Implementing Population-level Screening, Brief Intervention, and Referral to Treatment (SBIRT) for Hazardous Alcohol Use in Routine Cancer Care as a Novel Means of Secondary Cancer Risk Reduction - ABSTRACT Alcohol use is the third leading preventable cause of cancer. Among cancer survivors, alcohol use increases the risk for both recurrence and development of new primary cancers. Despite this, nearly 80% of survivors, including those receiving cancer treatment, continue to drink alcohol, with 38% of drinkers doing so at hazardous levels. Alcohol-related cancer risk is not typically addressed in routine cancer care. Many oncology clinicians report receiving inadequate training on how to address alcohol use during clinical encounters and state that current workflows do not enable alcohol-related intervention, necessitating the need to standardize and support delivery of routine, population-level alcohol screening and intervention among survivors in cancer care. To address this practice gap, we propose a pragmatic effectiveness trial leveraging Zelen’s method to randomize 1,200 head, neck, and esophageal cancer survivors to either a multilevel Screening, Brief Intervention, and Referral to Treatment (SBIRT) intervention, “MI-TRACS” (Multilevel Intervention to Track and Reduce Alcohol Consumption among Survivors), delivered as part of routine cancer care, or Enhanced Usual Care (EUC; screening plus education). At the system-level, MI-TRACS integrates automated and routine alcohol use screening, documentation, and treatment referrals within the electronic health record (EHR). At the clinician-level, it provides clinician training and EHR-integrated clinical decision- support tools to facilitate survivors’ treatment uptake and reinforce clinician knowledge and practice change related to alcohol-specific cancer risk. At the survivor-level, MI-TRACS features an EHR-integrated, evidence- based brief intervention, tailored for survivors, with an optional referral for brief motivational interviewing (MI) sessions or, if indicated, addiction medicine treatment in a specialty clinic. We hypothesize that participation in MI-TRACS will reduce hazardous alcohol use to a greater extent than EUC among survivors at high risk for alcohol-related problems. To increase uptake and overcome common challenges to SBIRT implementation in clinical settings (e.g., lack of fit and poor EHR integration), we will engage with multilevel partners to optimize MI-TRACS delivery within the cancer clinic’s workflow and ensure seamless integration with the EHR (Aim 1). We will subsequently test MI-TRACS’ effectiveness (Aim 2) and assess the primary outcome, reduction of hazardous alcohol use among high-risk survivors, via EHR data at 3 and 6 months after the initial screening, as well as MI-TRACS' reach, adoption, implementation, and maintenance (Aim 3) among survivors, clinicians, and clinic staff. We will contextualize findings from the EHR (e.g., completion of the brief intervention (survivors) and use of the decision-support tools (clinicians)) with survey and semi-structured interview data. All study activities will be guided by the Practical, Robust Implementation and Sustainability Model (PRISM), an implementation science framework for use in both intervention planning and evaluation.
