Integration of Genetic Testing and Counseling in Patients With Breast Cancer in a Large, Multisite Community-Based Practice

Abstract

PURPOSE Despite data-driven consensus recommendations, there remains significant nonadherence to genetic screening and testing. More than 300,000 patients are diagnosed with breast cancer annually, with one third of these estimated to be eligible for homologous recombination deficiency (HRD)/BRCA testing following National Comprehensive Cancer Network (NCCN) guidelines. Only 35% of eligible patients are referred for genetic counseling. METHODS The goal of this project was to apply NCCN guidelines for germline genetic testing to all new patients with breast cancer within a large community oncology practice to improve HRD/BRCA testing. Plan-Do-Study-Act methodology was used, and cycles were built on a proven teaching infrastructure. In cycle 1, providers were educated and directed to use electronic health record (EHR) templates in the setting of an initial diagnosis visit and treatment planning. Discreet data fields were created in the EHR during cycle 2 to streamline and automate the process. Appropriate patients were referred to the genetics team for further evaluation, counseling, and testing. Adherence to the plan was maintained and measured using data analytic reports and chart audits. RESULTS Of the 1,203 patients with breast cancer eligible for inclusion, 1,200 (99%) were screened according to NCCN guidelines. Of the screened patients, 631 (52.5%) met the referral/testing criteria. In total, 585 (92.7%) of the 631 were referred to a genetic specialist. Seven percent had previous referrals. A total of 449 (71%) patients were acceptable to genetics referral while 136 (21.5%) patients refused. CONCLUSION The implemented methods of education, NCCN guidelines imbedded within provider notes, and discreet data fields in the EHR have proven to be highly effective in screening appropriate patients and ordering subsequent genetic referrals.

Breaking Barriers: Integrating Germline Testing With Oncology Care

“…The data from the study by Mendenhall et al 7 are encouraging and provide a blueprint for other community practices to use and build upon to increase the rate of screening and germline testing in eligible patients with cancer. Low referral and testing rates for germline testing are a well-recognized concern across the field of oncology, and these trends are exacerbated for minority populations.…”

“…In the article that accompanies this editorial, Mendenhall et al 7 describe how their practice improved compliance with National Comprehensive Cancer Network (NCCN) guidelines for germline testing for patients with breast cancer in a large community oncology setting by implementing a streamlined genetic screening workflow. This workflow focused on (1) improving provider education around NCCN guidelines for germline testing in breast cancer, (2) using an electronic health record template to screen patients with newly diagnosed breast cancer for germline testing, and (3) implementing an audit process designed to promote provider adherence.…”

“…While the workflow described by Mendenhall et al 7 was designed to be scalable for other oncology practices in the community setting, the national shortage of genetics providers, which disproportionately affects patients in rural settings, may hinder practices implementing similar workflows. 13 Insufficient access to genetic counseling services may increase patient wait time between receiving the referral for genetic testing and testing/post-test genetic counseling.…”