"Mainstreaming" Germline Genetic Testing: How Nongenetics Providers Can Help Fill the Workforce Gap
Germline genetic testing can play an essential role in identifying cancer risk, guiding treatment decisions, and informing screening and/or preventive strategies for both patients and patient family members. Access to timely and convenient genetic testing can be challenging based on increased indications for testing, larger gene panels, and high numbers of positive tests which are overloading a limited genetics workforce. This is leading to long wait times and widening disparities in access to genetic testing. Dr. Chino welcomes Dr. Trevor Hoffman to discuss an intervention he helped pilot using non-genetics providers to increase access while maintaining quality. TRANSCRIPT Dr. Fumiko Chino: Hello and welcome to Put Into Practice, the podcast from the JCO Oncology Practice. I'm Dr. Fumiko Chino, an assistant professor in radiation oncology at MD Anderson Cancer Center with a research focus on access, affordability, and equity. Germline genetic testing can play an essential role to identify cancer risk, guide treatment directions, and inform screening or preventative strategies for both patients and patient family members. Access to timely and convenient genetic testing can be challenging based on increased indications for testing, larger gene panels, and high numbers of positive tests that are overloading a limited genetics workforce. This is leading to long wait times and widening disparities in access to genetic testing. I'm happy to welcome a guest today to discuss an intervention he helped pilot using non-genetics providers to increase access while maintaining quality. Dr. Trevor Hoffman, MD, PhD, is an associate professor in clinical medicine at the Kaiser Permanente Bernard J. Tyson School of Medicine and the Regional Chief of Medical Genetics in the Southern California Kaiser Permanente Medical Group. He leads a department of 10 medical geneticists and approximately 40 genetic counselors, serving 5 million Kaiser members in Southern California. He is the first author of a JCO OP manuscript, "Expanding Germline Hereditary Cancer Gene Panel Testing by Non-Genetics Providers," which was published earlier this year. Our full disclosures are available in the transcript of this episode, and we've already agreed to go by our first names for the podcast today. Trevor, it's wonderful to speak to you today. Dr. Trevor Hoffman: Thank you so much for inviting me on the pod. I'm really psyched about it. Dr. Fumiko Chino: Our specific topic today is something that I know you know a lot about, germline genetic testing. Despite broadened eligibility, only a small percentage of people diagnosed with cancer will undergo germline genetic testing, and I'd love your thoughts on the changes in genetic testing over your 20+ year career, and particularly, obviously for our respects, within the cancer patient population. The who, what, when, where, how, and wherefores of genetic testing and how this has evolved as our scientific knowledge has really improved over time. Dr. Trevor Hoffman: Yeah, it's been a wild ride considering everything I've seen happen in my own field. Back when I started in practice, we were doing like standard karyotypes and maybe sequencing a gene here or there by Sanger sequencing, and testing was cost prohibitive, thousands of dollars. You know, there were gene patents. You know, we were this little hidden department, like in the basement, that hardly anybody knew about, and we liked our little place in anonymity, and it was all good. Come the genomics revolution and next-generation sequencing, and, you know, all of a sudden you can, in one machine, sequence, you know, billions of letters of genetic code for hundreds of dollars. It was like a paradigm shift caused by technology. So that and the removal of gene patents, we've come, you know, in the ensuing years to hereditary cancer gene tests that's, you name it, depending on whether it's done 20, 30, 40, 70 genes for under $500 in most cases and can be done in a matter of a couple of weeks. That's a bit of a massive change. In oncology, we've seen that happen in terms of tumor NGS, right? Like, things are changing for all of us rapidly. And so multiply that across every specialty. In my field where we used to own every genetic test, like genetics would kind of order every test and determine who needed testing, that's not going to happen. Like, it's not going to work anymore. So we have to come up with better ways to sort of put it into the hands of people, make it easy, make it appropriate to maintain access. We can't do the white-glove service anymore where we see every single patient and touch every patient. That's the shortest version of my career in a nutshell. And you're living this too, right? Like many people listening to this podcast train oncology, like tumor NGS didn't exist, you know, and now all of a sudden it's like standard of care in our system. And you know, people have had to just learn by the seat of their pants. And so we're all in this crazy roller coaster together. Dr. Fumiko Chino: Yeah, it seems like the proliferation of testing and the vitality of the information gained from it, how important it is, it is unsustainable for the genetics workforce to stay in their closed basement system. As a radiation oncologist who lives in a basement, we have enough people in the basement. We're hoping to integrate them a little better into the larger community. Now, you were the first author of this recent report on the 3-year experience of mainstreaming hereditary cancer gene panel testing at Kaiser Permanente Southern