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Conner S, Theoryn T, Dusic E, Beers F, Knerr S, Norquist B, Shirts BH, Bowen D, Swisher EM, Wang C. Primary care provider practices, attitudes, and confidence with hereditary cancer risk assessment and testing: A mixed methods study. Genet Med 2025; 27:101307. [PMID: 39484797 PMCID: PMC12068322 DOI: 10.1016/j.gim.2024.101307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 10/22/2024] [Accepted: 10/23/2024] [Indexed: 11/03/2024] Open
Abstract
PURPOSE This study sought to better understand primary care providers' readiness to conduct population-based risk assessment and offer genetic testing for hereditary cancer. METHODS Sixty primary care providers completed a survey assessing their current practices, attitudes, and confidence with cancer risk assessment and testing. Sixteen participated in follow-up interviews. Descriptive statistics are presented and supported by qualitative data. RESULTS Providers preferred direct questioning over standardized screening tools. In interviews, providers said they are not ordering cancer-risk genetic testing even when it might be appropriate. Ninety-eight percent agree testing is important to clinical care, but 73% agree that it could negatively affect patients. Ninety percent were willing to offer targeted testing, but only 68% were willing to offer population-based risk assessment. Confidence performing different behaviors necessary in a cancer risk assessment varied, with only 32% confident responding to questions specifically related to genetic testing. CONCLUSION Providers are willing to offer genetic testing but unlikely to do so because they lack confidence in genetics-specific skill areas. Unsystematic approaches to family history screening and fears about follow-up complexity may exacerbate health disparities. Interventions to increase provider confidence in ascertaining and managing hereditary cancer are needed to achieve widespread adoption of population-based risk assessment and guideline-recommended genetic testing.
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Affiliation(s)
- Sarah Conner
- Genetic Analysis Center, Department of Biostatistics, School of Public Health, University of Washington, Seattle, WA.
| | - Tesla Theoryn
- Institute for Public Health Genetics, School of Public Health, University of Washington, Seattle, WA; Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle, WA
| | - Emerson Dusic
- Institute for Public Health Genetics, School of Public Health, University of Washington, Seattle, WA; Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle, WA
| | - Faith Beers
- Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle, WA
| | - Sarah Knerr
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA
| | - Barbara Norquist
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, School of Medicine, University of Washington, Seattle, WA
| | - Brian H Shirts
- Institute for Public Health Genetics, School of Public Health, University of Washington, Seattle, WA; Department of Laboratory Medicine and Pathology, School of Medicine, University of Washington, Seattle, WA
| | - Deborah Bowen
- Institute for Public Health Genetics, School of Public Health, University of Washington, Seattle, WA; Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle, WA
| | - Elizabeth M Swisher
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, School of Medicine, University of Washington, Seattle, WA
| | - Catharine Wang
- Department of Community Health Sciences, School of Public Health, Boston University, Boston, MA
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Rusnak A, Goulet D, Morrison S, Champagne M, Keely E, Liddy C, Carroll JC. Utility of eConsult to enhance delivery of cancer genetic services and identify hereditary cancer knowledge gaps in primary care. GENETICS IN MEDICINE OPEN 2025; 3:103422. [PMID: 40342337 PMCID: PMC12059387 DOI: 10.1016/j.gimo.2025.103422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2024] [Revised: 03/03/2025] [Accepted: 03/04/2025] [Indexed: 05/11/2025]
Abstract
Purpose This study analyzed the utility of electronic consultation (eConsult) for hereditary cancer (HC) and aimed to identify primary care practitioner (PCP) knowledge gaps. Methods A retrospective mixed-methods study was used to evaluate 200 randomly selected PCP eConsult cases submitted to cancer genetics specialists in Ontario, Canada. Results In 65% (129/200) of eConsults, PCPs indicated they received clear advice for a new course of action. In 34% (68/200), referral was contemplated but now avoided. In 8% (16/200), referral was advised when not originally planned. For 89% (177/200), eConsult was considered valuable. For most, (63%, 125/200), PCPs agreed eConsult addressed a clinical problem that should be incorporated into continuing medical education. PCPs' questions were mainly about cancer screening (114), genetic testing (107), or genetics referral (76). Geneticist recommendations were mainly about cancer screening (154), genetics referral (104), and the High-Risk Ontario Breast Cancer Screening Program (41). PCP knowledge gaps identified included cancer screening guidelines (112), genetics referral criteria (100), High-Risk Ontario Breast Cancer Screening Program screening criteria (71), and understanding of genetics principles (237). Conclusion eConsult is an effective tool for PCP access to HC specialists. Identifiable knowledge gaps emerge that could be used to enhance continuing medical education and drive innovative HC service delivery.
