Workflow, staffing are key to genetic testing in safety-net systems

In this video, Kalyani Narra, MD, discusses findings from a study examining referrals for prostate cancer–related genetic counseling within a safety-net health system.¹

The study observed that patients with higher-stage disease were significantly more likely to be referred for genetic counseling and testing. Narra explained that this pattern largely reflects clinical practice patterns rather than deliberate exclusion of earlier-stage patients. In particular, referrals for metastatic (stage IV) prostate cancer are firmly embedded in oncology workflows, with clinicians consistently reminded that these patients should be referred. As a result, patients with stage IV disease are almost universally directed to genetic counseling.

For patients with stage III disease—classified as high or very high risk—Narra noted that referral rates could still improve. In contrast, referrals among patients with stage I or II disease were relatively uncommon, with approximately 12% of these individuals receiving genetic testing referrals in the study. Narra suggested these cases were likely driven by additional risk factors such as younger age at diagnosis or family history of cancers associated with hereditary risk, including breast, ovarian, pancreatic, or metastatic prostate cancer. She emphasized that the detailed criteria outlined in clinical guidelines can be complex and difficult for clinicians to recall, which may contribute to under-referral among patients who technically qualify based on family history.

Narra also highlighted key elements of the system’s workflow that support genetic counseling implementation in a safety-net environment. A major factor is the presence of a dedicated, in-house genetic counseling service contracted through UT Southwestern. The genetic counselor plays an active role in multidisciplinary tumor boards, regularly reminding clinicians about referral criteria and reinforcing the importance of genetic testing. This consistent engagement helps keep the issue visible within the care team.

Telemedicine has also expanded access, allowing patients to choose either virtual or in-person visits. However, Narra emphasized that limited genetic counseling capacity remains a major barrier. If all eligible prostate cancer patients were referred according to national guidelines, additional counselors and expanded appointment availability would likely be required.

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