Background: Almost everyone has a family history of something. Unique to the VA, some Veterans are estranged from family or deployed when key health events occurred, so details may not be available. Regardless, collection of family history is part of the standard intake. Thus, Genomic Medicine Service fields many referrals to evaluate a ‘strong family history of…’ a variety of cancers that may not be accurately reported or are not hereditary. Three case studies will demonstrate the challenges of limited communication and conflicting expectations. We will then provide suggestions for improving genetic care for Veterans.
Case 1: “Are you saying I don’t need colonoscopies every 5 years starting at age 35?” This case involves a history of colon cancer in which testing the Veteran may impact medical management in the absence of genetic test results from the affected family member. It also addresses the importance of clarifying cancer types.
Case 2: “Well, maybe I can contact my family.” This Veteran reported she was estranged from her family–until the negative test result left her with an unacceptably high level of uncertainty.
Case 3: “What do you mean, you can’t interpret this blood test?” Genetic testing is not always ‘a simple blood test’, as demonstrated with this Veteran whose variant of uncertain significance (VUS) result won’t change medical management and may increase anxiety.
Discussion: In addition to professional guidelines, the relevant literature includes basic/discovery science and clinical implications of new genes with varying levels of penetrance. The lay press, with October as breast cancer awareness month (and March for colon cancer), has also increased public awareness, leading to Veteran-driven concerns. The major categories to be reviewed include professional guidelines, basic science, VUS reclassification, risk ascertainment models, testing strategies, and management studies.
Conclusions: Eight genetic counselors in Salt Lake City are providing clinical service for over 80 VAMCs and their associated CBOCs. The implications for clinical practice rest in developing clinical partnerships. These cases demonstrate the importance of the information included with the
referral. Also, the Veteran’s experience is enhanced when both the referring provider and genetic counselor share the same message regarding the genetic evaluation.
