Variant Of Uncertain Significance Result Research Articles

A content analysis of parents' reflections on pathogenic and uncertain pediatric oncology germline sequencing results.

Germline genomic sequencing is increasingly integrated into pediatric cancer care, with pathogenic cancer-predisposing variants identified among 5-18% of affected children and variants of uncertain significance (VUS) in up to 70%. Given the potential medical implications for children and their families, parents' psychosocial responses to learning results are important to understand. Parents of children with cancer who learned their children's germline pathogenic or VUS results following paired tumor and germline genomic sequencing described their cognitive and affective responses to results in an open-ended write-in question after disclosure (M = 10 months post-disclosure; range = 1-28). Responses were coded and categorized using content analysis, then compared across results using chi-square and Fisher's exact test. Parents of children with pathogenic (n = 9), VUS (n = 52), and pathogenic plus VUS results (n = 9) described negative emotions, positive reactions, mixed emotions (i.e., positive and negative emotions), and neutral reactions. Negative emotions were described significantly more frequently with pathogenic results than VUS only (χ2 = 5.19; p = .02), with peace of mind and empowerment only described for those with VUS. Parents also described approach(es) to coping (e.g., faith, plan of action) and reactions specific to the uncertainty of VUS (e.g., disappointment at no explanation for cancer etiology). A subset with VUS described decreasing worry/distress with increased understanding of results, whereas others displayed misconceptions regarding VUS. Screening for emotional adjustment is warranted for parents of children with cancer receiving pathogenic germline results, and screening for understanding is warranted with VUS. Findings highlight the importance of pre-and posttest genetic counseling.

Comparing the Diagnostic Yield of Germline Exome Versus Panel Sequencing in the Diverse Population of the Texas KidsCanSeq Pediatric Cancer Study.

To evaluate the relative diagnostic yield of clinical germline genomic tests in a diverse pediatric cancer population. The KidsCanSeq study enrolled pediatric cancer patients across six sites in Texas. Germline analysis included both exome sequencing and a therapy-focused pediatric cancer gene panel. The results were categorized by participants demographics, the presence of pathogenic or likely pathogenic (P/LP) variants, and variants of uncertain significance (VUS) in cancer predisposition genes (CPGs). Pediatric actionable CPGs were defined as those with cancer surveillance recommendations during childhood. Cancer P/LP variants were reported by at least one platform in 103 of 578 (17.8%) participants of which 76 were dominant cancer genes (13.1%) with no significant differences by self-described race or Hispanic ethnicity. However, the proportion of participants with VUS was greater in Asian and African American participants (P = .0029). Diagnostic yield was 16.6% for exome versus 8.5% for panel (P < .0001) with 42 participants with concordant germline results. Exome-only results included P/LP variants in 30 different CPGs in 54 participants, whereas panel-only results included seven participants with a copy number or structural P/LP variants in CPGs. There was no significant difference in diagnostic yield limited to pediatric actionable CPGs (P = .6171). Approximately 18% of a diverse pediatric cancer population had germline diagnostic findings with 50% of P/LP variants reported by only one platform because of CPGs not on the targeted panel and copy number variants (CNVs)/rearrangements not reported by exome. Although diagnostic yields were similar in this diverse population, increases in VUS results were observed in Asian and African American populations. Given the clinical significance of CNVs/rearrangements in this cohort, detection is critical to optimize germline analysis of pediatric cancer populations.

The Development and Evaluation of Novel Patient Educational Material for a Variant of Uncertain Significance (VUS) Result in Hereditary Cancer Genes.

A Variant of Uncertain Significance (VUS) is a difference in the DNA sequence with uncertain consequences for gene function. A VUS in a hereditary cancer gene should not change medical care, yet some patients undergo medical procedures based on their VUS result, highlighting the unmet educational needs among patients and healthcare providers. To address this need, we developed, evaluated, and refined novel educational materials to explain that while VUS results do not change medical care, it remains important to share any personal or family history of cancer with family members given that their personal and family medical history can guide their cancer risk management. We began by reviewing the prior literature and transcripts from interviews with six individuals with a VUS result to identify content and design considerations to incorporate into educational materials. We then gathered feedback to improve materials via a focus group of multidisciplinary experts and multiple rounds of semi-structured interviews with individuals with a VUS result. Themes for how to improve content, visuals, and usefulness were used to refine the materials. In the final round of interviews with an additional 10 individuals with a VUS result, materials were described as relatable, useful, factual, and easy to navigate, and also increased their understanding of cancer gene VUS results.

Real-world cancer care utilization among patients with breast cancer with germline variants of uncertain significance.

