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Dragojlovic N, Borle K, Kopac N, Nisselle A, Nuk J, Jevon M, Friedman JM, Elliott AM, Lynd LD. Workforce Implications of Increased Referrals to Hereditary Cancer Services in Canada: A Scenario-Based Analysis. Curr Oncol 2023; 30:7241-7251. [PMID: 37623006 PMCID: PMC10453026 DOI: 10.3390/curroncol30080525] [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: 06/24/2023] [Revised: 07/19/2023] [Accepted: 07/27/2023] [Indexed: 08/26/2023] Open
Abstract
Over the last decade, utilization of clinical genetics services has grown rapidly, putting increasing pressure on the workforce available to deliver genetic healthcare. To highlight the policy challenges facing Canadian health systems, a needs-based workforce requirements model was developed to determine the number of Canadian patients in 2030 for whom an assessment of hereditary cancer risk would be indicated according to current standards and the numbers of genetic counsellors, clinical geneticists and other physicians with expertise in genetics needed to provide care under a diverse set of scenarios. Our model projects that by 2030, a total of 90 specialist physicians and 326 genetic counsellors (1.7-fold and 1.6-fold increases from 2020, respectively) will be required to provide Canadians with indicated hereditary cancer services if current growth trends and care models remain unchanged. However, if the expansion in eligibility for hereditary cancer assessment accelerates, the need for healthcare providers with expertise in genetics would increase dramatically unless alternative care models are widely adopted. Increasing capacity through service delivery innovation, as well as mainstreaming of cancer genetics care, will be critical to Canadian health systems' ability to meet this challenge.
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Affiliation(s)
- Nick Dragojlovic
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC V6T 1Z3, Canada; (N.D.)
| | - Kennedy Borle
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC V6T 1Z3, Canada; (N.D.)
| | - Nicola Kopac
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC V6T 1Z3, Canada; (N.D.)
| | - Amy Nisselle
- Australian Genomics Health Alliance, Parkville, VIC 3052, Australia
- Murdoch Children’s Research Institute, Department of Pediatrics, The University of Melbourne, Parkville, VIC 3052, Australia
| | - Jennifer Nuk
- Hereditary Cancer Program, BC Cancer, Vancouver, BC V5Z 1J2, Canada
- Department of Medical Genetics, Faculty of Medicine, University of British Columbia, Vancouver, BC V6H 3N1, Canada
| | - Mandy Jevon
- Hereditary Cancer Program, BC Cancer, Vancouver, BC V5Z 1J2, Canada
| | - Jan M. Friedman
- Department of Medical Genetics, Faculty of Medicine, University of British Columbia, Vancouver, BC V6H 3N1, Canada
- BC Children’s Hospital Research Institute, Vancouver, BC V5Z 4H4, Canada
| | - Alison M. Elliott
- Department of Medical Genetics, Faculty of Medicine, University of British Columbia, Vancouver, BC V6H 3N1, Canada
- BC Children’s Hospital Research Institute, Vancouver, BC V5Z 4H4, Canada
- Women’s Health Research Institute, Vancouver, BC V6H 3N1, Canada
| | - Larry D. Lynd
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC V6T 1Z3, Canada; (N.D.)
- Centre for Health Evaluation & Outcome Sciences, Providence Health, Vancouver, BC V6Z IY6, Canada
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Bokkers K, Bleiker EMA, Aalfs CM, van Dalen T, Velthuizen ME, Duijveman P, Sijmons RH, Koole W, Schoenmaeckers EJP, Ausems MGEM. Surgical Oncologists and Nurses in Breast Cancer Care are Ready to Provide Pre-Test Genetic Counseling. Ann Surg Oncol 2023; 30:3248-3258. [PMID: 36853565 PMCID: PMC10175452 DOI: 10.1245/s10434-023-13229-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/24/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND Pre-test genetic counseling for patients with breast cancer is increasingly being provided by nongenetic healthcare professionals. We evaluated the attitudes, knowledge, and self-efficacy of surgeons, oncologists, and nurses regarding mainstream genetic testing and the feasibility to incorporate pre-test genetic counseling into routine care. METHODS We offered an online training to healthcare professionals from 13 hospitals and implemented a mainstream genetic testing pathway in 11/13 (85%) hospitals. Questionnaires were sent before (T0) and 6 months after (T1) completing the training. Those who did not complete the training received a questionnaire to assess their motivations. RESULTS In 11 hospitals, 80 (65%) healthcare professionals completed the training, of whom 70 (88%) completed both questionnaires. The attitudes, (perceived) knowledge and self-efficacy of healthcare professionals were high both at baseline and 6 months after completing the training. After 6 months, their perceived knowledge about the advantages and disadvantages of a genetic test and implications for family members had significantly improved (p = 0.012 and p = 0.021, respectively). For the majority (89%), the time investment for pre-test genetic counseling was less than 15 min per patient and as expected or better. Healthcare professionals considered the total time investment feasible to incorporate mainstream genetic testing into their daily practice. The main barrier to complete the training was lack of time. The online training was considered useful, with a rating of 8/10. CONCLUSION Surgical oncologists and nurses in breast cancer care feel well-equipped and motivated to provide pre-test genetic counseling after completion of an online training module.
