Advertisement

Familial Cancer

, Volume 16, Issue 1, pp 41–49 | Cite as

BRCA testing within the Department of Veterans Affairs: concordance with clinical practice guidelines

  • Danielle S. Chun
  • Brygida Berse
  • Vickie L. Venne
  • Scott L. DuVall
  • Kelly K. Filipski
  • Michael J. Kelley
  • Laurence J. Meyer
  • Michael S. Icardi
  • Julie A. Lynch
Original Article

Abstract

Guideline-concordant cancer care is a priority within the Department of Veterans Affairs (VA). In 2009, the VA expanded its capacity to treat breast cancer patients within VA medical centers (VAMCs). We sought to determine whether male and female Veterans diagnosed with breast cancer received BRCA testing as recommended by the National Comprehensive Cancer Network (NCCN) guidelines on Genetic/Familial High-Risk Assessment in Breast and Ovarian Cancer (v. 1.2010–1.2012). Using the 2011–2012 VA Central Cancer Registry and BRCA test orders from Myriad Genetics, we conducted a retrospective study. The outcome variable was a recommendation for genetic counseling or BRCA testing, determined by chart review. Independent variables expected to predict testing included region, site of care, and patient characteristics. We performed descriptive analysis of all patients and conducted multivariable logistic regression on patients who sought care at VAMCs that offered BRCA testing. Of the 462 Veterans who met NCCN testing criteria, 126 (27 %) received guideline-concordant care, either a referral for counseling or actual testing. No BRCA testing was recommended in 49 (50 %) VAMCs that provide cancer treatment. Surprisingly, patients with second primary breast cancer were less likely to be referred/tested (OR 0.39; CI 0.17, 0.89; p = 0.025). For patients under age 51, a yearly increase in age decreased likelihood of referral or testing (OR 0.85; CI 0.76, 0.94; p < 0.001). There were no differences in testing by race. In conclusion, there was significant underutilization and lack of access to BRCA testing for Veterans diagnosed with breast cancer. Our research suggests the need for clinical decision support tools to facilitate delivery of guideline-concordant cancer care and improve Veteran access to BRCA testing.

Keywords

Genetic testing Breast cancer BRCA Clinical guidelines 

Notes

Funding

This research was supported using resources and facilities at the VA Salt Lake City Health Care System with funding from the Department of Veterans Affairs Informatics and Computing Infrastructure (VINCI), VA HSR RES 13-457 (to S. L. DuVall). B. Berse and J. A. Lynch are funded by the National Cancer Institute through an Interagency Agreement. IAA 14001-0000-01001.

Compliance with ethical standards

Conflict of interest

J. A. Lynch and B. Berse completed a prostate cancer study that involved research collaboration with Myriad Genetics. Other authors declare no conflict of interest.

