302 Increasing Appropriate Referrals to Genetic Counseling at the Time of Endoscopy

Abstract

INTRODUCTION: The ACG recommends an initial assessment of family history of cancer and premalignant conditions be performed for all patients evaluated in gastroenterology practices to develop a preliminary determination of risk of familial cancer predisposition. Due to the fast-paced nature of practice and a knowledge gap, providers often miss referring high-risk patients for genetic counseling. For example, less than 2% of the projected 830,000 Lynch syndrome patients in the US are aware of their mutation status. In this quality improvement project, we implemented a one-page, patient-administered survey to identify those at high risk of common hereditary cancer syndromes and facilitate appropriate referral to genetic counseling. METHODS: We created a four-question survey based on National Comprehensive Cancer Network (NCCN) guidelines for genetic testing for several hereditary cancer syndromes, including Lynch syndrome and Hereditary Breast and Ovarian Cancer syndrome. It was provided to all English-speaking patients presenting for outpatient endoscopy, who voluntarily completed the survey in the waiting area. Completed surveys were assessed for meeting criteria for referral for genetic testing. The survey was implemented on April 1, 2019, and we assessed its initial impact by comparing the number of positive surveys (i.e. meeting NCCN guidelines for referral to genetic counseling) over two months post-implementation (Apr-May 2019) with the number of genetic counseling referrals by gastroenterology providers at our institution over two months pre-implementation (Feb-Mar 2019). RESULTS: In February-March 2019, 13 genetic counseling referrals were made by gastroenterology providers at our institution. In April-May 2019, 874 surveys were completed. 330 surveys (37.8%) had responses meeting NCCN guidelines for referral for genetic counseling and a high risk of familial cancer predisposition. 481 (55%) did not meet criteria for high-risk family history, and 63 (7.2%) had indeterminate responses, requiring additional evaluation to determine risk. CONCLUSION: We created a simple, self-administered survey that identified a far larger number of endoscopy patients meeting NCCN criteria for genetic counseling referral than the number of referrals placed over a comparable timeframe prior to implementation. To address the large gap in appropriate genetic counseling referrals, we aim to create a sustainable workflow for referral from endoscopy, and plan to assess patient follow-through on these referrals.