Genomic Medicine and Genetic Counseling in the Department of Veterans Affairs and Department of Defense

If I’m considering a referral, I do a deeper dive with the patient. Is the patient older or younger than 45 years? I pull up NCCN guidelines and we go through the entire checklist.

We have male breast cancer patients at the VA—probably more than the community—so we refer those patients. At the Louis Stokes Cleveland VAMC in Ohio, we have had some in-depth discussions about referring male breast cancer patients for genetic testing and whether it was beneficial to older patients with male breast cancer. Ultimately, we decided that it was important for our male veterans to be tested because it empowered them to have better understanding of their medical conditions that may not just have effect on them but on their offspring, and that that can be a source of psychological and emotional support.

I don’t refer most people to GMS once I go through the checklist. I appreciate the action for an e-consult within the CPRS telemedicine consult itself, as Renee noted. If it is not necessary, GMS makes it an e-consult. I try to communicate that I don’t know whether it is necessary or not so that GMS understands where I’m coming from.

Vickie Venne. In the US Department of Defense (DoD) the process is quite different. Mauricio, can you explain the clinical referral process, who is referred, and how that works from a laboratory perspective?

Maj De Castro, MD, FACMG, USAF. The VA has led the way in demonstrating how to best provide for the medical genetic needs of a large, decentralized population distributed all over the country. Over the last 5 to 10 years, the DoD has made strides in recognizing the role genetics plays in the practice of everyday medicine and redoubling efforts to meet the needs of servicemembers.

The way that it traditionally has worked in the DoD is that military treatment facilities (MTFs) that have dedicated geneticists and genetic counselors: Kessler Medical Center in Mississippi, Walter Reed National Military Medical
Center in Maryland, Tripler Army Medical Center in Hawaii, Madigan Army Medical Center in Washington, Brooke Army Medical Center in Texas, Naval Medical Center San Diego in California, and Naval Medical Center Portsmouth in Virginia. A patient seeking genetic evaluation, counseling, or testing in those larger facilities would be referred to the genetics service by their primary care manager. Wait times vary, but it would usually be weeks, maybe months. However, the great majority of MTFs do not have dedicated genetics support. Most of the time, those patients would have to be referred to the local civilian community—there was no process for them to be seen in in the military healthcare system—with wait times that exceed 6 to 8 months in some cases. This is due to just not a military but a national shortage of genetics professionals (counselors and physicians).

Last year we started the telegenetics initiative, which is small compared to the VA—it is comprised of 2 geneticists and 1 genetic counselor—but with the full intent of growing it over time. Its purpose is to extend the resources we
had to other MTFs. Genetics professionals stationed state-side can provide care to remote facilities with limited access to local genetics support such as Cannon Air Force Base (AFB) or overseas facilities such as Spangdahlem AFB in Germany.

We recognize there are military-specific needs for the DoD regarding the genetic counseling process that have to take into account readiness, genetic discrimination, continued ability to serve and fitness for duty. For this important reason, we are seeking to expand our telegenetics initiative. The goal is to be able to provide 100% of all genetic counseling in-house, so to speak.

Currently, providers at the 4 pilot sites (Cannon AFB, Fort Bragg, Spangdahlem AFB, and Guantanamo Bay) send us referrals. We triage them and assign the patient to see a geneticist or a counselor depending on the indication.