Improving referral for genetic risk assessment in ovarian cancer using an electronic medical record system.

Genetic cancer risk assessment has an integral role in helping patients understand their hereditary risk, facilitates their decisions about genetic testing, and often aids in their management (1-8). Ovarian cancer, the leading cause of death from gynecologic cancer, has one of the highest fractions attributable to inherited risks compared to other common solid tumors (9). Genetic testing is now available for many genes responsible for hereditary ovarian cancer, including BRCA1 and BRCA2 which are estimated to account for approximately 15% of ovarian cancer cases (9-13) and Lynch syndrome implicated in 2% of cases (14). New sequencing approaches are identifying germ-line mutations in many other genes implicated in an additional 6% of ovarian cases, including BARD1, BRIP1, CHEK2, MRE11A, NBN, RAD50, MSH6, PALB2, RAD50, RAD51C, and TP53 (13). Research suggests genetic testing be considered for all women with high-grade epithelial tumors or any serous ovarian cancer (10, 11, 15-17). The Society of Gynecologic Oncologists (SGO) endorses referral of these high-risk patients (2), whereas current National Comprehensive Cancer Network guidelines recommend that all women with epithelial ovarian cancer be referred for genetic counseling (18). However, physicians continue to under-refer and women to under-use genetic services (10, 16), which has generated research aimed at increasing patients’ use of risk assessment (19-24). Medical providers have an important role in referring cancer patients who might benefit the most from genetic assessment, but little is known about their patient selection and referral (25). Reported barriers to physicians’ referral for cancer genetics evaluation include limited hereditary cancer knowledge, lack of awareness of the availability of genetic services, physician training and the absence of anti-discrimination legislation (25, 26). The efficacy of interventions to increase medical providers’ referral has yet to be demonstrated. Our primary objective was to increase the frequency of physician referrals for genetic counseling for HBOC and Lynch syndromes for women newly diagnosed with epithelial ovarian, fallopian tube (FT), and primary peritoneal (PP) cancer by implementing a systematically generated electronic referral focused on referral of patients deemed high risk according to the SGO guidelines. Within this paper, subsequence reference to ovarian, FT and PR cancers will be noted as ovarian cancer.