<type> <coding> <system value="http://terminology.hl7.org/CodeSystem/plan-definition-type"/> <code value="eca-rule"/> </coding> </type> <status value="draft"/> <experimental value="true"/> <date value="2024-10-22"/> <publisher value="MITRE"/> <contact> <name value="MITRE"/> <telecom> <system value="url"/> <value value="https://www.mitre.org/"/> </telecom> </contact> <description value="Women who are at increased risk for breast cancer without current or previous diagnosis of breast cancer or ductal carcinoma in situ (DCIS) can be referred to a breast specialty clinic to consider risk reduction interventions."/> <copyright value="(C) 2024 The MITRE Corporation. All Rights Reserved. Approved for Public Release: 24-2711. Distribution Unlimited. Unless otherwise noted, this work is available under an Apache 2.0 license. It was produced by the MITRE Corporation for the Division of Cancer Prevention and Control, Centers for Disease Control and Prevention in accordance with the Statement of Work, contract number 75FCMC18D0047, task order number 75D30123F17931."/> <approvalDate value="2024-10-22"/> <lastReviewDate value="2024-10-22"/> <author> <name value="The Health FFRDC, operated by The MITRE Corporation, in support of the Division of Cancer Prevention and Control, Centers for Disease Control and Prevention."/> </author> <editor> <name value="Division of Cancer Prevention and Control, Centers for Disease Control and Prevention"/> </editor> <reviewer> <name value="Division of Cancer Prevention and Control, Centers for Disease Control and Prevention"/> </reviewer> <endorser> <name value="Division of Cancer Prevention and Control, Centers for Disease Control and Prevention"/> </endorser> <library value="Library/HighRiskReferral|1.0.0"/> <action id="HighRiskReferralGenetic"> <title value="Referral for high risk breast specialty evaluation"/> <description value="Consider referral to breast specialist to discuss primary risk reduction interventions. These may include medications to reduce risk (chemoprevention), risk reducing surgery or enhanced surveillance. Women at greater risk, such as those with a genetic marker or syndrome associated with increased risk of breast cancer, may derive more benefit than harm from risk-reducing medications."/> <documentation> <type value="citation"/> <label value="USPSTF"/> <display value="Breast Cancer: Medication Use to Reduce Risk"/> <citation value="US Preventive Services Task Force. Medication Use to Reduce Risk of Breast Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2019;322(9):857–867."/> <url value="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-medications-for-risk-reduction"/> <document> <url value="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-medications-for-risk-reduction"/> </document> </documentation> <condition> <kind value="applicability"/> <expression> <language value="text/cql-identifier"/> <expression value="CheckIsIncludedAndNotExcluded"/> </expression> </condition> <condition> <kind value="applicability"/> <expression> <language value="text/cql-identifier"/> <expression value="ExistsHighRiskReferralGenetic"/> </expression> </condition> <definitionCanonical value="http://cancerscreeningcds.github.io/bcsm-cds/ActivityDefinition/HighRiskSpecialtyReferralRequest|1.0.0"/> <dynamicValue> <path value="code.coding[0]"/> <expression> <language value="text/cql-identifier"/> <expression value="HighRiskReferralCode"/> </expression> </dynamicValue> <dynamicValue> <path value="reasonCode[0].coding[0]"/> <expression> <language value="text/cql-identifier"/> <expression value="HighRiskReferralReason"/> </expression> </dynamicValue> </action> <action id="HighRiskReferralChestXRT"> <title value="Referral for high risk breast specialty evaluation"/> <description value="Consider referral to breast specialist to discuss primary risk reduction interventions. These may include medications to reduce risk (chemoprevention), risk reducing surgery or enhanced surveillance. Women at greater risk, such as those with a history of chest radiotherapy, may derive more benefit than harm from risk-reducing medications."/> <documentation> <type value="citation"/> <label value="USPSTF"/> <display value="Breast Cancer: Medication Use to Reduce Risk"/> <citation value="US Preventive Services Task Force. Medication Use to Reduce Risk of Breast Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2019;322(9):857–867."