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Affiliation(s)
- Alison Rusnak
- Department of Genetics, Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Danica Goulet
- Ontario eConsult Centre of Excellence, The Ottawa Hospital, Ottawa, ON, Canada
| | - Shawna Morrison
- Department of Genetics, Children’s Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Marjolaine Champagne
- Medical Genetics, Department of Pediatrics, Centre Hospitalier Universitaire Sainte- Justine, University of Montreal, Montreal, QC, Canada
| | - Erin Keely
- Ontario eConsult Centre of Excellence, The Ottawa Hospital, Ottawa, ON, Canada
- Division of Endocrinology and Metabolism, The Ottawa Hospital, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, ON, Canada
| | - Clare Liddy
- Ontario eConsult Centre of Excellence, The Ottawa Hospital, Ottawa, ON, Canada
- C.T. Lamont Primary Health Care Research Centre, Bruyere Research Institute, Ottawa, ON, Canada
- Department of Family Medicine, University of Ottawa, ON, Canada
| | - June C. Carroll
- Ray D. Wolfe Department of Family Medicine, Mount Sinai Hospital, Sinai Health, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, ON, Canada
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Swisher EM, Harris HM, Knerr S, Theoryn TN, Norquist BM, Brant J, Shirts BH, Beers F, Cameron D, Dusic EJ, Riemann LA, Devine B, Raff ML, Kadel R, Cabral HJ, Wang C. Strategies to Assess Risk for Hereditary Cancer in Primary Care Clinics: A Cluster Randomized Clinical Trial. JAMA Netw Open 2025; 8:e250185. [PMID: 40053353 PMCID: PMC11889468 DOI: 10.1001/jamanetworkopen.2025.0185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2024] [Accepted: 12/30/2024] [Indexed: 03/10/2025] Open
Abstract
Importance Best practices for improving access to assessment of hereditary cancer risk in primary care are lacking. Objective To compare 2 population-based engagement strategies for identifying primary care patients with a family or personal history of cancer and offering eligible individuals genetic testing for cancer susceptibility. Design, Setting, and Participants The EDGE (Early Detection of Genetic Risk) clinical trial cluster-randomized 12 clinics from 2 health care systems in Montana, Wyoming, and Washington state to 1 of 2 engagement approaches for assessment of hereditary cancer risk in primary care. The study population included 95 623 English-speaking patients at least 25 years old with a primary care visit during the recruitment window between April 1, 2021, and March 31, 2022. Intervention The intervention comprised 2 risk assessment engagement approaches: (1) point of care (POC), conducted by staff immediately preceding clinical appointments, and (2) direct patient engagement (DPE), where letter and email outreach facilitated at-home completion. Patients who completed risk assessment and met prespecified criteria were offered genetic testing via a home-delivered saliva testing kit at no cost. Main Outcomes and Measures Primary outcomes were the proportion of patients with a visit who (1) completed the risk assessment and (2) completed genetic testing. Logistic regression models were used to compare the POC and DPE approaches, allowing for overdispersion and including clinic as a design factor. An intention-to-treat analysis was used to evaluate primary outcomes. Results Over a 12-month window, 95 623 patients had a primary care visit across the 12 clinics. Those who completed the risk assessment (n = 13 705) were predominately female (64.7%) and aged between 65 and 84 years (39.6%). The POC approach resulted in a higher proportion of patients completing risk assessment than the DPE approach (19.1% vs 8.7%; adjusted odds ratio [AOR], 2.68; 95% CI, 1.72-4.17; P < .001) but a similar proportion completing testing (1.5% vs 1.6%; AOR, 0.96; 95% CI, 0.64-1.46; P = .86). Among those eligible for testing, POC test completion was approximately half of that for the DPE approach (24.7% vs 44.7%; AOR, 0.49; 95% CI, 0.37-0.64; P < .001). The proportion of tested patients identified with an actionable pathogenic variant was significantly lower for the POC approach than the DPE approach (3.8% vs 6.6%; AOR, 0.61; 95% CI, 0.44-0.85; P = .003). Conclusions and Relevance In this cluster randomized clinical trial of risk assessment delivery, POC engagement resulted in a higher rate of assessment of hereditary cancer risk than the DPE approach but a similar rate of genetic testing completion. Using a combination of engagement strategies may be the optimal approach for greater reach and impact. Trial Registration ClinicalTrials.gov Identifier: NCT04746794.
