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  In this article
 »  Abstract
 » Introduction
 »  BRCA Test...
 »  Expanding Need f...
 »  Genetic Testing/...
 »  Mainstreaming GC...
 »  Current Models o...
 »  Social and Ethic...
 » GC Scenario in India
 »  Challenges Faced...
 »  Elements of an E...
 »  GC Case Study fr...
 »  GC Recommendatio...
 »  References
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  Table of Contents  
REVIEW ARTICLE
Year : 2019  |  Volume : 56  |  Issue : 5  |  Page : 38-47
 

Mainstreaming genetic counseling for BRCA testing into oncology clinics – Indian perspective


1 Molecular Oncology and Cancer Genetics, Max Hospital, Shalimar Bagh, New Delhi, India
2 Director, Medical oncology, Sahyadri Hospitals, Pune, Maharshtra, India
3 Department of Genetics and Molecular Medicine, Kamineni Hospitals, Hyderabad, Telangana, India
4 Breast Oncology, Max Super Speciality Hospital, Shalimar Bagh, New Delhi, India

Date of Web Publication29-Nov-2019

Correspondence Address:
Amit Verma
Molecular Oncology and Cancer Genetics, Max Hospital, Shalimar Bagh, New Delhi, India
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijc.IJC_458_19

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 » Abstract 


BReastCAncer (BRCA) susceptibility genes BRCA1 and BRCA2 are mainly associated with hereditary breast and ovarian cancer (HBOC) syndrome and present an estimated 45%–65% cumulative lifetime risk of developing breast cancer and an 11%–39% risk of ovarian cancer. HBOC is also linked to triple-negative breast cancer (TNBC). BRCA1 mutations in TNBC are observed in 36% of women age <40 years and 27% of women age <50 years. In India, the prevalence of BRCA1/2 mutation varies from 2.9% to 38% among families with genetic predisposition toward hereditary cancers. With HBOC being linked to early-onset breast cancer and increased susceptibility to other cancers, early screening for BRCA mutations has become a pressing need. Though genetic counseling (GC) for BRCA mutation testing is common in most of the developed countries, India still faces several challenges in mainstreaming the same. Many barriers to effective GC for BRCA testing are unique to India. There is a dearth of trained geneticists which puts the pressure on oncologists to give GC for which they neither have the time or training. Presence of multiethnic/linguistic population acts as a major hindrance along the way toward development of robust predictive and effective GC models for BRCA testing. The current review discusses the need and benefits of GC in breast cancer prevention, through BRCA testing, from an Indian perspective. The functional framework of GC and the role of genetic counselors are discussed in detail. In addition, importance of GC training and role of a multidisciplinary team approach for mainstreaming pre- and post-BRCA test GC is highlighted.


Keywords: BRCA 1/BRCA 2, breast cancer, genetic counseling, India, mutation testing


How to cite this article:
Verma A, Nag S, Hasan Q, Selvakumar VP. Mainstreaming genetic counseling for BRCA testing into oncology clinics – Indian perspective. Indian J Cancer 2019;56, Suppl S1:38-47

How to cite this URL:
Verma A, Nag S, Hasan Q, Selvakumar VP. Mainstreaming genetic counseling for BRCA testing into oncology clinics – Indian perspective. Indian J Cancer [serial online] 2019 [cited 2019 Dec 8];56, Suppl S1:38-47. Available from: http://www.indianjcancer.com/text.asp?2019/56/5/38/272015





