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Espinoza-Moya ME, Guertin JR, Floret A, Dorval M, Lapointe J, Chiquette J, Bouchard K, Nabi H, Laberge M. Mapping inter-professional collaboration in oncogenetics: Results from a scoping review. Crit Rev Oncol Hematol 2024; 199:104364. [PMID: 38729319 DOI: 10.1016/j.critrevonc.2024.104364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/15/2024] [Indexed: 05/12/2024] Open
Abstract
Inter-professional collaboration could improve timely access and quality of oncogenetic services. Here, we present the results of a scoping review conducted to systematically identify collaborative models available, unpack the nature and extent of collaboration proposed, synthesize evidence on their implementation and evaluation, and identify areas where additional research is needed. A comprehensive search was conducted in four journal indexing databases on June 13th, 2022, and complemented with searches of the grey literature and citations. Screening was conducted by two independent reviewers. Eligible documents included those describing either the theory of change, planning, implementation and/or evaluation of collaborative oncogenetic models. 165 publications were identified, describing 136 unique interventions/studies on oncogenetic models with somewhat overlapping collaborative features. Collaboration appears to be mostly inter-professional in nature, often taking place during risk assessment and pre-testing genetic counseling. Yet, most publications provide very limited information on their collaborative features, and only a few studies have set out to formally evaluate them. Better quality research is needed to comprehensively examine and make conclusions regarding the value of collaboration in this oncogenetics. We propose a definition, logic model, and typology of collaborative oncogenetic models to strengthen future planning, implementation, and evaluation in this field.
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Affiliation(s)
- Maria-Eugenia Espinoza-Moya
- Centre de Recherche du CHU de Québec-Université Laval, Hôpital du Saint-Sacrement, 1050, Chemin Ste-Foy, Québec, QC G1S 4L8, Canada; Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, 1050 Avenue de la Médecine, Université Laval, Québec, QC G1V 0A6, Canada
| | - Jason Robert Guertin
- Centre de Recherche du CHU de Québec-Université Laval, Hôpital du Saint-Sacrement, 1050, Chemin Ste-Foy, Québec, QC G1S 4L8, Canada; Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, 1050 Avenue de la Médecine, Université Laval, Québec, QC G1V 0A6, Canada
| | - Arthur Floret
- Centre de Recherche du CHU de Québec-Université Laval, Hôpital du Saint-Sacrement, 1050, Chemin Ste-Foy, Québec, QC G1S 4L8, Canada; Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, 1050 Avenue de la Médecine, Université Laval, Québec, QC G1V 0A6, Canada
| | - Michel Dorval
- Centre de Recherche du CHU de Québec-Université Laval, Hôpital du Saint-Sacrement, 1050, Chemin Ste-Foy, Québec, QC G1S 4L8, Canada; Centre de Recherche CISSS Chaudière-Appalaches, 143 Rue Wolfe, Lévis, QC G6V 3Z1, Canada; Faculty of Pharmacy, Université Laval, 1050 Av de la Médecine, Québec, QC G1V 0A6, Canada
| | - Julie Lapointe
- Centre de Recherche du CHU de Québec-Université Laval, Hôpital du Saint-Sacrement, 1050, Chemin Ste-Foy, Québec, QC G1S 4L8, Canada
| | - Jocelyne Chiquette
- Centre de Recherche du CHU de Québec-Université Laval, Hôpital du Saint-Sacrement, 1050, Chemin Ste-Foy, Québec, QC G1S 4L8, Canada; Centre des maladies du sein, CHU de Québec-Université Laval, Hôpital du Saint-Sacrement, 1050, Chemin Ste-Foy, Québec, QC G1S 4L8, Canada
| | - Karine Bouchard
- Centre de Recherche du CHU de Québec-Université Laval, Hôpital du Saint-Sacrement, 1050, Chemin Ste-Foy, Québec, QC G1S 4L8, Canada
| | - Hermann Nabi
- Centre de Recherche du CHU de Québec-Université Laval, Hôpital du Saint-Sacrement, 1050, Chemin Ste-Foy, Québec, QC G1S 4L8, Canada; Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, 1050 Avenue de la Médecine, Université Laval, Québec, QC G1V 0A6, Canada
| | - Maude Laberge
- Centre de Recherche du CHU de Québec-Université Laval, Hôpital du Saint-Sacrement, 1050, Chemin Ste-Foy, Québec, QC G1S 4L8, Canada; Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, 1050 Avenue de la Médecine, Université Laval, Québec, QC G1V 0A6, Canada; Vitam, Centre de recherche en santé durable, Université Laval, 2525, Chemin de la Canardière, Québec, QC G1J 0A4, Canada.