/> <url value="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-medications-for-risk-reduction"/> <document> <url value="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-medications-for-risk-reduction"/> </document> </documentation> <condition> <kind value="applicability"/> <expression> <language value="text/cql-identifier"/> <expression value="CheckIsIncludedAndNotExcluded"/> </expression> </condition> <condition> <kind value="applicability"/> <expression> <language value="text/cql-identifier"/> <expression value="ExistsHighRiskReferralChestXRT"/> </expression> </condition> <definitionCanonical value="http://cancerscreeningcds.github.io/bcsm-cds/ActivityDefinition/HighRiskSpecialtyReferralRequest|1.0.0"/> <dynamicValue> <path value="code.coding[0]"/> <expression> <language value="text/cql-identifier"/> <expression value="HighRiskReferralCode"/> </expression> </dynamicValue> <dynamicValue> <path value="reasonCode[0].coding[0]"/> <expression> <language value="text/cql-identifier"/> <expression value="HighRiskReferralReason"/> </expression> </dynamicValue> </action> <action id="HighRiskReferralAtypicalBiopsy"> <title value="Referral for high risk breast specialty evaluation"/> <description value="Consider referral to breast specialist to discuss primary risk reduction interventions. These may include medications to reduce risk (chemoprevention), risk reducing surgery or enhanced surveillance. Women at greater risk, such as those with a history of past atypical biopsy results, may derive more benefit than harm from risk-reducing medications."/> <documentation> <type value="citation"/> <label value="USPSTF"/> <display value="Breast Cancer: Medication Use to Reduce Risk"/> <citation value="US Preventive Services Task Force. Medication Use to Reduce Risk of Breast Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2019;322(9):857–867."/> <url value="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-medications-for-risk-reduction"/> <document> <url value="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-medications-for-risk-reduction"/> </document> </documentation> <condition> <kind value="applicability"/> <expression> <language value="text/cql-identifier"/> <expression value="CheckIsIncludedAndNotExcluded"/> </expression> </condition> <condition> <kind value="applicability"/> <expression> <language value="text/cql-identifier"/> <expression value="ExistsHighRiskReferralAtypicalBiopsy"/> </expression> </condition> <definitionCanonical value="http://cancerscreeningcds.github.io/bcsm-cds/ActivityDefinition/HighRiskSpecialtyReferralRequest|1.0.0"/> <dynamicValue> <path value="code.coding[0]"/> <expression> <language value="text/cql-identifier"/> <expression value="HighRiskReferralCode"/> </expression> </dynamicValue> <dynamicValue> <path value="reasonCode[0].coding[0]"/> <expression> <language value="text/cql-identifier"/> <expression value="HighRiskReferralReason"/> </expression> </dynamicValue> </action> <action id="HighRiskReferral5YRiskHigh"> <title value="Referral for high risk breast specialty evaluation"/> <description value="Refer to high risk breast specialist to discuss primary risk reduction interventions. These may include medications to reduce risk (chemoprevention), risk reducing surgery or enhanced surveillance. Women at greater risk, such as those with at least a 3% risk for breast cancer in the next 5 years, are likely to derive more benefit than harm from risk-reducing medications."/> <documentation> <type value="citation"/> <label value="USPSTF"/> <display value="Breast Cancer: Medication Use to Reduce Risk"/> <citation value="US Preventive Services Task Force. Medication Use to Reduce Risk of Breast Cancer: US Preventive Services Task Force Recommendation Statement. 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JAMA. 2019;322(9):857–867."