10512 Background: Receipt of variant of uncertain significance (VUS) results from germline genetic testing (GGT) is common, but should not influence treatment or surveillance interventions. We examined treatment and surveillance uptake among breast (BC) patients (pts) undergoing GGT. Methods: GGT (Invitae Corporation) and insurance claims (Komodo Healthcare Map) data were assembled for female pts with ICD code(s) for BC or DCIS from 2015-2023, GGT &lt;120 days post-diagnosis (dx) and &gt;1 year of claims pre- and post-GGT. Inclusion/exclusion criteria followed prior work (PMID 32027353). Genes analyzed for VUS and positive (&gt;1 pathogenic germline variant, PGV) results were those with high ( &gt; 50%; BRCA1/ 2, CDH1, PALB2, PTEN, TP53) or moderate (20-50%; ATM, BARD1, CHEK2, NF1, STK11, RAD51C/D) BC risk. Multivariable logistic regression models of the association between GGT results and interventions included race/ethnicity, age, family history, local/distant metastasis, and log-transformed time from BC dx to GGT. Chi-square tests were used to compare demographics of VUS pts to other pts. Significance was set to p &lt; 0.05. Results: The cohort consisted of 19,334 pts (2005 VUS, 16,062 negative, 1,267 positive): 68% White, 25% lymph node involvement, 63% cancer family history, 28% Medicare/Medicaid, mean (SD) age at testing: 53 (11) and mean (SD) days from dx to GGT: 37 (25). VUS pts were more likely to be non-White (p &lt; 0.001). VUS pts were not more likely than negative pts to undergo BC-related therapies or surveillance, except for (anthracycline) chemotherapy (Table). In contrast, positive pts had significantly greater odds than negative pts of bilateral mastectomy, platinum/anthracycline chemotherapy, PARP inhibitors, and breast MRI. Conclusions: In a contemporary, real-world cohort of nearly 20,000 BC patients, receipt of BC-related interventions was similar in VUS and negative pts. VUS results do not appear to prompt guideline-discordant management, though the finding of increased anthracycline use needs further study. [Table: see text]

Family communication of cancer genetic test results in an ethnically diverse population: a qualitative exploration of more than 200 patients.

Previous research on family communication of cancer genetic test results has primarily focused on non-Hispanic White patients with high-risk pathogenic variants (PV). There are limited data on patient communication of moderate-risk PVs, variants of uncertain significance (VUS), and negative results. This qualitative study examined communication of positive, negative, and VUS hereditary cancer multi-gene panel (MGP) results in an ethnically and socioeconomically diverse population. As part of a multicenter, prospective cohort study of 2000 patients who underwent MGP testing at three hospitals in California, USA, free-text written survey responses to the question: "Feel free to share any thoughts or experiences with discussing genetic test results with others" were collected from participant questionnaires administered at 3 and 12-months post results disclosure. Content and thematic analyses were performed using a theory-driven analysis, Theory of Planned Behavior (TPB), on 256 responses from 214 respondents. Respondents with high perceived utility of sharing genetic test results often reported positive attitudes towards sharing test results and direct encouragement for genetic testing of others. Respondents with high self-efficacy in the sharing process were likely to report high perceived utility of sharing, whereas patients with low self-efficacy more often had VUS results and were more likely to report uncertainty about sharing. Consistent with TPB, our findings suggest that clinician reinforcement of the utility of genetic testing may increase intent for patients to communicate genetic information. Our findings suggest that clinicians should focus on strategies to improve patient understanding of VUS results.

Written communication of whole genome sequencing results in the NHS Genomic Medicine Service: a multi-centre service evaluation.

Whole genome sequencing (WGS) is being used in diagnostic testing for certain clinical indications within the NHS Genomic Medicine Service (GMS) in England. Letter writing is an integral part of delivering results. However, no national guidelines for writing results from WGS exist. This multi-centre service evaluation used mixed methods to understand the content and readability of letters returning diagnostic, variant of uncertain significance (VUS), and no-finding results to paediatric rare disease patients. Eight Regional Genetics Services (response rate 47%) in England provided a total of 37 letters returning diagnostic (n = 13), VUS (n = 10), and no-finding (n = 14) results. Diagnostic and VUS results were usually delivered during an appointment; no-finding results were typically delivered by letter only. Letters were diverse in which content topics they covered and level of detail. No-finding letters (14/14) explained the result but were less likely to cover other topics. Diagnostic letters discussed the result (13/13), the condition (13/13), clinical genetics follow-up (13/13), clinical management (10/13), and adapting to the result (9/13). VUS letters explained the result (10/10), diagnostic uncertainty (10/10), and clinical genetics follow-up (10/10). Uncertainty was a common component of letters (33/37), irrespective of the result. Reanalysis or review after one or more years was suggested in 6/13 diagnostic, 7/10 VUS, and 6/14 no-finding letters. The mean reading level of letters corresponded to 15-17 years. Understanding how WGS results are conveyed to families during appointments, as well as how families interpret that information, is needed to provide a more comprehensive overview of results communication and inform best practices.

