Germline genetic testing can play an essential role in identifying cancer risk, guiding treatment decisions, and informing screening and/or preventive strategies for both patients and patient family members. Access to timely and convenient genetic testing can be challenging based on increased indications for testing, larger gene panels, and high numbers of positive tests which are overloading a limited genetics workforce. This is leading to long wait times and widening disparities in access to genetic testing. Dr. Chino welcomes Dr. Trevor Hoffman to discuss an intervention he helped pilot using non-genetics providers to increase access while maintaining quality. TRANSCRIPT Dr. Fumiko Chino: Hello and welcome to Put Into Practice, the podcast from the JCO Oncology Practice. I'm Dr. Fumiko Chino, an assistant professor in radiation oncology at MD Anderson Cancer Center with a research focus on access, affordability, and equity. Germline genetic testing can play an essential role to identify cancer risk, guide treatment directions, and inform screening or preventative strategies for both patients and patient family members. Access to timely and convenient genetic testing can be challenging based on increased indications for testing, larger gene panels, and high numbers of positive tests that are overloading a limited genetics workforce. This is leading to long wait times and widening disparities in access to genetic testing. I'm happy to welcome a guest today to discuss an intervention he helped pilot using non-genetics providers to increase access while maintaining quality. Dr. Trevor Hoffman, MD, PhD, is an associate professor in clinical medicine at the Kaiser Permanente Bernard J. Tyson School of Medicine and the Regional Chief of Medical Genetics in the Southern California Kaiser Permanente Medical Group. He leads a department of 10 medical geneticists and approximately 40 genetic counselors, serving 5 million Kaiser members in Southern California. He is the first author of a JCO OP manuscript, "Expanding Germline Hereditary Cancer Gene Panel Testing by Non-Genetics Providers," which was published earlier this year. Our full disclosures are available in the transcript of this episode, and we've already agreed to go by our first names for the podcast today. Trevor, it's wonderful to speak to you today. Dr. Trevor Hoffman: Thank you so much for inviting me on the pod. I'm really psyched about it. Dr. Fumiko Chino: Our specific topic today is something that I know you know a lot about, germline genetic testing. Despite broadened eligibility, only a small percentage of people diagnosed with cancer will undergo germline genetic testing, and I'd love your thoughts on the changes in genetic testing over your 20+ year career, and particularly, obviously for our respects, within the cancer patient population. The who, what, when, where, how, and wherefores of genetic testing and how this has evolved as our scientific knowledge has really improved over time. Dr. Trevor Hoffman: Yeah, it's been a wild ride considering everything I've seen happen in my own field. Back when I started in practice, we were doing like standard karyotypes and maybe sequencing a gene here or there by Sanger sequencing, and testing was cost prohibitive, thousands of dollars. You know, there were gene patents. You know, we were this little hidden department, like in the basement, that hardly anybody knew about, and we liked our little place in anonymity, and it was all good. Come the genomics revolution and next-generation sequencing, and, you know, all of a sudden you can, in one machine, sequence, you know, billions of letters of genetic code for hundreds of dollars. It was like a paradigm shift caused by technology. So that and the removal of gene patents, we've come, you know, in the ensuing years to hereditary cancer gene tests that's, you name it, depending on whether it's done 20, 30, 40, 70 genes for under $500 in most cases and can be done in a matter of a couple of weeks. That's a bit of a massive change. In oncology, we've seen that happen in terms of tumor NGS, right? Like, things are changing for all of us rapidly. And so multiply that across every specialty. In my field where we used to own every genetic test, like genetics would kind of order every test and determine who needed testing, that's not going to happen. Like, it's not going to work anymore. So we have to come up with better ways to sort of put it into the hands of people, make it easy, make it appropriate to maintain access. We can't do the white-glove service anymore where we see every single patient and touch every patient. That's the shortest version of my career in a nutshell. And you're living this too, right? Like many people listening to this podcast train oncology, like tumor NGS didn't exist, you know, and now all of a sudden it's like standard of care in our system. And you know, people have had to just learn by the seat of their