Evaluating genetic counseling uptake in safety-net prostate cancer care

In this video, Kalyani Narra, MD, a general medical oncologist at JPS Health Network in Fort Worth, Texas, discusses findings from her study examining prostate cancer–related genetic counseling referrals in a safety-net health care setting, with a focus on the impact of the 2018 National Comprehensive Cancer Network (NCCN) guideline expansion.¹

Narra explains that the observed increase in referrals after 2018 was unlikely to be driven by other contemporaneous factors. Unlike cancers such as ovarian or pancreatic cancer—where universal referral criteria allowed for electronic health record (EHR) prompts—prostate cancer referrals could not be automated without overwhelming the system, because not all patients qualify under NCCN criteria. As a result, no EHR prompt was implemented for prostate cancer, ruling out decision-support tools as a confounding factor. She also notes that staffing levels remained stable over the study period, and the practice operates as a small, standalone oncology group without institutional genetics leadership that might independently influence referral behavior. Together, these factors support the conclusion that the guideline expansion itself was the primary driver of increased referrals.

Despite improvements, Narra highlights persistent gaps in referral among eligible patients. Although all patients with stage IV disease meet NCCN criteria for germline testing, only 38% of these patients were referred. Similarly, among stage III patients—many of whom qualify due to high- or very high-risk disease—only 23% received referrals. These findings indicate that a substantial proportion of eligible patients were still missed, even after the guideline change.

Importantly, the study found no evidence of disparities in referral by race, ethnicity, or insurance status within this safety-net population. Black patients represented 46% of the overall cohort and the same proportion of referred patients. Uninsured patients were not disadvantaged; in fact, a higher proportion of referred patients were uninsured compared with the overall population. Narra emphasizes that although referral rates are not yet optimal, the study demonstrates meaningful progress and represents one of the first reports of genetic counseling implementation in a safety-net oncology setting, providing a foundation for continued improvement.

REFERENCE

1. Mbonu P, Mersch J, Heady J, et al. Prostate cancer-related genetic counseling in a safety-net healthcare setting. Urol Oncol. 2025 Dec 29:110967. doi:10.1016/j.urolonc.2025.12.003