California. Do you mind briefly discussing the background of what led to this project - again, sounds like limited workforce - and what your study team actually did, and then the actual findings? Dr. Trevor Hoffman: Yeah, I'd love to. So this kind of arose from, and mainstreaming is essentially in the genetics field, we call that like handing a test to a non-genetics provider to order. So that's kind of the term that has been applied to that. And essentially, we have to do that. And so this kind of arose through some personal relationships I had with cancer providers in our system, a couple of whom were down the hall from me. One of them was a GYN ONC provider, and the other was a breast surgeon. And so, I had both our breast surgeon and our GYN ONC doc approached me and say, "You know what? I'm seeing all these women and they have ovarian cancer, or they have breast cancer, and I know I'm doing surgery on these people. They need a hereditary cancer gene test. It's a no-brainer. And so I have to see them. I schedule my surgery. If it's breast cancer, I'm like, I'm not sure what the surgery is, and this woman may be 45, and it's like, well, I don't know what surgery to do, but we schedule a surgery in three weeks. We refer them to genetics. Genetics sees them, schedules an appointment, orders the test, the patient goes to the lab and gets the test." That all sounds great, right? But the patient may be overwhelmed. They may not know the importance of getting that appointment scheduled very quickly. In our system, we're under a regulatory guideline to see people within two weeks, but in lots of genetics practices out there, there are wait lists that are a year, two years, three years. The patient may not understand why the surgeon wants this result, right? And it's, you know, I listened to your last podcast about parking charges, right, being a barrier. So like, we're putting up all these barriers for patients with cancer, and then if the patient didn't get the test or do it, the surgeon's like, "I've got to cancel my surgery," and they're calling me. And so we kind of were like, "Hey, wait a minute, like, can I just order this myself in the surgery clinic or in the GYN ONC clinic? Because it's making their life easier." So it kind of arose out of one of these rare things in medicine, right? Like a win, win, win. For them it's a win. They need the info quick. They want to schedule their surgery, they want to know what they're doing. For the patient it's a win because then they don't have to make an appointment, pay the parking fee, all the barriers of getting that appointment done. And from our point of view, it's a win because like, I know before that patient walks in the door, I'm ordering that test for a 45-year-old woman with breast cancer, like it's a no-brainer. The other thing I would say is that from the point of view of the patient, seeing me for like a separate 60-minute appointment to discuss testing in that venue, they've got so many other things on their mind. The ability to hold onto all that information is just limited. So, you know, we see people and we still do in some contexts in these multidisciplinary clinics, but the retention of what I'm telling patients, honestly is low. They're worried they're going to die. They're worried about, "What surgery am I going to have?" "What am I going to do about my job?" And so we started doing it on a small scale, but the main thing was making it logistically easy for them. That's the key, is making it as simple and efficient as possible. And so for us, that was putting an order in our EMR that was like a couple of clicks. And then taking the worry off their minds that like, they're not going to be stuck like backpedaling and trying to counsel a patient. Like we're going to be there for you to counsel that patient when they're positive, right away. A lot of it's about reassuring and just making it easy and trust. And so like without that, like this never would have happened, you know, everybody would have stayed in their silo. So out of that, we kind of grew it and we're up now over 20,000 tests that have been ordered by oncology providers, physicians, case manager nurses for our breast cancer coordinators, PAs in some cases, nurse practitioners, all these people are doing this with clear guidelines, right? Like very clear indications for ordering and an assurance that we're going to see the patients who need to be seen. Dr. Fumiko Chino: Phenomenal program. I mean, to be honest, the waiting when there's more pressing things on your mind, to kind of get this sort of checkbox, "Okay, I'm negative, I'm going to, you know, I have a better clear decision-making chart for the type of surgery is," can be excruciating for both providers and patients. And it's also just wasteful, I think of a lot of people's time. I think you're accurate, which is that the subtleties and the decision-making flowcharts of genetic testing have been somewhat because of broadened eligibility at this point, it's more limited. There's less of the, "Okay, it was a second cousin who had a diagnosis, but we're really not sure if it was actually breast cancer." Like, it's much more of like, "Okay, if you're younger than 50, you qualify for genetic testing." Dr. Trevor Hoffman: Yeah. And we made the process very simple. Like anyone with breast cancer under 50, anyone with epithelial ovarian cancer, anyone with exocrine pancreatic cancer. So like stuff where, yeah, I agree. The NCCN drives me nuts because every six months they create this like Byzantine-like algorithm of indication. I think it's crazy. I can't keep up with it. So it's not fair to expect someone to climb through