Development and Pilot Implementation of the Genomic Risk Assessment for Cancer Implementation and Sustainment (GRACIAS) Intervention in Mexico

Abstract

PURPOSE Genomic cancer risk assessment (GCRA) is standard-of-care practice that uses genomic tools to identify individuals with increased cancer risk, enabling screening for early detection and cancer prevention interventions. GCRA is not available in most of Mexico, where breast cancer (BC) is the leading cause of cancer death and ovarian cancer has a high mortality rate. METHODS Guided by an implementation science framework, we piloted the Genomic Risk Assessment for Cancer Implementation and Sustainment (GRACIAS) intervention, combining GCRA training, practice support, and low-cost BRCA1/ 2 ( BRCA) gene testing at four centers in Mexico. The RE-AIM model was adapted to evaluate GRACIAS intervention outcomes, including reach, the proportion of new patients meeting adapted National Comprehensive Cancer Network criteria who participated in GCRA. Barriers to GCRA were identified through roundtable sessions and semistructured interviews. RESULTS Eleven clinicians were trained across four sites. Mean pre-post knowledge score increased from 60% to 67.2% (range 53%-86%). GCRA self-efficacy scores increased by 31% (95% CI, 6.47 to 55.54; P = .02). Participant feedback recommended Spanish content to improve learning. GRACIAS promoted reach at all sites: 77% in Universidad de Guadalajara, 86% in Instituto Nacional de Cancerología, 90% in Tecnológico de Monterrey, and 77% in Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán. Overall, a pathogenic BRCA variant was identified in 15.6% (195 of 1,253) of patients. All trainees continue to provide GCRA and address barriers to care. CONCLUSION We describe the first project to use implementation science methods to develop and deliver an innovative multicomponent implementation intervention, combining low-cost BRCA testing, comprehensive GCRA training, and practice support in Mexico. Scale-up of the GRACIAS intervention will promote risk-appropriate care, cancer prevention, and reduction in related mortality.

Germline pathogenic variants in Mexican patients with hereditary triple-negative breast cancer

“…All patients included in this study received GCRA and had genetic testing results available at the time of this analysis. Various methods were used for PV detection, 12 including a multigene panel test with a custom QIAseq (QIAGEN, Inc., Germantown, MD, USA) amplicon-based panel for detecting breast cancer predisposition variants (ATM, BRCA1, BRCA2, CDH1, CHEK2, NF1, PALB2, PTEN, RAD51C, RAD51D, TP53). The design includes the 5' and 3' untranslated regions, full exonal gene coverage, and extends 10 base-pairs into introns, and results in a consistent coverage of over 300-500x.…”

“…The barriers to implementing genetic cancer risk assessment (GCRA) services in the country include excessive costs, lack of coverage of genetic testing within the public health system, limited awareness of the benefits of identifying PVs, and limited number of physicians with GCRA expertise. 11,12 Previous studies in Mexican BC patients unselected for family history have demonstrated that 15% of cases overall are associated with BRCA PVs. 13 The frequency of BRCA PVs was higher (>20%) among young TNBC patients in two small studies, 14,15 and this molecular subtype accounts for 16-23% of BC cases in Mexico.…”

Young Women with Breast Cancer in Resource-Limited Settings: What We Know and What We Need to Do Better

“…A critical finding from the GRACIAS intervention is the patients’ feedback recommending the development of Spanish resources to improve learning. 78 …”

A RE-AIM Framework Analysis of DNA-Based Population Screening: Using Implementation Science to Translate Research Into Practice in a Healthcare System

“…RE-AIM is ideal for pragmatic contexts and facilitates evaluation of impact at the individual (reach/effectiveness) and institutional (adoption/implementation) levels simultaneously, since multi-level impact is critical for both translation and broader public health benefit ( Glasgow et al, 1999 ; Nilsen, 2015 ; Brownson, 2017 ; Glasgow and Estabrooks, 2018 ; Glasgow et al, 2019 ). Over the last two decades, RE-AIM has been used extensively in other contexts, yet it is only beginning to be applied to precision health ( Glasgow et al, 2019 ; Jones et al, 2021b ; Blazer et al, 2021 ; Kim et al, 2021 ; Miller et al, 2021 ; Sperber et al, 2021 ). In this study, we demonstrate the use of RE-AIM to conduct a post-hoc evaluation and report outcomes from two DNA screening programs at Geisinger with the goal of generating evidence needed for systematic implementation of DNA-based population screening.…”