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Muessig KR, Zepp JM, Keast E, Shuster EE, Reyes AA, Arnold B, Ingphakorn C, Gilmore MJ, Kauffman TL, Hunter JE, Knerr S, Feigelson HS, Goddard KAB. Retrospective assessment of barriers and access to genetic services for hereditary cancer syndromes in an integrated health care delivery system. Hered Cancer Clin Pract 2022; 20:7. [PMID: 35144679 PMCID: PMC8832647 DOI: 10.1186/s13053-022-00213-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 01/30/2022] [Indexed: 12/18/2022] Open
Abstract
Background A critical step in access to genetic testing for hereditary cancer syndromes is referral for genetic counseling to assess personal and family risk. Individuals meeting testing guidelines have the greatest need to be evaluated. However, referrals to genetics are underutilized in US patients with hereditary cancer syndromes, especially within traditionally underserved populations, including racial and ethnic minorities, low-income, and non-English speaking patients. Methods We studied existing processes for referral to genetic evaluation and testing for hereditary cancer risk to identify areas of potential improvement in delivering these services, especially for traditionally underserved patients. We conducted a retrospective review of 820 referrals to the Kaiser Permanente Northwest (KPNW) genetics department containing diagnosis codes for hereditary cancer risk. We classified referrals as high- or low-quality based on whether sufficient information was provided to determine if patients met national practice guidelines for testing. Through chart abstraction, we also assessed consistency with practice guidelines, whether the referral resulted in a visit to the genetics department for evaluation, and clinical characteristics of patients receiving genetic testing. Results Most referrals (n = 514, 63%) contained sufficient information to assess the appropriateness of referral; of those, 92% met practice guidelines for genetic testing. Half of referred patients (50%) were not offered genetic evaluation; only 31% received genetic testing. We identified several barriers to receiving genetic evaluation and testing, the biggest barrier being completion of a family history form sent to patients following the referral. Those with a referral consistent with testing guidelines, were more likely to receive genetic testing than those without (39% vs. 29%, respectively; p = 0.0058). Traditionally underserved patients were underrepresented in those receiving genetic evaluation and testing relative to the overall adult KPNW population. Conclusions Process improvements are needed to increase access to genetic services to diagnose hereditary cancer syndromes prior to development of cancer.
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Affiliation(s)
- Kristin R Muessig
- Department of Translational and Applied Genomics, Center for Health Research, Kaiser Permanente Northwest, 3800 N Interstate Avenue, Portland, OR, 97227, USA.
| | - Jamilyn M Zepp
- Department of Translational and Applied Genomics, Center for Health Research, Kaiser Permanente Northwest, 3800 N Interstate Avenue, Portland, OR, 97227, USA
| | - Erin Keast
- Center for Health Research, Kaiser Permanente Northwest, 3800 N Interstate Avenue, Portland, OR, 97227, USA
| | - Elizabeth E Shuster
- Center for Health Research, Kaiser Permanente Northwest, 3800 N Interstate Avenue, Portland, OR, 97227, USA
| | - Ana A Reyes
- Department of Translational and Applied Genomics, Center for Health Research, Kaiser Permanente Northwest, 3800 N Interstate Avenue, Portland, OR, 97227, USA
| | - Briana Arnold
- Department of Translational and Applied Genomics, Center for Health Research, Kaiser Permanente Northwest, 3800 N Interstate Avenue, Portland, OR, 97227, USA
| | - Chalinya Ingphakorn
- Center for Health Research, Kaiser Permanente Northwest, 3800 N Interstate Avenue, Portland, OR, 97227, USA
| | - Marian J Gilmore
- Department of Translational and Applied Genomics, Center for Health Research, Kaiser Permanente Northwest, 3800 N Interstate Avenue, Portland, OR, 97227, USA
| | - Tia L Kauffman
- Department of Translational and Applied Genomics, Center for Health Research, Kaiser Permanente Northwest, 3800 N Interstate Avenue, Portland, OR, 97227, USA
| | - Jessica Ezzell Hunter
- Department of Translational and Applied Genomics, Center for Health Research, Kaiser Permanente Northwest, 3800 N Interstate Avenue, Portland, OR, 97227, USA
| | - Sarah Knerr
- Department of Health Services, University of Washington, 1959 NE Pacific Street, Seattle, WA, 98195, USA
| | - Heather S Feigelson