/> <url value="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-medications-for-risk-reduction"/> <document> <url value="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-medications-for-risk-reduction"/> </document> </documentation> <condition> <kind value="applicability"/> <expression> <language value="text/cql-identifier"/> <expression value="CheckIsIncludedAndNotExcluded"/> </expression> </condition> <condition> <kind value="applicability"/> <expression> <language value="text/cql-identifier"/> <expression value="ExistsHighRiskReferral5YRiskHigherThanAverage"/> </expression> </condition> <definitionCanonical value="http://cancerscreeningcds.github.io/bcsm-cds/ActivityDefinition/HighRiskSpecialtyReferralRequest|1.0.0"/> <dynamicValue> <path value="code.coding[0]"/> <expression> <language value="text/cql-identifier"/> <expression value="HighRiskReferralCode"/> </expression> </dynamicValue> <dynamicValue> <path value="reasonCode[0].coding[0]"/> <expression> <language value="text/cql-identifier"/> <expression value="HighRiskReferralReason"/> </expression> </dynamicValue> </action> <action id="ConsiderLifeExpectancy"> <title value="Shared decision making for high risk specialty referral based on life expectancy"/> <description value="Patient may not be a candidate for chemoprevention if estimated life expectancy is < 10 years. 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JAMA. 2019;322(9):857–867."/> <url value="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-medications-for-risk-reduction"/> <document> <url value="https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/breast-cancer-medications-for-risk-reduction"/> </document> </documentation> <condition> <kind value="applicability"/> <expression> <language value="text/cql-identifier"/> <expression value="CheckIsIncludedAndNotExcluded"/> </expression> </condition> <condition> <kind value="applicability"/> <expression> <language value="text/cql-identifier"/> <expression value="ExistsConsiderLifeExpectancy"/> </expression> </condition> <definitionCanonical value="http://cancerscreeningcds.github.io/bcsm-cds/ActivityDefinition/CommunicateSDMConsiderLifeExpectancy|1.0.0"/> <dynamicValue> <path value="code.coding[0]"/> <expression> <language value="text/cql-identifier"/> <expression value="ConsiderLifeExpectancyCode"/> </expression> </dynamicValue> <dynamicValue> <path value="reasonCode[0].coding[0]"/> <expression> <language value="text/cql-identifier"/> <expression value="ConsiderLifeExpectancyReason"/> </expression> </dynamicValue> </action> <action id="HighRiskAssessment"> <title value="Perform 5 year risk assessment"/> <description value="A 5 year risk assessment, either informal or formal using a validated instrument, will help determine if the patient may benefit from referral for high risk breast specialty evaluation. 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These may include: increasing age, younger age at menarche, older age at first live birth, nulliparity/lower parity, number of prior breast biopsies, heterogeneously and/or extremely dense breasts."/> <definitionCanonical value="http://cancerscreeningcds.github.io/bcsm-cds/ActivityDefinition/5YearRiskAssessmentRequest|1.0.0"/> <dynamicValue> <path value="code.coding[0]"/> <expression> <language value="text/cql-identifier"/> <expression value="HighRiskAssessmentCode"/> </expression> </dynamicValue> <dynamicValue> <path value="reasonCode[0].coding[0]"/> <expression> <language value="text/cql-identifier"/> <expression value="HighRiskAssessmentReason"/> </expression> </dynamicValue> </action> <action id="5YRiskAssessmentTool"> <title value="5 year risk assessment instrument"/> <description value="The NCI Breast Cancer Risk Assessment Tool and the Breast Cancer Surveillance Consortium Risk Calculator are based on models tested in US populations and are publicly available for clinicians and patients to use."/> <documentation> <type value="documentation"/> <label value="NCI Breast Cancer Risk Assessment Tool"/> <display value="National Cancer Institute (NCI) Breast Cancer Risk Assessment Tool"/> <url value="https://bcrisktool.cancer.gov/"/> <document> <url value="https://bcrisktool.cancer.gov/"/> </document> </documentation> <documentation> <type value="documentation"/> <label value="BCSC Risk Calculator"/> <display value="Breast Cancer Surveillance Consortium (BCSC) Risk Calculator"/> <url value="https://tools.bcsc-scc.ucdavis.edu/BC5yearRisk"/> <document> <url value="https://tools.bcsc-scc.ucdavis.edu/BC5yearRisk"/> </document> </documentation> <definitionCanonical value="http://cancerscreeningcds.github.io/bcsm-cds/ActivityDefinition/5YearRiskAssessmentRequest|1.0.0"/> <dynamicValue> <path value="code.coding[0]"/> <expression> <language value="text/cql-identifier"/> <expression value="HighRiskAssessmentToolCode"/> </expression> </dynamicValue> <dynamicValue> <path value="reasonCode[0].coding[0]"/> <expression> <language value="text/cql-identifier"/> <expression value="HighRiskAssessmentToolReason"/> </expression> </dynamicValue> </action> </action> </PlanDefinition>

