Unlocking learner potential: A course director's experience building an Educational Escape Room for Cancer Risk Assessment

Using a traditional lecture format alone often limits students' opportunities to engage with and apply the concepts taught in a classroom. This report describes the design, curricular implementation, and application of an innovative educational escape room as an active learning tool for genetic counselor educators to teach cancer risk assessment skills. A Cancer Risk Assessment Escape Room is a novel way to offer experiential learning and to assess a learner's critical thinking and ability to apply cancer risk assessment models to evolving clinical scenarios. This successful implementation of an interactive escape room can be adapted to other genetic counseling competencies. The use of an escape room allows learners to actively engage in and apply content taught in lectures before entering clinical internships.

| 1223 REISER recommendations for general population and high-risk breast cancer to assess cancer risks and identify appropriate screening strategies based on risk (Figure 1).
Five evolving patient case scenarios were developed that included personal and family history breast cancer risk factors (Table 1).Learners were instructed to download the cancer risk assessment models and genetic testing guidelines prior to the activity.As participants entered the classroom, they drew color-coded keys identifying their team assignments.Teams were presented a pedigree with a family history of breast cancer.They were asked to incorporate expanding variables and for each to choose the most appropriate model for risk calculation.Each team calculated a 5-year and lifetime breast cancer risk and estimated a mutation probability for each scenario.In addition, they were asked to accurately assess changes in screening management and whether genetic testing was appropriate for each example.Color-coded team envelopes with correct and incorrect calculations and clinical management recommendations were offered to each group.Upon choosing the envelope with the correct risk estimate and intervention, a new key with the next set of clues (risk variables) was released.The last set of clues earned a final key to escape the room at the end of class.

| Modifications and reflection on utility
The Cancer Risk Assessment Escape Room was first incorporated into our Clinical Cancer Genetic course in early spring of 2020.The first year was an in-person classroom experience.Clues and keys were set up throughout the room.Although the physical classroom was small, learners responded favorably with competitive engagement.All students completed the activity within the one-hour class.
Through the experience, we learned that some of the student's personal computers were not compatible with all the risk assessment models.For this reason, we instructed future learners to download models and apply a test run in advance of the Escape Room.
Our University pivoted to remote learning due to the Covid-19 pandemic soon after the first Cancer Risk Assessment Escape Room.
Therefore, we developed a virtual Cancer Risk Assessment Escape Room.This was supported through the use of Zoom breakout rooms.
Learners were provided with the same scenarios and progressive clues.Similarly, learners used the cancer risk models to calculate breast cancer risks and, with correct risk estimates, were allowed to enter the next breakout room for the next clue.They again earned keys and escaped from one breakout room to the next.In the final breakout room, they were greeted with a key and message they had

What is known about this topic
The traditional lecture format limits opportunities for students to apply what they are learning in the classroom.
Evidence supports utilizing immersive learning experiences to promote content application, critical thinking, and student engagement in learning.We used the same clinical scenarios with only minor changes each year.As new genetic testing guidelines are published and risk assessment models are updated, instructors will likely need to reassess case scenarios, clues, and risk assessment answers annually.

| DISCUSS ION
A Cancer Risk Assessment Escape Room is an innovative way to assess a learner's critical thinking and knowledge about cancer risk assessment models.This experiential learning experience allows students to work through patient cases, integrate risk models and practice guidelines, and better engage with the content prior to their clinical rotations in cancer genetics.While our experience is limited to 3 years with a small number of learners (n = 24), this activity has been well received by learners.Students report they enjoyed a fun and creative way to learn about cancer risk assessment.Specific positive comments include, "the Escape Room activity allowed me to engage with the materials in an interactive way" and "the opportunity for kinesthetic learning is one that stands out to me." Future research is ongoing and includes evaluating the implementation and effectiveness of our Cancer Risk Assessment Escape Room.
escaped.In contrast to the previous in-person Escape Room where only one facilitator was in attendance, additional instructions and facilitators were required to support the virtual experience.A genetic counselor facilitator was present in each breakout room to address questions, assess correct risk estimates and move learners to the next room as they progressed through the case.Not all teams Cancer risk assessment escape room clues and keys.Gail, National Cancer Institute Breast Cancer Risk Assessment Tool at bcris ktool.cancer.gov;Claus, Claus tables from Claus et al., 1994; Tyrer-Cuzick, Tyrer-Cuzick Model Breast Cancer Risk Evaluation Tool version 8 at ibis.ikono pedia.com;NCCN, current National Comprehensive Cancer Network Genetic/Familial High Risk Assessment: Breast, Ovarian, and Pancreas Guidelines at NCCN.org; Chemoprevention; indication based on Gail model 5 year breast cancer risk of 1.7%; Breast MRI indication based on Lifetime breast cancer risk of ≥20%.
F I G U R E 1 Required knowledge/ implementation for evolving cancer risk assessment variables.TA B L E 1