Researchers from general obstetrics and gynecology (ob.gyn.) practices in New York and Connecticut have shown that (HBOC).
Dr. Michelle Lightfoot
Genetic screening and testing can reduce the morbidity and mortality from breast, ovarian, and endometrial cancers through prevention and early detection. Mark S. DeFrancesco, MD, of Westwood Women’s Health, Waterbury, Conn., and his colleagues reported that, in spite of the American College of Obstetricians and Gynecologists’ recommendation for ob.gyns. to regularly screen, counsel, and refer accordingly for HBOC (Obstet Gynecol. 2015;125:153843), the “incorporation of hereditary cancer risk assessment and testing remains underutilized in the [ob.gyn.] setting.” The authors have addressed this issue in their own practice with promising results and important caveats (Obstet Gynecol 2018;132:1121-9).
The intervention included a process evaluation, improvements to patient work flow, and training of providers by genetic counselors and engineering personnel from the testing laboratory (Myriad Genetics), which provided support for the study. Patients in the study completed a family history questionnaire and, those meeting National Comprehensive Cancer Center Network criteria for genetic testing, were given pretest counseling and offered testing on the same day or referral for testing within 2 weeks.
Of the 3,811 women who completed the questionnaire, 24% (906) met NCCN criteria, 90% of whom were offered testing. However, only 52% (165) of patients who agreed to testing underwent genetic evaluation. This included 70% of patients who were offered same-day testing and 35% of patients who were offered a referral appointment for testing.
Conversations about HBOC and genetic testing can be complicated and may not be a patient’s initial priority. The authors should be commended for identifying the vast majority of high-risk patients. However, only half of patients meeting criteria completed testing and 10% who should have been offered testing were not – numbers still well below target.
Incorporation of family history questionnaires should become commonplace in the generalist’s office and optimizing EHRs may be an opportunity for rapid risk interpretation. As the success of same-day genetic testing was striking, opportunities for partnerships with insurance companies and private laboratories are likely needed to make this a more feasible option. Lastly, assessing women’s knowledge and attitudes around genetic testing could help to more specifically address barriers to testing in future interventions.
Improving genetic screening and testing completion rates requires a coordinated effort. Using tools and applications to optimize convenience (same-day testing, telemedicine) and simplification (electronic screening platforms), we can strive to appropriately detect all women at high risk for hereditary breast and ovarian cancers.
Michelle Lightfoot is a gynecologic oncology fellow at the Ohio State University in Columbus. She has no relevant financial disclosures. Email her at obnews@mdedge.com.