Remote delivery of cancer genetic testing in veterans with metastatic prostate cancer: A Million Veteran Program study.
Authors: Montgomery Robert Bruce , Lynch Julie Ann , Brown Jessica , Maxwell Kara Noelle , Kabilovic Nismeta , Stoll Katie , Simon Julie , Kogan Maria , Whitbourne Stacey B. , Muralidhar Sumitra , Ramoni Rachel , Gaziano J. Michael , Cheng Heather H. , Etzioni Ruth Douglas , Pritchard Colin C. 
Published: June 2024

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Background: Germline pathogenic alterations are found in approximately 10% of men with metastatic prostate cancer (mPC) and can inform precision therapy, surveillance, and cancer prevention for family. National guidelines recommend germline genetic testing be offered to all men with mPC, yet uptake of testing in the community has been documented to be 10-12% with many barriers to testing. We conducted a study to determine uptake of testing using remote consenting and testing for veterans with mPC who had participated in the Department of Veteran’s Affairs (VA) Million Veteran Program (MVP). We wanted to know if remote testing could augment point-of-care counseling and ordering to increase uptake of germline testing. Methods: This prospective study enrolled veterans who participated in MVP study with a diagnosis of mPC. Veterans were contacted by mail with an option to opt-out of future contact. Those who did not opt-out were mailed information about the study and received a follow-up call to establish interest in germline testing with a CLIA-level germline test. Those expressing interest provided verbal informed consent and were mailed a saliva collection kit for a multigene cancer predisposition gene panel test. Results were disclosed by phone and mailed to the patient with genetic counseling support and were sent to the oncology provider by email, phone or both. Two research coordinators and two part-time genetic counselors provided consenting, counseling and return of results. A study evaluating facilitated communication of results to first degree relatives (FDR) and germline testing of FDR was a component of study. Results: As of 2/6/2024, 1952 veterans who were alive with an incident diagnosis of mPC were identified through MVP and did not opt out. Informational letters were sent to the home address of all eligible participants. 683 (35%) of veterans completed informed consent and 457 (23% of total original cohort) completed testing. Among the participants, 70% were White, 21% were Black, 0.5% Asian and 8% unknown, 13% had a germline pathogenic variant. Documentation of positive germline results from study in the chart reports was 58%. Of 30 results relevant for targeted therapy, 16 have received that therapy, 11 were not yet appropriate and 3 patients did not receive targeted therapy. Twenty-nine FDR were contacted and tested through the pilot study of facilitated contact and testing. Conclusions: We evaluated uptake of germline testing using a remote, VA system-wide approach to identify and offer genetic testing for veterans with mPC with access and cost issues removed. We completed germline testing at rates higher than those reported in the community with modest personnel requirements, in a diverse population of patients. Documentation of results in the electronic medical record can be improved. Remote genetic testing can augment uptake of testing in large integrated health care systems.