Project 1 BRAVE Strategy (Breast cancer Risk Assessment, achieVing Equity)

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PROJECT SUMMARY: FULL PROJECT 1 Each year ~12,000 women ages 18-45 are diagnosed with breast cancer in the United States (US). Overrepresentation of aggressive cancers, advanced stage disease at diagnosis, and inferior outcomes are seen in this population of young women. Further, breast cancer mortality disparities in young women result in increased early loss of life amongst women from low socioeconomic status (SES), those dwelling in rural areas, and those from racial minority groups. Access to care, delays in diagnosis and treatment, and differences in tumor biology partially explain these disparities. Identifying racially, geographically, and socioeconomically diverse young women at high risk for breast cancer offers an opportunity to reduce cancer disparities through early screening and detection of breast cancer. Integrating the use of existing breast cancer risk assessment (RA) tools into clinical care is a means to identify these young women. While RA is recommended for all women no later than age 30, this has not yet been translated to clinical practice and thus women are not receiving RA prior to the age of 50 years when screening is recommended for those at average risk. Women at high risk, in contrast, should start screening as young as age 25 (e.g., for those identified to have a BRCA1 or BRCA2 mutation). As most women ages 25-49 years of age do not now receive RA, and breast cancer in these women presents with a more aggressive phenotype at later stage associated with inferior outcomes, implementation strategies for RA in this age group should be developed. If women ages 25-49 receive RA and are identified as high-risk, they can be screened earlier than age 50 to diagnose cancer at an earlier stage, when the disease is most successfully treated. The central goal of the Breast cancer Risk Assessment: achieVing Equity (BRAVE) study is to reduce breast cancer disparities by testing strategies to implement evidence-based breast cancer RA in a state-level public health program that serves a racially and ethnically diverse population of low-income women. The BRAVE study aims to assess the feasibility, reach, acceptability, and appropriateness of select customized strategies to increase uptake of breast cancer RA. We will achieve these aims through conducting a novel, stepped-wedge trial employing a mixed methods study design. The primary outcome is the proportion of women aged 25-49 having RA. Secondary outcomes include the numbers of women: 1) identified as high-risk; 2) pursuing risk- adherent screening; and 3) diagnosed with breast cancer. Implementation outcomes include reach, feasibility, acceptability, and appropriateness. Data collected will inform a future multi-site cluster randomized clinical trial to test the implementation strategies on a larger scale over a longer duration, enriched for underserved populations such as minority and rural dwellers.