Creation and Implementation of an Environmental Scan to Assess Cancer Genetics Services at Three Oncology Care Settings
An environmental scan (ES) is an efficient mixed-methods approach to collect and interpret relevant data for strategic planning and project design. To date, the ES has not been used nor evaluated in the clinical cancer genetics setting. We created and implemented an ES to inform the design of a quality improvement (QI) project to increase the rates of adherence to national guidelines for cancer genetic counseling and genetic testing at three unique oncology care settings (OCS). The ES collected qualitative and quantitative data from reviews of internal processes, past QI efforts, the literature, and each OCS. The ES used a data collection form and semi-structured interviews to aid in data collection. The ES was completed within 6 months, and sufficient data were captured to identify opportunities and threats to the QI project’s success, as well as potential barriers to, and facilitators of guideline-based cancer genetics services at each OCS. Previously unreported barriers were identified, including inefficient genetic counseling appointment scheduling processes and the inability to track referrals, genetics appointments, and genetic test results within electronic medical record systems. The ES was a valuable process for QI project planning at three OCS and may be used to evaluate genetics services in other settings.
KeywordsQuality improvement Environmental scan Hereditary cancer Cancer genetics Genetic counseling Genetic testing Health systems
We would like to thank Pamela Dickerson, Rhonda Broome, and Gail Frankeberger for their assistance with MD Anderson Cancer Network-related questions, Dr. Laura Bashoura of the MD Anderson Cancer Center Quality Improvement Assessment Board for her guidance on the QI project, the Department of Scientific Publications, the leadership of the MD Anderson Cancer Network and MD Anderson Physician Network, and the leadership of the MD Anderson Cancer Moon Shots Program for their support.
Concept or design of the study: Erica M. Bednar, Michael T. Walsh Jr., Ellen Baker, Kimberly I. Muse, Holly D. Oakley, Banu K. Arun, Karen H. Lu
Acquisition, analysis, or interpretation of data for the study: Erica M. Bednar, Kimberly I. Muse, Holly D. Oakley, Rebekah C. Krukenberg, Cara S. Dresbold, Sandra B. Jenkinson, Amanda L. Eppolito, Kelly B. Teed, Molly H. Klein, Nichole A. Morman, Elizabeth C. Bowdish, Pauline Russ, Emaline E. Wise, Julia N. Cooper, Michael W. Method, John W. Henson, Andrew V. Grainger
Drafted or critically revised the article for important intellectual content: Erica M. Bednar, Michael T. Walsh Jr., Ellen Baker, Kimberly I. Muse, Holly D. Oakley, Rebekah C. Krukenberg, Cara S. Dresbold, Sandra B. Jenkinson, Amanda L. Eppolito, Kelly B. Teed, Molly H. Klein, Nichole A. Morman, Elizabeth C. Bowdish, Pauline Russ, Emaline E. Wise, Julia N. Cooper, Michael W. Method, John W. Henson, Andrew V. Grainger, Banu K. Arun, Karen H. Lu
Final approval of the version of the article to be published: Erica M. Bednar, Michael T. Walsh Jr., Ellen Baker, Kimberly I. Muse, Holly D. Oakley, Rebekah C. Krukenberg, Cara S. Dresbold, Sandra B. Jenkinson, Amanda L. Eppolito, Kelly B. Teed, Molly H. Klein, Nichole A. Morman, Elizabeth C. Bowdish, Pauline Russ, Emaline E. Wise, Julia N. Cooper, Michael W. Method, John W. Henson, Andrew V. Grainger, Banu K. Arun, Karen H. Lu
Agree to be accountable for all aspects of the article in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: Erica M. Bednar, Michael T. Walsh Jr., Ellen Baker, Kimberly I. Muse, Holly D. Oakley, Rebekah C. Krukenberg, Cara S. Dresbold, Sandra B. Jenkinson, Amanda L. Eppolito, Kelly B. Teed, Molly H. Klein, Nichole A. Morman, Elizabeth C. Bowdish, Pauline Russ, Emaline E. Wise, Julia N. Cooper, Michael W. Method, John W. Henson, Andrew V. Grainger, Banu K. Arun, Karen H. Lu
This project was funded by the MD Anderson Breast Cancer and Ovarian Cancer Moon Shots™ Programs and Phillips 66. This work was also supported by the NIH/NCI under award number P30CA016672.
