Radiology Practice Partners With Genetic Counselors on Cancer Risk
At the 22nd Annual National Interdisciplinary Breast Center Conference in Las Vegas, Nevada, Ellen Nipe, Sherrill Little, MD, and colleagues presented the poster session “Systematic Risk Assessment in a Large Imaging Center” on March 13, 2012, reporting the results of an experiment at Booth Radiology (Woodbury, New Jersey). The practice currently offers cancer-risk assessment, in the form of genetic counseling, for its breast-cancer–screening patients, and the poster session covered results garnered from October through December 2011. Little, a radiologist at the practice, says, “We wanted to provide full-service women’s health care. A lot of these women are at a significantly increased risk of cancer and either don’t know it or have never been evaluated.” In fact, research¹ indicates that only 19% of physicians who ordered a BRCA1/2 test for patients correctly identified low- and high-risk scenarios; in a survey², 90% of physicians believed genetics were important to their practice, but fewer than 25% felt comfortable discussing genetic-testing results with patients. Nipe, who is chief technologist for mammography at the practice, adds that genetic testing is sufficiently sensitive that the practice felt that it should not be handled internally: “We wanted someone who had the right experience to talk to the patients and give them the information they need,” she says. “We don’t have that experience, but we wanted to do what was right for the patient.” Counseling Collaboration Booth Radiology partners with genetic counseling company InformedDNA to offer genetic testing to its breast-cancer–screening patients. “The patients fill out family-history questionnaires,” Nipe explains. “They indicate whether they have a personal history of certain cancers, if a blood relative has had certain cancers, and so on; at the bottom, they check if they want to forward their information to InformedDNA for a personalized risk assessment.” From there, patients who indicate interest are contacted by InformedDNA to make an appointment to meet with a genetic counselor. The role of the counselor is to help patients understand the potential risks and benefits of genetic testing, and to help them interpret the results if BRCA1 or BRCA2 is present. Colleen Farr, Booth Radiology’s patient-care specialist, explains that the radiology practice handles obtaining blood samples from patients who want to proceed with testing, and is also at the center of communication among patients’ various physicians. “Their physicians are contacted by our nurse, and the patients get a letter from InformedDNA with their results,” she says. “If they qualify for annual breast MRI screening, we send them a letter saying so.” Of 120 patients who have participated in the genetic profiling so far, Farr says, 17 had a lifetime breast-cancer risk of over 20%, qualifying them for annual MRI screening; a slightly higher number had a lifetime risk of 15% to 20% (a level at which the American Cancer Society recommends considering MRI screening). Farr notes that, like many radiology facilities, Booth Radiology has used the Tyrer–Cuzick risk-assessment model for breast cancer in the past. “We have that program, but it does require a lot of time from our technologists,” she says. “When we do the short version (with the questionnaire) and send the information to InformedDNA, they do a lot of that work for us.” Downstream Potential By identifying patients who are at an increased risk of developing cancer, Booth Radiology puts itself in a position to capture downstream revenue from complementary screening methods. Nipe notes that one patient for whom MRI screening was recommended then underwent an MRI-guided biopsy after a suspicious area was detected. “We have patients who underwent the risk assessment and loved it,” she says. “They loved the information they were able to get and how much they understood, and they were pleased.” Little stresses that whether (and where) high-risk patients choose to undergo additional imaging is up to them. In addition, many patients opt out of the profiling. “It’s interesting: A minority choose to have the profiling done—10% or 15%, at most,” she says. “A lot of women don’t qualify, and of those who do, many choose not to go through with the testing after talking to the InformedDNA people. We’ve had three patients who qualified for BRCA testing, but then backed out and ended up not getting it done.” The reason might be that patients are afraid of the results—which, Nipe says, is all the more reason for them to work with a genetic counselor to understand what information they might obtain as a result of testing and what it might mean. “We initially planned to test women for the BRCA gene ourselves,” she notes, “but our clinicians were very uncomfortable doing that because they don’t have the experience in genetic counseling. We were very impressed with InformedDNA and felt comfortable referring our patients to it.” Results Based on the study, Booth Radiology concluded that systematic risk assessment is feasible within a large, busy imaging center and is an effective approach to identifying women who are candidates for additional screening (or even chemoprevention). According to the practice’s research, around 7% of screening mammography patients are candidates for genetic-counseling referral. Little concludes, “It’s not something obstetrician/gynecologists or family-practice physicians are doing. If we can catch some of those people who are at high risk (but don’t know it), we can get them thorough follow-up care and potentially catch cancers earlier.” Cat Vasko is editor of ImagingBiz.com and associate editor of Radiology Business Journal.