- Institute for Health Research Kaiser Permanente Colorado, 10065 E Harvard Avenue #300, Denver, CO, 80231, USA
| | - Katrina A B Goddard
- Department of Translational and Applied Genomics, Center for Health Research, Kaiser Permanente Northwest, 3800 N Interstate Avenue, Portland, OR, 97227, USA
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Nazareth S, Hayward L, Simmons E, Snir M, Hatchell KE, Rojahn S, Slotnick RN, Nussbaum RL. Hereditary Cancer Risk Using a Genetic Chatbot Before Routine Care Visits. Obstet Gynecol 2021; 138:860-870. [PMID: 34735417 PMCID: PMC8594498 DOI: 10.1097/aog.0000000000004596] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/26/2021] [Accepted: 09/02/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine user uptake and experience with a clinical chatbot that automates hereditary cancer risk triage by collecting personal and family cancer history in routine women's health care settings. METHODS We conducted a multicenter, retrospective observational study of patients who used a web-based chatbot before routine care appointments to assess their risk for hereditary breast and ovarian cancer, Lynch syndrome, and adenomatous polyposis syndromes. Outcome measures included uptake and completion of the risk-assessment and educational section of the chatbot interaction and identification of hereditary cancer risk as evaluated against National Comprehensive Cancer Network criteria. RESULTS Of the 95,166 patients invited, 61,070 (64.2%) engaged with the clinical chatbot. The vast majority completed the cancer risk assessment (89.4%), and most completed the genetic testing education section (71.4%), indicating high acceptability among those who opted to engage. The mean duration of use was 15.4 minutes (SD 2 hours, 56.2 minutes) when gaps of inactivity longer than 5 minutes were excluded. A personal history of cancer was reported by 19.1% (10,849/56,656) and a family history of cancer was reported by 66.7% (36,469/54,652) of patients who provided the relevant information. One in four patients (14,850/54,547) screened with the chatbot before routine care appointments met National Comprehensive Cancer Network criteria for genetic testing. Among those who were tested, 5.6% (73/1,313) had a disease-causing pathogenic variant. CONCLUSION A chatbot digital health tool can help identify patients at high risk for hereditary cancer syndromes before routine care appointments. This scalable intervention can effectively provide cancer risk assessment, engage patients with educational information, and facilitate a path toward preventive genetic testing. FUNDING SOURCE Implementation of the chatbot in clinics was funded by industry support from commercial genetic testing laboratories Ambry, Invitae, and Progenity.
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Yoon S, Goh H, Fung SM, Tang S, Matchar D, Ginsburg GS, Orlando LA, Ngeow J, Wu RR. Experience and Perceptions of a Family Health History Risk Assessment Tool among Multi-Ethnic Asian Breast Cancer Patients. J Pers Med 2021; 11:jpm11101046. [PMID: 34683187 PMCID: PMC8536959 DOI: 10.3390/jpm11101046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 10/07/2021] [Accepted: 10/18/2021] [Indexed: 11/16/2022] Open
Abstract
A family health history-based risk assessment is particularly valuable for guiding cancer screening and treatment strategies, yet an optimal implementation depends upon end-users' values and needs. This is not only true prior to disease development, but also for those already affected. The aim of this study is to explore perceptions of the value of knowing one's family health history (FHH)-based risk, experience using a patient-facing FHH tool and the potential of the tool for wider implementation. Twenty multi-ethnic Asian patients undergoing breast cancer treatment in Singapore completed an FHH-based risk assessment. Semi-structured one-on-one interviews were conducted and data were thematically analyzed. All participants were female and slightly more than half were Chinese. The acceptance and usage of an FHH risk assessment tool for cancers and its broader implementation was affected by a perceived importance of personal control over early detection, patient concerns of anxiety for themselves and their families due to risk results, concerns for genetic discrimination, adequacy of follow-up care plans and Asian cultural beliefs toward disease and dying. This study uniquely sheds light on the factors affecting Asian breast cancer patients' perceptions about undergoing an FHH-based risk assessment, which should inform steps for a broader implementation in Asian healthcare systems.
