Example of A Clinical Care Gap: Oncologists and Genetic Counselors

Just over 2 years ago Cigna, the health insurance company that is expected to officially merge with Anthem soon, established a mandate for its beneficiaries to require genetic counseling from a board-certified genetic counselor or medical geneticist prior to a genetic test for hereditary condition to be reimbursed. The listed conditions included breast and ovarian cancer, familial adenomatous polyposis and other colorectal cancer syndromes, and the heart rhythm disorder long QT syndrome. The premise of the requirement was lack of understanding among both providers and patients.

Now a new study, published in JAMA Oncology has analyzed factors that characterize the use of these tests and their impact on patient-reported outcomes, and found a widespread gap in counseling services for patients who undergo BRCA testing.

The study—a collaboration between the third largest commercial health insurer Aetna, several academic medical institutions, American Cancer Society, and Facing Our Risk of Cancer Empowered (FORCE, a national nonprofit that raises awareness on hereditary breast and ovarian cancer) analyzed data from over 11,000 commercially-insured women whose clinicians ordered BRCA testing for a period of 1 year from December 2011 and December 2012. While only about 35% (3874) of these women responded to a questionnaire mailed by Aetna, clinician-reported data of 2613 deidentified non-responders was also included in the study.

The authors identified a racial bias among the respondents: about 69% were white non-Hispanics. Further, a majority were college-educated (81.4%), married (75.8%), and had higher incomes (55.4%). However, only about 37% of women reported that they had been counseled by a genetics physician prior to testing—the lowest rates of counseling were reported by patients of obstetrician/gynecologists. Despite the “knowledge is value” belief, a majority of patients who were not counseled stated that their physicians had not recommended the service. The author’s analysis also found that those who were counseled understood the implications of the genetic test much better and were satisfied with the decision.

In their discussion, the authors write that the low rates of counseling services were a surprise, considering the “clear professional society guidelines and published research that consistently document its importance in informed decision making and facilitating better patient outcomes.” They conclude that these less-than adequate rates of counseling can have a significant impact on patient outcomes.