The last few years have seen a growing trend for patients to undergo genetic testing without first seeing a genetic counselor or other genetic specialist. As I have commented before, genetic counselors are no longer the gatekeepers of genetic testing. Anyone can obtain DNA analysis through non-genetics specialists or any health care provider, on Amazon.com and other internet sites, and at their workplaces (which, honestly, makes me very uneasy; it is going to be awfully difficult for some employers to keep their noses out of their employees’ genetic information and it may provide an opportunity to chisel away at the protections afforded by GINA). Many genetic counselors have accepted this as a fact of life, even if we are not altogether comfortable with it.
Historically, the genetic counseling profession has done a poor job of demonstrating its value to the health care system. Our importance seemed pretty obvious to us and because we didn’t have much in the way of competition we were never strongly motivated to undertake large scale studies to prove our worth.
Comparative studies are starting to address the value of pre-test counseling by a genetic counselor, particularly in the field of hereditary cancer genetic testing. This as a good thing. Still, it bothers me if studies claim that genetic counseling is failing patients because fewer people undergo genetic testing if they need to see a genetic counselor first. Sure, genetic testing should be readily available to those who need it, and barriers need to be removed. If seeing a genetic counselor turns out to be one of those barriers, then we need to do something about that. But test uptake may not always be in the best interests of patients.
For example, the most common reason an unaffected patient declines genetic testing after seeing me for hereditary cancer counseling is that, for the moment, they are the “wrong” person to test to most accurately determine their hereditary cancer risks. Even though the patient may technically meet standard criteria for genetic testing, they may still not be the best person to test within the context of their specific family history. Not undergoing genetic testing is not due to a lack of timely access to me, the cost of my services, or me somehow talking them out of testing. Instead, after reviewing their family history, it turns out that testing their mother with breast cancer or their brother with colon cancer is the most appropriate person to test before deciding if the patient and other unaffected relatives should undergo testing. If that affected relative has a normal genetic test result, then testing my patient and other relatives is usually a waste of money.
It is also difficult to interpret a negative test result in a family where a mutation has not already been identified. Now, I am a grizzled veteran of the Family Dynamics Wars, and I realize that sometimes that affected relative is deceased or just not willing to undergo testing, and you have to make do with the realities of the situation at hand. And, of course, this argument does not apply to testing patients who have been diagnosed with cancer (although it may apply in situations where patients meet NCCN guidelines but not their insurer’s criteria for coverage, but an affected relative does meet their insurer’s criteria). Still, testing an affected relative should be utilized whenever feasible because it is clinically and economically the most effective strategy. Therefore, if a study finds that test uptake is increased when patients do not first see a genetic counselor, the researchers are obliged to demonstrate that this is not simply due to more cases of the “wrong” person being tested or the providers not willing to take the time to work with the extended family.
Along these same lines, in many situations, even genetic test results of an affected relative are often uninformative for risk assessment. Such families may still need to be followed as high risk, with screening and risk reducing protocols based on family history and clinician judgment. Effectiveness studies therefore need to investigate whether there are differences in clinical recommendations provided to patients who see a genetic counselor compared to those who do not.
Studies of genetic counseling vs. no genetic counseling also need to provide data on patient adherence to screening and other risk reduction guidelines. Increased test uptake is not particularly helpful if patients do not have the motivation or wherewithal to undergo breast MRI, salpingo-oophorectomy, join the Annual Colonoscopy For Life Club, or whatever else is recommended. Other outcomes that effectiveness studies should address include communication of test results to family members, interpretation of variants of uncertain significance, and patients’ psychological adaptation to their risk status. I imagine many of you reading this posting can suggest additional outcomes that need to be addressed.
My other concern about reduced genetic counselor involvement with pre-test counseling is that “counseling” will eventually be reduced to a pamphlet or a brief video, perhaps provided by the testing lab itself. This is already a major concern with how NIPT is presented to pregnant women, and I can see it becoming a problem in other areas of genetic testing. No matter how earnestly labs may claim that their educational material is not a subtle sales pitch, they are only human and can easily be blinded by their business needs. This is an area where GCs can develop better and less biased educational materials.
If research demonstrates that other genetic testing delivery models are more effective than, or at least non-inferior to (non-inferior sounds like a back-handed compliment,doesn’t it?), the traditional approach of First See A GC Before Your Test, then the genetic counseling profession should re-focus itself and use our many other skills to work towards improving patients’ lives and the medical care system. Besides, I have never liked conflating genetic counseling with genetic testing.
I do worry, though, that either the research will not be conducted, or that, even in the face of evidence to the contrary, market forces will dictate testing strategies. I am not concerned that it would portend the end of the genetic counseling profession. Genetic counselors are forever expanding their professional roles, and in fact have continually reinvented themselves since, well, we first invented ourselves in the 1970s. Like David Bowie, we never stood still and as soon as you had us pinned down as Ziggy Stardust, all of a sudden we were Aladdin Sane, and already sprouting within him are the seeds of The Thin White Duke (well, okay, it’s a stretch comparing genetic counselors to David Bowie, but you get my point). What matters is that all patients affected with or at risk for hereditary disorders receive the most competent and compassionate care delivered effectively, equitably, and timely.
Bobbin Sane
(Graphic by Emily Singh)
The DNA Exchange 