Background: Pancreatic adenocarcinoma is an aggressive cancer with a 13% five-year survival rate. To prolong survival, early implementation of treatment is necessary. Germline genetic testing is recommended by national guidelines regardless of stage, personal, and family history of cancer. It can impact treatment decision-making and clinical trial selection. Many institutions rely on genetic counselors (GCs) for evaluation and testing, and challenges in referral timelines and bandwidth can delay testing. There is a critical need in our interdisciplinary Pancreatic Cancer Clinic to expedite diagnosis and decrease unnecessary GC referrals.

Methods: Using a plan-do-study-act (PDSA) model of quality improvement, baseline data for 20 referrals between August 2023 to December 2023 were obtained. The average time between referral placement and date of service by a GC and the time to result in reporting were recorded.The change consisted in shifting the responsibility for ordering germline tests to the lead oncologist, using an EMR-integrated order for the Tempus xG+ 88-gene blood panel. The order and lab collection occurred on the same day. Results were routed directly to the medical oncologist. For patients with negative results, patients were informed, and no further action was taken. When the result was positive for a pathogenic mutation or a variant of unknown significance (VUS), a referral was placed for GC. The goal of the study was to obtain genetic risk results faster to aid decision-making, decrease the time from referral to see GCs, and reduce the number of necessary referrals.

Results: At baseline, the range from referral to GC appointment was 32-35 days, the reporting time of testing panels was 12-15 days, and the total time from referral to result was 45 to 50 days. The first PDSA cycle ran from 4/18/24-1/15/25, the selected panel was ordered and resulted for 51 patients. The average order-to-result time was 17.0 days . Of 51 tests ordered, 30 patients (59%) resulted as positive or VUS, which qualified for genetics referral placement. Of those 30, 28 (55% of total) who were local were referred to our Cancer Genetics Program. The average result to referral placement was 9 days. For 28 patients who were referred internally, the average referral placement to the first appointment offered was 16.7 days. Two patients had mutations that affected treatment decision making. In summary, germline testing led to 39% decrease in the number of referrals and reduced the time to see GCs by 18 days. Results reporting improved from an average of 45 days to 17 days.

Conclusions: This medical oncologist-led germline testing workflow is considered efficient and an excellent option for any resource-limited program for optimal resource utilization and treatment decisions influenced by genetic risk. Future steps will focus on refining the testing process, order entry, and reporting.

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