all that stuff. Make it simple. And we're in this sort of slow-moving period where we're just moving to universal testing, probably first for everybody who just gets cancer is the next threshold. And even in breast cancer, like the American College of Breast Surgeons says everybody with breast cancer should get hereditary cancer testing, whereas the NCCN isn't quite there, but we're moving towards that. Like everybody who gets cancer gets germline testing. And then shortly after that, we're probably going to be at population screening. It's coming. Will it get there in my career? I bet. Dr. Fumiko Chino: Now, there were two recent JCO OP articles focused on genetic testing in prostate cancer. There was the "ASCO Guideline Clinical Insights on Germline and Somatic Genomic Testing for Those with Metastatic Prostate Cancer," and then also a qualitative study on patient perspectives and decision-making regarding germline testing. And what kind of struck me about both of these papers was that one, everyone with metastatic prostate cancer now qualifies for germline testing, which was news to me as someone who doesn't treat prostate cancer. But that two, patients really may not view testing as a priority. They may delay or decline testing because of either cancer treatment burden or some of the people had actually already gotten tested in the interviews and had just forgotten they'd even received testing. The studies kind of highlight that implementing germline testing at scale in eligible populations can be really challenging. I know you talked a little bit about trying to dummy-proof and facilitate these easy clicks with the EMR, but can you talk about the specific provider or patient barriers that you've encountered in your practice and outside of the mainstreaming? Dr. Trevor Hoffman: Well, you can make arguments in a lot of different directions here, right? So the other frustration I didn't bring up at the beginning for our oncologists, GYN ONC surgeons, and breast surgeons was they'd send the patient over to me and they don't know me from a hole in the wall, whereas that surgeon may have saved my life, right? Like I'm going to do what that person says. They'd come and see me or a genetic counselor, and you know, we offer the patient testing and you know, we kind of want them to be able to choose and all that. And then they're sort of like, "Oh, I do- I may- I don't really need this, you know, maybe I do need this, whatever." And so then the patient would like decline it, and that's fine. I don't want to push tests on people, but there's also a patient-provider like thing there when the oncologist or the surgeon or the GYN ONC is recommending or offering a test, that relationship with the patient impacts whether they do it or not. And so that is a barrier. You know, I honestly see fewer barriers for doing testing in mainstreaming. And honestly, you know, in our system more tests are being now ordered by mainstream providers than by my own department in our system. It actually, it took a couple of years to get there, but we started this in 2021, and we reached a threshold where non-genetics provider test orders actually surpassed our own department about a year ago. And it's been steadily going up. So I honestly feel like there's fewer barriers when mainstreaming is employed than not. Now, do all patients get the same level of pre-test counseling? No, they don't. And I think we just have to make rational choices and understand that like we can do things one way and not reach a fraction because we know 80% of the people with BRCA1 and 2 aren't diagnosed. So like we have to make some choices. I think on the balance, I favor access over not. So I don't see a lot of barriers. Now, are we doing other things to try and find these patients out there without looking in the people, the population with cancer? Sure. We know again, we know population level screening is coming. And so we're piloting some things like an email questionnaire that's being sent to Kaiser members where they're asked a series of questions about their family history of cancer. And without ever talking to a human, answers to those various questions can generate a hereditary cancer gene panel order that then the patient goes and gets, and they never talk to a person when that happens. It's all through an online thing, and we see the positive patients in that setting to counsel them. And the patients who have negative results or VUSs, get some information about what that means and doesn't mean, and we can always talk to them, they're able to call us. But we know this time is coming and change is coming, so we're trying to like grapple with like how that's going to happen. Dr. Fumiko Chino: You mentioned VUSs and that's actually my next question because the VUS is like the thyroid nodule, the bane of my existence. Dr. Trevor Hoffman: The lung nodule, sure. Dr. Fumiko Chino: Yes, the lung nodule, the thyroid nodule, exactly. And with the rise of these germline testings, we're just seeing so many increased diagnoses of VUSs, the 'variant of unknown significance'. Your study found that they were two times more common than an actual pathologic or likely pathologic variant, again, that's consistent with what I've kind of seen before. And about one-third of people who were tested actually had at least one. I noticed that in your study, the VUS result actually triggered one of the automatic patient emails, there was a VUS-specific messaging content, there was a chatbot link and results, but it didn't automatically shepherd you to have a conversation with a counselor. And I've certainly had in my own clinic some kind of difficult discussions