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Byrne M, Sia TY, Fong C, Khurram A, Waters M, Kemel YM, Zhou Q, Ranganathan M, Long Roche K, Chi DS, Saban S, Wu M, Varice N, Hamilton JG, Carrot-Zhang J, Abu-Rustum NR, Iasonos A, Ellenson LH, Mandelker D, Weigelt B, Brown CL, Aghajanian C, Stadler Z, Liu YL. Mainstreaming in parallel with ovarian cancer tumor testing to improve genetic testing uptake. Gynecol Oncol 2024; 183:126-132. [PMID: 38493020 DOI: 10.1016/j.ygyno.2024.03.005] [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: 01/25/2024] [Revised: 03/01/2024] [Accepted: 03/05/2024] [Indexed: 03/18/2024]
Abstract
OBJECTIVES Although genetic testing (GT) is universally recommended for patients with epithelial ovarian cancer (EOC), rates are low (34%). In 1/2019, we implemented mainstreaming-GT in parallel with tumor testing via MSK-IMPACT within oncology clinics. We sought to determine GT rates pre/post-mainstreaming and patient characteristics associated with GT. METHODS Patients with newly diagnosed EOC seen at our institution from 7/1/2015-3/31/2022 were included. Clinical data were abstracted including social determinants of health (SDOH) variables, race/ethnicity, marital status, insurance, language, comorbidities, employment, and Yost index, a measure of socioeconomic status. GT rates were calculated overall and pre-/post-mainstreaming (1/2019). Logistic regression models were fit to identify variables associated with GT. RESULTS Of 1742 patients with EOC, 1591 (91%) underwent GT. Rates of GT increased from 87% to 95% after mainstreaming (p < 0.001). Among 151 patients not undergoing GT, major reasons were lack of provider recommendation (n = 76, 50%) and logistical issues (n = 38, 25%) with few declining (n = 14, 9%) or having medical complications preventing GT (n = 7, 4.6%). High-grade serous histology, advanced stage (III/IV), and having a spouse/partner were associated with increased GT uptake (p < 0.01). Among SDOH variables, there were no differences by insurance, Yost score, language, comorbidities, employment, or race/ethnicity. In multivariable models, likelihood of GT increased with mainstreaming, even after adjustment for histology, stage, and marital status (OR 3.77; 95% CI: 2.56-5.66). CONCLUSIONS Mainstreaming increased the likelihood of GT in patients with EOC. We found lower testing rates in patients without partners/spouses, non-high-grade serous histology, and early-stage disease, representing potential areas for future interventions.
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Affiliation(s)
- Maureen Byrne
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Tiffany Y Sia
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Christopher Fong
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Aliya Khurram
- Clinical Genetics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Michele Waters
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Yelena M Kemel
- Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Qin Zhou
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Megha Ranganathan
- Clinical Genetics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Kara Long Roche
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, United States of America
| | - Dennis S Chi
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, United States of America
| | - Sally Saban
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Michelle Wu
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Nancy Varice
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Jada G Hamilton
- Clinical Genetics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Psychiatry, Weill Cornell Medical College, New York, NY, United States of America; Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Jian Carrot-Zhang
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Nadeem R Abu-Rustum
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, United States of America
| | - Alexia Iasonos
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Lora H Ellenson
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Diana Mandelker
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Britta Weigelt
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Carol L Brown
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, United States of America
| | - Carol Aghajanian
- Gynecologic Medical Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Medicine, Weill Cornell Medical College, New York, NY, United States of America
| | - Zsofia Stadler
- Clinical Genetics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Medicine, Weill Cornell Medical College, New York, NY, United States of America
| | - Ying L Liu
- Clinical Genetics Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Gynecologic Medical Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Medicine, Weill Cornell Medical College, New York, NY, United States of America.