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Affiliation(s)
- Elizabeth M. Swisher
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Washington, Seattle
| | - Heather M. Harris
- Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle
| | - Sarah Knerr
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle
| | - Tesla N. Theoryn
- Institute for Public Health Genetics, School of Public Health, University of Washington, Seattle
- Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle
| | - Barbara M. Norquist
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Washington, Seattle
| | - Jeannine Brant
- Collaborative Science and Innovation, Billings Clinic, Billings, Montana
- Clinical Science & Innovation Department, City of Hope, Duarte, California
| | - Brian H. Shirts
- Institute for Public Health Genetics, School of Public Health, University of Washington, Seattle
- Department of Laboratory Medicine and Pathology, School of Medicine, University of Washington, Seattle
| | - Faith Beers
- Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle
| | - DaLaina Cameron
- Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle
| | - Emerson J. Dusic
- Department of Bioethics and Humanities, School of Medicine, University of Washington, Seattle
- Institute for Public Health Genetics, School of Public Health, University of Washington, Seattle
| | - Laurie A. Riemann
- Collaborative Science and Innovation, Billings Clinic, Billings, Montana
| | - Beth Devine
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle
- Department of Pharmacy, School of Medicine, University of Washington, Seattle
| | - Michael L. Raff
- Medical Genetics, Mary Bridge Children’s, MultiCare Health System, Tacoma, Washington
| | - Rabindra Kadel
- Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, Boston, Massachusetts
| | - Howard J. Cabral
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Catharine Wang
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts
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Liu YL, Sia TY, Varice N, Wu M, Byrne M, Khurram A, Kemel Y, Sheehan M, Galle J, Sabbatini P, Brown C, Roche KL, Chi D, Solit DB, Mueller J, Stadler ZK, Hamilton JG, Aghajanian C, Abu-Rustum NR. Optimizing Mainstreaming of Genetic Testing in Parallel With Ovarian and Endometrial Cancer Tumor Testing: How Do We Maximize Our Impact? JCO Precis Oncol 2024; 8:e2400525. [PMID: 39715484 DOI: 10.1200/po-24-00525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2024] [Revised: 10/05/2024] [Accepted: 11/22/2024] [Indexed: 12/25/2024] Open
Abstract
PURPOSE Although germline genetic testing (GT) is recommended for all patients with ovarian cancer (OC) and some patients with endometrial cancer (EC), uptake remains low with multiple barriers. Our center performs GT in parallel with somatic testing via a targeted sequencing assay (MSK-IMPACT) and initiates testing in oncology clinics (mainstreaming). We sought to optimize our GT processes for OC/EC. METHODS We performed a quality improvement study to evaluate our GT processes within gynecologic surgery/medical oncology clinics. All eligible patients with newly diagnosed OC/EC were identified for GT and tracked in a REDCap database. Clinical data and GT rates were collected by the study team, who reviewed data for qualitative themes. RESULTS From February 2023 to April 2023, we identified 116 patients with newly diagnosed OC (n = 57) and EC (n = 59). Patients were mostly White (62%); English was the preferred language for 90%. GT was performed in 52 (91%) patients with OC (seven external, 45 MSK-IMPACT) and in 44 (75%) patients with EC (three external, 41 MSK-IMPACT). GT results were available within 3 months for 100% and 95% of patients with OC and EC, respectively. Reasons for not undergoing GT included being missed by the clinical team where there was no record that GT was recommended, feeling overwhelmed, financial and privacy concerns, and language barriers. In qualitative review, we found that resources were concentrated in the initial visit with little follow-up to encourage GT at subsequent points of care. CONCLUSION A mainstreaming approach that couples somatic and germline GT resulted in high testing rates in OC/EC; however, barriers were identified. Processes that encourage GT at multiple care points and allow self-directed, multilingual digital consenting should be piloted.
