Attitudes and training needs of oncologists and surgeons in mainstreaming breast cancer genetic counseling in a low‐to‐middle income Asian country

Abstract

With the advent of poly‐ADP‐ribose polymerase inhibitor (PARPi) therapies, the focus of genetic testing for breast, ovarian, and other cancers has shifted from risk management to treatment decision‐making in high‐resource settings. Due to the shortage of genetic counselors worldwide, alternative ways of delivering genetic counseling have been explored, including training nongenetics healthcare professionals (NGHPs) to provide genetic counseling. However, little is known about the feasibility of adopting such models in healthcare settings with insufficient specialists, where population health literacy is low and where access to new therapies may be limited. In this study, we evaluated the attitudes, considerations, and self‐efficacy of oncologists, breast surgeons, and general surgeons in mainstreaming breast cancer genetic counseling in Malaysia, a middle‐income Asian country with a universal healthcare system. We developed a 32‐item survey via a modified Delphi method, which was then distributed via a purposive and network sampling approach. While 77% of respondents expressed interest in providing breast cancer genetic counseling, 85% preferred to refer patients directly to genetic services for genetic counseling and testing. The main considerations for mainstreaming were the cost of genetic testing and PARPi therapy, as well as the availability of support from genetics professionals. Respondents reported a lack of confidence in communicating genetic risk, particularly to patients with poor health literacy, and in the clinical management of patients with variants of uncertain significance. Our results highlight the urgent need to train more NGHPs in providing genetic counseling and testing in low‐to‐middle income countries, and suggest that the mainstay for genetic counseling in this setting may be for risk management rather than access to PARPi therapy.

Surgical Oncologists and Nurses in Breast Cancer Care are Ready to Provide Pre-Test Genetic Counseling

“…shown conflicting results, with both HCPs having a positive attitude toward mainstream GT, 17,18,24 but also expressing concern about their ability to provide adequate pre-test GC. 13,19,21 A possible explanation for the positive attitude and high participation rate in our training is the close involvement of HCPs in shaping our new pathway. This allowed them to raise concerns and consider the new pathway.…”

“…This is notable, because previous research into mainstream GT in breast cancer care has shown significant involvement of oncologists between 30 and 100%, probably due to differences in care pathways. 19,[34][35][36][37] In our study, patients eligible for GT were initially seen by the surgical team. However, the importance of GT by medical oncologists is expected to increase due to the rise of PARP-inhibiting therapies in carriers of germline BRCA1/2 pathogenic variants.…”

“…[15][16][17] Ideally, these initiatives include training, because many HCPs lack knowledge or confidence to offer pre-test GC. 13,[18][19][20][21] Mainstream GT has been shown to be feasible and acceptable for both patients and HCPs. 22,23 However, research has focused primarily on ovarian cancer patients.…”

Safety of Pregnancy After Breast Cancer in BRCA Mutation Carriers

“…5 Similar access issues are seen in Southeast Asia. [6][7][8] Disparate access to these technologies in the low-and middle-income countries of Africa and Asia is especially alarming in the context of their disproportionately rising rates of breast cancer, with much of these increases experienced by younger/premenopausal women. Data on agestandardized breast cancer incidence demonstrate the highest burden of diagnoses among premenopausal-aged women in sub-Saharan Africa and in Southeast Asia relative to other regions of the world.…”

“…Despite frequency of triple-negative breast cancer (a documented risk factor for BRCA mutation-related hereditary cancer susceptibility) being notably higher in western sub–Saharan African women, population-based data on BRCA mutation carrier status are sparse because of testing costs and a lack of genetic counseling services . Similar access issues are seen in Southeast Asia …”