title: Gaps in Incorporating Germline Genetic Testing Into Treatment Decision-Making for Early-Stage Breast Cancer.
abstract: Purpose Genetic testing for breast cancer risk is evolving rapidly, with growing use of multiple-gene panels that can yield uncertain results. However, little is known about the context of such testing or its impact on treatment. Methods A population-based sample of patients with breast cancer diagnosed in 2014 to 2015 and identified by two SEER registries (Georgia and Los Angeles) were surveyed about genetic testing experiences (N = 3,672; response rate, 68%). Responses were merged with SEER data. A patient subgroup at higher pretest risk of pathogenic mutation carriage was defined according to genetic testing guidelines. Patients' attending surgeons were surveyed about genetic testing and results management. We examined patterns and correlates of genetic counseling and testing and the impact of results on bilateral mastectomy (BLM) use. Results Six hundred sixty-six patients reported genetic testing. Although two thirds of patients were tested before surgical treatment, patients without private insurance more often experienced delays. Approximately half of patients (57% at higher pretest risk, 42% at average risk) discussed results with a genetic counselor. Patients with pathogenic mutations in BRCA1/2 or another gene had the highest rates of BLM (higher risk, 80%; average risk, 85%); however, BLM was also common among patients with genetic variants of uncertain significance (VUS; higher risk, 43%; average risk, 51%). Surgeons' confidence in discussing testing increased with volume of patients with breast cancer, but many surgeons (higher volume, 24%; lower volume, 50%) managed patients with BRCA1/2 VUS the same as patients with BRCA1/2 pathogenic mutations. Conclusion Many patients with breast cancer are tested without ever seeing a genetic counselor. Half of average-risk patients with VUS undergo BLM, suggesting a limited understanding of results that some surgeons share. These findings emphasize the need to address challenges in personalized communication about genetic testing.
authors.affiliation: Allison W. Kurian, Stanford University, Stanford; Ann S. Hamilton, Keck School of Medicine, University of Southern California, Los Angeles, CA; Yun Li, M. Chandler McLeod, and Steven J. Katz, University of Michigan, School of Public Health; Sarah T. Hawley, University of Michigan, Veterans Administration Center for Clinical Management Research, Ann Arbor Veterans Affairs Health Care System; Reshma Jagsi, University of Michigan, Center for Bioethics and Social Science in Medicine, Ann Arbor, MI; Kevin C. Ward, Emory University, Rollins School of Public Health, Atlanta, GA; and Monica Morrow, Memorial Sloan Kettering Cancer Center, New York, NY.
authors.forename: Allison W
authors.initials: AW
authors.lastname: Kurian
authors.affiliation: Allison W. Kurian, Stanford University, Stanford; Ann S. Hamilton, Keck School of Medicine, University of Southern California, Los Angeles, CA; Yun Li, M. Chandler McLeod, and Steven J. Katz, University of Michigan, School of Public Health; Sarah T. Hawley, University of Michigan, Veterans Administration Center for Clinical Management Research, Ann Arbor Veterans Affairs Health Care System; Reshma Jagsi, University of Michigan, Center for Bioethics and Social Science in Medicine, Ann Arbor, MI; Kevin C. Ward, Emory University, Rollins School of Public Health, Atlanta, GA; and Monica Morrow, Memorial Sloan Kettering Cancer Center, New York, NY.
authors.forename: Yun
authors.initials: Y
authors.lastname: Li
authors.affiliation: Allison W. Kurian, Stanford University, Stanford; Ann S. Hamilton, Keck School of Medicine, University of Southern California, Los Angeles, CA; Yun Li, M. Chandler McLeod, and Steven J. Katz, University of Michigan, School of Public Health; Sarah T. Hawley, University of Michigan, Veterans Administration Center for Clinical Management Research, Ann Arbor Veterans Affairs Health Care System; Reshma Jagsi, University of Michigan, Center for Bioethics and Social Science in Medicine, Ann Arbor, MI; Kevin C. Ward, Emory University, Rollins School of Public Health, Atlanta, GA; and Monica Morrow, Memorial Sloan Kettering Cancer Center, New York, NY.
authors.forename: Ann S
authors.initials: AS
authors.lastname: Hamilton
authors.affiliation: Allison W. Kurian, Stanford University, Stanford; Ann S. Hamilton, Keck School of Medicine, University of Southern California, Los Angeles, CA; Yun Li, M. Chandler McLeod, and Steven J. Katz, University of Michigan, School of Public Health; Sarah T. Hawley, University of Michigan, Veterans Administration Center for Clinical Management Research, Ann Arbor Veterans Affairs Health Care System; Reshma Jagsi, University of Michigan, Center for Bioethics and Social Science in Medicine, Ann Arbor, MI; Kevin C. Ward, Emory University, Rollins School of Public Health, Atlanta, GA; and Monica Morrow, Memorial Sloan Kettering Cancer Center, New York, NY.
