Cancer genetics evaluation: Barriers to and improvements for referral

Despite the availability of cancer susceptibility testing, little information exists regarding physicians' selection and referral of eligible patients. This study provides insight into whom, why, and when physicians refer for cancer genetics evaluation, as well as their comfort level within this role. Eighty-two physicians ( 51 primary care, 15 gynecology, 11 surgery and 5 oncology) completed a survey ( response rate: 34%) regarding cancer genetics referral practices. Of these, 59% reported an awareness of the hospital's cancer genetics program. Program awareness was greater among oncologists, surgeons, and gynecologists than among primary care physicians ( p < 0.0001). Patients were referred for enhanced risk assessment ( 88%), improved medical management ( 85%), and concern for family members ( 83%). Patient eligibility was based on family cancer history ( 96%), patient cancer history ( 83%), and patient request ( 73%). Patients were not referred mainly due to patient disinterest ( 54%) or physician concern about either insurance coverage ( 44%) or insurance discrimination ( 31%). Primary care physicians were less comfortable with identifying patients for referral ( p < 0.001) and with discussing genetics ( p < 0.002) than specialists. The largest barriers to referral were lack of program awareness and limited knowledge regarding patient eligibility, improved insurance coverage, and antidiscrimination legislation. Physician-targeted marketing and education may improve the referral process.