Purpose: Cancer genetics is a rapidly evolving field, with new syndromes and new genes associated with familial cancer syndromes reported yearly. Traditionally, the VA has not focused on familial cancer syndromes; however, this is changing as intensive management of patients with a genetic cancer syndrome has been shown to affect survival. In addition, the latest American Cancer Society guidelines mandate that cancer risk evaluation be made available to maintain accreditation. The number and type of genetic cancer consult referrals can provide insight into the referrals that are expected within the VA system.
Method: A cancer risk evaluation clinic was set up and has been running since 2011. Patients were seen in the clinic, and a family pedigree was generated. Patients who were estimated by tables or probability models to have a 10% or greater likelihood of detecting a deleterious mutation were counseled, following American Society for Clinical Oncology guidelines and offered genetic testing. The type of consults and testing recommended are presented.
Results: The Raymond G. Murphy VAMC sees about 70 prostate cancer, 40 colorectal cancer (CRC), and 8 breast cancer cases per year. Fifty-four veterans were referred for genetic cancer risk evaluation in the first 2 years of the clinic. Of these, 20 were referred for possible BRCA testing, 10 for Lynch syndrome testing, 20 for evaluation of polyposis, and 3 for miscellaneous testing.
Conclusions: The study outlined the need for (1) a dedicated budget and facility contract with gene test providers for genetic testing; (2) quality control with evaluation by certified genetic counselors or equivalent; (3) continuing education of referring providers. Findings included that: (1) rates for BRCA referral seem to be consistent with those seen in private practice; (2) high referral rate for attenuated familial adenomatous polyposis (FAP), a rare disorder (< 0.5% of all CRC; likely due to robust VA screening program for CRC, but highlights need for more stringent criteria for attenuated FAP testing); and (3) low recognition/referral rate for Lynch syndrome (about 3% of all CRC) also highlights the need for general screening program.