Compliance with Ethical Standards
Conflict of Interest
Authors Bednar, Walsh, Baker, Muse, Oakley, Krukenberg, Dresbold, Jenkinson, Eppolito, Teed, Klein, Morman, Bowdish, Russ, Wise, Cooper, Method, Henson, Grainger, Arun, and Lu (all authors) declare that they have no conflict of interest.
Human Studies and Informed Consent
For this study, formal consent was not required. No studies of human subjects were carried out by the authors for this article. No patient identifying information was obtained for this study. Informed consent was not required for this study. The work described in this article was the planning component of a quality improvement project, approved by the University of Texas MD Anderson Cancer Center Quality Improvement Assessment Board. The quality improvement project was subsequently reviewed by each collaborating site’s institutional review board and approved as a clinical, non-research project, subject to ongoing review.
No animal studies were carried out by the authors for this article.
- Alsop, K., Fereday, S., Meldrum, C., deFazio, A., Emmanuel, C., George, J., Dobrovic, A., Birrer, M. J., Webb, P. M., Stewart, C., Friedlander, M., Fox, S., Bowtell, D., & Mitchell, G. (2012). BRCA mutation frequency and patterns of treatment response in BRCA mutation-positive women with ovarian cancer: a report from the Australian Ovarian Cancer Study Group. Journal of Clinical Oncology, 30(21), 2654–2663. https://doi.org/10.1200/JCO.2011.39.8545.CrossRefPubMedPubMedCentralGoogle Scholar
- Batte, B. A., Bruegl, A. S., Daniels, M. S., Ring, K. L., Dempsey, K. M., Djordjevic, B., et al. (2014). Consequences of universal MSI/IHC in screening ENDOMETRIAL cancer patients for Lynch syndrome. Gynecologic Oncology, 134(2), 319–325. https://doi.org/10.1016/j.ygyno.2014.06.009.CrossRefPubMedPubMedCentralGoogle Scholar
- Beamer, L. C., Grant, M. L., Espenschied, C. R., Blazer, K. R., Hampel, H. L., Weitzel, J. N., & MacDonald, D. J. (2012). Reflex immunohistochemistry and microsatellite instability testing of colorectal tumors for Lynch syndrome among US cancer programs and follow-up of abnormal results. Journal of Clinical Oncology, 30(10), 1058–1063. https://doi.org/10.1200/JCO.2011.38.4719.CrossRefPubMedPubMedCentralGoogle Scholar
- Bednar, E. M., Oakley, H. D., Sun, C. C., Burke, C. C., Munsell, M. F., Westin, S. N., & Lu, K. H. (2017). A universal genetic testing initiative for patients with high-grade, non-mucinous epithelial ovarian cancer and the implications for cancer treatment. Gynecologic Oncology, 146(2), 399–404. https://doi.org/10.1016/j.ygyno.2017.05.037.CrossRefPubMedPubMedCentralGoogle Scholar
- Calzone, K. A., Prindiville, S. A., Jourkiv, O., Jenkins, J., DeCarvalho, M., Wallerstedt, D. B., Liewehr, D. J., Steinberg, S. M., Soballe, P. W., Lipkowitz, S., Klein, P., & Kirsch, I. R. (2005). Randomized comparison of group versus individual genetic education and counseling for familial breast and/or ovarian cancer. Journal of Clinical Oncology, 23(15), 3455–3464. https://doi.org/10.1200/JCO.2005.04.050.CrossRefPubMedGoogle Scholar
- Chun, D. S., Berse, B., Venne, V. L., DuVall, S. L., Filipski, K. K., Kelley, M. J., Meyer, L. J., Icardi, M. S., & Lynch, J. A. (2016). BRCA testing within the Department of Veterans Affairs: concordance with clinical practice guidelines. Familial Cancer, 16(1), 41–49. https://doi.org/10.1007/s10689-016-9921-5.CrossRefGoogle Scholar
- Commission on Cancer. (2016). Cancer Program Standards: Ensuring Patient-Centered Care. www.facs.org/quality-programs/cancer/coc: American College of Surgeons.
- Cragun, D., Bonner, D., Kim, J., Akbari, M. R., Narod, S. A., Gomez-Fuego, A., Garcia, J. D., Vadaparampil, S. T., & Pal, T. (2015). Factors associated with genetic counseling and BRCA testing in a population-based sample of young Black women with breast cancer. Breast Cancer Research and Treatment, 151(1), 169–176. https://doi.org/10.1007/s10549-015-3374-7.CrossRefPubMedPubMedCentralGoogle Scholar
- Crowl, A., Sharma, A., Sorge, L., & Sorensen, T. (2015). Accelerating quality improvement within your organization: applying the model for improvement. Journal of the American Pharmacists Association, 55(4), e364-e376. https://doi.org/10.1331/JAPhA.2015.15533.
