Pathways to Precision Cancer Care: Integrating Genetic Services into a Nationwide, Risk-Adjusted Cancer Program
Health Services and Implementation
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Primary Categories:
- Health services and Implementation
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Secondary Categories:
- Health services and Implementation
Introduction:
Some common cancers are driven by hereditary risk factors. However primary care providers often do not have the time or expertise to recognize significant indications in personal or family history, are unable to develop and follow-through on personalized cancer screening plans for high-risk individuals, and may be unfamiliar with eligibility criteria for genetic testing. There is a meaningful opportunity to drive improved care by connecting patient-provided information, genetic testing, and fully supported personalized cancer screening protocols.
Here, we describe a model for a risk-informed approach to cancer screening that integrates services in a telemedicine-based “Virtual Cancer Clinic”. Below we detail the implementation of the program, participant demographics, and health outcomes of the first 3,697 participants in this program. (NOTE: preliminary data, tracking to 10k participants by ACMG).
Methods:
Participants self-selected into the Virtual Cancer Clinic, offered as a part of their employer-sponsored healthcare. They provided relevant personal and family history through an online form or in conversation with an integrated healthcare provider (GC or MD). If the patient met NCCN testing criteria (or if the employer supported broader access to genetic testing), they were ordered an at-home clinical genetic test for 29 genes associated with hereditary cancer. Results were returned to participants immediately accompanied with a risk-adjusted cancer screening plan based on NCCN guidelines. Care gaps were identified, and patients were directly supported in addressing those gaps through at-home testing or ordering and scheduling support for in-person evaluations.
Results:
Of the 3,697 participants, the majority were assigned female at birth (59.2%), 49 years or younger (73.1%), and white (62.6%). Participants were located in 49 states, the District of Columbia, and Puerto Rico, with the highest concentration in California and Pennsylvania. A total of 1,509 (40.8%) completed genetic testing. 69 positive genetic findings were identified (4.6%), 34 of which were in individuals 39 years or younger, when screening and prevention can have a lifelong impact on cancer risk. The most common findings were in CHEK2, BRCA2, and ATM. Interestingly, about one fourth (27.5%, n=19) of positive results were in people from “open access” genetics programs that would not have met NCCN genetic testing criteria. All participants were offered post-test genetic counseling via phone, virtual consults with a physician, and care navigation. A total of 109 participants (7.2%) completed a physician consultation (n=25 positive and n=84 negative results), and 96 participants (6.4%) had a genetic counseling appointment (n=61 positive and n=35 negative results).
Of the 61 participants with positive genetic results who completed genetic counseling, 47 (77.0%) had gaps in their genetics-informed cancer screening. The care team helped schedule screenings or consults for 15 participants (31.9%), including 2 mammograms, 7 breast MRIs, 2 upper endoscopies, 1 colonoscopy, and 2 at-home PSA tests. The care team also made 9 referrals to local high-risk specialists such as breast and gynecologic surgeons, dermatologists, gastroenterologists, and genetics clinics for additional management. The remaining participants received genetic-informed cancer management counseling through the program but chose to pursue cancer screening independently. We present some common reasons patients report for why care gaps persisted or why they were unaware of their high-risk status.
Conclusion:
Taken together, these data suggest that a virtual, personalized cancer management model enables broad access to risk assessment and follow-up care. Integrating genetics into a cancer clinic enables a novel access point to comprehensive cancer risk assessment. The participant support services made available through this clinic – namely, genetic counselors, physicians, and care advocates – can help minimize health system burden and expedite risk-adjusted cancer screening and prevention for patients.
Some common cancers are driven by hereditary risk factors. However primary care providers often do not have the time or expertise to recognize significant indications in personal or family history, are unable to develop and follow-through on personalized cancer screening plans for high-risk individuals, and may be unfamiliar with eligibility criteria for genetic testing. There is a meaningful opportunity to drive improved care by connecting patient-provided information, genetic testing, and fully supported personalized cancer screening protocols.
Here, we describe a model for a risk-informed approach to cancer screening that integrates services in a telemedicine-based “Virtual Cancer Clinic”. Below we detail the implementation of the program, participant demographics, and health outcomes of the first 3,697 participants in this program. (NOTE: preliminary data, tracking to 10k participants by ACMG).
Methods:
Participants self-selected into the Virtual Cancer Clinic, offered as a part of their employer-sponsored healthcare. They provided relevant personal and family history through an online form or in conversation with an integrated healthcare provider (GC or MD). If the patient met NCCN testing criteria (or if the employer supported broader access to genetic testing), they were ordered an at-home clinical genetic test for 29 genes associated with hereditary cancer. Results were returned to participants immediately accompanied with a risk-adjusted cancer screening plan based on NCCN guidelines. Care gaps were identified, and patients were directly supported in addressing those gaps through at-home testing or ordering and scheduling support for in-person evaluations.
Results:
Of the 3,697 participants, the majority were assigned female at birth (59.2%), 49 years or younger (73.1%), and white (62.6%). Participants were located in 49 states, the District of Columbia, and Puerto Rico, with the highest concentration in California and Pennsylvania. A total of 1,509 (40.8%) completed genetic testing. 69 positive genetic findings were identified (4.6%), 34 of which were in individuals 39 years or younger, when screening and prevention can have a lifelong impact on cancer risk. The most common findings were in CHEK2, BRCA2, and ATM. Interestingly, about one fourth (27.5%, n=19) of positive results were in people from “open access” genetics programs that would not have met NCCN genetic testing criteria. All participants were offered post-test genetic counseling via phone, virtual consults with a physician, and care navigation. A total of 109 participants (7.2%) completed a physician consultation (n=25 positive and n=84 negative results), and 96 participants (6.4%) had a genetic counseling appointment (n=61 positive and n=35 negative results).
Of the 61 participants with positive genetic results who completed genetic counseling, 47 (77.0%) had gaps in their genetics-informed cancer screening. The care team helped schedule screenings or consults for 15 participants (31.9%), including 2 mammograms, 7 breast MRIs, 2 upper endoscopies, 1 colonoscopy, and 2 at-home PSA tests. The care team also made 9 referrals to local high-risk specialists such as breast and gynecologic surgeons, dermatologists, gastroenterologists, and genetics clinics for additional management. The remaining participants received genetic-informed cancer management counseling through the program but chose to pursue cancer screening independently. We present some common reasons patients report for why care gaps persisted or why they were unaware of their high-risk status.
Conclusion:
Taken together, these data suggest that a virtual, personalized cancer management model enables broad access to risk assessment and follow-up care. Integrating genetics into a cancer clinic enables a novel access point to comprehensive cancer risk assessment. The participant support services made available through this clinic – namely, genetic counselors, physicians, and care advocates – can help minimize health system burden and expedite risk-adjusted cancer screening and prevention for patients.