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Affiliation(s)
- Ying L Liu
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical School, New York, NY
| | - Tiffany Y Sia
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Nancy Varice
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Michelle Wu
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Maureen Byrne
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Aliya Khurram
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Yelena Kemel
- Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Margaret Sheehan
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jesse Galle
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Paul Sabbatini
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical School, New York, NY
| | - Carol Brown
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Obstetrics and Gynecology, Weill Cornell Medical School, New York, NY
| | - Kara Long Roche
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Obstetrics and Gynecology, Weill Cornell Medical School, New York, NY
| | - Dennis Chi
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Obstetrics and Gynecology, Weill Cornell Medical School, New York, NY
| | - David B Solit
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical School, New York, NY
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Jennifer Mueller
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Obstetrics and Gynecology, Weill Cornell Medical School, New York, NY
| | - Zsofia K Stadler
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical School, New York, NY
| | - Jada G Hamilton
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Psychiatry, Weill Cornell Medical School, New York, NY
| | - Carol Aghajanian
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Medicine, Weill Cornell Medical School, New York, NY
| | - Nadeem R Abu-Rustum
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
- Department of Obstetrics and Gynecology, Weill Cornell Medical School, New York, NY
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Russell CD, Daley AV, Van Arnem DR, Hila AV, Johnson KJ, Davies JN, Cytron HS, Ready KJ, Armstrong CM, Sylvester ME, Caleshu CA. Validation of a guidelines-based digital tool to assess the need for germline cancer genetic testing. Hered Cancer Clin Pract 2024; 22:24. [PMID: 39516903 PMCID: PMC11545665 DOI: 10.1186/s13053-024-00298-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Accepted: 10/17/2024] [Indexed: 11/16/2024] Open
Abstract
BACKGROUND Efficient and scalable solutions are needed to identify patients who qualify for germline cancer genetic testing. We evaluated the clinical validity of a brief, patient-administered hereditary cancer risk assessment digital tool programmed to assess if patients meet criteria for germline genetic testing, based on personal and family history, and in line with national guidelines. METHODS We applied the tool to cases seen in a nationwide telehealth genetic counseling practice. Validity of the tool was evaluated by comparing the tool's assessment to that of the genetic counselor who saw the patient. Patients' histories were extracted from genetic counselor-collected pedigrees and input into the tool by the research team to model how a patient would complete the tool. We also validated the tool's assessment of which specific aspects of the personal and family history met criteria for genetic testing. Descriptive statistics were used. RESULTS Of the 152 cases (80% female, mean age 52.3), 56% had a personal history of cancer and 66% met genetic testing criteria. The tool and genetic counselor agreed in 96% of cases. Most disagreements (4/6; 67%) occurred because the genetic counselor's assessment relied on details the tool was not programmed to collect since patients typically don't have access to the relevant information (pathology details, risk models). We also found complete agreement between the tool and research team on which specific aspects of the patient's history met criteria for genetic testing. CONCLUSION We observed a high level of agreement with genetic counselor assessments, affirming the tool's clinical validity in identifying individuals for hereditary cancer predisposition testing and its potential for increasing access to hereditary cancer risk assessment.
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Affiliation(s)
- Callan D Russell
- Genome Medical, 611 Gateway Blvd Suite 120, South San Francisco, CA, 94080, USA
- Northside Hospital, 1000 Johnson Ferry Rd NE, Atlanta, GA, 30342, USA
| | - Ashley V Daley
- Genome Medical, 611 Gateway Blvd Suite 120, South San Francisco, CA, 94080, USA
| | - Durand R Van Arnem
- Genome Medical, 611 Gateway Blvd Suite 120, South San Francisco, CA, 94080, USA
| | - Andi V Hila
- Genome Medical, 611 Gateway Blvd Suite 120, South San Francisco, CA, 94080, USA
| | - Kiley J Johnson
- Genome Medical, 611 Gateway Blvd Suite 120, South San Francisco, CA, 94080, USA
| | - Jill N Davies
- Genome Medical, 611 Gateway Blvd Suite 120, South San Francisco, CA, 94080, USA
| | - Hanah S Cytron
- Genome Medical, 611 Gateway Blvd Suite 120, South San Francisco, CA, 94080, USA
| | - Kaylene J Ready
- GeneMatters, 611 Gateway Blvd Suite 120, South San Francisco, CA, 94080, USA
| | - Cary M Armstrong
- Genome Medical, 611 Gateway Blvd Suite 120, South San Francisco, CA, 94080, USA
| | - Mark E Sylvester
- Genome Medical, 611 Gateway Blvd Suite 120, South San Francisco, CA, 94080, USA
| | - Colleen A Caleshu
- Genome Medical, 611 Gateway Blvd Suite 120, South San Francisco, CA, 94080, USA.