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Marjon N, Guerra R, Freeman A, Mak J, Cheung S, Gordon K, Blanco A, Ueda S, Chen LM. Same day service: A genetic testing station model to improve germline genetic testing in patients with ovarian cancer. Gynecol Oncol 2023; 177:53-59. [PMID: 37639903 DOI: 10.1016/j.ygyno.2023.07.019] [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: 04/06/2023] [Revised: 07/24/2023] [Accepted: 07/28/2023] [Indexed: 08/31/2023]
Abstract
OBJECTIVE Genetic testing for ovarian cancer (OC) patients is essential to consideration of PARP inhibitor therapy. To improve access, we piloted a Genetic Testing Station (GTS) allowing patients to have a same-day genetic testing visit facilitated by Genetic Counselor Assistants (GCAs) under the supervision of Genetic Counselors (GCs). METHODS The GTS was implemented December 2018 and operated through February 2020. Gynecologic Oncologists offered ovarian cancer patients a same-day GTS visit with a GCA. The patient received education via videos designed by GCs and then provided consent, a brief family history, and a sample for a standardized 133-gene panel. Results were provided by a GC. Patients were retrospectively identified by querying the medical record for OC patients seen 12 months prior to and 18 months after GTS implementation. RESULTS A total of 482 patients pre-GTS were compared to 625 patients post-GTS. Genetic testing increased from 68.5% to 75.4% (p = 0.012) after implementation, primarily in patients with epithelial histologies (80% vs 89% in pre-GTS vs post-GTS, p = 0.005). Time from referral for genetic testing to obtaining results was evaluated in the post-GTS cohort, comparing patients who had traditional counseling to those who utilized the GTS. Time to obtaining results was 21 days in the GTS group (95% CI [10, 34]) compared to 56 days (95% CI [41,76]) in the traditional genetic counseling group. CONCLUSIONS The GTS reduces barriers to care and facilitates discussion of precision treatment within a timely fashion while optimizing GC clinic time. Access improvement remains integral to improving uptake of genetic testing.
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Affiliation(s)
- Nicole Marjon
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Gynecoloigc Oncology, University of California San Francisco, San Francisco, CA 94143, USA.
| | - Rosa Guerra
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Gynecoloigc Oncology, University of California San Francisco, San Francisco, CA 94143, USA
| | - Alexandra Freeman
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Gynecoloigc Oncology, University of California San Francisco, San Francisco, CA 94143, USA
| | - Julie Mak
- Department Cancer Genetics and Prevention, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA 94115, USA
| | - Stephanie Cheung
- Department Cancer Genetics and Prevention, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA 94115, USA
| | - Kelly Gordon
- Department Cancer Genetics and Prevention, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA 94115, USA
| | - Amie Blanco
- Department Cancer Genetics and Prevention, Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA 94115, USA
| | - Stefanie Ueda
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Gynecoloigc Oncology, University of California San Francisco, San Francisco, CA 94143, USA
| | - Lee-May Chen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Division of Gynecoloigc Oncology, University of California San Francisco, San Francisco, CA 94143, USA
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Bokkers K, Bleiker E, Velthuizen M, Koelemij R, Burgmans J, Klinkenbijl J, Schouten van der Velden A, Vermulst N, Huizinga B, Witkamp A, Frakking T, Brohet R, Aalfs C, Koole W, Schoenmaeckers E, Ausems M. Patients’ experiences with pre-test genetic counseling provided by breast cancer healthcare professionals: Results from a large prospective multicenter study. Breast 2023; 69:349-357. [PMID: 37018966 PMCID: PMC10122003 DOI: 10.1016/j.breast.2023.03.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Pre-test genetic counseling of patients with breast cancer is increasingly being offered by non-genetic healthcare professionals. We aimed to evaluate the experiences of patients with breast cancer receiving pre-test genetic counseling from a non-genetic healthcare professional (i.e., surgeon or nurse). METHODS Patients who were diagnosed with breast cancer and received pre-test counseling from their surgeon or nurse (mainstream group), and patients who received pre-test counseling from a clinical geneticist (usual care group) were invited to participate in our multicenter study. Between September 2019 and December 2021, patients received a questionnaire after pre-test counseling (T0) and four weeks after receiving their test results (T1) to evaluate psychosocial outcomes, knowledge, discussed topics and satisfaction. RESULTS We included 191 patients in our mainstream and 183 patients in our usual care group and received, respectively 159 and 145 follow-up questionnaires. Levels of distress and decisional regret were comparable in both groups. Decisional conflict was higher in our mainstream group (p = 0.01), but only 7% had clinically relevant decisional conflict (vs 2% in usual care group). The possible implications of a genetic test on (secondary) breast or ovarian cancer risks were less frequently discussed in our mainstream group (p = 0.03 and p = 0.000, respectively). In both groups knowledge about genetics was comparable, satisfaction was high and the majority of patients in both groups preferred to give both verbal and written consent for genetic testing. CONCLUSION Mainstreamed genetic care provides sufficient information for the majority of breast cancer patients to decide about genetic testing with minimal distress.