Assessing management practices for variants of uncertain significance among genetic counselors in pediatrics.

Increased utilization of genomic sequencing in pediatric medicine has increased the detection of variants of uncertain significance (VUS). Periodic VUS reinterpretation can clarify clinical significance and increase diagnostic yield, highlighting the importance of systematic VUS tracking and reinterpretation. There are currently no standardized guidelines or established best practices for VUS management, and our understanding of how genetic counselors (GCs) track and manage VUS results for pediatric patients is limited. In this exploratory study, GCs in pediatric clinics in North America were surveyed about their VUS management practices. A total of 124 responses were included in the analysis. The majority (n = 115, 92.7%) of GCs reported that VUS management workflows were at the discretion of each individual provider in their workplace. Approximately half (n = 65, 52%) kept track of patient VUS results over time, and GCs with lower patient volumes were more likely to do so (p = 0.04). While 95% (n = 114) of GCs had requested VUS reinterpretation at least once, only 5% (n = 6) requested it routinely. Most (n = 80, 86%) GCs notified patients when a VUS was reclassified, although methods of recontact differed when the reclassification was an upgrade versus a downgrade. GCs who asked patients to stay in touch through periodic recontact or follow-up appointments were more likely to request VUS reinterpretation (p = 0.01). The most frequently reported barriers to requesting reinterpretation regularly were patients being lost to follow-up (n = 39, 33.1%), insufficient bandwidth (n = 27, 22.9%), and lack of standardized guidelines (n = 25, 21.2%). GCs had consistent overall practices around VUS management around investigation, disclosure, reinterpretation, and recontact, but specific methods used differed and were at the discretion of each provider. These results showcase the current landscape of VUS management workflows in pediatrics and the challenges associated with adopting more uniform practices. The study findings can help inform future strategies to develop standardized guidelines surrounding VUS management.

Release of reclassified VUS results of now deceased patients to family members: Practices and opinions.

Variants of uncertain significance (VUS) are commonly identified in genetic testing. The rate at which a VUS is reclassified depends on multiple factors. However, as the amount of time it might take for a VUS to be reclassified varies, some patients with a VUS genetic testing result might have passed away before the VUS is reclassified. A VUS that is reclassified after the patient's death has clinical implications for the deceased patient's family members. The disclosure of reclassified VUS results for a deceased patient has complex legal and ethical implications. There are no established guidelines on how the reclassified VUS result for a deceased patient should be disclosed to at-risk relatives. An online survey was sent to members of the National Society of Genetic Counselors (NSGCs) to elicit practices and opinions regarding this issue. A total of 153 (4%) NSGC members completed the survey. Thirty-seven (24.2%) respondents reported having received a reclassified VUS for a deceased patient. Respondents were more likely to attempt disclosure if the variant was reclassified as pathogenic (93.5%) versus benign (76.5%), although the difference did not reach statistical significance (p = 0.06). Respondents more often reported the impact on family members (85.5%) than the decedent's right to privacy (15.0%) as extremely important when considering disclosure to family members. A legal mechanism to allow disclosure to relatives was supported by 70.6% of respondents and 97.4% felt the issue was important enough to pursue if such a process was in place. Only 9.8% of respondents supported a legal requirement of consent before disclosing to family members when a VUS is reclassified after the patient has passed away. Our results indicate that there is no consensus for how these results should be handled and a mechanism for disclosure of reclassified results to family members is supported.

Rates and Classification of Variants of Uncertain Significance in Hereditary Disease Genetic Testing