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Chambers DA, Goddard KAB. Advancing Implementation Science in Cancer Genomics: Progressing from Discovery to Population Health Benefit. Public Health Genomics 2024; 27:161-167. [PMID: 39374589 DOI: 10.1159/000541577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Accepted: 09/17/2024] [Indexed: 10/09/2024] Open
Affiliation(s)
- David A Chambers
- Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
| | - Katrina A B Goddard
- Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Rockville, Maryland, USA
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Kaphingst KA, Kohlmann WK, Lorenz Chambers R, Bather JR, Goodman MS, Bradshaw RL, Chavez-Yenter D, Colonna SV, Espinel WF, Everett JN, Flynn M, Gammon A, Harris A, Hess R, Kaiser-Jackson L, Lee S, Monahan R, Schiffman JD, Volkmar M, Wetter DW, Zhong L, Mann DM, Ginsburg O, Sigireddi M, Kawamoto K, Del Fiol G, Buys SS. Uptake of Cancer Genetic Services for Chatbot vs Standard-of-Care Delivery Models: The BRIDGE Randomized Clinical Trial. JAMA Netw Open 2024; 7:e2432143. [PMID: 39250153 PMCID: PMC11385050 DOI: 10.1001/jamanetworkopen.2024.32143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 07/12/2024] [Indexed: 09/10/2024] Open
Abstract
Importance Increasing numbers of unaffected individuals could benefit from genetic evaluation for inherited cancer susceptibility. Automated conversational agents (ie, chatbots) are being developed for cancer genetics contexts; however, randomized comparisons with standard of care (SOC) are needed. Objective To examine whether chatbot and SOC approaches are equivalent in completion of pretest cancer genetic services and genetic testing. Design, Setting, and Participants This equivalence trial (Broadening the Reach, Impact, and Delivery of Genetic Services [BRIDGE] randomized clinical trial) was conducted between August 15, 2020, and August 31, 2023, at 2 US health care systems (University of Utah Health and NYU Langone Health). Participants were aged 25 to 60 years, had had a primary care visit in the previous 3 years, were eligible for cancer genetic evaluation, were English or Spanish speaking, had no prior cancer diagnosis other than nonmelanoma skin cancer, had no prior cancer genetic counseling or testing, and had an electronic patient portal account. Intervention Participants were randomized 1:1 at the patient level to the study groups at each site. In the chatbot intervention group, patients were invited in a patient portal outreach message to complete a pretest genetics education chat. In the enhanced SOC control group, patients were invited to complete an SOC pretest appointment with a certified genetic counselor. Main Outcomes and Measures Primary outcomes were completion of pretest cancer genetic services (ie, pretest genetics education chat or pretest genetic counseling appointment) and completion of genetic testing. Equivalence hypothesis testing was used to compare the study groups. Results This study included 3073 patients (1554 in the chatbot group and 1519 in the enhanced SOC control group). Their mean (SD) age at outreach was 43.8 (9.9) years, and most (2233 of 3063 [72.9%]) were women. A total of 204 patients (7.3%) were Black, 317 (11.4%) were Latinx, and 2094 (75.0%) were White. The estimated percentage point difference for completion of pretest cancer genetic services between groups was 2.0 (95% CI, -1.1 to 5.0). The estimated percentage point difference for completion of genetic testing was -1.3 (95% CI, -3.7 to 1.1). Analyses suggested equivalence in the primary outcomes. Conclusions and Relevance The findings of the BRIDGE equivalence trial support the use of chatbot approaches to offer cancer genetic services. Chatbot tools can be a key component of sustainable and scalable population health management strategies to enhance access to cancer genetic services. Trial Registration ClinicalTrials.gov Identifier: NCT03985852.