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Vlaming M, Bleiker EMA, van Oort IM, Kiemeney LALM, Ausems MGEM. Mainstream germline genetic testing in men with metastatic prostate cancer: design and protocol for a multicenter observational study. BMC Cancer 2022; 22:1365. [PMID: 36581909 PMCID: PMC9801568 DOI: 10.1186/s12885-022-10429-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 12/07/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND In international guidelines, germline genetic testing is recommended for patients with metastatic prostate cancer. Before undergoing germline genetic testing, these patients should receive pre-test counseling. In the standard genetic care pathway, pre-test counseling is provided by a healthcare professional of a genetics department. Because the number of patients with metastatic prostate cancer is large, the capacity in the genetics departments might be insufficient. Therefore, we aim to implement so-called mainstream genetic testing in the Netherlands for patients with metastatic prostate cancer. In a mainstream genetic testing pathway, non-genetic healthcare professionals discuss and order germline genetic testing. In our DISCOVER study, we will assess the experiences among patients and non-genetic healthcare professionals with this new pathway. METHODS A multicenter prospective observational cohort study will be conducted in 15 hospitals, in different regions of the Netherlands. We developed an online training module on genetics in prostate cancer and the counseling of patients. After completion of this module, non-genetic healthcare professionals will provide pre-test counseling and order germline genetic testing in metastatic prostate cancer patients. Both non-genetic healthcare professionals and patients receive three questionnaires. We will determine the experience with mainstream genetic testing, based on satisfaction and acceptability. Patients with a pathogenic germline variant will also be interviewed. We will determine the efficacy of the mainstreaming pathway, based on time investment for non-genetic healthcare professionals and the prevalence of pathogenic germline variants. DISCUSSION This study is intended to be one of the largest studies on mainstream genetic testing in prostate cancer. The results of this study can improve the mainstream genetic testing pathway in patients with prostate cancer. TRIAL REGISTRATION The study is registered in the WHO's International Clinical Trials Registry Platform (ICTRP) under number NL9617.
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Affiliation(s)
- Michiel Vlaming
- grid.7692.a0000000090126352Division Laboratories, Pharmacy and Biomedical Genetics, dept. of Genetics, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Eveline M. A. Bleiker
- grid.430814.a0000 0001 0674 1393Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands ,grid.10419.3d0000000089452978Department of Clinical Genetics, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands ,grid.430814.a0000 0001 0674 1393Family Cancer Clinic, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Inge M. van Oort
- grid.10417.330000 0004 0444 9382Department of Urology, Radboud university medical center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Lambertus A. L. M. Kiemeney
- grid.10417.330000 0004 0444 9382Department of Urology, Radboud university medical center, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands ,grid.10417.330000 0004 0444 9382Department for Health Evidence, Radboud university medical center, Geert Grooteplein Zuid 21, 6525 EZ Nijmegen, The Netherlands
| | - Margreet G. E. M. Ausems
- grid.7692.a0000000090126352Division Laboratories, Pharmacy and Biomedical Genetics, dept. of Genetics, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
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Bokkers K, Bleiker EMA, Hoogendam JP, Velthuizen ME, Schreuder HWR, Gerestein CG, Lange JG, Louwers JA, Koudijs MJ, Ausems MGEM, Zweemer RP. Mainstream genetic testing for women with ovarian cancer provides a solid basis for patients to make a well-informed decision about genetic testing. Hered Cancer Clin Pract 2022; 20:33. [PMID: 36076240 PMCID: PMC9461259 DOI: 10.1186/s13053-022-00238-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 08/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is a growing need for genetic testing of women with epithelial ovarian cancer. Mainstream genetic testing provides an alternative care pathway in which non-genetic healthcare professionals offer pre-test counseling themselves. We aimed to explore the impact of mainstream genetic testing on patients' experiences, turnaround times and adherence of non-genetic healthcare professionals to the mainstream genetic testing protocol. METHODS Patients receiving pre-test counseling at the gynecology departments between April 2018 and April 2020 were eligible to participate in our intervention group. Patients receiving pre-test counseling at the genetics department between January 2017 and April 2020 were eligible to participate in our control group. We evaluated patients' experiences with questionnaires, consisting of questions regarding knowledge, satisfaction and psychosocial outcomes. Patients in the intervention group were sent two questionnaires: one after pre-test counseling and one after receiving their DNA test result. Patients in our control group were sent one questionnaire after receiving their test result. In addition, we collected data regarding turnaround times and adherence of non-genetic healthcare professionals to the mainstream genetic testing protocol. RESULTS Participation was 79% in our intervention group (105 out of 133 patients) and 60% in our control group (91 out of 152 patients). Knowledge regarding genetics, decisional conflict, depression, anxiety, and distress were comparable in the two groups. In the intervention group, the risk of breast cancer in patients carrying a pathogenic germline variant was discussed less often (49% versus 74% in control group, p ≤ 0.05), and the mean score of regret about the decision to have genetic testing was higher than in the control group (mean 12.9 in the intervention group versus 9.7 in the control group, p ≤ 0.05), although below the clinically relevant threshold of 25. A consent form for the DNA test and a checklist to assess family history were present for ≥ 95% of patients in the intervention group. CONCLUSION Mainstream genetic testing is an acceptable approach to meet the increase in genetic testing among women with epithelial ovarian cancer.
