Integrating Germline Genetics Into Precision Oncology Practice in the Veterans Health Administration: Challenges and Opportunities
Objectives: The advent of germline testing as a standard-of-care practice for certain tumor types and patients presents unique opportunities and challenges for the field of precision oncology. This article describes strategies to address workforce capacity, organizational structure, and genetics education needs within the US Department of Veterans Affairs (VA) with the expectation that these approaches may be applicable to other health care systems.
Observations: Germline information can have health, reproductive, and psychosocial implications for veterans and their family members, which can pose challenges when delivering germline information in the setting of cancer care. Additional challenges include the complexity inherent in the interpretation of germline information, the national shortage of genetics professionals, limited awareness and knowledge about genetic principles among many clinicians, and organizational barriers, such as the inability to order genetic tests and receive results in the electronic health record. These challenges demand thoughtful implementation planning at the health care system level to develop sustainable strategies for the delivery of high-quality genetic services in precision oncology practice.
Conclusions: The VA is uniquely positioned to address the integration of germline genetic testing into precision oncology practice due to its outsized role in treating veterans with cancer, training the health care workforce, and developing, testing, and implementing innovative models of clinical care.
We recently surveyed genetics professionals in the VA about their practices and capacity to increase patient throughput (Table). Currently in the VA, there are 8 clinical geneticists, not all of whom practice clinical genetics, and 13 genetic counselors. Five VA programs provide clinical genetic services to local and nearby VA facilities near Boston, Massachusetts; Houston, Texas; Los Angeles and San Francisco, California; and Salt Lake City, Utah. These programs, first developed in 2008, typically are staffed by 1 or 2 genetics professionals. Most patients who are referred to the VA genetics programs are evaluated for hereditary cancer syndromes. Multiple modes of delivery may be used, including in-person, telehealth, telephone, and provider-to-provider e-consults in the EHR.
In 2010, in response to increased demand for clinical genetics services, the VA launched the Genomic Medicine Service (GMS), a national program with a centralized team of 9 genetic counselors based in Salt Lake City. GMS provides telehealth genetic counseling services exclusively to veterans onsite and at about 90 VA facilities across the country. More recently, the addition of a clinical geneticist and APRN with genetics expertise has allowed GMS to provide more comprehensive genetic consultative services.
All VA genetics programs are currently at full capacity with long waits for an appointment. To expand clinical genetic services, the VA genetics professionals responding to our survey reported a need for additional support (eg, administrative, care coordination, clinical), resources (eg, clinical space, salary support), and organizational change (eg, division of Medical Genetics at facility level, services provided at the level of the Veterans Integrated Service Network). Given the dearth of genetic care providers in the community, referral to non-VA care is not a viable option in many markets. In addition, avoiding referral outside of the VA could help to ensure continuity of care, more efficient care, and reduce the risk of duplication of testing, and polypharmacy.34-37
As part of its precision oncology initiative, VA is focusing on building clinical genetics services capacity. To increase access to clinical genetic services and appropriate genetic testing, the VA needs more genetics professionals, including clinical geneticists, genetic counselors, and genetic nurses–ideally a workforce study could be performed to inform the right staffing mix needed. To grow the genetics workforce in the long term, the VA could leverage its academic affiliations to train the next generation of genetics professionals. The VA has an important role in training medical professionals. By forming affiliations with medical schools and universities, the VA has become the largest provider of health care training in the US.38
Genetic Health Care Organization in the VA
Understanding a patient’s genetic background increasingly has become more and more important in the clinic, which necessitates a major shift in health care. Unfortunately, on a national scale, the number of clinical genetics professionals has not kept pace with the need-limiting the ability to grow the traditional genetics workforce in the VA in the near term.29-31 Thus, we must look to alternative genetic health care models in which other members of the health care team assume some of the genetic evaluation and counseling activities while caring for their cancer patients with referral to a clinical genetics team, as needed.39
