support Breast and Cervical Cancer Screening in Primary Care Practice

“…Conceptual models of cancer screening identify a role for risk assessment and communication between providers and patients as important aspects of effective screening processes. [4][5][6][7] Prior studies indicate that the adoption of system-based strategies such as health information technology (HIT) and decision support improves the quality of primary care delivery, including uptake of cancer screening. [8][9][10] However, they also report a lack of HIT and practice-based systems to support screening in primary care.…”

Variation in Screening Abnormality Rates and Follow-Up of Breast, Cervical and Colorectal Cancer Screening within the PROSPR Consortium

“…An essential premise in establishing PROSPR, initially comprised of three centers focused on breast cancer, three on colorectal cancer, and one on cervical cancer screening, is that variation at multiple levels-health system, clinic, provider, and patient-may be leveraged through comparative effectiveness research to elucidate best cancer screening practices. To advance research in this area, the consortium has developed conceptual models for studying screening processes of care [5][6][7] that extend the work of Zapka and Taplin. 8 These models detail the screening process from risk assessment through diagnosis and treatment as steps with interfaces requiring a transfer of information and/or responsibility across providers, and elucidate transitions where threats to timely follow-up may occur at multiple levels.…”