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Affiliation(s)
- Kyra Bokkers
- Department of Genetics, Division Laboratories, Pharmacy and Biomedical Genetics, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - Eveline M A Bleiker
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.,Family Cancer Clinic, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.,Department of Clinical Genetics, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Jacob P Hoogendam
- Department of Gynecological Oncology, University Medical Center Utrecht, Heidelberglaan 100, PO Box 85500, 3584 CX, Utrecht, The Netherlands
| | - Mary E Velthuizen
- Department of Genetics, Division Laboratories, Pharmacy and Biomedical Genetics, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - Henk W R Schreuder
- Department of Gynecological Oncology, University Medical Center Utrecht, Heidelberglaan 100, PO Box 85500, 3584 CX, Utrecht, The Netherlands
| | - Cornelis G Gerestein
- Department of Gynecological Oncology, University Medical Center Utrecht, Heidelberglaan 100, PO Box 85500, 3584 CX, Utrecht, The Netherlands.,Department of Gynecology, Meander Medical Center, Maatweg 3, 3813 TZ, Amersfoort, The Netherlands
| | - Joost G Lange
- Department of Gynecology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, the Netherlands
| | - Jacqueline A Louwers
- Department of Gynecology, Diakonessenhuis, Bosboomstraat 1, 3582 KE, Utrecht, The Netherlands
| | - Marco J Koudijs
- Department of Genetics, Division Laboratories, Pharmacy and Biomedical Genetics, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - Margreet G E M Ausems
- Department of Genetics, Division Laboratories, Pharmacy and Biomedical Genetics, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - Ronald P Zweemer
- Department of Gynecological Oncology, University Medical Center Utrecht, Heidelberglaan 100, PO Box 85500, 3584 CX, Utrecht, The Netherlands.
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Sadinsky MB, Power J, Ambrosio E, Palma L, Zeng X, Foulkes WD, Weber E. Patient Experience with a Gynecologic Oncology-Initiated Genetic Testing Model for Women with Tubo-Ovarian Cancer. Curr Oncol 2022; 29:3565-3575. [PMID: 35621678 PMCID: PMC9139592 DOI: 10.3390/curroncol29050288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/22/2022] [Accepted: 05/13/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Up to 20% of women diagnosed with tubo-ovarian carcinoma carry a germline pathogenic variant in a cancer-predisposing gene (e.g., BRCA1/BRCA2). Identifying these variants can help to inform eligibility for therapies, guide surveillance and prevention of new primary cancers, and assess risk to family members. The Gynecologic Oncology-Initiated Genetic Testing Model (GOIGT) was initiated at the McGill University Health Centre (MUHC) to streamline universal germline genetic testing for this population, while addressing the limited resources in the public healthcare system. This study aimed to evaluate the patient experience of participating in this model. Methods: Study participants were patients diagnosed with high-grade non-mucinous epithelial tubo-ovarian cancer who underwent genetic testing through the GOIGT model between 1 January 2017 and 31 December 2020. Eligible participants completed the retrospective questionnaires at least one month after result disclosure. Results: A total of 126 patients were tested through the GOIGT model during the study period, of which 56 were invited to participate. Thirty-four participants returned the study questionnaire. Overall, participants did not report decision regret following the genetic testing and were satisfied with the GOIGT model. Participants reported low levels of uncertainty and distress related to the implications of their test results for themselves and their family members. Conclusions: The results of this study support the continued implementation of mainstreamed genetic testing models for women with high-grade non-mucinous tubo-ovarian cancer. Further studies are required to compare experiences for patients with different genetic test results.