 » Introduction Top


The discovery of tumor-suppressor genes, BReastCAncer gene (BRCA) 1 in 1994 and BRCA2 in 1995, sparked a host of genetic association studies that implicated BRCA gene mutations in several disease conditions such as breast cancer (including male breast cancer), ovarian, prostate and pancreatic cancers, Fanconi's anemia, and Wilm's tumor.[1] However, BRCA1/2 genes were found mainly to be associated with hereditary breast and ovarian cancer (HBOC) syndrome. Studies suggest that BRCA1 accounts for 0.7%–29%and BRCA2 accounts for 1.5%–25% of the mutations observed in HBOC.[2] With 10% of breast cancers and up to 25% of ovarian cancers being hereditary in nature, there has been a tremendous interest in studying BRCA sequence variants in patients who have a family history of breast, ovarian, and other relevant cluster cancers.[3],[4] HBOC has also been associated with triple-negative breast cancer (TNBC). BRCA1 mutations in TNBC observed in 36% of women age <40 years and 27% of women age <50 years[5],[6] also increase the risk of contralateral breast cancer.[7] With HBOC being linked to early-onset breast cancer and increased susceptibility to other cancers, there is a need to start BRCA mutation surveillance early.[6],[8]

A woman's lifetime probability of developing breast cancer is approximately 1 in 8,[9] while it is 1 in 75 for ovarian cancer.[10] However, the risk of developing breast/ovarian cancers in BRCA 1/2 mutation carriers is higher. A pooled analysis of pedigree data of 8,139 index cases from 22 studies, unselected for family history, showed that the estimated cumulative lifetime risk of developing breast cancer (by age 70 years) due to germline mutations in BRCA1 and BRCA2 was 65% and 45%, respectively, and the risk of developing ovarian cancer was 39% and 11%, respectively.[11] The cumulative risk of breast cancer in males (at age 70 years) for BRCA 1 and BRCA2 mutation carriers is estimated to be 1.2% and 3.8%, respectively.[12] In men with BRCA 2 mutation, there is a three-fold higher risk of prostate cancer compared with the general population.[12] It has been demonstrated that the risk of developing breast/ovarian cancer may be significantly reduced if the BRCA 1/2 pathogenic sequence variant carriers are identified and offered regular surveillance and/or prophylactic mastectomy/salpingo-oophorectomy.[13]

Though important, the identification of at-risk individuals is associated with several challenges. In most developed countries, individuals at a high risk of developing breast or ovarian cancer undergo genetic counseling (GC) prior to BRCA mutation testing. GC plays an important role in selecting individuals suitable for genetic testing by accurately constructing their family pedigree along with obtaining relevant medical histories. However, GC and genetic testing have still not been mainstreamed into cancer management programs in many countries, including India. Also, though family-history-associated breast cancer is common, BRCA mutations are rare with an estimated occurrence of only 3.4%–15.5% even in high-risk families.[14] Wide variations observed in the frequency and spectrum of these mutations across geographies and ethnicities preclude the development of robust predictive models that can assess the pretest probability of identifying a BRCA1/2 mutation.[15] In India, for example, due to a dearth of high-quality BRCA1/2 mutation screening and geographic differences in test prices, the reported prevalence of these mutations varies from as low as 2.9% to as high as 38% among families with genetic predisposition toward hereditary cancers.[2],[16]

GC has been associated with improved adherence to cancer risk management strategies and lower patient distress levels, better informed surgical decision-making, high patient satisfaction, and cost savings.[17] However, in India counseling is usually provided by an oncologist who may not have the time or expertise to provide the level of GC needed to enable and empower patients to choose the type of testing for their families that they are comfortable with. When available, referral to genetic counselors is an important component of cancer care for individuals with a personal or family history of cancer characteristic of hereditary cancer syndromes.[18]

Most Asian countries currently lack the requisite number of trained genetic counselors.[17],[19],[20] In India, clinical GC for hereditary cancers is at a very nascent stage, with the availability of only a handful of cancer genetic clinics.[15] While in several Asian countries the profession of GC is still developing, in developed countries, the growing demand for genetic testing has surpassed the number of genetic counselors available, emphasizing the need for novel modes of delivering GC.[21],[22] Given the current challenges associated with GC, healthcare providers are incorporating collaborative models for GC that require training of non-GC specialists and use the services of multidisciplinary teams to mainstream GC into routine care.[23]

The aim of this review is to discuss the need and benefits of GC in breast cancer prevention, through BRCA testing, from an Indian perspective. It will highlight ethical considerations, framework of pre- and post-BRCA test GC, role of genetic counselors in preventive oncology, and multidisciplinary team approach to mainstream GC, highlighting the importance of GC training for medical oncologists and developing GC models with a focus on the importance of remote telephonic GC especially for rural areas/regions.