authors.forename: Kevin C
authors.initials: KC
authors.lastname: Ward
authors.affiliation: Allison W. Kurian, Stanford University, Stanford; Ann S. Hamilton, Keck School of Medicine, University of Southern California, Los Angeles, CA; Yun Li, M. Chandler McLeod, and Steven J. Katz, University of Michigan, School of Public Health; Sarah T. Hawley, University of Michigan, Veterans Administration Center for Clinical Management Research, Ann Arbor Veterans Affairs Health Care System; Reshma Jagsi, University of Michigan, Center for Bioethics and Social Science in Medicine, Ann Arbor, MI; Kevin C. Ward, Emory University, Rollins School of Public Health, Atlanta, GA; and Monica Morrow, Memorial Sloan Kettering Cancer Center, New York, NY.
authors.forename: Sarah T
authors.initials: ST
authors.lastname: Hawley
authors.affiliation: Allison W. Kurian, Stanford University, Stanford; Ann S. Hamilton, Keck School of Medicine, University of Southern California, Los Angeles, CA; Yun Li, M. Chandler McLeod, and Steven J. Katz, University of Michigan, School of Public Health; Sarah T. Hawley, University of Michigan, Veterans Administration Center for Clinical Management Research, Ann Arbor Veterans Affairs Health Care System; Reshma Jagsi, University of Michigan, Center for Bioethics and Social Science in Medicine, Ann Arbor, MI; Kevin C. Ward, Emory University, Rollins School of Public Health, Atlanta, GA; and Monica Morrow, Memorial Sloan Kettering Cancer Center, New York, NY.
authors.forename: Monica
authors.initials: M
authors.lastname: Morrow
authors.affiliation: Allison W. Kurian, Stanford University, Stanford; Ann S. Hamilton, Keck School of Medicine, University of Southern California, Los Angeles, CA; Yun Li, M. Chandler McLeod, and Steven J. Katz, University of Michigan, School of Public Health; Sarah T. Hawley, University of Michigan, Veterans Administration Center for Clinical Management Research, Ann Arbor Veterans Affairs Health Care System; Reshma Jagsi, University of Michigan, Center for Bioethics and Social Science in Medicine, Ann Arbor, MI; Kevin C. Ward, Emory University, Rollins School of Public Health, Atlanta, GA; and Monica Morrow, Memorial Sloan Kettering Cancer Center, New York, NY.
authors.forename: M Chandler
authors.initials: MC
authors.lastname: McLeod
authors.affiliation: Allison W. Kurian, Stanford University, Stanford; Ann S. Hamilton, Keck School of Medicine, University of Southern California, Los Angeles, CA; Yun Li, M. Chandler McLeod, and Steven J. Katz, University of Michigan, School of Public Health; Sarah T. Hawley, University of Michigan, Veterans Administration Center for Clinical Management Research, Ann Arbor Veterans Affairs Health Care System; Reshma Jagsi, University of Michigan, Center for Bioethics and Social Science in Medicine, Ann Arbor, MI; Kevin C. Ward, Emory University, Rollins School of Public Health, Atlanta, GA; and Monica Morrow, Memorial Sloan Kettering Cancer Center, New York, NY.
authors.forename: Reshma
authors.initials: R
authors.lastname: Jagsi
authors.affiliation: Allison W. Kurian, Stanford University, Stanford; Ann S. Hamilton, Keck School of Medicine, University of Southern California, Los Angeles, CA; Yun Li, M. Chandler McLeod, and Steven J. Katz, University of Michigan, School of Public Health; Sarah T. Hawley, University of Michigan, Veterans Administration Center for Clinical Management Research, Ann Arbor Veterans Affairs Health Care System; Reshma Jagsi, University of Michigan, Center for Bioethics and Social Science in Medicine, Ann Arbor, MI; Kevin C. Ward, Emory University, Rollins School of Public Health, Atlanta, GA; and Monica Morrow, Memorial Sloan Kettering Cancer Center, New York, NY.
authors.forename: Steven J
authors.initials: SJ
authors.lastname: Katz
mesh_terms: D001291:Attitude of Health Personnel; D001943:Breast Neoplasms / Q000235:genetics* / Q000473:pathology / Q000628:therapy*; D000066491:Clinical Decision-Making; D003142:Communication; D005260:Female; D019398:Genes, BRCA1; D024522:Genes, BRCA2; D005817:Genetic Counseling / Q000706:statistics & numerical data*; D005820:Genetic Testing; D005845:Georgia; D018095:Germ-Line Mutation; D006801:Humans; D007348:Insurance, Health; D015141:Los Angeles; D008495:Medical Oncology / Q000706:statistics & numerical data; D008875:Middle Aged; D009367:Neoplasm Staging; D062526:Patient Navigation; D010818:Practice Patterns, Physicians'; D000072036:Prophylactic Mastectomy / Q000706:statistics & numerical data; D012307:Risk Factors; D018426:SEER Program; D000071077:Surgical Oncology / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires; D013997:Time Factors