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Affiliation(s)
- Michaela Bercovitch Sadinsky
- Department of Human Genetics, McGill University, Montreal, QC H3A0C7, Canada; (L.P.); (W.D.F.); (E.W.)
- Division of Medical Genetics, Jewish General Hospital, McGill University, Montreal, QC H3T1E2, Canada
- Correspondence: ; Tel.: +1-438-401-8300
| | - Joanne Power
- Division of Gynecologic Oncology, McGill University Health Centre, Montreal, QC H4A3J1, Canada; (J.P.); (E.A.); (X.Z.)
| | - Enza Ambrosio
- Division of Gynecologic Oncology, McGill University Health Centre, Montreal, QC H4A3J1, Canada; (J.P.); (E.A.); (X.Z.)
| | - Laura Palma
- Department of Human Genetics, McGill University, Montreal, QC H3A0C7, Canada; (L.P.); (W.D.F.); (E.W.)
- Division of Medical Genetics, McGill University Health Centre, Montreal, QC H4A3J1, Canada
| | - Xing Zeng
- Division of Gynecologic Oncology, McGill University Health Centre, Montreal, QC H4A3J1, Canada; (J.P.); (E.A.); (X.Z.)
| | - William D. Foulkes
- Department of Human Genetics, McGill University, Montreal, QC H3A0C7, Canada; (L.P.); (W.D.F.); (E.W.)
- Division of Medical Genetics, Jewish General Hospital, McGill University, Montreal, QC H3T1E2, Canada
- Division of Medical Genetics, McGill University Health Centre, Montreal, QC H4A3J1, Canada
- Department of Specialized Medicine, Lady David Institute, Jewish General Hospital, McGill University, Montreal, QC H3T1E2, Canada
- Cancer Research Program, Research Institute of the McGill University Health Centre, McGill University, Montreal, QC H4A3J1, Canada
| | - Evan Weber
- Department of Human Genetics, McGill University, Montreal, QC H3A0C7, Canada; (L.P.); (W.D.F.); (E.W.)
- Division of Medical Genetics, McGill University Health Centre, Montreal, QC H4A3J1, 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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Bos W, Bunnik EM. Informed consent practices for exome sequencing: An interview study with clinical geneticists in the Netherlands. Mol Genet Genomic Med 2022; 10:e1882. [PMID: 35150093 PMCID: PMC8922961 DOI: 10.1002/mgg3.1882] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 12/21/2021] [Accepted: 01/14/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Genomic sequencing is being used more frequently in the clinic, not only by clinical geneticists, but also by other specialists ("mainstreaming"). The use of genomic sequencing gives rise to challenges regarding informed consent, as it can yield more, and more complex results. METHODS This study maps the informed consent process for exome sequencing in the Netherlands by means of semistructured interviews with 14 clinical geneticists. Interviewees were asked about their strategies for informing patients about exome sequencing and supporting patients in their decision making, about what they think of as essential information elements, about the challenges they experience, and about their preferences for future policy and practice. RESULTS Clinical geneticists typically discuss the following topics: the nature and aim of the test, the possible results (including unsolicited or incidental findings and Variants of Uncertain Significance) of the test and the consequences of those results for the patient and their family members. Some clinical geneticists use a layered approach to informed consent, meaning that they give short and concise information at first, and provide more detailed information depending on the situation or the needs of the patient. CONCLUSION During pre-test counseling for genomic sequencing, clinical geneticists use various strategies to enhance patient understanding and personalization of the informed consent process. Going forward, layering information may be part of a solution to ethical challenges of informed consent, also in mainstream settings.