 » BRCA Testing and Its Implications Top


It needs to be noted that identification of BRCA mutation carries a lot of implications which impact the patient and the unaffected family members. Identification of BRCA 1/2 pathogenic variants also has therapeutic implication, which can impact patient outcomes. Poly (adenosine diphosphate-ribose) polymerase (PARP) inhibitors (PARPi) such as olaparib, niraparib, and rucaprib have been shown to specifically target BRCA 1/2 mutant cells. In the phase III OlympiAD study, women with BRCA-mutation-associated metastatic breast cancer who received olaparib showed a 42% reduction in risk of progression or death compared with patients who received chemotherapy.[24] The approval of PARPi for treatment of relapsed/refractory breast and ovarian cancers has led to a paradigm shift in treating these patients by harnessing their germline BRCA mutations.[25],[26],[27],[28],[29],[30] For ovarian cancers, BRCA testing is now being done at an earlier stage in patient care because the presence of pathogenic BRCA variants has started influencing ovarian cancer treatment decisions.[13] Hence, new GC approaches may be required to meet this shift in BRCA testing.[13]

BRCA1/2 gene testing

As per the National Comprehensive Cancer Network (NCCN) guidelines for genetic testing in hereditary breast or ovarian cancer version 3.2019, BRCA testing is recommended if the individual is from a family known to be harboring a pathogenic or a likely pathogenic variant. In addition, regardless of family history, some individuals with a BRCA-related cancer may benefit from genetic testing to determine the eligibility to targeted testing, that is, PARP inhibitors. This essentially means that therapeutically, all patients with a BRCA-related cancer should ideally be genetically tested.[31]

Germline BRCA testing results and their interpretations are discussed in [Table 1].[32]
Table 1: Germline BRCA testing results and their interpretations

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The process followed for variant classification is schematically presented in [Figure 1].
Figure 1: Variant classification

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Long-term follow-ups are mandatory with regular retrospective reviewing of literature to pick up any change in the status of mutation classification.

A more detailed analysis of Variants of Uncertain Significance (VUS) is presented in [Table 2].
Table 2: Classification of VUS

Click here to view



 » Expanding Need for GC in BRCA Testing Top


GC helps in deciding the optimum time for a genetic test vis-à-vis the patient's cancer treatment; selecting patients without a family history of HBOC for genetic test; and deciding the alternative tests for patients, who do not have a BRCA mutation based on the criteria of a strong family history. Several VUS have been reported in Indian breast cancer patients;[16],[35] these VUS have been found in moderate-penetrance genes, for which management guidelines have not been firmly established. Interpretation of genetic results in patients with VUS is a complex challenge for which GC is essential.

Changes in gene patent laws and advances in sequencing technologies have dramatically improved the reach of genetic testing. Genetic testing is now poised to become increasingly important in the prevention, diagnosis, and treatment of HBOC.[36],[37],[38],[39] GC can prevent unnecessary genetic tests being done, and thus save undue anxiety to individuals who do not require the test.[40],[41] Therefore, there is an urgent need for the innovative delivery models of GC necessary to ensure that every individual has access to a genetic counselor.[42]


 » Genetic Testing/counseling Guidelines Top


The different genetic testing and counseling guidelines proposed by various medical professional societies are presented in [Table 3].[5],[43],[44],[45],[46]
Table 3: Different genetic testing and counseling guidelines

Click here to view


A retrospective chart review that analyzed referral patterns in 314 women who met the NCCN guidelines for genetic testing found that those patients who choose prophylactic contralateral mastectomy were more likely to have been referred for GC (63.6% vs. 36.4%, P < 0.0001).[47] However, GC and genetic testing have been shown to be underutilized in women who meet referral guidelines.[47],[48] Therefore, there is a need to incorporate GC into clinical practice.


