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Effect of Breast Cancer Pathway Implementation on Rate of Referrals for Genetic Counseling and Testing


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In a study reported in JCO Oncology Practice, Stephanie L. Graff, MD, and colleagues found that patients with breast cancer seen by a physician with training in using an established pathway for genetic counseling and testing referral were more frequently referred for such services vs patients seen by non–pathway-trained physicians or those seen before pathway implementation.    

Stephanie L. Graff, MD

Stephanie L. Graff, MD

Study Details

The study included data on 3,113 eligible patients with a diagnosis of breast cancer between January 1999 and October 2018 within the Sarah Cannon Cancer Institute Network, covering seven regions across six states and including 38 nonacademic community-based health-care facilities. Pathway criteria for genetic counseling and testing referral were established in March 2016. Physician training and participation in the pathway program was voluntary, with no incentive offered for participation.

Patient eligibility criteria were the same as pathway criteria for genetic counseling and testing referral, consisting of any of the following:

  • Breast cancer onset younger than age 50
  • Male breast cancer
  • Two or more family members affected by breast or ovarian cancer (family or self)
  • Triple-negative biology younger than age 60
  • Two primary breast cancers
  • Ashkenazi Jewish ancestry.

Patients were divided into three cohorts: patients treated before pathway implementation (n = 988), those treated by non–pathway-trained physicians after pathways were established (n = 1,094), and those treated by pathway-trained physicians (n = 1,031). Nurse navigators documented eligible patients who were referred for genetic counseling and testing using a care coordination software system.

Key Findings

Overall, 71.8% of eligible patients were referred for genetic counseling and testing if treated by a pathway physician compared with 36.5% of patients treated by non–pathway-trained physicians  (P < .001 vs on-pathway) and 21.4% of patients treated before pathway implementation (P < .001 vs on-pathway; P < .001 vs off-pathway).

KEY POINTS

  • 71.8% of eligible patients were referred for genetic counseling and testing if treated by a pathway physician compared with 36.5% of patients treated by non–pathway-trained physicians and 21.4% of patients treated before pathway implementation.
  • “After implementation of pathways and appropriate training of physicians on those pathways, genetic counseling and testing referral among appropriate patients significantly improved,” according to the study authors.

In analysis of cohorts matched for age, race, and geographic location, rates of genetic counseling and testing referral were 71.1% for on-pathway patients vs 40.9% for off-pathway patients, 72.4% for on-pathway patients vs 26.8% for pre-pathway patients, and 39.1% for off-pathway patients vs 23.0% for pre-pathway patients, with all differences being statistically significant (all P < .017).   

The investigators concluded, “After implementation of pathways and appropriate training of physicians on those pathways, genetic counseling and testing referral among appropriate patients significantly improved. Pathway training represents a potential solution to improve genetic counseling and testing referral among patients with breast cancer.”

Dr. Graff, of Sarah Cannon Cancer Institute at HCA Midwest Health, is the corresponding author for the JCO Oncology Practice article.

Disclosure: For full disclosures of the study authors, visit ascopubs.org.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.
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