Abstract PO1-08-07: Utilization Management: The Impact of Laboratory Genetic Counseling Oversight on BRCA1 and BRCA2 Targeted Analysis Orders
Authors: Vanderwall Rebecca , Noeth Dagny , Goulbourne Angelica , Goode Katherine , Ruegg Teresa , Hayden Melissa , Spence W. Christine 
Published: May 2024

Abstract
INTRODUCTION: While multigene hereditary cancer testing has become a common order for individuals with personal and/or family histories of cancer, targeted genetic testing (TGT) remains a cost-effective test option for cascade testing of individuals with a known gene mutation in the family. In order to proceed with TGT, the genetic testing laboratory must receive documentation of the specific variant. Intervention of a genetic counseling team (GCT), which includes laboratory genetic counselors and genetic counseling assistants, can play a major role in utilization management for genetic testing companies, including obtaining and reviewing mutation reports and offering clinically appropriate and cost-effective test options. Given previously reported low rates of cascade testing for family members of mutation carriers and the potential barriers of ordering TGT testing, we sought to review the success of providers ordering BRCA1 and BRCA2 TGT testing and the GCT role in management of these orders.
METHODS: Per standard operating procedure at Labcorp, the GCT reviews all hereditary cancer genetic test orders before they begin processing through prior authorization and laboratory analysis. When societal guidelines dictate, GCT intervention may occur to request genetic testing reports and offer to update testing appropriately. A retrospective review of GCT notes on TGT orders was conducted, with review of all BRCA1 and BRCA2 TGT orders accessioned between January 1 and February 28, 2023. Orders that were updated or cancelled before GCT review were excluded from analysis. All other TGT orders were coded into one of seven categories: (1) ordered for TGT, mutation report provided, proceed without GCT intervention; (2) ordered for TGT, mutation report obtained after GCT intervention, proceed with TGT; (3) ordered for TGT, no report obtained, updated to BRCA1 and BRCA2 comprehensive sequencing and deletion/duplication analysis with or without other hereditary cancer genes (COMP) with authorization from ordering provider via GCT intervention; (4) ordered for TGT, report obtained, updated to COMP via GCT intervention; (5) ordered for TGT, no report or authorization to update testing obtained during GCT intervention, testing cancelled; (6) ordered for TGT and COMP, no report, TGT cancelled; and (7) ordered for COMP, mutation report obtained, updated to TGT with authorization from ordering provider after GCT intervention. Time between accessioning and initial GCT resolution was also collected.
RESULTS: A total of 198 TGT orders and associated GCT notes were reviewed. 24 orders (12.1%) proceeded with TGT without GCT intervention (category 1) with an average turn-around-time of 1 day. GCT intervention was required for 158 (79.8%) of TGT orders with an average turn-around-time of 5 days. After GCT review and/or intervention, 60 (30.3%) orders proceeded with TGT analysis (categories 1, 2, and 7); 23 (11.6%) of these were originally ordered for COMP, then updated when a mutation report was obtained (category 7). Testing was updated from TGT to COMP because no mutation report was obtained in 78 (39.3%) cases (category 3). In 7 (3.5%) TGT orders, testing was updated to COMP even though a mutation report was obtained (category 4).
CONCLUSION: TGT analysis is beneficial for cascade testing, but access to a mutation report as a requirement to proceed can be a barrier. More strategies are needed to provide education for ordering providers and patients on the benefit of sharing familial mutation reports for cascade testing. Efficiency of testing increases when patients and providers have access to records and provide this information to laboratories up-front. Laboratory GCTs are invaluable resources in reviewing nuanced genetic test orders, educating providers in the strengths and limitations of different genetic test options, and working to ensure patients receive clinically appropriate and cost-effective testing.
Citation Format: Rebecca Vanderwall, Dagny Noeth, Angelica Goulbourne, Katherine Goode, Teresa Ruegg, Melissa Hayden, W. Christine Spence. Utilization Management: The Impact of Laboratory Genetic Counseling Oversight on BRCA1 and BRCA2 Targeted Analysis Orders [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO1-08-07.