Abstract
We examined facilitators and barriers to adoption of genomic services for colorectal care, one of the first genomic medicine applications, within the Veterans Health Administration to shed light on areas for practice change. We conducted semi-structured interviews with 58 clinicians to understand use of the following genomic services for colorectal care: family health history documentation, molecular and genetic testing, and genetic counseling. Data collection and analysis were informed by two conceptual frameworks, the Greenhalgh Diffusion of Innovation and Andersen Behavioral Model, to allow for concurrent examination of both access and innovation factors. Specialists were more likely than primary care clinicians to obtain family history to investigate hereditary colorectal cancer (CRC), but with limited detail; clinicians suggested templates to facilitate retrieval and documentation of family history according to guidelines. Clinicians identified advantage of molecular tumor analysis prior to genetic testing, but tumor testing was infrequently used due to perceived low disease burden. Support from genetic counselors was regarded as facilitative for considering hereditary basis of CRC diagnosis, but there was variability in awareness of and access to this expertise. Our data suggest the need for tools and policies to establish and disseminate well-defined processes for accessing services and adhering to guidelines.
Highlights
Use of genomic health services to identify Lynch syndrome (LS), or hereditary nonpolyposis colon cancer (HNPCC), the most common hereditary colon cancer, is one of the first evidence-based genomic medicine applications
The purpose of our study was to address this gap by identifying comprehensive factors impacting adoption of genomic services for Veterans diagnosed with colorectal cancer (CRC) within the Veterans Health Administration (VHA), focusing on four genomic services typically used together to identify risk for LS: family health history documentation, genetic counseling, molecular testing, and genetic testing
We interviewed 58 clinicians from five specialties: primary care (n = 11); oncology (n = 13); surgery (n = 7); gastroenterology (n = 18); pathology (n = 9); these clinicians were from 14 high oncology-volume and 9 low oncology-volume facilities
Summary
Use of genomic health services to identify Lynch syndrome (LS), or hereditary nonpolyposis colon cancer (HNPCC), the most common hereditary colon cancer, is one of the first evidence-based genomic medicine applications. Longstanding guidelines recommend that all persons younger than age 50 diagnosed with colorectal cancer (CRC) receive one or more of the following genomic services to identify LS: family history assessment, genetic counseling, molecular tumor analysis, and genetic testing [1,2,3]. What is your current VHA position (manager, staff physician, service chief)?. Please tell me what genomic services are available at your VHA facility to identify hereditary colorectal cancer. (ASK ABOUT: MSI/IHC analysis, genetic sequencing, and genetic counseling.) Requesting Services. IF PARTICIPANT MAKES REFERRALS FOR GENOMIC SERVICES, ASK: What factors help you decide which patients to refer [Specify what type of test: MSI, IHC, genetic sequencing]? IF PARTICIPANT MAKES REFERRALS FOR GENOMIC SERVICES, ASK: What factors help you decide which patients to refer [Specify what type of test: MSI, IHC, genetic sequencing]? (Probes: Age of diagnosis, presence of family history, known mutation in family.)
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