Integrating Germline Genetics Into Precision Oncology Practice in the Veterans Health Administration: Challenges and Opportunities

Abstract

Objectives: The advent of germline testing as a standard-of-care practice for certain tumor types and patients presents unique opportunities and challenges for the field of precision oncology. This article describes strategies to address workforce capacity, organizational structure, and genetics education needs within the US Department of Veterans Affairs (VA) with the expectation that these approaches may be applicable to other health care systems.

Observations: Germline information can have health, reproductive, and psychosocial implications for veterans and their family members, which can pose challenges when delivering germline information in the setting of cancer care. Additional challenges include the complexity inherent in the interpretation of germline information, the national shortage of genetics professionals, limited awareness and knowledge about genetic principles among many clinicians, and organizational barriers, such as the inability to order genetic tests and receive results in the electronic health record. These challenges demand thoughtful implementation planning at the health care system level to develop sustainable strategies for the delivery of high-quality genetic services in precision oncology practice.

Conclusions: The VA is uniquely positioned to address the integration of germline genetic testing into precision oncology practice due to its outsized role in treating veterans with cancer, training the health care workforce, and developing, testing, and implementing innovative models of clinical care.

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Genetic Consultation: A Shared Decision-Making Process Genetic testing for hereditary cancer syndromes typically is offered in the setting of genetic consultation comprised of evaluation and counseling processes. Genetic evaluation for a hereditary condition is a process informed by comprehensive review and synthesis of medical history, social history, exposure history, family history, physical examination, and results from pathology reports, laboratory tests, imaging, procedures, and consultations. Genetic evaluation results in a differential diagnosis, including both genetic and nongenetic diagnoses. If indicated, a genetic testing strategy is recommended to further inform the differential diagnosis or risk assessment. Clinical decision making based on the genetic diagnosis may include recommendations for additional diagnostic evaluation (eg, imaging or procedures), disease management and prevention, reproductive options, lifestyle changes, and longitudinal follow-up. Genetic counseling is a communication process that facilitates patient decision making surrounding the genetic evaluation. Patient preferences, values, family dynamics, educational level, and cultural norms are considered and inform the patient’s perception and knowledge of their genetic diagnosis or risk, and self-efficacy to cope with and make decisions based on this information.