Variants of uncertain significance (VUSs) are rampant in clinical genetic testing, frustrating clinicians, patients, and laboratories because the uncertainty hinders diagnoses and clinical management. A comprehensive assessment of VUSs across many disease genes is needed to guide efforts to reduce uncertainty. To describe the sources, gene distribution, and population-level attributes of VUSs and to evaluate the impact of the different types of evidence used to reclassify them. This cohort study used germline DNA variant data from individuals referred by clinicians for diagnostic genetic testing for hereditary disorders. Participants included individuals for whom gene panel testing was conducted between September 9, 2014, and September 7, 2022. Data were analyzed from September 1, 2022, to April 1, 2023. The outcomes of interest were VUS rates (stratified by age; clinician-reported race, ethnicity, and ancestry groups; types of gene panels; and variant attributes), percentage of VUSs reclassified as benign or likely benign vs pathogenic or likely pathogenic, and enrichment of evidence types used for reclassifying VUSs. The study cohort included 1 689 845 individuals ranging in age from 0 to 89 years at time of testing (median age, 50 years), with 1 203 210 (71.2%) female individuals. There were 39 150 Ashkenazi Jewish individuals (2.3%), 64 730 Asian individuals (3.8%), 126 739 Black individuals (7.5%), 5539 French Canadian individuals (0.3%), 169 714 Hispanic individuals (10.0%), 5058 Native American individuals (0.3%), 2696 Pacific Islander individuals (0.2%), 4842 Sephardic Jewish individuals (0.3%), and 974 383 White individuals (57.7%). Among all individuals tested, 692 227 (41.0%) had at least 1 VUS and 535 385 (31.7%) had only VUS results. The number of VUSs per individual increased as more genes were tested, and most VUSs were missense changes (86.6%). More VUSs were observed per sequenced gene in individuals who were not from a European White population, in middle-aged and older adults, and in individuals who underwent testing for disorders with incomplete penetrance. Of 37 699 unique VUSs that were reclassified, 30 239 (80.2%) were ultimately categorized as benign or likely benign. A mean (SD) of 30.7 (20.0) months elapsed for VUSs to be reclassified to benign or likely benign, and a mean (SD) of 22.4 (18.9) months elapsed for VUSs to be reclassified to pathogenic or likely pathogenic. Clinical evidence contributed most to reclassification. This cohort study of approximately 1.6 million individuals highlighted the need for better methods for interpreting missense variants, increased availability of clinical and experimental evidence for variant classification, and more diverse representation of race, ethnicity, and ancestry groups in genomic databases. Data from this study could provide a sound basis for understanding the sources and resolution of VUSs and navigating appropriate next steps in patient care.

Cancer patients' experience of receiving variant of uncertain significance results: An Asian perspective.

Due to a lack of ancestry-matched, functional, and segregation data, Asians have a higher rate of receiving a variant of uncertain significance (VUS) result following panel testing. Managing VUS results presents challenges, as it often leads to increased anxiety and distress among cancer patients undergoing genetic testing. This exploratory study aims to investigate the experience of Asian cancer patients upon receiving a VUS result. A qualitative, semi-structured interview study was conducted, involving cancer patients who had received a VUS result through the Cancer Genetics Service of the National Cancer Centre Singapore. Twenty participants were interviewed, and their responses were transcribed and analyzed using thematic analysis to identify key themes. Thematic analysis revealed five major themes: (1) VUS results are interpreted as uncertain outcomes; (2) a VUS result provides relief and prompts positive behavioral adjustments; (3) patients employ fatalism and religion as coping mechanisms to navigate uncertainty; (4) genetic counselors, family, and the community offer reassurance and support; (5) patients value updates on variant classifications for future management. While this novel study provides unique insights into the perspectives of Asian patients who receive VUS results, it also highlights patients' effective management of VUS results and uncertainty, which has implications for improving counseling practices in Asia. Emphasis must be placed on accurate interpretation and clear communication of VUS results to dispel the possibility of misconceptions, misdiagnosis, and mismanagement in cancer care.

Disparities in germline genetic testing results from a cohort of 493,515 black and white patients.

10550 Background: When undergoing germline genetic testing (GGT), Black patients (pts) are more likely than non-Hispanic White (NHW) pts to receive uncertain results and less likely to receive definitive molecular diagnoses as the Black genome is less well-characterized. As GGT is increasingly pertinent to cancer care, it is important to explore the scope of these disparities. Methods: A retrospective cohort of clinician-reported Black and NHW pts who underwent GGT (43-84 genes) from 2015-2022 was evaluated. Frequencies of pathogenic/likely pathogenic (P/LP) and variant of uncertain significance (VUS) results were compared between Black and NHW pts. Rate and type of VUS reclassifications were also compared. Differences in proportions were determined using Chi-square test and significance was set at 0.05. Results: The cohort consisted of 493,515 pts (48,684 [10%] Black and 444,831 [90%] NHW). VUS results were significantly more frequent and P/LP results significantly less frequent for Black compared to NHW pts (46% vs. 32% and 9 vs.13%, respectively). This was also true for pts who reported a history of cancer, across all common hereditary cancer types (Table). Comparing Black to NHW pts, there were more unique instances of VUS reclassifications over time (13% of 13,629 vs. 9% of 53,195 unique VUS), including 12% vs. 8% downgraded to benign/likely benign and 0.9% vs. 1.3% upgraded to P/LP. Conclusions: Lower rates of actionable results limit risk-reducing interventions for Black pts and their families. However, VUS rates continue to decline, particularly in Black pts, as more individuals (of any race or ethnicity) are sequenced. Clinicians can be reassured that most (but not all) VUS that are reclassified are downgraded to benign. [Table: see text]

Implementation of universal pan-cancer germline genetic testing in an Arab population: The jordanian exploratory cancer fenetics (Jo-ECAG) study.