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Affiliation(s)
- Wendy Bos
- Department of Medical Ethics, Philosophy and History of MedicineErasmus MC, University Medical Centre RotterdamRotterdamthe Netherlands
| | - Eline M. Bunnik
- Department of Medical Ethics, Philosophy and History of MedicineErasmus MC, University Medical Centre RotterdamRotterdamthe Netherlands
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Positive experiences of healthcare professionals with a mainstreaming approach of germline genetic testing for women with ovarian cancer. Fam Cancer 2021; 21:295-304. [PMID: 34617209 PMCID: PMC9203381 DOI: 10.1007/s10689-021-00277-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 09/28/2021] [Indexed: 12/24/2022]
Abstract
According to current guidelines, all women with epithelial ovarian cancer are eligible for genetic testing for BRCA germline pathogenic variants. Unfortunately, not all affected women are tested. We evaluated the acceptability and feasibility for non-genetic healthcare professionals to incorporate germline genetic testing into their daily practice. We developed and implemented a mainstreaming pathway, including a training module, in collaboration with various healthcare professionals and patient organizations. Healthcare professionals from 4 different hospitals were invited to participate. After completing the training module, gynecologic oncologists, gynecologists with a subspecialty training in oncology, and nurse specialists discussed and ordered genetic testing themselves. They received a questionnaire before completing the training module and 6 months after working according to the new pathway. We assessed healthcare professionals’ attitudes, perceived knowledge, and self-efficacy, along with the feasibility of this new mainstream workflow in clinical practice, and evaluated the use and content of the training module. The participation rate for completing the training module was 90% (N = 19/21). At baseline and after 6 months, healthcare professionals had a positive attitude, high perceived knowledge and high self-efficacy toward discussing and ordering genetic testing. Knowledge had increased significantly after 6 months. The training module was rated with an average of 8.1 out of 10 and was considered useful. The majority of healthcare professionals (9/15) was able to discuss a genetic test in five to 10 min. After completion of a training module, non-genetic healthcare professionals feel motivated and competent to discuss and order genetic testing themselves.
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Uptake and acceptability of a mainstreaming model of hereditary cancer multigene panel testing among patients with ovarian, pancreatic, and prostate cancer. Genet Med 2021; 23:2105-2113. [PMID: 34257420 PMCID: PMC8556289 DOI: 10.1038/s41436-021-01262-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 06/14/2021] [Accepted: 06/15/2021] [Indexed: 02/07/2023] Open
Abstract
Purpose: To address demands for timely germline information to guide treatments, we evaluated experiences of patients with ovarian, pancreatic, and prostate cancer with a mainstreaming genetic testing model wherein multigene panel testing was ordered by oncologists with standardized pre-test patient education, and genetic counselors delivered results and post-test genetic counseling via telephone. Methods: Among 1203 eligible patients, we conducted a prospective single-arm study to examine patient uptake and acceptability (via self-report surveys at baseline and three-weeks and three-months following result return) of this mainstreaming model. Results: Only 10% of eligible patients declined participation. Among 1054 tested participants, 10% had pathogenic variants (PV), 16% had variants of uncertain significance (VUS), and 74% had no variant identified (NV). Participants reported high initial acceptability, including high satisfaction with their testing decision. Variability over time in several outcomes existed for participants with PV or NV: Those with NV experienced a temporary increase in depression (pTime<0.001; pTime2<0.001), and those with PV experienced a small increase in genetic testing distress (p=0.03). Findings suggested that result type, sex, and cancer type were also associated with outcomes including clinical depression and uncertainty. Conclusion: This mainstreaming model may offer a feasible approach for extending access to germline genetic information.
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O’Shea R, Taylor N, Crook A, Jacobs C, Jung Kang Y, Lewis S, Rankin NM. Health system interventions to integrate genetic testing in routine oncology services: A systematic review. PLoS One 2021; 16:e0250379. [PMID: 34010335 PMCID: PMC8133413 DOI: 10.1371/journal.pone.0250379] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 04/06/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Integration of genetic testing into routine oncology care could improve access to testing. This systematic review investigated interventions and the tailored implementation strategies aimed at increasing access to genetic counselling and testing and identifying hereditary cancer in oncology. METHODS The search strategy results were reported using the PRISMA statement and four electronic databases were searched. Eligible studies included routine genetic testing for breast and ovarian cancer or uptake after universal tumour screening for colorectal or endometrial cancer. The titles and abstracts were reviewed and the full text articles screened for eligibility. Data extraction was preformed using a designed template and study appraisal was assessed using an adapted Newcastle Ottawa Scale. Extracted data were mapped to Proctor's et al outcomes and the Consolidated Framework for Implementation Research and qualitatively synthesised. RESULTS Twenty-seven studies, published up to May 2020, met the inclusion criteria. Twenty-five studies ranged from poor (72%), fair to good (28%) quality. Most interventions identified were complex (multiple components) such as; patient or health professional education, interdisciplinary practice and a documentation or system change. Forty-eight percent of studies with complex interventions demonstrated on average a 35% increase in access to genetic counselling and a 15% increase in testing completion. Mapping of study outcomes showed that 70% and 32% of the studies aligned with either the service and client or the implementation level outcome and 96% to the process or inner setting domains of the Consolidated Framework for Implementation Research. CONCLUSION Existing evidence suggests that complex interventions have a potentially positive effect towards genetic counselling and testing completion rates in oncology services. Studies of sound methodological quality that explore a greater breadth of pre and post implementation outcomes and informed by theory are needed. Such research could inform future service delivery models for the integration of genetics into oncology services.
