1102 — New delivery models improve access to germline testing for patients with advanced prostate cancer

Lead/Presenter: Maren Scheuner, 
All Authors: Scheuner MT (San Francisco VA Health Care System, UCSF School of Medicine), Sales P (San Francisco VA Health Care System) Hoggatt K (San Francisco VA Health Care System, UCSF School of Medicine) Washington S (San Francisco VA Health Care System, UCSF School of Medicine) Ferino E (San Francisco VA Health Care System, UCSF School of Medicine) Serway C (VA National Oncology Program Office) Ahmed S (VA National Oncology Program Office) Kelley MJ (VA National Oncology Program Office)

Objectives:
The VA Oncology Clinical Pathway for Prostate Cancer is the first to include both tumor and germline testing to inform treatment and clinical trial eligibility for advanced disease. Anticipating increased germline testing demand, new delivery models were created to augment the existing traditional model of referring patients to genetics providers (VA or non-VA) for germline testing. The new models include: a non-traditional model where oncology clinicians perform all pre- and post-test activities and consult genetics when needed, and a hybrid model where oncology clinicians obtain informed consent and place e-consults for germline test ordering, results disclosure, and genetics follow-up, as needed. We sought to assess germline testing by delivery model.

Methods:
Data sources included the National Precision Oncology Program (NPOP) dashboard and reports from the NPOP-contracted germline testing laboratories. Patient inclusion criteria: living as of 5/2/2021 with VA oncology or urology visits after 5/2/2021. We used multivariate regression to assess associations between patient characteristics and germline testing between 5/3/2021 (pathway launch) and 5/2/2022, accounting for clustering of patients within ordering clinicians.

Results:
We identified 16,041 patients from 129 VA facilities with average age 75 (SD = 8.2, 36-102), 28.7% Black and 60.0% White. Throughout the first year, 896 (5.6%) patients had germline testing ordered by 60 clinicians at 67 facilities with 52.2% of orders by the hybrid model, 32.1% the non-traditional model, and 15.4% the traditional model. The hybrid and non-traditional models were typically not used together at a site; whereas the traditional model did co-exist with the other models. Implementation strategies included: electronic health record tools (informed consent template, germline test order build) for the hybrid and non-traditional models; information resources (how-to guide for germline test ordering, power point presentation) for the nontraditional model; and technical assistance for the non-traditional model. Patient characteristics positively associated with germline testing included care at hybrid model (OR = 6.03, 95% CI:4.62-7.88) or non-traditional model facilities (OR = 5.66, 95% CI:4.24-7.56) compared with the traditional model, completing tumor molecular testing (OR = 5.80, 95%CI: 4.98-6.75), and Black compared with White race (OR = 1.24, 95%CI: 1.06-1.45). Compared to patients aged < 66, patients aged 66-75 and 76-85 were less likely to have germline testing (OR = 0.74, 95%CI: 0.60-0.90 and OR = 0.67, 95%CI: 0.53-0.84, respectively).

Implications:
Though only a small percentage of patients with advanced prostate cancer had NPOP-supported germline testing since the pathway launch, the new delivery models were instrumental to improving access to germline testing. Yet all three delivery models are likely necessary to ensure adoption of germline testing given the variation in local resources and patient and provider needs and preferences. Ongoing evaluation will help to understand observed demographic differences in germline testing and the effectiveness of the implementation strategies in use to promote adoption of the new germline testing delivery models.

Impacts:
Continued spread and uptake of the hybrid and non-traditional models for germline testing should result in improve outcomes for patients with advanced prostate cancer by increasing use of treatments targeting molecular findings and by informing eligibility for clinical trials.