References

  1. 1.
    U.S. Department of Veterans Affairs (2010) Sociodemographic characteristics and use of VHA care. Women Veterans in the Veterans Health Administration. Palo Alto, CA, SourcebookGoogle Scholar
  2. 2.
    Colonna S, Halwani A, Ying J, Buys S, Sweeney C (2015) Women with breast cancer in the Veterans Health Administration: demographics, breast cancer characteristics, and trends. Med Care 53:S149–S155CrossRefPubMedGoogle Scholar
  3. 3.
    Aggarwal A, Liu ML, Krasnow SH (2014) Breast cancer in male veteran population: an analysis from VA cancer registry. J Commun Support Oncol 12:293–297CrossRefGoogle Scholar
  4. 4.
    Breastcancer.org (2015) Male breast cancer (cited 2015 December 14). http://www.breastcancer.org/symptoms/types/male_bc
  5. 5.
    ACOG Committee on Practice Bulletins (2009) Hereditary breast and ovarian cancer syndrome. Gynecol Oncol 113:6–11CrossRefGoogle Scholar
  6. 6.
    Gage M, Wattendorf D, Henry LR (2012) Translational advances regarding hereditary breast cancer syndromes. J Surg Oncol 105:444–451CrossRefPubMedGoogle Scholar
  7. 7.
    Petrucelli N, Daly MB, Feldman GL (2010) Hereditary breast and ovarian cancer due to mutations in BRCA1 and BRCA2. Genet Med 12:245–259CrossRefPubMedGoogle Scholar
  8. 8.
    Kalimutho M, Parsons K, Mittal D, Lopez JA, Srihari S, Khanna KK (2015) Targeted therapies for triple-negative breast cancer: combating a stubborn disease. Trends Pharmacol Sci 36:822–846CrossRefPubMedGoogle Scholar
  9. 9.
    Lynch HT, Snyder C, Casey MJ (2013) Hereditary ovarian and breast cancer: What have we learned? Ann Oncol Suppl 8:viii83–viii95. doi: 10.1093/annonc/mdt313.
  10. 10.
    Robson ME, Storm CD, Weitzel J, Wollins DS, Offit K (2010) American Society of Clinical Oncology policy statement update: genetic and genomic testing for cancer susceptibility. J Clin Oncol 28:893–901CrossRefPubMedGoogle Scholar
  11. 11.
    Robson ME, Bradbury AR, Arun B et al (2015) American Society of clinical oncology policy statement update: genetic and genomic testing for cancer susceptibility. J Clin Oncol 33:3660–3667CrossRefPubMedGoogle Scholar
  12. 12.
    Nelson HD, Fu R, Goddard K et al (2013) Risk assessment, genetic counseling, and genetic testing for BRCA-related cancer: systematic review to update the US Preventive Services Task Force Recommendation. Rockville, MDGoogle Scholar
  13. 13.
    U.S. Preventive Services Task Force (2013) Final recommendation statement BRCA-related cancer: risk assessment, genetic counseling, and genetic testing. Ann Intern Med December 24 (cited November 5, 2014). http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/brca-related-cancer-risk-assessment-genetic-counseling-and-genetic-testing
  14. 14.
    National Comprehensive Cancer Network (2015) Clinical practice guidelines in oncology. Genetic/Familial High-Risk Assessment: breast and ovarian. Version 2.2015 (cited November 30, 2015). http://www.nccn.org/professionals/physician_gls/pdf/genetics_screening.pdf
  15. 15.
    Foulkes WD (2008) Inherited susceptibility to common cancers. N Engl J Med 359:2143–2153CrossRefPubMedGoogle Scholar
  16. 16.
    Levy DE, Byfield SD, Comstock CB et al (2011) Underutilization of BRCA1/2 testing to guide breast cancer treatment: black and Hispanic women particularly at risk. Genet Med 13:349–355CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Veterans Health Administration (2010) VHA handbook 1330.1. Health Care Services for Women Veterans (cited November 30, 2015). http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=2246
  18. 18.
    U.S. Department of Veterans Affairs (2015) Veterans Affairs Central Cancer Registry (VACCR) (cited 2015 December 14). https://catalog.data.gov/dataset/veterans-administration-central-cancer-registry-vaccr
  19. 19.
    U.S. Department of Veterans Affairs (2015) VHA Support Service Center (VSSC) (cited 2015 December 14). http://vssc.med.va.gov/
  20. 20.
    Wright JD, Chen L, Tergas AI et al (2016) Underuse of BRCA testing in patients with breast and ovarian cancer. Am J Obstet Gynecol. doi: 10.1016/j.ajog.2016.02.011 Google Scholar
  21. 21.
    Bellcross CA, Peipins LA, McCarty FA et al (2015) Characteristics associated with genetic counseling referral and BRCA1/2 testing among women in a large integrated health system. Genet Med 17:43–50CrossRefPubMedGoogle Scholar
  22. 22.
    Kautter J, Lynch J, Coomer N, Berse B, Leahy S (2015) Design and implementation support for the treatment of certain complex diagnostic laboratory tests demonstration, final report; prepared for the Center for Medicare and Medicaid ServicesGoogle Scholar
  23. 23.
    Schlich-Bakker KJ, ten Kroode HF, Warlam-Rodenhuis CC, van den Bout J, Ausems MG (2007) Barriers to participating in genetic counseling and BRCA testing during primary treatment for breast cancer. Genet Med 9:766–777CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht (outside the USA) 2016

Authors and Affiliations

  • Danielle S. Chun
    • 1
    • 2
  • Brygida Berse
    • 3
    • 4
    • 5
  • Vickie L. Venne
    • 1
  • Scott L. DuVall
    • 1
    • 2
  • Kelly K. Filipski
    • 6
  • Michael J. Kelley
    • 7
    • 8
  • Laurence J. Meyer
    • 1
    • 2
  • Michael S. Icardi
    • 9
    • 10
  • Julie A. Lynch
    • 2
    • 5
    • 11
  1. 1.VA Salt Lake City Health Care SystemSalt Lake CityUSA
  2. 2.University of Utah School of MedicineSalt Lake CityUSA
  3. 3.Veterans Health AdministrationBedfordUSA
  4. 4.Boston University School of MedicineBostonUSA
  5. 5.RTI InternationalWalthamUSA
  6. 6.National Cancer InstituteRockville, BethesdaUSA
  7. 7.Durham VA Medical CenterDurhamUSA
  8. 8.Duke UniversityDurhamUSA
  9. 9.Veterans Health AdministrationIowa CityUSA
  10. 10.University of IowaIowa CityUSA
  11. 11.VA Salt Lake City Health Care SystemBedfordUSA

Personalised recommendations