You really couldn’t fault breast cancer specialist Yanin Chavarri-Guerra, M.D., M.Sc., if occasionally during her hectic workday at Mexico City’s Salvador Zubirán National Institute of Health Sciences and Nutrition she stops, looks around, smiles and quietly says, “Gracias.”
That’s because a grateful Chavarri-Guerra and several colleagues across Mexico can now do much more for their patients thanks to a unique program created and put into place by a multidisciplinary “dream team” at City of Hope.
It’s called the Genomic Risk Assessment for Cancer Implementation and Sustainment, or GRACIAS, and its mission is just as big as its clever name: to bring life-changing and lifesaving genetic screening and counseling services — with an emphasis on breast cancer — to a population that desperately needs it.
“Access to genetic testing in Mexico is limited, mainly due to its high cost and lack of clinicians with specialized training,” Chavarri-Guerra recently wrote. This is especially troubling in a country where cancer diagnoses are on the rise and breast cancer is the leading cause of cancer death in women. A robust program of low cost genetic screening to search for factors causing inherited cancer risks, such as BRCA mutations, could go a long way toward preventing many cancer cases before they begin. But bringing such a program to Mexico, where even mammograms are hard to come by, is a daunting challenge.
City of Hope, a leader in research, clinical care and professional training in the fast-growing field of cancer genetics, decided to step in to help fill that void, drawing on its existing expertise.
From the beginning it was clear that the GRACIAS team would not just “parachute” into Mexico, spend some money, give a few lectures and leave. It took close to a decade to evolve the GRACIAS plan, methodically assessing the needs of physicians, patients and other stakeholders, then putting the proper pieces in place to make sure the program would take root and flourish.
A Systemic Approach
To achieve that goal, City of Hope turned to implementation science, an evolving research discipline that applies multiple methods and a systematic approach to facilitate the integration of evidence-based practice into clinical care.
“It’s basically looking at what’s not reaching people,” Blazer explained, “then getting all the key stakeholders engaged to identify barriers and work together to close the gap and get proven risk assessment and prevention services to patients and families.” Blazer and other team members recently described the process in an article in the Journal of Clinical Oncology.
Many oncologists at City of Hope already had relationships with counterparts in Mexico, based on years of conversations and conferences run by the American Society of Clinical Oncology and others. Those contacts helped shape the first phase of the project: identifying four hospitals and choosing 11 physicians to take part.
Chavarri-Guerra was one of the first selected.
“I joined GRACIAS in 2016 and spent a year in the Division of Clinical Cancer Genomics” at City of Hope,” she recalled. “When I came back to Mexico, I was able to open our own oncogenetics department, and it’s completely changed the way we evaluate patients.”
Low-Cost Screening
Training that first batch of doctors was an important first step. GRACIAS also secured grant money, primarily from the Breast Cancer Research Fund, to enable these newly minted experts to offer initial genetic screening services for about $20, a fraction of the typical cost, putting this critical tool within reach of thousands of people.
Well over 1,500 patients in Mexico have already taken advantage of this opportunity to learn about their risk and do something about it with preventive measures (such as risk-reduction surgeries). Plus, patients can share information about inherited risk to help get their at-risk loved ones screened — and this can slow or maybe even end a family’s legacy of cancer. “They [the patients] are so grateful!” Chavarri-Guerra said. “They feel empowered by the information they receive.”
GRACIAS also built a networking system — continuing professional education and training, discussion forums, conferences, site visits and one-to-one collaborations — to help sustain the program and make sure the doctors stay connected and get up-to-date support.
And growth is happening, physically and politically.
Several additional institutions have signed up for GRACIAS, including a booming program developed and directed by Cynthia Villarreal Garza, M.D., D.Sc., at Hospital Zambrano Hellion TecSalud, in Monterrey, and six other institutions across Mexico, all of which now get screening referrals from hospitals throughout Mexico.
Perhaps even more important, Chavarri-Guerra says the government of Mexico is slowly accepting the concept that genetic screening must be included in proper medical care. “I was invited by the Ministry of Health to consult on genetics,” she said. “And I believe it will soon become part of the norm.”
A Win-Win
The benefits of GRACIAS have proven to be a two-way win. Cancer genetics professionals in the U.S. are now reaching out to Chavarri-Guerra and her colleagues to refer the relatives of their high-risk patients from Mexico who would benefit from screening. And colleagues in the U.S. are inspired by the skill and dedication of their Mexican colleagues, especially their ability to “do more with less.”
“Things we’re learning in Mexico,” explained Blazer, “can help us here. Things like efficiencies in care, leveraging resources.” Plus, data gathered in Mexico will grow City of Hope’s genetic registry, perhaps ultimately making it possible to identify still more mutations that point to higher cancer risk. “These are things that bring benefits that cross all borders. It’s a wonderful success story.”
For information on the GRACIAS program or the City of Hope Intensive Course and Clinical Cancer Genomics Community of Practice, contact Kathleen Blazer at cgep@coh.org.