- Eichmeyer, J. N., Burnham, C., Sproat, P., Tivis, R., & Beck, T. M. (2014). The value of a genetic counselor: improving identification of cancer genetic counseling patients with chart review. Journal of Genetic Counseling, 23(3), 323–329. https://doi.org/10.1007/s10897-013-9664-5.CrossRefPubMedGoogle Scholar
- Febbraro, T., Robison, K., Wilbur, J. S., Laprise, J., Bregar, A., Lopes, V., Legare, R., & Stuckey, A. (2015). Adherence patterns to National Comprehensive Cancer Network (NCCN) guidelines for referral to cancer genetic professionals. Gynecologic Oncology, 138(1), 109–114. https://doi.org/10.1016/j.ygyno.2015.04.029.CrossRefPubMedPubMedCentralGoogle Scholar
- Grumbach, K., Lucey, C. R., & Johnston, S. C. (2014). Transforming from centers of learning to learning health systems: the challenge for academic health centers. JAMA - Journal of the American Medical Association, 311(11), 1109–1110. https://doi.org/10.1001/jama.2014.705.CrossRefPubMedGoogle Scholar
- Hamilton, J. G., Abdiwahab, E., Edwards, H. M., Fang, M. L., Jdayani, A., & Breslau, E. S. (2016). Primary care providers' cancer genetic testing-related knowledge, attitudes, and communication behaviors: a systematic review and research agenda. Journal of General Internal Medicine, 32(3), 315–324. https://doi.org/10.1007/s11606-016-3943-4.CrossRefPubMedPubMedCentralGoogle Scholar
- Hampel, H., Bennett, R. L., Buchanan, A., Pearlman, R., Wiesner, G. L., Guideline Development Group, A. C. o. M. G,. .. National Society of Genetic Counselors Practice Guidelines, C (2015). A practice guideline from the American College of Medical Genetics and Genomics and the National Society of genetic counselors: Referral indications for cancer predisposition assessment. Genetics in Medicine, 17(1), 70–87. https://doi.org/10.1038/gim.2014.147.CrossRefPubMedGoogle Scholar
- Harris, P. A., Taylor, R., Thielke, R., Payne, J., Gonzalez, N., & Conde, J. G. (2009). Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics, 42(2), 377–381. https://doi.org/10.1016/j.jbi.2008.08.010.CrossRefPubMedGoogle Scholar
- Hartman, A. R., Kaldate, R. R., Sailer, L. M., Painter, L., Grier, C. E., Endsley, R. R., Griffin, M., Hamilton, S. A., Frye, C. A., Silberman, M. A., Wenstrup, R. J., & Sandbach, J. F. (2012). Prevalence of BRCA mutations in an unselected population of triple-negative breast cancer. Cancer, 118(11), 2787–2795. https://doi.org/10.1002/cncr.26576.CrossRefPubMedGoogle Scholar
- Institute for Healthcare Improvement. (2012). Science of improvement: establishing measures. Resources: How to Improve. Retrieved from http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementEstablishingMeasures.aspx
- Institute of Medicine. (2001). Crossing the quality chasm: a new health system for the 21st century. Washington, DC: The National Academies Press.Google Scholar
- Irons, R. F., Contino, K. M., Horte, J. J., Levin, B., Mattie, K. D., Wight, M., Kwiatt, M. E., Behling, K. C., Edmonston, T. B., & McClane, S. J. (2017). Success of referral to genetic counseling after positive lynch syndrome screening test. International Journal of Colorectal Disease., 32, 1345–1348. https://doi.org/10.1007/s00384-017-2849-x.CrossRefPubMedGoogle Scholar
- Karlitz, J. J., Hsieh, M. C., Liu, Y., Blanton, C., Schmidt, B., Jessup, J. M., Wu, X. C., & Chen, V. W. (2015). Population-based lynch syndrome screening by microsatellite instability in patients </=50: prevalence, testing determinants, and result availability prior to colon surgery. American Journal of Gastroenterology, 110(7), 948–955. https://doi.org/10.1038/ajg.2014.417.CrossRefPubMedGoogle Scholar
