Innovation in germline and somatic tumor testing pathways for ovarian cancer patients

Objectives: New approvals for upfront maintenance therapy with parp inhibitors in ovarian cancer now indicate a need for germline genetic testing and potentially somatic testing including homologous repair deficiency (HRD) within several months of diagnosis. However, national rates of germline testing are approximately 30%1 despite being recommended for all patients. Current practice now indicates that it is even more important to obtain results quicker and more efficiently at the time of a new diagnosis of ovarian cancer. We sought to apply novel healthcare innovation techniques to this problem space to improve rates of germline and somatic tumor testing in ovarian cancer patients. Methods: A total of 4 pilots ranging from “low to high touch” were performed in an experimental rapid cycle model, each lasting approximately 2-3 weeks. In Pilot 1, providers were “nudged” via email, text or electronic medical record (EMR) alert as per their preference that an upcoming patient was missing either genetic testing or tumor testing (HRD or somatic testing). In Pilot 2, choice architecture was used to pend orders for genetics consultation into the upcoming patient encounter in the EMR. In Pilot 3, a “Concierge Approach” was applied to capture patients in real time who were approached in person at the clinic appointment and offered immediate genetic counseling/testing. In Pilot 4, a text messaging platform was used to schedule patients for a counseling/testing appointment. Descriptive statistics were performed. Results: Results: Pilot 1: 30 “nudges” were placed but only 50% of encounters documented discussion or ordering of genetic testing. Pilot 2: 75% of pended orders were signed, with 7/12 (58.3%) of patients scheduling a genetic counseling appointment. Pilot 3: 4/6 (66.7%) of patients completed a genetic counseling appointment when offered in real time at the visit and 3/4 (75%) completed testing. Pilot 4: If patients consented to texting for scheduling (50%), the majority of patients were scheduled for counseling or obtained outside testing results (n=8/9, 88.9%). Attendance rates at appointments scheduled via text were 100% (n=5/5). Potential trends in racial disparities were identified within the n=59 patients missing germline or somatic testing, with an increased proportion of Black patients (27.1%) and Asian/Other (13.6%) missing testing, higher than the baseline practice demographics. Conclusions: Behavioral economics can be utilized to improve rates of genetic and somatic testing for ovarian cancer patients. Patients typically complete genetic counseling/testing if an appointment is offered in real time. A ‘warm hand-off’ is needed for outreach via text for awareness and engagement, however once enrolled, patients participated via text for scheduling and discussion of prior results at high percentages. A ‘concierge approach’ is highly successful but not scalable for all but could be used to ‘rescue’ missed patients. Potential racial disparities need further exploration to ensure solutions are equitable and applicable to all patients. The growth of precision medicine could benefit from automation and choice architecture utilizing the EMR. This would allow for surfacing of missing clinical data by removing the mental burden of the work required to complete genetic and somatic testing.’