PROJECT SUMMARY Brief and low-cost family history-based screening assessments to identify families at high risk for BRCA- associated cancers have been endorsed by national guidelines (e.g., USPSTF) and public health organizations (e.g., CDC). Public health departments offer an infrastructure for systematically reaching women historically left out of cancer genomic advances (e.g., uninsured, Black women, rural residents). Georgia is among the few states to have implemented statewide family history screening for BRCA-associated cancers. Despite its potential, current clinic-based approaches that identify at risk women are not sustainable and show limited reach. Additionally, uptake of follow-up cancer screening is suboptimal and solely focuses on women screened as high genetic risk. Therefore, we propose a two-phase study to adapt Georgia’s existing statewide family history screening program and evaluate its effectiveness to increase the number and diversity of women who receive family history assessment and the opportunity to access risk-stratified follow-up services. Guided by the Exploration, Preparation, Implementation and Sustainment (EPIS) framework, the aims of this two-phase study are: Phase I (Exploration & Preparation stages), Aim 1: Conduct a multilevel adaptation of GA CORE’s existing statewide family history screening program for BRCA-associated cancers to maximize sustainable program reach and improve communication suitability and effectiveness. Phase II (Implementation stage), Aim 2: Use a multi- site, parallel group, cluster randomized controlled trial to evaluate effectiveness of the adapted program relative to the current screening program in promoting uptake of family history screening and correct screening result interpretation among women ages 25 and older who are receiving care in up to 6 of 14 Public Health Clinics in Southwest Georgia. Secondary outcomes include the uptake of appropriate risk-stratified screening (e.g., high risk: genetic consultation and testing; low risk: appropriate breast imaging screening). Aim 3: Use the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework to conduct an implementation research evaluation to measure program process indicators (e.g., reach, fidelity, barriers/facilitators) that may influence program implementation and sustainability. Our application will be among the first to evaluate a sustainable multi-level population-based approach to implement evidence-based cancer genetic screening and to increase the likelihood for fair distribution of genomic advances among diverse populations in rural areas.

PROJECT NARRATIVE We propose to adapt Gegoria’s existing statewide family history screening program for BRCA-associated cancers with the goal to increase the number and diversity of women who receive family history assessment and the opportunity to access risk-stratified cancer prevention in rural public health clinics. Study findings will further inform program dissemination and sustainability across all 187 Georgia public health clinics, and yield insights enabling improved implementation of other genomic applications at the population level and among other rural, underserved communities.