The Athena Breast Health Network integrates clinical care and research to drive improvements in breast health care. Through a collaborative environment and infrastructure for data collection and sharing, Athena provides a framework for quality improvement and development of new standards across UC campuses. The network includes primary care providers, oncology specialists, radiologists, pathologists, and researchers and is developing tools to harmonize the collection and analysis of data in multiple areas of care. Current initiatives to achieve these objectives are described below.
Risk Assessment & Evaluation
A major Athena innovation has been the introduction of breast cancer risk assessment as a standard part of care for healthy women receiving screening mammography. Women who are screened at an Athena-affiliated clinic provide information electronically about their health history, lifestyle behaviors, and family history of cancer. Automated risk assessment using validated risk models is performed based on these data, and women identified as being at elevated risk are referred to a Breast Health Specialist, who provides risk consultations and oversees further referrals, as appropriate. Accompanying this clinical program is an ongoing research effort to evaluate the impact of communicating risk information. The first phase of this project addresses the impact on women receiving the information, focusing on anxiety, risk perception, and uptake of referrals for follow-up services. Future phases will address effects on use of medical services, including diagnostic procedures and prevention interventions, and use of risk information by primary care providers and radiologists.
There is substantial variability in interpretation of mammography images and in the subsequent work-up of suspicious findings among radiology practices. An Athena Imaging consortium has initiated a project to standardize interpretation of mammograms and to establish reporting mechanisms that distinguish low- and high-risk findings. The group has developed a library of de-identified imaging cases with known clinical and pathologic outcomes. Ten UC radiologists evaluated images from a subset of 250 cases in this library and assigned BI-RADS scores (standardized mammography reporting categories) and risk estimates for invasive cancer and ductal carcinoma in situ (DCIS). Ultimately, the study will help to establish new standards and interventions to safely reduce unnecessary biopsies for benign and very low risk lesions.
Athena pathologists have undertaken an initiative to standardize staining and interpretation of breast cancer biomarkers, focusing on the immunohistochemical stains for estrogen and progesterone receptors (ER/PR), Her-2/neu, and Ki-67, collectively referred to as “IHC4”. Accuracy and reproducibility in the assessment of these biomarkers are important for guiding breast cancer treatment. Athena pathologists have implemented interventions to reduce technical and observer variation in IHC4 practice across the five UC medical centers. These efforts are intended to maintain the highest quality across the UC system and to facilitate implementation of multi-site clinical protocols, including an IHC4 tool for clinical use.
Improving Survivorship Care
Given the large and growing number of cancer survivors, optimizing survivorship care has become a national priority. An ongoing Athena study has generated information on practice patterns and structures for providing care for breast cancer survivors at each University of California medical center. Through semi-structured interviews with oncology specialists and primary care providers, the first phase of the study generated data on delivery of posttreatment breast cancer care. The research identified a need for greater care coordination within oncology and across other specialties within the UC system; it offered potential interventions to improve coordination and to avoid over- and under-utilization of services. Findings are reported in the article, “Provider perceptions and expectations of breast cancer posttreatment care,” published in the Journal of Cancer Survivorship in March 2013.
A multi-disciplinary Athena team has developed a roadmap for a risk-based screening mammography program, which would be offered to Athena participants as an alternative to usual care. Women who elect to participate in risk-based screening would receive a comprehensive risk assessment (including the current Athena questionnaire, single nucleotide polymorphism (SNP) testing, and breast density measurement). Their risk profiles would then be used to personalize screening frequency: very low risk women would be offered less frequent screening schedules while women at high risk would receive enhanced surveillance and prevention options.
Athena Innovations Become New Standards of Care
Athena is partnering with UC Care, a new self-insured health plan offering care for UC employees that will be provided by the five UC medical centers. Starting in 2014, the Athena Breast Health Network’s risk assessment and prevention counseling services–provided by the Athena Breast Health Specialists–will become a covered benefit to all UC employees and their dependents who enroll in the new UC Care plan and receive a mammogram at a UC medical center. Additional key benefits include the elimination of the prior authorization requirements for molecular profiling tests for breast cancer tumors, and a partial drug fill program that will allow cancer patients and their physicians to determine if a drug is well tolerated before filling and paying for a 30 day supply. The inclusion of Athena benefits into the UC Care health plan is an exciting step in creating a new standard of care and in developing a more sustainable model for the program.