Identifying and addressing barriers to germline testing in ovarian cancer.

Abstract

e17554 Title: Identifying and addressing barriers to germline testing in ovarian cancer Background: Ovarian cancer is the fifth leading cause of death in women, with 300,000 women diagnosed annually worldwide. Approximately 20% of cases are attributable to a hereditary predisposition (e.g., BRCA 1/2). All patients with a diagnosis of epithelial ovarian cancer should undergo germline genetic testing, though <50% of patients in the U.S. have received it. Within our health system, which includes over 60 cancer centers, approximately 2/3 of patients diagnosed with epithelial ovarian cancer have received germline testing. Knowledge of a germline pathogenic variant may inform prognosis, guide treatment, aid management of other cancer risks, and lead to testing and implementation of risk-appropriate management in family members. Our goal is to identify action areas for future quality improvement initiatives to increase testing rates. Methods: We conducted semi-structured individual and small group interviews with members of the Gynecologic Oncology and Cancer Genetics offices. Interview length varied by office member involvement in germline testing (10 – 60 minutes). Interviews focused on current workflow for germline testing for ovarian cancer patients, barriers to testing, and suggestions for improvement. Interviews were recorded and transcribed, coded, and analyzed using inductive thematic analysis, with at least two coders per interview. Results: Fifteen gynecologic oncologists, one medical geneticist, 11 advanced practice providers (physician assistants and nurse practitioners), seven genetic counselors, and 25 office staff members (nurses, surgery schedulers, medical assistants, administrative personnel) participated. Participants identified several barriers to germline testing, including lack of standardized process for testing and inconsistent follow up among providers and staff; patient concerns about cost; multifactorial logistical, emotional, and physical challenges of cancer care for patients; and patients’ lack of information about benefits of testing. Possible solutions included mainstream testing; alignment on one testing and follow-up pathway across providers; increased focus by providers on patient cost concerns; multidisciplinary clinic to streamline cancer care; increased use of telemedicine; and empowering patients with information about benefits of testing for themselves and their family members. Additional focus on equity was also identified as an area of need within ovarian cancer care. Conclusions: Approach to germline testing for ovarian cancer patients is currently dependent on individual workflow, resulting in persistent barriers to testing. Streamlining the testing process may make testing easier for clinicians and patients. Efforts to identify and evaluate interventions to increase testing rates, with a focus to ensure equity of care, are needed.