with patients because VUS, like we don't know what we should do, it doesn't necessarily change our management, but it's not very satisfying, especially if it's in one of those kind of high-value genes. What's your approach to explaining VUSs? How many people on the study - I noticed that they could request a visit with a genetic counselor - did you have a lot of discussions about VUSs based on this mainstream testing? Dr. Trevor Hoffman: I'm going to just comment on something you said in the question, which is like, we don't really know what to do with these. And I'll be honest with you, like, I don't either, right? Like I don't have any magic. There's no curtain to pull back, like, you know, and the Wizard of Oz. So I think VUSs are a problem for everybody. Again, we just have to make choices here, I think. At the end of the day, we're not tracking this as a data metric. We aren't getting tons of consults, given the number of tests that we're doing. We're not getting tons of requests by patients or providers to do a consult specifically for a VUS. But again, at the end of the day, like I'm not going to be able to change that variant classification, and you truly shouldn't be using VUSs to make decisions. That's just the truth. You really should be using things like other factors. And again, nothing provides certainty, right? So is the family history consistent with a hereditary condition? Is the patient's personal history or tumor type strongly suggestive of that? You've just got to make the best decision you can. And when we rolled this out, we said, "Look, we're happy to take a consult if you if you want." And again, I understand like from people that look at this, there are suspicious VUSs and there are like ones that are completely can be written off right away. And those are tough. So we always, and we told people all the way like if you're not comfortable explaining this or the patient's asking you a million questions, we're happy to see that patient. It's not a huge uptake. And honestly, at the end of the day, like VUSs are just right now going to be with us for a while. And again, I'd rather diagnose a ton of patients that have a known pathogenic variant than spend that limited amount of patient hours we have talking to a patient with a VUS. Yeah, a third of all patients have a VUS. Most VUSs are probably normal human variation. The reclassifications that we get, you know, 90, 95% go to likely benign, maybe 5 to 10% are so-called upgraded to pathogenic. If you ask me how many VUSs are in your genome, it's tens if not hundreds of thousands of VUSs, depending on what we're sequencing, right? If we're sequencing exons, it's probably thousands, tens of thousands. If we're looking at everything, it's hundreds of thousands, right? So we're dealing with a little bit of difficulty with human nature, which is when we see something like put on a report, we have this immediate inability to ignore it. I don't have any magic answers, but a lot of the time, these are just me or whomever explaining that we really don't know what this means. For some people that's helpful, and for some people it's just kind of like, "Why did I do this for?" - the patient side. Dr. Fumiko Chino: Now in the context of a robust family history, early-onset breast cancer, multiple family members, obviously it takes on more meaning than if it's just a regular … you know, postmenopausal breast cancer happens to be triple negative, and that's why they, you know, triggered the genetic testing. And so I 100% agree. It shouldn't be the thing that drives decision-making. It doesn't supersede something like a robust family history. Dr. Trevor Hoffman: We haven't had a lot of issues come up around that with our providers or our patients. You know, I'd say the biggest concern of like the mainstream doctors was they were worried about like GINA, the Genetic Information Nondiscrimination Act. And I'm like, "People, come on, this person has cancer, right? Like their life insurance is not going to change if they have a hereditary cancer result that's positive or a VUS or whatever, like they have breast cancer. Their insurability for life is probably not going to change." So, and we spent decades telling people, "Oh, you can't do this, right? Like you're not capable of doing it. We have to do this, right?" And so it's, it's also about like, that's kind of old thinking and times have changed, and we've got to do things differently. Dr. Fumiko Chino: Provider education is so important because 100% like I was told you don't order your own genetic testing. It's, you have to go through the official route. And then that meant intrinsically in my mind, "Okay, that's a delay I need to build into my treatment plan." As a radiation oncologist, again usually people who are referred for testing already have it before they meet me, but sometimes you'll just someone will slip through and you're like, "Okay, we need to wait and not start anything until we get the results of this." So it definitely still happens. I was struck by the findings on the study that 10% of the group who had positive results, which was about over 100 patients, through the mainstream testing did not actually end up meeting with the genetics team to discuss the results. And this was compared to 0% of the people who initially met with the genetics providers that had positive results. None of them skipped counseling. So can you speak to kind of how you think this occurred, what the potential solutions you might consider for this gap in the future from your team? Dr. Trevor Hoffman: Yeah, so I'm going to pat myself and my department on the back because we saw 100% of the