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Affiliation(s)
- Rosie O’Shea
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Discipline of Genetic Counselling, Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Natalie Taylor
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Cancer Research Division, Cancer Council NSW, Sydney, New South Wales, Australia
| | - Ashley Crook
- Discipline of Genetic Counselling, Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Chris Jacobs
- Discipline of Genetic Counselling, Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Yoon Jung Kang
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Cancer Research Division, Cancer Council NSW, Sydney, New South Wales, Australia
| | - Sarah Lewis
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Nicole M. Rankin
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
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McAlarnen L, Stearns K, Uyar D. Challenges of Genomic Testing for Hereditary Breast and Ovarian Cancers. Appl Clin Genet 2021; 14:1-9. [PMID: 33488111 PMCID: PMC7814235 DOI: 10.2147/tacg.s245021] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 12/26/2020] [Indexed: 12/18/2022] Open
Abstract
Completion of genetic testing is increasingly important for the complex care of patients with suspected hereditary breast and ovarian cancers (HBOC) and their at-risk family members. Identification of individuals with pathogenic variants has implications for targeted treatment recommendations, risk reduction strategies, increased surveillance recommendations, as well as the genetic testing of family members, known as cascade testing or screening. Due to advances in technology and decreasing costs, what was once single-gene genetic testing has evolved into large-scale multi-gene panel genomic testing. As germline genomic testing for HBOC becomes more and more available, it is important to identify the challenges that are associated with its use. In this manuscript, we review the current issues faced by germline genomic testing for HBOC which include effectively managing the marked increases in genetic referrals, interpreting the vast amount of information yielded by newer testing methods such as next generation sequencing (NGS), recognizing the need for better cascade screening strategies, potential exacerbation of health disparities and improving support for patients navigating the emotional impact related to positive, negative and indeterminate testing results.
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Affiliation(s)
- Lindsey McAlarnen
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kristen Stearns
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Denise Uyar
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, WI, USA
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Scott N, O'Sullivan J, Asgeirsson K, Macmillan D, Wilson E. Changing practice: moving to a specialist nurse-led service for BRCA gene testing. ACTA ACUST UNITED AC 2020; 29:S6-S13. [DOI: 10.12968/bjon.2020.29.10.s6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Some 5–10% of all breast cancers are associated with a pathogenic variant in a breast cancer-associated gene (BRCA1/BRCA2). Historically, with referral to the Nottingham University Hospitals NHS Trust's clinical genetics department for genetic testing, waiting times were on average 12–14 weeks for an initial appointment and 4–6 months to obtain results from the date of testing. A specialist, nurse-led mainstreaming cancer genetics (MCG) service was set up in the trust's Nottingham Breast Institute (NBI) to: reduce waiting times for the initial consultation, counselling, consent and obtaining results for BRCA1/BRCA2 gene testing; and to ensure appropriate patients with breast cancer were offered genetic testing. Two breast clinical nurse specialists were trained so they could counsel, consent and give results for the BRCA1/BRCA2 gene testing directly to patients. Average waiting times for results from the time of testing were reduced to 35.8 days under the nurse-led service, which enabled oncologists and patients to consider individual treatment options at an earlier time. The MCG service reduced waiting times, resulting in an improved, more streamlined service for patients undergoing genetic testing. The MCG service extended the scope of practice of the breast nurse clinical specialists, embedded an expert advanced nursing role in the breast multidisciplinary team and developed nurse mentoring opportunities.
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Affiliation(s)
- Nicola Scott
- Breast Clinical Nurse Specialist and Specialist in Breast Family History, Nottingham Breast Institute, Nottingham University Hospitals NHS Trust
| | - Jackie O'Sullivan
- Breast Clinical Nurse Specialist and Specialist in Breast Family History, Nottingham Breast Institute, Nottingham University Hospitals NHS Trust
| | - Kristjan Asgeirsson
- Consultant Oncoplastic Breast Surgeon, Nottingham Breast Institute, Nottingham University Hospitals NHS Trust
| | - Douglas Macmillan
- Consultant Oncoplastic Breast Surgeon, Nottingham Breast Institute, Nottingham University Hospitals NHS Trust
| | - Emma Wilson
- Associate Professor in Public Health, University of Nottingham
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