- Kinney, A. Y., Butler, K. M., Schwartz, M. D., Mandelblatt, J. S., Boucher, K. M., Pappas, L. M., Gammon, A., Kohlmann, W., Edwards, S. L., Stroup, A. M., Buys, S. S., Flores, K. G., & Campo, R. A. (2014). Expanding access to BRCA1/2 genetic counseling with telephone delivery: a cluster randomized trial. Journal of the National Cancer Institute, 106(12), dju328. https://doi.org/10.1093/jnci/dju328.CrossRefPubMedPubMedCentralGoogle Scholar
- Lancaster, J. M., Powell, C. B., Chen, L. M., Richardson, D. L., & Committee, S. G. O. C. P. (2015). Society of Gynecologic Oncology statement on risk assessment for inherited gynecologic cancer predispositions. Gynecologic Oncology, 136(1), 3–7. https://doi.org/10.1016/j.ygyno.2014.09.009.CrossRefPubMedGoogle Scholar
- Langley, G. J., Moen, R. D., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: A practical approach to enhancing organizational performance (Second ed.). San Francisco, CA: Jossey-Bass.Google Scholar
- Lu, K. H., Wood, M. E., Daniels, M., Burke, C., Ford, J., Kauff, N. D.,. .. American Society of Clinical, O (2014). American Society of Clinical Oncology expert statement: Collection and use of a cancer family history for oncology providers. Journal of Clinical Oncology, 32(8), 833–840. https://doi.org/10.1200/JCO.2013.50.9257.CrossRefPubMedPubMedCentralGoogle Scholar
- Macdonald, D. J., Deri, J., Ricker, C., Perez, M. A., Ogaz, R., Feldman, N., et al. (2012). Closing the loop: an interactive action-research conference format for delivering updated medical information while eliciting Latina patient/family experiences and psychosocial needs post-genetic cancer risk assessment. Familial Cancer, 11(3), 449–458. https://doi.org/10.1007/s10689-012-9535-5.CrossRefPubMedPubMedCentralGoogle Scholar
- McCarthy, A. M., Bristol, M., Domchek, S. M., Groeneveld, P. W., Kim, Y., Motanya, U. N.,. .. Armstrong, K. (2016). Health care segregation, physician recommendation, and racial disparities in BRCA1/2 testing among women with breast Cancer. Journal of Clinical Oncology, 34(22), 2610–2618. https://doi.org/10.1200/JCO.2015.66.0019.CrossRefPubMedPubMedCentralGoogle Scholar
- Meyer, L. A., Anderson, M. E., Lacour, R. A., Suri, A., Daniels, M. S., Urbauer, D. L.,. .. Lu, K. H. (2010). Evaluating women with ovarian cancer for BRCA1 and BRCA2 mutations. Obstetrics and Gynecology, 115(5), 945–952. https://doi.org/10.1097/AOG.0b013e3181da08d7.CrossRefPubMedPubMedCentralGoogle Scholar
- Modell, S. M., Greendale, K., Citrin, T., & Kardia, S. L. (2016). Expert and advocacy group consensus findings on the horizon of public health genetic testing. Healthcare (Basel), 4(1). https://doi.org/10.3390/healthcare4010014.
- Nair, N., Bellcross, C., Haddad, L., Martin, M., Matthews, R., Gabram-Mendola, S.,. .. Meaney-Delman, D. (2017). Georgia primary care providers’ knowledge of hereditary breast and ovarian cancer syndrome. Journal of Cancer Education, 32(1), 119–124. https://doi.org/10.1007/s13187-015-0950-9.CrossRefPubMedGoogle Scholar
- National Comprehensive Cancer Network. (2017a). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): Genetic/Familial High-Risk Assessment: Breast and Ovarian. Retrieved 10/18/2017, from National Comprehensive Cancer Network, Inc. www.nccn.org
- National Comprehensive Cancer Network. (2017b). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines): Genetic/Familial High Risk Assessment: Colorectal. from National Comprehensive Cancer Network, Inc. www.nccn.org
- Petzel, S. V., Vogel, R. I., McNiel, J., Leininger, A., Argenta, P. A., & Geller, M. A. (2014). Improving referral for genetic risk assessment in ovarian cancer using an electronic medical record system. International Journal of Gynecological Cancer, 24(6), 1003–1009. https://doi.org/10.1097/IGC.0000000000000148.CrossRefPubMedPubMedCentralGoogle Scholar
- Powell, C. B., Littell, R., Hoodfar, E., Sinclair, F., & Pressman, A. (2013). Does the diagnosis of breast or ovarian cancer trigger referral to genetic counseling? International Journal of Gynecological Cancer, 23(3), 431–436. https://doi.org/10.1097/IGC.0b013e318280f2b4.CrossRefPubMedGoogle Scholar