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Affiliation(s)
- K Bokkers
- Division Laboratories, Pharmacy and Biomedical Genetics, Department of Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - E M A Bleiker
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Family Cancer Clinic, The Netherlands Cancer Institute, Amsterdam, The Netherlands.,Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - C M Aalfs
- Division Laboratories, Pharmacy and Biomedical Genetics, Department of Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - T van Dalen
- Department of surgery, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - M E Velthuizen
- Division Laboratories, Pharmacy and Biomedical Genetics, Department of Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - P Duijveman
- Division Laboratories, Pharmacy and Biomedical Genetics, Department of Genetics, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of surgery, St. Antonius Hospital, Utrecht, The Netherlands
| | - R H Sijmons
- Department of Genetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - W Koole
- Division Laboratories, Pharmacy and Biomedical Genetics, Department of Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - M G E M Ausems
- Division Laboratories, Pharmacy and Biomedical Genetics, Department of Genetics, University Medical Center Utrecht, Utrecht, The Netherlands.
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Charron M, Kaiser B, Dauge A, Gallois H, Lapointe J, Dorval M, Nabi H, Joly Y. Integrating hereditary breast and ovarian cancer genetic counselling and testing into mainstream clinical practice: Legal and ethical challenges. Crit Rev Oncol Hematol 2022; 178:103797. [PMID: 36031172 DOI: 10.1016/j.critrevonc.2022.103797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 07/07/2022] [Accepted: 08/21/2022] [Indexed: 11/30/2022] Open
Abstract
Health professionals not specialized in genetics are expected to take an increasing role in genetic services delivery. This article aims to identify legal and ethical challenges related to a collaborative oncogenetics service model, where non-genetic health professionals provide genetic services to patients. Through a scoping literature review, we identified issues to the provision of hereditary breast and ovarian cancer, or other hereditary adult cancers, genetic testing under this model. Concerns that arose in the literature were informed consent, lack of adherence to best practice guidelines, lack of education of non-genetic health professionals on the provision of genetic services, psychological impacts of genetic testing, continuity of care, the complexity of genetic test results, confidentiality, risks of medical mismanagement, and the associated medical responsibility liabilities. Despite these challenges, there is a growing consensus towards the feasibility of cancer genetic testing being undertaken by non-genetic healthcare professionals in a collaborative oncogenetics service model.
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Affiliation(s)
- Marilou Charron
- Centre of Genomics and Policy (CGP), McGill University, Montreal, Québec, Canada.
| | - Beatrice Kaiser
- Centre of Genomics and Policy (CGP), McGill University, Montreal, Québec, Canada
| | - Aurélie Dauge
- Centre of Genomics and Policy (CGP), McGill University, Montreal, Québec, Canada
| | - Hortense Gallois
- Centre of Genomics and Policy (CGP), McGill University, Montreal, Québec, Canada
| | - Julie Lapointe
- Oncology Division, CHU de Québec - Université Laval Research Center, Québec, Canada
| | - Michel Dorval
- Faculty of Pharmacy, Université Laval, Researcher Oncology Division, CHU de Québec - Université Laval Research Center, Canada
| | - Hermann Nabi
- Faculty of Medicine, Université Laval, Researcher Oncology Division, CHU de Québec - Université Laval Research Center, Canada
| | - Yann Joly
- Centre of Genomics and Policy (CGP), McGill University, Montreal, Québec, Canada
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Bokkers K, Vlaming M, Engelhardt EG, Zweemer RP, van Oort IM, Kiemeney LALM, Bleiker EMA, Ausems MGEM. The Feasibility of Implementing Mainstream Germline Genetic Testing in Routine Cancer Care-A Systematic Review. Cancers (Basel) 2022; 14:cancers14041059. [PMID: 35205807 PMCID: PMC8870548 DOI: 10.3390/cancers14041059] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/10/2022] [Accepted: 02/17/2022] [Indexed: 01/27/2023] Open
Abstract
Simple Summary Germline genetic testing for patients with cancer can have important implications for treatment, preventive options, and for family members. In a mainstream genetic testing pathway, pre-test counseling is performed by non-genetic healthcare professionals, thereby making genetic testing more accessible to all patients who might benefit from it. These mainstream genetic testing pathways are being implemented in different hospitals around the world, and for different cancer types. It is important to evaluate how a mainstream genetic testing pathway can be made sustainable and if quality of genetic care is maintained. We show in this systematic review that it is feasible to incorporate a mainstream genetic testing pathway into routine cancer care while maintaining quality of care. A training procedure for non-genetic healthcare professionals and a close collaboration between genetics and other clinical departments are highly recommended to ensure sustainability. Abstract Background: Non-genetic healthcare professionals can provide pre-test counseling and order germline genetic tests themselves, which is called mainstream genetic testing. In this systematic review, we determined whether mainstream genetic testing was feasible in daily practice while maintaining quality of genetic care. Methods: PubMed, Embase, CINAHL, and PsychINFO were searched for articles describing mainstream genetic testing initiatives in cancer care. Results: Seventeen articles, reporting on 15 studies, met the inclusion criteria. Non-genetic healthcare professionals concluded that mainstream genetic testing was possible within the timeframe of a routine consultation. In 14 studies, non-genetic healthcare professionals completed some form of training about genetics. When referral was coordinated by a genetics team, the majority of patients carrying a pathogenic variant were seen for post-test counseling by genetic healthcare professionals. The number of days between cancer diagnosis and test result disclosure was always lower in the mainstream genetic testing pathway than in the standard genetic testing pathway (e.g., pre-test counseling at genetics department). Conclusions: Mainstream genetic testing seems feasible in daily practice with no insurmountable barriers. A structured pathway with a training procedure is desirable, as well as a close collaboration between genetics and other clinical departments.
