Cancer Risk Assessment for Personalized Screening and Prevention of Cancer

1. Cancer Risk Assessment for Personalized Screening and Prevention of Cancer Caroline Peterson, D.O. FACOOG Director, Cancer Screening and Prevention for Kettering Health Network

2. Innovation and Collaboration Results • Best Outcomes • Cost Savings • Revenue Enhancement Centered Centered • Patient Medical Home • Best Practice • Preventative Care • Quality Measures Concept • Population Health • Innovation/Technology • Evidence Based Medicine

4. Incorporating Hereditary Cancer Risk Assessment Into Your Practice

6. Summary: Currently known genetic markers for Breast Cancer ER- BrCa Pre-Menopausal ER+ BrCa Post-Menopausal

7. Precision Medicine

8. Risk Stratification

9. Moving Forward Together Moving Forward Together

10. Information Challenges Implementation Confusion

11. The Ambry C.A.R.E. Process Recommendations Customized Analyse Customized Efficiency Lake Health Systems – Recommended Ambry C.A.R.E. Workflow Progeny Screening & Risk Model Assessment Begin, and Progeny Risk Assessment Report is Generated Schedule Patient at CPC or GYN Clinic GT Results Reported within Progeny CPP Collects GT Sample / Submits to Ambry via Progeny/Ambry Port GT Order Patient Reviews Pre-Test Education Video Yes Notify Patient that they are considered High Risk – Provide High Risk Pamphlet Patient Meets Testing Criteria No Patient Notified w/ Avg Risk Pamphlet – Schedule next Screen 1 Yr out

12. Gynecological and Medical History

13. Surgical and Family History

14. Pedigree

15. Cancer Risk Assessment Calculation The clinician will click the “Calculate” button and all risk factors are sent to the CRA Health cancer risk calculator. Within 15 seconds, all CRA Health risk models send the cancer risk scores back to the patients Epic medical record discretely. Results will be available in the risk screening navigator and in the patients chart.

16. Cancer Risk Recommendations in Epic

17. Cancer Risk Results and Statements in Epic

18. MammoScreening ASSESSMENT : Negative (1) Recommendation Routine screening mammogram in 1 year. Cancer Risk Assessment was performed. Analysis reveals the following: 5-year breast cancer risk: 3.3% Lifetime breast cancer risk: 12.9% HNPCC Mutation risk (Lynch Syndrome) : 0.1% HBOC Risk: Elevated Risk Calculation Thresholds: >=20% LIFETIME BREAST, CONSIDER GENETIC TESTING AND BREAST MRI. >5% HNPCC Mutation risk (Lynch Syndrome), CONSIDER GENETIC TESTING. Elevated HBOC Risk, CONSIDER GENETIC TESTING. • HBOC Risk: Elevated

19. Case Example #1 CHEK2 positive result • Cancer Family History Information • Patient: breast ca (lobular) @ 50 • Mother: breast ca @ 46 • Maternal Grandmother: breast ca @ 56 • Patient Information • 57 year old female • DN, 3/25/1959 • Medicare Replacement • $0 out of pocket

20. Case Example #2 PMS2 positive result • Cancer Family History Information • Patient: NO CANCER DIAGNOSIS • Maternal Aunt: breast ca @ 50 • Maternal Grandmother: breast ca @ 67 • Paternal Uncle: CRC @ 62 • Paternal Cousin: CRC @ 35 • Patient Information • 31 year old female • NS, 6/9/1985 • Key Benefit Adminstrators • $0 out of pocket

21. Pedigree

22. Moving Forward Together Moving Forward Together

23. Case Example #3 HIGH RISK NEGATIVE result • Cancer Family History Information • Patient: NO CANCER DIAGNOSIS • Mother: breast ca @ 45 • Maternal Grandmother: breast ca @ 65 • Patient Information • 48 year old female • DEH, 9/19/1969 • Medical Mutual of OH • $0 out of pocket

24. Hereditary Risk Mutation & Risk Breast Ca Risk Breast Ca Claus Chemoprevention MRI Personalized screening Gail Chemoprevention Personalized screening Hormonal BRCAPRO Genetic Testing Chemoprevention MRI Personalized screening Tyrer Cuzick Genetic Testing Chemoprevention MRI Personalized screening Pathologic

25. MammoScreening ASSESSMENT : Negative (1) Recommendation Routine screening mammogram in 1 year. Cancer Risk Assessment was performed. Analysis reveals the following: 5-year breast cancer risk: 3.3% Lifetime breast cancer risk: 23% HNPCC Mutation risk (Lynch Syndrome) : 0.1% HBOC Risk: Elevated Risk Calculation Thresholds: >=20% LIFETIME BREAST, CONSIDER GENETIC TESTING AND BREAST MRI. >5% HNPCC Mutation risk (Lynch Syndrome), CONSIDER GENETIC TESTING. Elevated HBOC Risk, CONSIDER GENETIC TESTING. • Lifetime breast cancer risk: 23% • >=20% LIFETIME BREAST, CONSIDER GENETIC TESTING AND BREAST MRI.

26. Workflow-integrated Clinical Decision Support • Patient-entered family history and risk factors via Tablet or website • Risk calculations using standard models  Recommendations >20% risk of breast cancer(Tyrer Cuzick, BRCAPRO, Claus) • Elevated-Risk Patients Receive appropriate MBI/MRI Screening 26

27. Breast Cancer Develops Before it’s Detected

28. Chemoprevention • Risk Reducing Medications • SERMS : Selective Estrogen Regulating Modulators • Tamoxifen – Nalvadex, Soltamox • Raloxifene – Evista • Ospemifene – Osphena • Bazedoxifene + Conjugated Estrogen - Duavee

29. MammoScreening ASSESSMENT : Negative (1) Recommendation Routine screening mammogram in 1 year. Cancer Risk Assessment was performed. Analysis reveals the following: 5-year breast cancer risk: 3.3% Lifetime breast cancer risk: 23% HNPCC Mutation risk (Lynch Syndrome) : 5.6% HBOC Risk: Elevated Risk Calculation Thresholds: >=20% LIFETIME BREAST, CONSIDER GENETIC TESTING AND BREAST MRI. >5% HNPCC Mutation risk (Lynch Syndrome), CONSIDER GENETIC TESTING. Elevated HBOC Risk, CONSIDER GENETIC TESTING. • 5-year breast cancer risk: 3.3% • HNPCC Mutation risk (Lynch Syndrome) : 5.6% • >5% HNPCC Mutation risk (Lynch Syndrome), CONSIDER GENETIC TESTING. • Elevated HBOC Risk, CONSIDER GENETIC TESTING.

30. A single gene can be associated with multiple cancers. Multiple cancers can be associated with a single gene. If you are using a narrower testing approach, you may miss critical information, which may compromise patient outcomes.

33. Overall Objective Point A: Screening Sites Imaging, OB, GI, PCP Point B: Cancer Prevention Center

34. Preventive Care Navigation Surgery: Prophylactic Surgeries $ 5,4,97,800 Breast MRI: Annual Colonoscopy: More Frequent A Preventative Care: Ongoing management