pants. And so we're all in this crazy roller coaster together. Dr. Fumiko Chino: Yeah, it seems like the proliferation of testing and the vitality of the information gained from it, how important it is, it is unsustainable for the genetics workforce to stay in their closed basement system. As a radiation oncologist who lives in a basement, we have enough people in the basement. We're hoping to integrate them a little better into the larger community. Now, you were the first author of this recent report on the 3-year experience of mainstreaming hereditary cancer gene panel testing at Kaiser Permanente Southern California. Do you mind briefly discussing the background of what led to this project - again, sounds like limited workforce - and what your study team actually did, and then the actual findings? Dr. Trevor Hoffman: Yeah, I'd love to. So this kind of arose from, and mainstreaming is essentially in the genetics field, we call that like handing a test to a non-genetics provider to order. So that's kind of the term that has been applied to that. And essentially, we have to do that. And so this kind of arose through some personal relationships I had with cancer providers in our system, a couple of whom were down the hall from me. One of them was a GYN ONC provider, and the other was a breast surgeon. And so, I had both our breast surgeon and our GYN ONC doc approached me and say, "You know what? I'm seeing all these women and they have ovarian cancer, or they have breast cancer, and I know I'm doing surgery on these people. They need a hereditary cancer gene test. It's a no-brainer. And so I have to see them. I schedule my surgery. If it's breast cancer, I'm like, I'm not sure what the surgery is, and this woman may be 45, and it's like, well, I don't know what surgery to do, but we schedule a surgery in three weeks. We refer them to genetics. Genetics sees them, schedules an appointment, orders the test, the patient goes to the lab and gets the test." That all sounds great, right? But the patient may be overwhelmed. They may not know the importance of getting that appointment scheduled very quickly. In our system, we're under a regulatory guideline to see people within two weeks, but in lots of genetics practices out there, there are wait lists that are a year, two years, three years. The patient may not understand why the surgeon wants this result, right? And it's, you know, I listened to your last podcast about parking charges, right, being a barrier. So like, we're putting up all these barriers for patients with cancer, and then if the patient didn't get the test or do it, the surgeon's like, "I've got to cancel my surgery," and they're calling me. And so we kind of were like, "Hey, wait a minute, like, can I just order this myself in the surgery clinic or in the GYN ONC clinic? Because it's making their life easier." So it kind of arose out of one of these rare things in medicine, right? Like a win, win, win. For them it's a win. They need the info quick. They want to schedule their surgery, they want to know what they're doing. For the patient it's a win because then they don't have to make an appointment, pay the parking fee, all the barriers of getting that appointment done. And from our point of view, it's a win because like, I know before that patient walks in the door, I'm ordering that test for a 45-year-old woman with breast cancer, like it's a no-brainer. The other thing I would say is that from the point of view of the patient, seeing me for like a separate 60-minute appointment to discuss testing in that venue, they've got so many other things on their mind. The ability to hold onto all that information is just limited. So, you know, we see people and we still do in some contexts in these multidisciplinary clinics, but the retention of what I'm telling patients, honestly is low. They're worried they're going to die. They're worried about, "What surgery am I going to have?" "What am I going to do about my job?" And so we started doing it on a small scale, but the main thing was making it logistically easy for them. That's the key, is making it as simple and efficient as possible. And so for us, that was putting an order in our EMR that was like a couple of clicks. And then taking the worry off their minds that like, they're not going to be stuck like backpedaling and trying to counsel a patient. Like we're going to be there for you to counsel that patient when they're positive, right away. A lot of it's about reassuring and just making it easy and trust. And so like without that, like this never would have happened, you know, everybody would have stayed in their silo. So out of that, we kind of grew it and we're up now over 20,000 tests that have been ordered by oncology providers, physicians, case manager nurses for our breast cancer coordinators, PAs in some cases, nurse practitioners, all these people are doing this with clear guidelines, right? Like very clear indic
