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Caeser R, Chiang J, Tan ES, Tai ES, Ngeow J. Cascade testing for hereditary cancer in Singapore: how population genomics help guide clinical policy. Fam Cancer 2024; 23:133-140. [PMID: 38662262 DOI: 10.1007/s10689-024-00376-1] [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: 03/11/2024] [Accepted: 03/14/2024] [Indexed: 04/26/2024]
Abstract
Hereditary Cancer makes up around 5-10% of all cancers. It is important to diagnose hereditary cancer in a timely fashion, as not only do patients require long-term care from a young age, but their relatives also require management. The main approach to capture at-risk relatives is cascade testing. It involves genetic testing of relatives of the first detected carrier of a pathogenic variant in a family i.e. the proband. The current standard of care for cascade testing is a patient-mediated approach. Probands are then advised to inform and encourage family members to undergo genetic testing. In Singapore, cascade testing is inefficient, around 10-15%, lower than the 30% global average. Here, we describe the cascade testing process and its effort to increase testing in Singapore. Precision Health Research, Singapore (PRECISE), was set up to coordinate Singapore's National Precision Medicine strategy and has awarded five clinical implementation pilots, with one of them seeking to identify strategies for how cascade testing for hereditary cancer can be increased in a safe and cost-efficient manner. Achieving this will be done through addressing barriers such as cost, manpower shortages, exploring a digital channel for contacting at-risk relatives, and getting a deeper insight into why genetic testing gets declined. If successful, it will likely result in care pathways that are a cost-effective public health intervention for identifying individuals at risk. Surveillance and management of those unaffected at-risk individuals, if caught early, will result in improved patient outcomes, and further reduce the healthcare burden for the economy.
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Affiliation(s)
- Rebecca Caeser
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Centre Singapore, Singapore, 169610, Singapore
- Oncology Academic Clinical Program, Duke-NUS Medical School, Singapore, Singapore
| | - Jianbang Chiang
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Centre Singapore, Singapore, 169610, Singapore
- Oncology Academic Clinical Program, Duke-NUS Medical School, Singapore, Singapore
| | - Ee Shien Tan
- Duke-National University of Singapore (NUS) Medical School, National University of Singapore, Singapore, Singapore
- Genetics Service, Department of Pediatrics, Kadang Kerbau (KK) Women's and Children's Hospital, Singapore, Singapore
| | - E Shyong Tai
- Duke-National University of Singapore (NUS) Medical School, National University of Singapore, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Precision Health Research, Singapore, Singapore
| | - Joanne Ngeow
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Centre Singapore, Singapore, 169610, Singapore.
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, 308232, Singapore.
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Chiang J, Chua Z, Chan JY, Sule AA, Loke WH, Lum E, Ong MEH, Graves N, Ngeow J. Strategies to improve implementation of cascade testing in hereditary cancer syndromes: a systematic review. NPJ Genom Med 2024; 9:26. [PMID: 38570510 PMCID: PMC10991315 DOI: 10.1038/s41525-024-00412-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 03/13/2024] [Indexed: 04/05/2024] Open
Abstract
Hereditary cancer syndromes constitute approximately 10% of all cancers. Cascade testing involves testing of at-risk relatives to determine if they carry the familial pathogenic variant. Despite growing efforts targeted at improving cascade testing uptake, current literature continues to reflect poor rates of uptake, typically below 30%. This study aims to systematically review current literature on intervention strategies to improve cascade testing, assess the quality of intervention descriptions and evaluate the implementation outcomes of listed interventions. We searched major databases using keywords and subject heading of "cascade testing". Interventions proposed in each study were classified according to the Effective Practice and Organization of Care (EPOC) taxonomy. Quality of intervention description was assessed using the TIDieR checklist, and evaluation of implementation outcomes was performed using Proctor's Implementation Outcomes Framework. Improvements in rates of genetic testing uptake was seen in interventions across the different EPOC taxonomy strategies. The average TIDieR score was 7.3 out of 12. Items least reported include modifications (18.5%), plans to assess fidelity/adherence (7.4%) and actual assessment of fidelity/adherence (7.4%). An average of 2.9 out of 8 aspects of implementation outcomes were examined. The most poorly reported outcomes were cost, fidelity and sustainability, with only 3.7% of studies reporting them. Most interventions have demonstrated success in improving cascade testing uptake. Uptake of cascade testing was highest with delivery arrangement (68%). However, the quality of description of interventions and assessment of implementation outcomes are often suboptimal, hindering their replication and implementation downstream. Therefore, further adoption of standardized guidelines in reporting of interventions and formal assessment of implementation outcomes may help promote translation of these interventions into routine practice.
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Affiliation(s)
- Jianbang Chiang
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Centre Singapore, Singapore, 169610, Singapore
- Oncology Academic Clinical Program, Duke-NUS Medical School, Singapore, Singapore, 169857, Singapore
| | - Ziyang Chua
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Centre Singapore, Singapore, 169610, Singapore
| | - Jia Ying Chan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, 308232, Singapore
| | - Ashita Ashish Sule
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117597, Singapore
| | - Wan Hsein Loke
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117597, Singapore
| | - Elaine Lum
- Health Services & Systems Research, Duke-NUS Medical School, Singapore, 169857, Singapore
| | - Marcus Eng Hock Ong
- Health Services & Systems Research, Duke-NUS Medical School, Singapore, 169857, Singapore
- Department of Emergency Medicine, Singapore General Hospital, Singapore, 169608, Singapore
| | - Nicholas Graves
- Health Services & Systems Research, Duke-NUS Medical School, Singapore, 169857, Singapore
| | - Joanne Ngeow
- Cancer Genetics Service, Division of Medical Oncology, National Cancer Centre Singapore, Singapore, 169610, Singapore.
- Oncology Academic Clinical Program, Duke-NUS Medical School, Singapore, Singapore, 169857, Singapore.
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, 308232, Singapore.
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Affiliation(s)
- Hwei Wuen Chan
- Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore,Department of Ophthalmology, National University Hospital, Singapore
| | - Shaun Seh Ern Loong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Roger Sik Yin Foo
- Cardiovascular Disease Translational Research Programme, Yong Loo Lin School of Medicine, National University of Singapore,Department of Cardiology, National University Heart Centre, National University Health System, Singapore E-mail:
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