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Affiliation(s)
- Sungwon Yoon
- Health Services and Systems Research, Center for Population Health Research Institute, Duke-NUS Medical School, Singapore Health Services, 8 College Road, Singapore 169857, Singapore;
| | - Hendra Goh
- Health Services and Systems Research, Duke-NUS Medical School, Singapore 169857, Singapore; (H.G.); (S.T.); (D.M.)
| | - Si Ming Fung
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Centre Singapore, Singapore 169610, Singapore; (S.M.F.); (J.N.)
| | - Shihui Tang
- Health Services and Systems Research, Duke-NUS Medical School, Singapore 169857, Singapore; (H.G.); (S.T.); (D.M.)
| | - David Matchar
- Health Services and Systems Research, Duke-NUS Medical School, Singapore 169857, Singapore; (H.G.); (S.T.); (D.M.)
- Department of Medicine, Duke University School of Medicine, Durham, NC 27708, USA
| | - Geoffrey S. Ginsburg
- Center for Applied Genomics and Precision Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC 27708, USA; (G.S.G.); (L.A.O.)
| | - Lori A. Orlando
- Center for Applied Genomics and Precision Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC 27708, USA; (G.S.G.); (L.A.O.)
| | - Joanne Ngeow
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Centre Singapore, Singapore 169610, Singapore; (S.M.F.); (J.N.)
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 308232, Singapore
| | - Rebekah Ryanne Wu
- Center for Applied Genomics and Precision Medicine, Department of Medicine, Duke University School of Medicine, 304 Research Dr. Box 90141, Office 264, Durham, NC 27708, USA
- Correspondence:
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Haga SB, Orlando LA. The enduring importance of family health history in the era of genomic medicine and risk assessment. Per Med 2020; 17:229-239. [PMID: 32320338 DOI: 10.2217/pme-2019-0091] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Improving disease risk prediction and tailoring preventive interventions to patient risk factors is one of the primary goals of precision medicine. Family health history is the traditional approach to quickly gather genetic and environmental data relevant to the patient. While the utility of family health history is well-documented, its utilization is variable, in part due to lack of patient and provider knowledge and incomplete or inaccurate data. With the advances and reduced costs of sequencing technologies, comprehensive sequencing tests can be performed as a risk assessment tool. We provide an overview of each of these risk assessment approaches, the benefits and limitations and implementation challenges.
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Affiliation(s)
- Susanne B Haga
- Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, 101 Science Drive, Box 3382, Durham, NC 27708, USA
| | - Lori A Orlando
- Center for Applied Genomics & Precision Medicine, Duke University School of Medicine, 101 Science Drive, Box 3382, Durham, NC 27708, USA
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Abul-Husn NS, Kenny EE. Personalized Medicine and the Power of Electronic Health Records. Cell 2019; 177:58-69. [PMID: 30901549 PMCID: PMC6921466 DOI: 10.1016/j.cell.2019.02.039] [Citation(s) in RCA: 145] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 02/13/2019] [Accepted: 02/22/2019] [Indexed: 02/06/2023]
Abstract
Personalized medicine has largely been enabled by the integration of genomic and other data with electronic health records (EHRs) in the United States and elsewhere. Increased EHR adoption across various clinical settings and the establishment of EHR-linked population-based biobanks provide unprecedented opportunities for the types of translational and implementation research that drive personalized medicine. We review advances in the digitization of health information and the proliferation of genomic research in health systems and provide insights into emerging paths for the widespread implementation of personalized medicine.
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Affiliation(s)
- Noura S Abul-Husn
- The Center for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA; The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eimear E Kenny
- The Center for Genomic Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA; The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Genetics and Genomic Sciences, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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