10591 Background: Germline genetic testing (GGT) has a significant impact on cancer care. While universal testing has been selectively implemented in the U.S., less is known about adoption of this approach in other ethnic groups. This study reports on GGT results among newly diagnosed cancer patients (pts) in Jordan. Methods: Jo-ECAG was a prospective study of newly diagnosed cancer pts between April 2021 and September 2022 who underwent 84 gene GGT. Patients were classified based on the 2020 National Comprehensive Cancer Network (NCCN) GGT criteria as meeting (in criteria, IC) or not meeting criteria (out of criteria, OOC). Demographics and clinical history were clinician-provided. Pts who were carriers for autosomal recessive conditions were excluded from pathogenic germline variant (PGV) count. Differences in proportions were determined using two-tailed Fisher’s exact test and the significance was set at p≤ 0.05. Results: The cohort consisted of 3,313 Arabic cancer pts, predominantly female (69.8%), with a median age of 54 at testing. Breast was the most commonly diagnosed cancer (50.4%), followed by colorectal (14.9%) and prostate (14.3%). 52% of pts tested were guidelines-based (IC). 460 PGVs were identified in 426 (12.9%) pts. PGVs were most commonly identified in APC (predominantly I1307K variant, 144 pts, 4.4%), BRCA2 (72, 2.2%), BRCA1 (36, 1.1%), CHEK2 (26, 0.8%) and ATM (25, 0.8%). While IC pts were more likely than OOC pts to have a PGV (15.7% vs 9.8%, p&lt;0.0001), 156 (36.6%) pts with PGVs were OOC. 232 (54.5%) pts had PGVs in DNA damage response and repair/homologous recombination repair (DDR/HRR) genes, including 61 (26.3%) OOC pts. 3,602 variants of uncertain significance (VUS) were identified in 2,199 (66.4%) pts with 1,868 of these pts having only VUS results (56.4%), but the frequency in the latter group was not different between IC and OOC pts (p=0.42). Conclusions: Universal GGT of all new cancer pts was successfully implemented and led to actionable findings that would have been missed with guidelines-based testing. With the exception of an overrepresentation of APC I1307K variants, PGV rates were similar to Western ethnic groups. Over half of pts had PGVs in DDR/HRR genes that confer potential eligibility for targeted therapies and/or clinical trials. While VUS rates were high, they were similar between IC and OOC pts. Additional efforts to sequence underrepresented populations and develop variant interpretation methods agnostic to ancestry may help to mitigate these disparities.

Abstract P5-04-01: Screening Patterns of Mammography and Breast Magnetic Resonance Imaging Following Cancer Genetic Testing in an Integrated Health Care System