 » Mainstreaming GC for BRCA Testing Into Oncology Clinics Top


Mainstreaming is the provision of providing germline GC within a routine cancer clinic, such as an oncology outpatient clinic. In this setting, treatment-focused information is often provided to the patient by a non-genetics specialist, and then formal genetics follow-up is arranged for patients who are found to have a pathological variant or complex family history. Mainstreaming ensures that the core principles of patient autonomy and informed consent are maintained while providing the requisite expertise to deal with the associated psychosocial and family issues.[49],[50]

A wide gap still exists between patients who undergo and those who actually get the genetic testing done. In the American BRCA Outcomes and Utilization of Testing (ABOUT) study, 11,159 patients with patients breast cancer underwent BRCA testing on the advice of their clinician; however, only 36.8% of them received GC.[51] Unsurprisingly, respondents who received GC demonstrated better knowledge and understanding of the implications of BRCA mutations and greater overall satisfaction.[51] Contrary to 1990s when professionals were concerned about the psychological impact of learning one's genetic status, today, there is plenty of evidence to suggest that the mean level of psychological distress following disclosure of genetic test results remains below the clinical threshold, indicating little need for psychological intervention.[52] In fact, non-mutation carriers have reported a decline in psychological distress several weeks and months after result disclosure, while mutation carriers have shown a stable or decreasing level of distress shortly after result disclosure and up to 12 months after result disclosure.[53] Distress levels have also been shown to decrease in HBOC patients who underwent GC before definitive surgery.[54]

Models for mainstreaming that involve upskilling of cancer specialists to perform GC and testing are limited by other growing clinical demands within a single oncology consultation, reducing the capacity for observant GC.[22],[50] Linking genetic and oncology services through an embedded genetic counselor eases the time stress on the oncology consultation while increasing the efficiency of GC, facilitating a coordinated approach for patient care.[50],[55] In addition, the direct relationship between the treating specialists and the genetics service ensures that the most up-to-date information, testing technology, and clinical trial access are rapidly incorporated into clinical practice across both specialties.[50]


 » Current Models of GC Worldwide Top


Various GC models like DNA-direct model (The Netherlands),[56] telephone-based counseling,[57] Royal Marsden testing model (UK),[58] and Huntington protocol[53] are being widely followed across the world to ensure that all individuals at risk undertake genetic testing.[13] The important models incorporating GC are discussed below.

DNA-direct model (The Netherlands)

The “DNA-direct” model is a telephone-based GC model for patients with breast cancer. This model focuses on a patient-centric approach which prevents unnecessary extraneous information from reaching the patient. A telephone call provides information, which is followed by a written information sheet sent to his or her home. This is followed by BRCA testing, and a face-to-face counseling is done where the results are disclosed by a genetic counselor and customized advice disbursed.[56]

Telephone-based counseling model (USA)

To reduce costs and ensure higher access to GC (especially in non-urban areas), telephone-based counseling was provided in the United States for healthy relatives or patients after successful breast or ovarian cancer treatment.[57]

This GC model could help improve the GC scenario in countries like India with large population living in rural and remote locales and the existence of few trained genetic counselors. Although there is a risk that uptake rates might be lower for telephone-based counseling, compared with in-person counseling, this drawback is overshadowed by the much higher reach of this mode of GC, which could help in identifying a higher number of individuals requiring genetic testing.

Royal Marsden testing model (UK)

This GC model started at the Royal Marsden Hospital in London requires non-genetic healthcare providers to undertake online training and follow clear protocols that delineate the patient pathway and the approval process for genetic testing.[58] Based on this model, genetic testing can be completed at the time of their oncology appointment. Although oncology team members are trained to handle the pretest counseling themselves, patients can be referred to the cancer genetics unit (CGU) in case further discussions are needed. All pathogenic mutation carriers are required to see a geneticist at the CGU and this is not mandatory for individuals with normal results, although ideally the genetic testing outcome and their exact implications for both results (be it positive or negative) need to be conveyed.