Id: flow-HighRiskReferral

Url: High Risk Referral

Version: 1.0.0

Title: High Risk Referral

Status: draft

Experimental: true

Type:

system: http://terminology.hl7.org/CodeSystem/plan-definition-type

code: eca-rule

Date: 2024-10-22

Publisher: MITRE

Description:

Women who are at increased risk for breast cancer without current or previous diagnosis of breast cancer or ductal carcinoma in situ (DCIS) can be referred to a breast specialty clinic to consider risk reduction interventions.

Knowledge Capability: executable

Knowledge Representation Level: structured

Copyright:

(C) 2024 The MITRE Corporation. All Rights Reserved. Approved for Public Release: 24-2711. Distribution Unlimited. Unless otherwise noted, this work is available under an Apache 2.0 license. It was produced by the MITRE Corporation for the Division of Cancer Prevention and Control, Centers for Disease Control and Prevention in accordance with the Statement of Work, contract number 75FCMC18D0047, task order number 75D30123F17931.

Approval Date: 2024-10-22

Libraries:

Library/HighRiskReferral|1.0.0

Actions:

Referral for high risk breast specialty evaluation: Consider referral to breast specialist to discuss primary risk reduction interventions. These may include medications to reduce risk (chemoprevention), risk reducing surgery or enhanced surveillance. Women at greater risk, such as those with a genetic marker or syndrome associated with increased risk of breast cancer, may derive more benefit than harm from risk-reducing medications.
If: Applicability: (CheckIsIncludedAndNotExcluded)
Applicability: (ExistsHighRiskReferralGenetic)
Then: Definition: http://cancerscreeningcds.github.io/bcsm-cds/ActivityDefinition/HighRiskSpecialtyReferralRequest|1.0.0
Dynamic Values:
code.coding[0]: (HighRiskReferralCode)
reasonCode[0].coding[0]: (HighRiskReferralReason)

Referral for high risk breast specialty evaluation: Consider referral to breast specialist to discuss primary risk reduction interventions. These may include medications to reduce risk (chemoprevention), risk reducing surgery or enhanced surveillance. Women at greater risk, such as those with a history of chest radiotherapy, may derive more benefit than harm from risk-reducing medications.
If: Applicability: (CheckIsIncludedAndNotExcluded)
Applicability: (ExistsHighRiskReferralChestXRT)
Then: Definition: http://cancerscreeningcds.github.io/bcsm-cds/ActivityDefinition/HighRiskSpecialtyReferralRequest|1.0.0
Dynamic Values:
code.coding[0]: (HighRiskReferralCode)
reasonCode[0].coding[0]: (HighRiskReferralReason)

Referral for high risk breast specialty evaluation: Consider referral to breast specialist to discuss primary risk reduction interventions. These may include medications to reduce risk (chemoprevention), risk reducing surgery or enhanced surveillance. Women at greater risk, such as those with a history of past atypical biopsy results, may derive more benefit than harm from risk-reducing medications.
If: Applicability: (CheckIsIncludedAndNotExcluded)
Applicability: (ExistsHighRiskReferralAtypicalBiopsy)
Then: Definition: http://cancerscreeningcds.github.io/bcsm-cds/ActivityDefinition/HighRiskSpecialtyReferralRequest|1.0.0
Dynamic Values:
code.coding[0]: (HighRiskReferralCode)
reasonCode[0].coding[0]: (HighRiskReferralReason)