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Affiliation(s)
- Kimberly A. Kaphingst
- Huntsman Cancer Institute, Salt Lake City, Utah
- Department of Communication, University of Utah, Salt Lake City
| | | | | | - Jemar R. Bather
- School of Global Public Health, New York University, New York
| | | | | | - Daniel Chavez-Yenter
- Huntsman Cancer Institute, Salt Lake City, Utah
- Department of Communication, University of Utah, Salt Lake City
| | - Sarah V. Colonna
- Huntsman Cancer Institute, Salt Lake City, Utah
- Veterans Administration Medical Center, Salt Lake City, Utah
| | | | | | - Michael Flynn
- Department of Internal Medicine, University of Utah, Salt Lake City
- Department of Pediatrics, University of Utah, Salt Lake City
- Community Physicians Group, University of Utah Health, Salt Lake City
| | | | - Adrian Harris
- School of Global Public Health, New York University, New York
| | - Rachel Hess
- Department of Internal Medicine, University of Utah, Salt Lake City
- Department of Population Health Sciences, University of Utah, Salt Lake City
| | | | - Sang Lee
- Perlmutter Cancer Center, NYU Langone Health, New York
| | - Rachel Monahan
- Perlmutter Cancer Center, NYU Langone Health, New York
- Department of Population Health, NYU Grossman School of Medicine, New York
| | - Joshua D. Schiffman
- Huntsman Cancer Institute, Salt Lake City, Utah
- Department of Pediatrics, University of Utah, Salt Lake City
| | | | - David W. Wetter
- Huntsman Cancer Institute, Salt Lake City, Utah
- Department of Population Health Sciences, University of Utah, Salt Lake City
| | | | - Devin M. Mann
- Department of Population Health, NYU Grossman School of Medicine, New York
| | - Ophira Ginsburg
- Center for Global Health, National Cancer Institute, Rockville, Maryland
| | | | - Kensaku Kawamoto
- Department of Biomedical Informatics, University of Utah, Salt Lake City
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, University of Utah, Salt Lake City
| | - Saundra S. Buys
- Huntsman Cancer Institute, Salt Lake City, Utah
- Department of Internal Medicine, University of Utah, Salt Lake City
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8
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Wagner IM, Xuan Z, Lu H, Wang C. Racial Disparities in Accessing Care along the Continuum of Cancer Genetic Service Delivery. Cancer Epidemiol Biomarkers Prev 2024; 33:55-62. [PMID: 37819271 DOI: 10.1158/1055-9965.epi-23-0596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 08/01/2023] [Accepted: 10/09/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Public health calls to ensure equity in genomics and precision medicine necessitate a closer examination of how these efforts might differentially affect access to genetic services across demographic subgroups. This study set out to examine racial/ethnic disparities along the cancer genetic service delivery continuum. METHODS Retrospective data are drawn from 15 clinical sites across 6 U.S. States. Individuals who screened at-risk for hereditary cancer were: (i) referred/scheduled to see a genetic counselor (referral workflow), or (ii) offered genetic testing at the point-of-care (POC testing workflow). Logistic regression analyses evaluated the associations between race/ethnicity and several outcomes including appointment scheduling, genetic counseling, and genetic testing, controlling for demographics, clinical factors, and county-level covariates. RESULTS A total of 14,527 patients were identified at-risk. Genetic testing uptake was significantly higher at POC sites than referral sites (34% POC vs. 11% referral, P < 0.001). Race/ethnicity was significantly associated with testing uptake among all sites, with non-Hispanic Blacks having lower odds of testing compared with non-Hispanic Whites [aOR = 0.84; 95% confidence interval (CI), 0.71-1.00; P = 0.049]. Moreover, this disparity was observed at referral sites, but not POC sites. Among patients scheduled, non-Hispanic Blacks had lower odds of counseling (aOR = 0.28; 95% CI, 0.17-0.47; P < 0.001). CONCLUSIONS Findings suggest that factors influencing genetic counseling show rates may be driving disparities in genetic testing. IMPACT Strategies to reduce barriers to seeing a genetic counselor, including modifications to clinical workflow, may help mitigate racial/ethnic disparities in genetic testing.
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Affiliation(s)
- Ingrid M Wagner
- Department of Epidemiology and Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Ziming Xuan
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts
| | - Haibo Lu
- Cancer IQ, Inc., Chicago, Illinois
| | - Catharine Wang
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts
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