Emily Heidt

Cost-Effectiveness of Remote Tailored Risk Communication and Navigation for Hereditary Genetic Risk Assessment Uptake: Economic Evaluation From the Genetic Risk Assessment for Cancer Education and Empowerment Trial

PURPOSE The Genetic Risk Assessment for Cancer Education and Empowerment Project demonstrated that tailored counseling and navigation (TCN) substantially increased the rate of genetic evaluation (GE) in women with high-risk breast or ovarian cancer (odds ratio, 8.9 [95% CI, 3.4 to 23.5] for TCN v usual care [UC]). This study sought to estimate the cost and cost-effectiveness of TCN in a clinic setting from a societal perspective. METHODS We identified the components of the intervention and downstream outcomes which would result in resource use. We assessed time spent by staff, cost of mailings, cost of patient time, and cost of testing and counseling in 6 months. Incremental cost-effectiveness ratios were calculated for outcomes of interest. We assessed the sensitivity of our results to assumptions via one-way sensitivity analyses. In addition, we assessed how results would change if a higher volume of patients was given TCN, with a health coach working full-time. RESULTS TCN costs $68,924 in US dollars (USD) to deliver per 212 patients, or $325 USD per patient. The intervention cost was $2,154 USD per record-verified GE. Much of this was attributed to training costs for health coaches ($50,223 USD). When including testing and counseling, the incremental cost effectiveness ratio (ICER) of TCN versus UC was $3,250 USD per additional GE. This was most sensitive to TCN effectiveness (ie, GE rate in TCN patients) and cost of testing. Cost-effectiveness would be more favorable with higher coaching volume (ICER of $1,730 USD/GE). CONCLUSION Implementing TCN in a clinic setting would come with notable costs, and current reimbursement policies for telemedicine may not be sufficient. Cost-effectiveness of TCN can be improved if subsequent interventions are more efficacious or are delivered to greater patient volumes.

Improving Uptake of Cancer Genetic Risk Assessment in a Remote Tailored Risk Communication and Navigation Intervention: Large Effect Size but Room to Grow

PURPOSECancer genetic risk assessment (CGRA) is recommended for women with ovarian cancer or high-risk breast cancer, yet fewer than 30% receive recommended genetic services, with the lowest rates among underserved populations. We hypothesized that compared with usual care (UC) and mailed targeted print (TP) education, CGRA uptake would be highest among women receiving a phone-based tailored risk counseling and navigation intervention (TCN).METHODSIn this three-arm randomized trial, women with ovarian or high-risk breast cancer were recruited from statewide cancer registries in Colorado, New Jersey, and New Mexico. Participants assigned to TP received a mailed educational brochure. Participants assigned to TCN received the mailed educational brochure, an initial phone-based psychoeducational session with a health coach, a follow-up letter, and a follow-up navigation phone call.RESULTSParticipants' average age was 61 years, 25.4% identified as Hispanic, 5.9% identified as non-Hispanic Black, and 17.5% lived in rural areas. At 6 months, more women in TCN received CGRA (18.7%) than those in TP (3%; odds ratio, 7.4; 95% CI, 3.0 to 18.3; P < .0001) or UC (2.5%; odds ratio, 8.9; 95% CI, 3.4 to 23.5; P < .0001). There were no significant differences in CGRA uptake between TP and UC. Commonly cited barriers to genetic counseling were lack of provider referral (33.7%) and cost (26.5%), whereas anticipated difficulty coping with test results (14.0%) and cost (41.2%) were barriers for genetic testing.CONCLUSIONTCN increased CGRA uptake in a group of geographically and ethnically diverse high-risk breast and ovarian cancer survivors. Remote personalized interventions that incorporate evidence-based health communication and behavior change strategies may increase CGRA among women recruited from statewide cancer registries.

Genetic Risk Assessment for Cancer Education and Empowerment (GRACE) Project

GRACE is a randomized 3-arm trial to determine the comparative effectiveness of two remote cancer communication interventions: 1) a targeted generic print (TP) or 2) a tailored telephone-based counseling and navigation intervention (TCN). Post-award, the target sample size was revised to (n=642) with NIH permission.