Presented at The Menopause Society’s 2024 Annual Meeting

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Introduction:

Based on reported personal and family history, a substantial portion of the population is at increased risk of developing cancer and require additional risk management.  Ten percent of all U.S. women are at high risk for breast cancer and at least 4% of the US population is estimated to have an inherited cancer risk. Yet, many are unaware of their risk until diagnosed, reflecting significant gaps in routine screening. This inconsistency in cancer risk assessment underscores the urgent need for systematic risk assessment tools and long-term management strategies in routine care settings.

Numerous barriers contribute to the gap in effective cancer risk management. Providers often lack the time needed to collect detailed family histories, educate patients, and stay up-to-date with evolving genetic testing guidelines. Ambiguous eligibility criteria, complex test ordering processes, and limited access to genetic expertise all further complicate matters. Additionally, the steps in this process are usually fragmented rather than integrated into electronic medical records (EMRs), which impedes the efficient identification and management of at-risk individuals.

To address these challenges, Ms. Medicine, the largest women’s health focused concierge primary care network in the United States, partnered with Nest Genomics to implement Nest. Nest is an EMR-integrated, HIPAA-compliant software platform designed to seamlessly incorporate genetic data into patient care, enabling clinicians and patients to better personalize care and to manage individualized risk. 

Methods:

Ahead of their appointment, patients receive email or text invitations and reminders to complete a cancer risk assessment via the Nest patient navigator. Nest evaluates eligibility for genetic testing using national guidelines and specific breast cancer risk models for females. Within the EMR integrated Nest app, clinicians can review and modify the patient’s history, genetic testing eligibility, and recommended actions like breast MRI and chemoprevention. Clinicians can choose to order genetic testing, and Nest will send all the required information directly to the lab and return the structured results to the EMR. Nest’s clinical decision support then allows clinicians to create a personalized management plan based on the patient's risk and genetic results. Nest will automatically create orders within the EMR tied to actionable steps in the approved care plan and populate the encounter note. The Nest patient navigator helps patients understand their cancer risk and adhere to their care plan.

Results

Since implemented on January 21st 2024, the comprehensive cancer risk assessment was run on 66 patients at a new Ms. Medicine clinic in Ohio. 78 patients were invited to Nest to complete the risk assessment ahead of their appointment. Seventy opened the invite (90%) and of those, 66 (94%) completed the cancer risk assessment. For patients not invited ahead of visit (n=4) or invited not completed ahead of visit (n=5), a clinician ran the assessment within the Nest app in the EMR during the visit.  Three patients (3/66, 5%) received recommendations for both breast MRI and chemoprevention. Thirty three (50%) met genetic testing criteria, of those meeting criteria 16 (48%) had genetic testing ordered. Nest was used to create a personalized care plan for 30 patients and of those 17 (57%) reviewed the care plan when prompted by Nest. 

Conclusions

Implementing the Nest platform in concierge family medicine settings has proven to be a feasible and effective strategy for identifying and improving the management of at-risk individuals. The use of the Nest platform helps providers overcome barriers to cancer risk management and standardizes the process for all patients. The platform and its workflows will continue to be refined based on feedback from participants and clinicians, as well as screening uptake and outcomes. Nest and Ms. Medicine plan to expand to more sites and apply the insights gained from the cancer risk assessment workflow to other specialties, such as cardiology.

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