patients that we diagnosed with, I'm just kidding. But no, you know, 10% you could say, "Oh my gosh, that's awful. Those patients never got counseling. That's a horror show." For this paper, I looked in the chart of every single one of those patients that we didn't see just because I was curious and wanted to know like why was this? Like what was the barrier? Why weren't they coming to see us? And, you know, in our system, we offer everybody a phone appointment. They do not need to come in. So we can call anybody on the phone and do anything over the phone. You know, so we looked at things like was the patient like super sick? Were they on hospice or palliative care? Were they too sick to just have the visit? And honestly, it didn't seem like that was a strong correlation. I would say for many of the patients, and I don't have a specific number, but there were a lot a lot, a lot of the patients that we never saw who when you looked at the documentation, they'd been told the result and actually counseled by their cancer provider. That speaks to just that, you know, there are and and again, as we all learn, right, in this genomics precision medicine revolution, I looked in some of these charts and said, "You know, I can see why the patient didn't want to come see me because the oncologist clearly documented like a whole counseling session, information given. We're not asking them to do that, but they did it, right?" And then the patient felt like, "What do I need out of this, right?" And so that was definitely a substantial fraction. There was another fraction, I think, and we didn't specifically study this, but I think people have different, like I said, motivations for doing testing. It may be being pitched to them as like, "Hey, we need to know this for your treatment. You know, it may be that has to do with like a PARP inhibitor or whatever." And so they may not really have at the top of their agenda like counseling family members. Maybe they don't have kids. There were some instances where patients refused an appointment, but we couldn't always figure out why, but that's definitely, that's some of it. And then yeah, I mean, there were probably were some people who, you know, had too much in their mind, they were too sick, whatever. And so we, we definitely after seeing that have come up with ways of, you know, if a patient refuses an appointment with our department, we're going to send them a written counseling basically to their home address. Like, "Hey, this is your result. You know, you have a hereditary cancer condition. This is some information about it. You know, and if you do want to talk to us or your family members want to talk to us, call us," to sort of like augment that space where we're just like maybe not sure what's going on. But I will say I was kind of almost reassured in a good way because I do feel like there were some people out there who were just kind of doing counseling that was satisfactory to the patient, I think, and seemed very reasonable. And so I still think at the end of the day, it's probably better for that person to have had that test, gotten the result, gotten the care informed by that result and not talked to us than not doing any of it. Dr. Fumiko Chino: And definitely seen, you know, like siblings who are like, mom was BRCA positive, sister's BRCA positive, the last female member was tested because of their breast cancer and they just, we just need to check off the box so we know they're going to get the PARP inhibitor, and it was sort of the necessary prolonged hour-long genetics conversation may be of less benefit for them. Again, in the old days, I feel like when we were very territorial about our specialties, I think that could have led to some conflict, but it sounds like, again, the genetics team is just in general like information wants to be free. If you have a direct need for counseling your patients on the specific thing, that's also potentially totally adequate and appropriate. Dr. Trevor Hoffman: We're hoping with everything we're doing that the information's getting to the patient and the family members. The number of patients in that 10% that I think were unaware of their result is probably a tiny, tiny number of people. Dr. Fumiko Chino: Now, an earlier study you conducted found that variants identified on tumor-based DNA sequencing could trigger germline testing and thus serve as an opportunity to diagnose hereditary cancer. This study that you pointed out to me was published in 2022 in Familial Cancer and showed that a universal tumor DNA safety net screen, is what it was called, could be an important strategy augmenting traditional genetic counseling. So in this study of the newly diagnosed people via the safety net, about a third had a pathogenic or a likely pathogenic mutation, and intriguingly enough to me, two-thirds of those people wouldn't have met NCCN testing guidelines. So this sort of like- the tumor can point the way. How do you think that these study findings should help inform providers trying to navigate this sort of genomic universe? Dr. Trevor Hoffman: Right. So we're talking about like clinical things that generate a germline test, right? Woman under 50 with breast cancer, boom, order the test, right? And again, all of this is around like diagnosing people, getting the test and diagnosing the undiagnosed. So, we recognized once all this tumor NGS started launching that like there were all these people floating around that had, "Oh, guy with lung cancer and he has a tumor variant in BRCA1. Woman with brain cancer, tumor variant BRCA2." And a lot of those patients were just kind of like floating out there. We'd get the