Referral for high risk breast specialty evaluation: Refer to high risk breast specialist to discuss primary risk reduction interventions. These may include medications to reduce risk (chemoprevention), risk reducing surgery or enhanced surveillance. Women at greater risk, such as those with at least a 3% risk for breast cancer in the next 5 years, are likely to derive more benefit than harm from risk-reducing medications.
If: Applicability: (CheckIsIncludedAndNotExcluded)
Applicability: (ExistsHighRiskReferral5YRiskHigh)
Then: Definition: http://cancerscreeningcds.github.io/bcsm-cds/ActivityDefinition/HighRiskSpecialtyReferralRequest|1.0.0
Dynamic Values:
code.coding[0]: (HighRiskReferralCode)
reasonCode[0].coding[0]: (HighRiskReferralReason)

Consider referral for high risk breast specialty evaluation: Consider referral to breast specialist to discuss primary risk reduction interventions. These may include medications to reduce risk (chemoprevention), risk reducing surgery or enhanced surveillance.
If: Applicability: (CheckIsIncludedAndNotExcluded)
Applicability: (ExistsHighRiskReferral5YRiskHigherThanAverage)
Then: Definition: http://cancerscreeningcds.github.io/bcsm-cds/ActivityDefinition/HighRiskSpecialtyReferralRequest|1.0.0
Dynamic Values:
code.coding[0]: (HighRiskReferralCode)
reasonCode[0].coding[0]: (HighRiskReferralReason)

Shared decision making for high risk specialty referral based on life expectancy: Patient may not be a candidate for chemoprevention if estimated life expectancy is < 10 years. Factors that may impact this estimation should be considered prior to referral. A validated tool such as www.eprognosis.com can help guide decision making.
If: Applicability: (CheckIsIncludedAndNotExcluded)
Applicability: (ExistsConsiderLifeExpectancy)
Then: Definition: http://cancerscreeningcds.github.io/bcsm-cds/ActivityDefinition/CommunicateSDMConsiderLifeExpectancy|1.0.0
Dynamic Values:
code.coding[0]: (ConsiderLifeExpectancyCode)
reasonCode[0].coding[0]: (ConsiderLifeExpectancyReason)

Perform 5 year risk assessment: A 5 year risk assessment, either informal or formal using a validated instrument, will help determine if the patient may benefit from referral for high risk breast specialty evaluation. Women at higher than average 5 year risk may be candidates for referral to breast specialist to discuss primary risk reduction interventions. These may include medications to reduce risk (chemoprevention), risk reducing surgery or enhanced surveillance.
If: Applicability: (CheckIsIncludedAndNotExcluded)
Applicability: (ExistsHighRiskAssessment)
Then:

Informal 5 year risk assessment: Perform assessment based on personal risk factors conferring increased risk of breast cancer. These may include: increasing age, younger age at menarche, older age at first live birth, nulliparity/lower parity, number of prior breast biopsies, heterogeneously and/or extremely dense breasts.
Then: Definition: http://cancerscreeningcds.github.io/bcsm-cds/ActivityDefinition/5YearRiskAssessmentRequest|1.0.0
Dynamic Values:
code.coding[0]: (HighRiskAssessmentCode)
reasonCode[0].coding[0]: (HighRiskAssessmentReason)

5 year risk assessment instrument: The NCI Breast Cancer Risk Assessment Tool and the Breast Cancer Surveillance Consortium Risk Calculator are based on models tested in US populations and are publicly available for clinicians and patients to use.
Then: Definition: http://cancerscreeningcds.github.io/bcsm-cds/ActivityDefinition/5YearRiskAssessmentRequest|1.0.0
Dynamic Values:
code.coding[0]: (HighRiskAssessmentToolCode)
reasonCode[0].coding[0]: (HighRiskAssessmentToolReason)