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Affiliation(s)
- Kyra Bokkers
- Division Laboratories, Pharmacy and Biomedical Genetics, Department of Genetics, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands; (K.B.); (M.V.)
| | - Michiel Vlaming
- Division Laboratories, Pharmacy and Biomedical Genetics, Department of Genetics, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands; (K.B.); (M.V.)
| | - Ellen G. Engelhardt
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands; (E.G.E.); (E.M.A.B.)
| | - Ronald P. Zweemer
- Department of Gynecological Oncology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands;
| | - Inge M. van Oort
- Department of Urology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands; (I.M.v.O.); (L.A.L.M.K.)
| | - Lambertus A. L. M. Kiemeney
- Department of Urology, Radboud University Medical Center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands; (I.M.v.O.); (L.A.L.M.K.)
- Department for Health Evidence, Radboud University Medical Center, Geert Grooteplein Zuid 21, 6525 EZ Nijmegen, The Netherlands
| | - Eveline M. A. Bleiker
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands; (E.G.E.); (E.M.A.B.)
- Department of Clinical Genetics, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Family Cancer Clinic, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Margreet G. E. M. Ausems
- Division Laboratories, Pharmacy and Biomedical Genetics, Department of Genetics, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands; (K.B.); (M.V.)
- Correspondence: ; Tel.: +31-88-75-538-00
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5
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Berger-Höger B, Vitinius F, Fischer H, Beifus K, Köberlein-Neu J, Isselhard A, Töpper M, Wiedemann R, Rhiem K, Schmutzler R, Stock S, Steckelberg A. Nurse-led decision coaching by specialized nurses for healthy BRCA1/2 gene mutation carriers - adaptation and pilot testing of a curriculum for nurses: a qualitative study. BMC Nurs 2022; 21:42. [PMID: 35139834 PMCID: PMC8829999 DOI: 10.1186/s12912-022-00810-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 01/10/2022] [Indexed: 11/17/2022] Open
Abstract
Background Women with BRCA1/2 mutations are at high risk to develop breast and ovarian cancer. To support these women to participate in shared decision-making, structured nurse-led decision coaching combined with an evidence-based decision aid may be employed. In preparation of the interprofessional randomized controlled trial to evaluate a decision coaching program to support preventive decisions of healthy female BRCA 1/2 gene mutation carriers (EDCP-BRCA), we adapted and piloted an existing training program for specialized nurses and included elements from an existing physician communication training. Methods The training was adapted according to the six-step-approach for medical curriculum development. The educational design is based on experience- and problem-based learning. Subsequently, we conducted a qualitative pilot study. Nurses were recruited from six German centers for familial breast and ovarian cancer. The acceptability and feasibility were assessed by structured class observations, field notes and participants’ feedback. Data were analyzed using qualitative content analysis. The training was revised according to the results. Due to the COVID-19 pandemic, the patient intervention was adapted as a virtual coaching and a brief additional training for nurses was added. Results The training consists of two modules (2 + 1 day) that teach competences in evidence-based medicine and patient information, (risk) communication and decision coaching. One pilot test was conducted with six nurses of which three were specialized and experienced in patient counselling. A final set of eight main categories was derived from the data: framework conditions; interaction; schedule, transparency of goals, content, methods, materials and practical relevance and feasibility. Overall, the training was feasible and comprehensible. Decision coaching materials were awkward to handle and decision coaching role plays were set too short. Therefore, materials will be sent out in advance and the training was extended. Conclusions Specialized nurses are rarely available and nurse-led counselling is not routinely implemented in the centers of familial breast and ovarian cancer. However, training of less qualified nurses seems feasible. Decision coaching in a virtual format seems to be a promising approach. Further research is needed to evaluate its feasibility, acceptability and effectiveness. Trial registration The main trial is registered under DRKS-ID: DRKS00015527. Supplementary Information The online version contains supplementary material available at 10.1186/s12912-022-00810-8.