Abstract Background Patients at high-risk for breast cancer with genetic mutations are recommended to receive annual breast MRI in adjunct to annual mammography. Despite 15 years of clinical guidelines, uptake of annual breast MRI remains low. Further, little is known about screening patterns across genetic test results in patients tested for hereditary cancer susceptibility as part of usual care. Methods We conducted a retrospective cohort study in an integrated health system among women aged ≥18 years old, without prior breast cancer who had genetic testing for high penetrance hereditary cancer susceptibility genes between January 1, 2010 and December 31, 2018. Genetic test orders and results (pathogenic or likely pathogenic (P/LP) variant(s), negative, or variant of uncertain significance (VUS)) were obtained from health system administrative and laboratory data. Mammogram and breast MRI use data were extracted from electronic health records and claims data. To characterize screening patterns, we calculated average proportion of time covered (PTC) as the number of days covered by mammography and/or breast MRI divided by the number of days from screening eligibility until the earliest censoring event: end of observation period, reached age 75 years, breast cancer diagnosis, death, bilateral mastectomy, or disenrollment in the health system. Per National Comprehensive Cancer Network (NCCN) guidelines, women with P/LP variants in BRCA1/2, TP53, PALB2, CHEK2, ATM, and NF1 became eligible for screening on either the day they received their genetic test result or reached age eligibility and received one year of covered time for each mammogram or MRI imaging procedure received. Per Healthcare Effectiveness Data and Information Set (HEDIS) performance measures, all other women became eligible for screening at age 50 years and received two years of covered time for each mammogram received. Average PTC was calculated overall, by genetic test results, and by screening type. Poisson regression was used to determine the association between average PTC and patient-level factors (age at test, race/ethnicity, and genetic mutations) and guideline factors (recommended screening age state). Results Of 1,167 women meeting the inclusion criteria, 140 (12%) had P/LP in high penetrance breast cancer susceptibility genes (Table 1). Average PTC for individuals with a high penetrance susceptibility gene was 34.4% for MRI, 47.6% for mammogram, 63.2% for either MRI or mammogram, and 19.0% for both screening tests. The average PTC for those who tested negative, had VUS only, and had P/LP variants in genes unrelated to breast cancer was 50.3%, 44.4%, and 40.6%, respectively. Poisson regression model showed that among those with P/LP variants in high penetrance breast cancer genes, average PTC for annual MRI was positively associated with recommended screening initiation age ≥40 years (incident rate ratio [IRR]=2.07, 95% confidence interval [CI]: 1.94-2.20), higher absolute lifetime risk of breast cancer (IRR=1.38, 95% CI: 1.31-1.49), being 40-59 years old at genetic testing (IRR=1.04, 95% CI: 1.01-1.06), and non-Hispanic White race/ethnicity (IRR=1.10, 95% CI: 1.06-1.14). Conclusions Use of breast screening in women who had a P/LP variant(s) in high penetrance breast cancer susceptibility genes was low and not consistent with clinical guidelines, but comparable to the use of screening in women with negative and VUS results. Our findings suggest the need to improve screening in high-risk women with known genetic mutations and women at average risk. Table 1. Average PTC by NCCN and HEDIS recommendation. Citation Format: Boya Guo, Sarah Knerr, Karen Wernli, Kathleen Mittendorf, Heather Feigelson, Marian Gilmore, Gail Jarvik, Tia Kauffman, Erin Keast, Beth Liles, Frances Lynch, Kristin Muessig, Sonia Sasaki, David Veenstra, Jamilyn Zepp, Ben Wilfond, Katrina Goddard, Beth Devine. Screening Patterns of Mammography and Breast Magnetic Resonance Imaging Following Cancer Genetic Testing in an Integrated Health Care System [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P5-04-01.

Genomic uncertainty and genetic counsellors' professional authority.

Genomic tests regularly produce Variants of Uncertain Significance (VUS), mutations of which currently little is known but may turn out to be disease-causing. The communication of such variants in the United States is typically delegated to genetic counsellors. Based on in-depth interviews, we examined this communication as an indicator of the genetic counsellor's professional status: did they take a subordinate position by reporting out the results as provided by laboratories or did they assert professional authority by interpreting and possibly reducing the uncertainty of VUS results? We found that genetic counsellors put their professional spin on VUS results and they prepared patients for the full range of possible interpretations by normalising the existence of VUS results; intervened in the ecology of testing laboratories to stack the deck in favour of the expected results; and conducted their own research to reclassify a VUS. They marshalled organisational, technical, scientific and communication expertise to ease the sting of uncertainty but were ultimately limited by their role in the counselling encounter rather than in the basic research or laboratory community. We concluded that genetic counsellors use uncertainty to assert professional authority that interpreted genetic test results in light of the patient's symptoms and risk profile and uncertainty tolerance.

Cancer patients' understandings of genetic variants of uncertain significance in clinical care.

Genetic variants of uncertain significance (VUSs) pose a growing challenge for patient communication and care in precision genomic medicine. To better understand patient perspectives of VUSs, we draw on qualitative analysis of semi-structured interviews with 22 cancer patients and individuals with cancer family history who received a VUS result. The majority of patients did not recall receiving VUS results and those who remembered expressed few worries, while respondents who were tested because of a family history of cancer were more concerned about the VUS results. Personal characteristics, medical condition, family history, expectations prior to testing, and motivations for pursuing testing influence the ways patients came to terms with the uncertainty of the VUS result. We conclude by discussing the relevance of the findings to the debate on the responsibility of the patient in checking back for VUS reclassification and to implications for genetic counseling that emphasizes tailoring the pre- and post-test discussion of VUS as appropriate to the patients’ informational as well as emotional needs.Supplementary informationThe online version contains supplementary material available at 10.1007/s12687-022-00594-z.

Impact of returning unsolicited genomic results to nongenetic health care providers in the eMERGE III Network

PurposeAs genomic sequencing becomes more common, medically actionable secondary findings will increasingly be returned to health care providers (HCPs), who will be faced with managing the resulting patient care. These findings are generally unsolicited, ie, unrelated to the sequencing indication and/or ordered by another clinician. MethodsTo understand the impact of receiving unsolicited results, we interviewed HCPs who received genomic results for patients enrolled in the Electronic Medical Records and Genomics (eMERGE) Phase III Network, which returned results on >100 actionable genes to eMERGE participants and HCPs. ResultsIn total, 16 HCPs across 3 eMERGE sites were interviewed about their experience of receiving a positive (likely pathogenic or pathogenic), negative, or variant of uncertain significance result for a patient enrolled in eMERGE Phase III and about managing their patient on the basis of the result. Although unsolicited, HCPs felt responsible for managing the patient’s resulting medical care. HCPs indicated that clinical utility depended on the actionability of results, and whereas comfort levels varied, confidence was improved by the availability of subspecialist consults. HCPs were concerned about patient anxiety, insurability, and missing an actionable result in the electronic health record. ConclusionOur findings help inform best practices for return of unsolicited genomic screening findings in the future.