occasional referral asking about it, you know, that kind of thing. And so, fortunately again, at Kaiser everything is under one roof. And so, you know, all our tumor NGS results were basically being stored in a, in a research database essentially. And so we started pulling tumor variants, this is a couple of years ago now, just to see what's in here. You know, like how many patients are floating around in this, have we tested them, have we not? And so, we started pulling all the BRCA1, all the BRCA2, all the Lynch syndrome genes. And we're up to about 10 genes now that we're kind of like across the board, anybody that has a tumor variant in those genes, like we are basically reaching out to those patients and saying, "Hey, there's probably a 40, 50% likelihood." So, and again, back to BRCA1 and 2, you know, about half of those tumor variants were germline. Didn't matter what the family history. And like you said, a lot of the patients who had a germline BRCA1 or 2 and a mutation in their tumor, like didn't have a tumor that would like, and sometimes not even a family history, that would suggest that this problem ran in their families. And that has to do with like people in Southern California may not know their family history. Their entire family may be living in a different country, all these things, or they just may be unlucky. They may have just gotten lung cancer and have this too. So, yeah, we started a project and are continuing that. And again, some systems have Lynch syndrome screens for mismatch repair immunocytochemistry. We've expanded that to a molecular screen for tumors. It's another way we're diagnosing the undiagnosed in this area. So we aren't doing it for every single hereditary cancer gene. So like TP53 is the classic gene that's like mutated in all these people's tumors and almost never is that germline. But for things like BRCA1 and 2, Lynch syndrome, a lot of the breast and ovarian cancer susceptibility genes, the likelihood of if you see that in a tumor and the variant allele frequency is anywhere between 30 and 70%, there's probably a roughly 50% chance that that is a germline mutation, we should be looking at that. The unfortunate thing is when we first started this, it was sad, but there were some patients that had died. You know, and I called some families where, you know, someone had died and said, "Look, your loved one had a mutation in their brain cancer of BRCA1." I didn't have a single person scream at me. Most of the time they were like, "Thank you for calling me." And sometimes it was like, "Oh yeah, well, that explains why his sister had breast cancer at 35 and, you know, blah, blah, blah." So, now it's more real-time. So, you know, we're doing that test in our own lab, and so every week, as they find these mutations in tumors, we get handed a list, we call the patient, and offer them a test. So we have to come up with better ways of diagnosing all these people because we're not doing a good job, and that's just another tool in the toolbox that we've applied at Kaiser to do that. And other systems, I'm not- this is being done in other places. I'd imagine your institution, there's probably some movement or process to do this too, would be my guess. Dr. Fumiko Chino: I think our classic paradigms of screening and referral have definitely fallen down in this kind of new era of proliferation of germline testing. We are wrapping up the podcast. I want to leave just a little bit of time at the end. Is there anything that we missed covering? We haven't even talked about direct-to-consumer testing and the 23andMe of it all. Happy to have any last thoughts for you before we wrap up. Dr. Trevor Hoffman: Yeah, it's a crazy world out there. I've been talking a lot about access. It used to be that you could just immediately swat away any direct-to-consumer testing as like bogus or not accurate, and, you know, 23andMe, I'm dancing on the grave of their bankruptcy, but that's not true anymore. And it's good. At the end of the day, it's good. I think the direct-to-consumer testing being done by the good people, if you want to call it that, you know, the Color Genomics, the Invitaes, you know, where they have true counseling abilities as part of what they're offering people, I think is good. And we do see some patients come in who've done a direct-to-consumer test. It's really hard now because it's like you can't just blow everything off, and that's making it hard for us, for primary care doctors, you name it. And so, yeah, it's a crazy world out there. Dr. Fumiko Chino: Seems like the Wild Wild West in some respects. Dr. Trevor Hoffman: Yes. Dr. Fumiko Chino: Well, I really appreciate you, you know, for this great conversation today. I want to thank you, Dr. Hoffman, as well as our listeners for tuning in. You can find the links to the papers that we discussed in the transcript of this episode. Dr. Trevor Hoffman: Thank you so much. Dr. Fumiko Chino: If you value the insights that you hear on the JCO OP Put Into Practice podcast, please take a moment to rate, review, and subscribe wherever you get your podcasts. I hope you'll join us next month for Put Into Practice's next episode. Until then, please stay safe. The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. Guest statements on the podcast do not express the opinions of ASCO. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement. Conflicts of Interest Fumiko Chino Employment Company: MD Anderson Cancer Center Consulting or Advisory Role Company: Institute for Value Based Medicine Research Funding Company: Merck Trevor Hoffman No Relationships to Disclose
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