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Affiliation(s)
- Birte Berger-Höger
- Institute for Health and Nursing Science, Faculty of Medicine Martin Luther University Halle-Wittenberg, Halle (Saale), Germany.
| | - Frank Vitinius
- Department of Psychosomatics and Psychotherapy, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Hannah Fischer
- Department of Psychosomatics and Psychotherapy, Faculty of Medicine, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Karolina Beifus
- Center for Health Economics and Health Services Research, Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, Germany
| | - Juliane Köberlein-Neu
- Center for Health Economics and Health Services Research, Schumpeter School of Business and Economics, University of Wuppertal, Wuppertal, Germany
| | - Anna Isselhard
- Institute of Health Economics and Clinical Epidemiology, University Hospital of Cologne, Cologne, Germany
| | - Maren Töpper
- Institute of Health Economics and Clinical Epidemiology, University Hospital of Cologne, Cologne, Germany
| | - Regina Wiedemann
- Center for Familial Breast and Ovarian Cancer, Center for Integrated Oncology (CIO), University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Kerstin Rhiem
- Center for Familial Breast and Ovarian Cancer, Center for Integrated Oncology (CIO), University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Rita Schmutzler
- Center for Familial Breast and Ovarian Cancer, Center for Integrated Oncology (CIO), University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Stephanie Stock
- Institute of Health Economics and Clinical Epidemiology, University Hospital of Cologne, Cologne, Germany
| | - Anke Steckelberg
- Institute for Health and Nursing Science, Faculty of Medicine Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
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6
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Bartley N, Best MC, Biesecker BB, Fisher A, Goldstein D, Meiser B, Thomas DM, Ballinger ML, Butow P. Effectively communicating comprehensive tumor genomic profiling results: Mitigating uncertainty for advanced cancer patients. PATIENT EDUCATION AND COUNSELING 2022; 105:452-459. [PMID: 34016496 DOI: 10.1016/j.pec.2021.05.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 05/07/2021] [Accepted: 05/11/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To understand advanced cancer patients' experience of uncertainty when receiving comprehensive tumor genomic profiling (CTGP) results, and their perceptions of how healthcare provider (HCP) communication impacts uncertainty. METHODS Thirty-seven semi-structured interviews with advanced cancer patients were conducted within two weeks of patients receiving CTGP results. Transcripts were thematically analyzed, using an inductive approach. RESULTS We identified three themes that illustrate patient experience of uncertainties when receiving CTGP results: 1. Type and degree of uncertainty fluctuates along with changing illness circumstances and the nature of the CTGP results; 2. HCPs' co-ordination of care and communication shapes uncertainty, with immediate, clearer and simpler information promoting certainty; and 3. Patients felt that communicating results to reduce relatives' uncertainty is important, with patients choosing the time and process for achieving this and desiring HCPs support. CONCLUSION Oncology patients are confronted with an array of uncertainties. Clear, simple communication from HCPs about results and their implications, and support to manage uncertainty, will be of benefit. PRACTICE IMPLICATIONS If CTGP is to become routine clinical practice, clear communication will be crucial in reducing uncertainty. Awareness of potential uncertainties experienced by patients when receiving results, will assist HCPs to address uncertainties, reduce uncertainty where possible, and offer targeted support to patients struggling with uncertainty.
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Affiliation(s)
- Nicci Bartley
- School of Psychology, The University of Sydney, Sydney, Australia.
| | - Megan C Best
- School of Psychology, The University of Sydney, Sydney, Australia; Institute of Ethics and Society, The University of Notre Dame, Sydney, Australia.
| | | | - Alana Fisher
- School of Psychology, The University of Sydney, Sydney, Australia.
| | - David Goldstein
- Prince of Wales Clinical School, University of NSW, Sydney, Australia.
| | - Bettina Meiser
- Psychosocial Research Group, Prince of Wales Clinical School, University of NSW, Sydney, Australia.
| | - David M Thomas
- Cancer Theme, Garvan Institute of Medical Research, Sydney, Australia; St Vincent's Clinical School, University of NSW, Sydney, Australia.
| | - Mandy L Ballinger
- Cancer Theme, Garvan Institute of Medical Research, Sydney, Australia; St Vincent's Clinical School, University of NSW, Sydney, Australia.
| | - Phyllis Butow
- School of Psychology, The University of Sydney, Sydney, Australia.
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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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