EP103: Speech development gene pathways: Would genome sequencing in nonverbal individuals provide a link?

Speech and language delays or loss is one of the first symptoms reported in many neurodevelopmental disorders. We evaluated genome sequencing (GS) results in a subset of patients from the precision genomics clinic who had limited speech or were nonverbal, with or without autism spectrum disorder (ASD), intellectual delays, and seizures to identify common genetic variants/network. Clinical genome sequencing was obtained and relevant genetic variants were analyzed to identify recurring pathways or genes. Fifteen individuals in our cohort had this combination of phenotypic characteristics. Four had pathogenic or likely pathogenic variants in SLC16A2, PHF6, ERCC8 genes that were relevant to the phenotype, and one in MME, an incidental finding; 10 patients had one or more variants of uncertain significance (VUS) and 1 had a negative test result reported. SLC16A2 causes Allan-Herndon-Dudley syndrome, which causes an X-linked intellectual delay combined with abnormal thyroid hormone levels. The gene encodes for a Monocarboxylate transporter 8 protein. It also functions as a specific thyroid hormone transporter with abnormalities speculated to result from transport of triiodothyronine into neurons. Variants in PHF6 cause Borjeson-Forssman-Lehmann syndrome. This gene encodes a transcriptional regulator which suppresses ribosomal RNA transcription. ERCC8, which causes Cockayne syndrome A, is part of the nucleotide excision repair/protein ubiquitination pathway. Several patients were found to have VUS results with autosomal dominant inheritance in genes found to cause similar symptoms to their phenotypes. Additionally, some patients were found to have multiple VUS results in several genes found to be associated with neurodevelopmental disorders and epilepsy raising question of compounding effects. No common pathway was identified in this small cohort of positive patients. We continue to evaluate for shared pathways among individuals with VUS results and additionally reanalyze rare variants. GS provides an opportunity to evaluate regions of the genome that are not picked up by traditional genetic testing. The genome harbors many rare variants with some likely contributing to these patients’ phenotypic findings. However, given the novelty of GS, a direct correlation requires additional patients with GS testing and phenotypic correlation to determine significance.

Patient and public preferences for being recontacted with updated genomic results: a mixed methods study.

Variants of uncertain significance (VUS) are frequently reclassified but recontacting patients with updated results poses significant resource challenges. We aimed to characterize public and patient preferences for being recontacted with updated results. A discrete choice experiment (DCE) was administered to representative samples of the Canadian public and cancer patients. DCE attributes were uncertainty, cost, recontact modality, choice of results, and actionability. DCE data were analyzed using a mixed logit model and by calculating willingness to pay (WTP) for types of recontact. Qualitative interviews exploring recontact preferences were analyzed thematically. DCE response rate was 60% (n = 1003, 50% cancer patient participants). 31 participants were interviewed (11 cancer patients). Interviews revealed thatparticipants expected to be recontacted. Quantitatively, preferences for how to be recontacted varied based on certainty of results. For certain results, WTP was highest for being recontacted by a doctor with updates ($1075, 95% CI: $845, $1305) and for contacting a doctor to request updates ($1038, 95%CI: $820, $1256). For VUS results, WTP was highest for an online database ($1735, 95% CI: $1224, $2247) and for contacting a doctor ($1705, 95% CI: $1102, $2307). Qualitative data revealed that preferences for provider-mediated recontact were influenced by trust in healthcare providers. Preferences for a database were influenced by lack of trust in providers and desire for control. Patients and public participants support an online database (e.g. patient portal) to recontact for VUS, improving feasibility, and provider-mediated recontact for certain results, consistent with usual care.

