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Expanding Germline Hereditary Cancer Gene Panel Testing by Non-Genetics Providers: 3-year Experience in Large Integrated Healthcare Delivery System

Cancer Genetics and Therapeutics
  • Primary Categories:
    • Cancer
  • Secondary Categories:
    • Cancer
Introduction:
Demand for germline hereditary cancer genetic testing has increased due to reduced costs, gene discovery, expanding indications, and precision cancer therapies. The traditional model for germline testing- where a genetics provider performs all steps of the testing process including pre-test counseling, test ordering, results disclosure, and post-test counseling- is no longer able to meet testing needs, especially for cancer patients needing timely germline testing for treatment decisions. "Mainstreaming" has emerged as an alternative approach to increase testing capacity and efficiency, where non-genetics providers perform these steps, and genetics providers focus on post-test counseling for positive results. Mainstreaming for germline hereditary cancer genetic testing has only been implemented and studied on a small scale in hundred(s) of patients.

Methods:
This study reports a three-year experience with mainstreaming hereditary cancer gene panel testing at Kaiser Permanente Southern California (KPSC). The study compared demographic characteristics, cancer diagnoses, and test results between patients tested by genetics providers (traditional model) versus non-genetics providers (mainstreaming) over 3 years. Over 32,000 germline hereditary cancer gene panels were completed, including nearly 12,000 tests through mainstreaming.

Results:
Mainstreaming substantially increased testing capacity and volume. Patients undergoing mainstream testing were more likely to have cancer, be male, and self-report being Asian or Black than the non-mainstream group. The positive test rate was slightly lower in the mainstreaming group (11%) compared to the traditional testing model (15%), with similar rates of variants of uncertain significance (VUS). Post-test genetic counseling was high in both groups. 

Conclusion:
This study demonstrates that mainstreaming can be successfully implemented in a large healthcare system and significantly expand testing capacity. Mainstream approaches may reduce historical biases in access to germline heredtiary cancer genetic testing in medical genetics by certain racial/ethnic groups and for patients with less knowledge about their family history. 

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