- PQ Systems. (n.d.). Affinity diagram. Quality Advisor. Retrieved from http://www.pqsystems.com/qualityadvisor/DataAnalysisTools/affinity_diagram.phpGoogle Scholar
- Robson, M. E., Storm, C. D., Weitzel, J., Wollins, D. S., Offit, K., & American Society of Clinical, O. (2010). American Society of Clinical Oncology policy statement update: genetic and genomic testing for cancer susceptibility. Journal of Clinical Oncology, 28(5), 893–901. https://doi.org/10.1200/JCO.2009.27.0660.CrossRefPubMedGoogle Scholar
- Schwartz, M. D., Valdimarsdottir, H. B., Peshkin, B. N., Mandelblatt, J., Nusbaum, R., Huang, A. T.,. .. King, L. (2014). Randomized noninferiority trial of telephone versus in-person genetic counseling for hereditary breast and ovarian cancer. Journal of Clinical Oncology, 32(7), 618–626. https://doi.org/10.1200/JCO.2013.51.3226.CrossRefPubMedPubMedCentralGoogle Scholar
- Society for Human Resource Management. (2012). Strategic planning: what are the basics of environmental scanning? Retrieved from www.shrm.org/resourcesandtools/tools-and-samples/hr-qa/pages/cms_021670.aspxGoogle Scholar
- Society of Gynecologic Oncology. (2014a). SGO Clinical Practice Statement: Genetic Testing for Ovarian Cancer. SGO Clinical Practice. Retrieved from https://www.sgo.org/clinical-practice/guidelines/genetic-testing-for-ovarian-cancer/
- Society of Gynecologic Oncology. (2014b). SGO Clinical Practice Statement: Screening for Lynch Syndrome in Endometrial Cancer. Retrieved from https://www.sgo.org/clinical-practice/guidelines/screening-for-lynch-syndrome-in-endometrial-cancer/
- Sperber, N. R., Andrews, S. M., Voils, C. I., Green, G. L., Provenzale, D., & Knight, S. (2016). Barriers and facilitators to adoption of genomic Services for Colorectal Care within the Veterans Health Administration. J Pers Med, 6(2). https://doi.org/10.3390/jpm6020016.
- Stuckey, A., Febbraro, T., Laprise, J., Wilbur, J. S., Lopes, V., & Robison, K. (2014). Adherence patterns to National Comprehensive Cancer Network Guidelines for referral of women with breast Cancer to genetics professionals. American Journal of Clinical Oncology, 00(00), 1–5.Google Scholar
- Sussner, K. M., Jandorf, L., & Valdimarsdottir, H. B. (2011). Educational needs about cancer family history and genetic counseling for cancer risk among frontline healthcare clinicians in New York City. Genetics in Medicine, 13(9), 785–793. https://doi.org/10.1097/GIM.0b013e31821afc8e.CrossRefPubMedPubMedCentralGoogle Scholar
- Tague, N. R. (2004). Affinity diagram. Learn About Quality: About Idea Creation Tools. Retrieved from http://asq.org/learn-about-quality/idea-creation-tools/overview/affinity.htmlGoogle Scholar
- Tague, N. R. (2005). Fishbone (Ishikawa) Diagram. Learn About Quality: About 7 Basic Quality Tools. Google Scholar
- Vadaparampil, S. T., Scherr, C. L., Cragun, D., Malo, T. L., & Pal, T. (2015). Pre-test genetic counseling services for hereditary breast and ovarian cancer delivered by non-genetics professionals in the state of Florida. Clinical Genetics, 87(5), 473–477. https://doi.org/10.1111/cge.12405.CrossRefPubMedGoogle Scholar
- Willis, A. M., Smith, S. K., Meiser, B., Ballinger, M. L., Thomas, D. M., & Young, M. A. (2016). Sociodemographic, psychosocial and clinical factors associated with uptake of genetic counseling for hereditary cancer: a systematic review. Clinical Genetics, 92(2), 121–133. https://doi.org/10.1111/cge.12868.CrossRefPubMedGoogle Scholar
- Wright, J. D., Chen, L., Tergas, A. I., Accordino, M., Ananth, C. V., Neugut, A. I., & Hershman, D. L. (2016). Underuse of BRCA testing in patients with breast and ovarian cancer. American Journal of Obstetrics and Gynecology, 214(6), 761–763. https://doi.org/10.1016/j.ajog.2016.02.011.CrossRefPubMedGoogle Scholar