Genetic testing documentation in survivorship care plans in patients with breast cancer.

e24110 Background: Genetic testing results for germline mutations impact care of cancer survivors, thus are important to include in a survivorship care plan (SCP). In 2014, the Commission on Cancer adopted the American Society of Clinical Oncology’s SCP template and included a section on cancer genetic testing and results. However, data on its implementation is scant. We assessed documentation of genetic testing results in SCPs in various genetic test result groups and by primary oncology treatment team (PT) and consulting survivorship team (ST). Methods: We conducted a retrospective chart review of breast cancer patients who had a survivorship visit at our institution from February 2015 to January 2020, were seen by a genetic counselor (GC), and had genetic testing for germline mutations for hereditary predisposition to cancer (GGT). We compared the extent of documentation of GGT between the PT and ST’s SCPs, and among result categories (positive, negative, and variant of uncertain significance (VUS)) for occurrence of genetic testing, name of panel tested, GC recommendations, GC name/contact information, and name of gene involved and site of mutation (when applicable). Results: Among 398 women with breast cancer (DCIS 3%, Stage I 47%, Stage II 40%, Stage III 10%), median age was 49 years (range 27-77 years); 91% were non-Hispanic white, 4.7% black, 2.7% Asian, and 1% were Hispanic. GGT was documented in 93.7% of SCPs overall. GGT results were positive in 12.8%, negative in 65.8%, and VUS in 21.4%. The ST (75% SCPs) more often included GGT documentation in SCP as compared to PT (95.7% vs 87.9%, p = 0.006). There was no difference in GGT documentation by result category (positive 96.1%, negative 92.4%, VUS 96.5%, p = 0.3). GGT documentation was more detailed by ST as compared to PT, with name of panel tested included in 97% vs 92% of SCPs (p &lt; 0.001). Of those with positive or VUS results, the name of the involved gene was included in 95% vs 77% (p = 0.003), and the site of mutation in 82% vs 48% (p &lt; 0.001) of SCPs (ST vs PT). Only 56% of SCPs in the positive results group included all GC’s screening and follow up recommendations, while 84.7% in the VUS and 92% in the negative results group included them (p &lt; 0.001). GC name/contact information were more often documented in ST’s SCPs (66% vs 8%; p &lt; 0.001), with overall reporting being low in all result categories (positive 49%, negative 54%, VUS 48%). Conclusions: Overall, SCPs were likely to have documentation of GGT occurrence, name of tested panel and involved genes, but less frequently included the specific mutation identified, GC contact information, or GC recommendations for those with positive results. Documentation tended to be more complete for SCPs performed by ST rather than by PT. The causes of this discrepancy are unclear and may be related to different levels of comfort with and knowledge of GGT. Further study is needed to identify knowledge gaps and processes to improve documentation of GGT in SCPs.

Management impact of preoperative germline genetic testing in patients with breast cancer at the Lifespan Cancer Institute.

10523 Background: Breast cancer is a heterogenous disease and management is complex. Advances in next generation sequencing has allowed genetic testing to be more accessible. However, conveying results to patients and care team can be challenging due to various variant classifications. Diagnostic results have the potential to guide management. Nondiagnostic results can be misinterpreted. The extent to which preoperative genetic testing affects management of newly diagnosed breast cancer is unknown. Methods: Newly diagnosed breast cancer patients were identified via review of breast tumor board between May 2019 and March 2019 followed by chart review to collect detailed information. Results: 408 newly diagnosed breast cancer cases were queried. Genetic evaluation was recommended and completed in 68%, not recommended (did not meet NCCN criteria) in 30% and declined in 2.7%. The genetic evaluation recommended cohort was associated with a higher mastectomy rate in comparison with when not recommended (31% vs. 9%, p=0.0001). Of those who completed genetic testing: 12% harbored a pathogenic/likely pathogenic variant (PV/LPV), 26% had a nondiagnostic variant of uncertain significance (VUS) and 61% had negative testing. Comparison between nondiagnostic test results (negative and VUS) and diagnostic test results revealed significantly increased number of women in the diagnostic group who chose mastectomy over breast conservation therapy (BCT, nondiagnostic 20% vs diagnostic 39%, p=0.018). When negative, VUS, and PV/LPV were each independently analyzed, diagnostic test results again revealed a significantly increased number of mastectomies over BCT (p&lt;0.05). Comparison of surgical choices in nondiagnostic VUS vs. negative results was not significantly different (Table). Comparing the surgical timelines, completing a genetic evaluation did not affect surgery timing (mean 2.3 vs. 2.2 months, p&gt;0.5). Conclusions: Germline genetic testing in patients with newly diagnosed breast cancer impacts clinical management. Those harboring a diagnostic result were more likely to choose mastectomy over BCT. Not surprisingly, mastectomy rate was higher among those where genetic evaluation was recommended, possibly due to concerning personal or family history. The mastectomy rate was higher among those with a diagnostic result, indicating an understanding of the genetic testing significance by patients and the care team. More importantly, those who harbored nondiagnostic VUS did not make significantly different surgical choices compared with negative genetic testing, highlighting the critical role of proper genetic counseling and being part of the care team. We conclude consideration of genetic evaluation is clinically useful and feasible without affecting the surgical timeline.[Table: see text]