Huntington protocol

A version of the “Huntington protocol” has been adopted for the counseling of unaffected individuals who want to determine whether they have inherited a familial pathogenic mutation in BRCA. In these guidelines, individuals who undergo predictive testing are recommended to undergo two to four counseling sessions over a 3-month period, before the test results are disclosed. GC is offered to the family if a pathogenic mutation is discovered.[53]

However, it needs to be noted that most current guidelines are not sufficient to identify all mutation carriers.[59] If patients eligible for BRCA testing are selected only on the basis of family history, then it has been seen that about 15%–44% of women with ovarian cancer with no apparent family history but carrying BRCA pathogenic mutation are likely to be missed.[60],[61],[62] The limitations associated with recommendations in guidelines are compounded by problems associated with their implementation; a percentage of individuals do not follow recommended referrals to genetics services.[17],[47],[48]


 » Social and Ethical Implications of Genetic Testing: an Important Consideration in GC Models Top


The main ethical and social implications of BRCA testing include informed consent, privacy and confidentiality, a person's right to know or not to know their genetic information, carriers' responsibility to share genetic information with relatives at risk, physicians' “duty to warn” relatives about familial risk, reproductive choices, availability of prenatal or preimplantation diagnosis, appropriate testing of children and adolescents, equitable access to testing, disposition of biological samples, and genetic discrimination.[63] Genetic knowledge is a two-edged sword as it may help a person take control of her life or make her a fatalist. An important aim of GC is to help individuals accept their genetic differences and protect them and their families from untoward social and ethical implications of genetic testing by helping them adopt a non-determinist view of genetic information, to educate them about their genetic responsibility, and assuage their concerns regarding genetic discrimination and genetic exceptionalism.[63]

Religious traditions could also impact decision-making around genetics testing, and there is a need to enhance the understanding of culturally sensitive issues among genetic counselors to ensure ethical care.[64],[65]

Approximately 10% of all breast cancer is hereditary, and <1% of the general population is estimated to carry a mutation in BRCA 1 or BRCA 2. BRCA mutations are associated with a relative increased lifetime risk of breast cancer which is a mere 2.7–6.4 times more than the average risk. In effect, there is a need to caution people about the limited predictive power of genetic testing, especially outside high-risk families, due to the relatively low gene penetrance, the possibility of new unidentified mutations with different significance, and the role of environmental factors in carcinogenesis and tumor progression.[63]

In addition, another ethical issue has arisen due to the increasing popularity of direct-to-consumer (DTC) genetic testing. Recently, the Food and Drug Administration (FDA) has approved direct BRCA testing by laboratories. The availability of DTC genetic testing has compounded the issues of genetic responsibility and genetic discrimination.[63] Though this is not yet followed in India, DTC approach should be implemented with caution due to various deleterious emotional impact of unnecessary BRCA testing on the patients.[66]


 » GC Scenario in India Top


Important geo-ethnic variations have been observed in the frequency and spectrum of BRCA1/2 mutations among families with HBOC.[15] Therefore, understanding the contribution of BRCA1 and BRCA2 mutation in any given population is very important.[67] In India, in a recent study which evaluated more than 1000 unrelated breast cancer patients using Next-Generation Sequencing, 30.1% were found to be mutation carriers, 84.9% of the mutations were detected in the BRCA1/2 genes, and only 15.1% in non-BRCA genes. Interestingly, 75% of variants were detected in patients age <40 years at diagnosis and/or with a first-degree family member(s) affected by breast and/or ovarian cancers.[68] In another study conducted at a tertiary care hospital in India, detailed verbal autopsy and pedigree analysis through GC found that 24 of 127 (18.9%) breast and ovarian cancer cases undergoing treatment required BRCA1/2 genetic testing; 13 (54%) of these patients had a mutation in BRCA1/2, 9 (69%) had a BRCA1 mutation, while 4 (31%) had a BRCA2 mutation. Subsequent posttest GC recommended targeted mutation analysis for 64 high-risk members in these families with mutations.[69] Though a small study, it reflects the beneficial effects of GC in BRCA testing in India. India is a multilingual country and a majority of patients prefer to converse in their native language. In India, the traditional counseling model is face-to-face counseling in India. Telephone, video, and Skype counseling options should be added especially for technologically adept urban patients or implement virtual consultation models to enable its reach over a wider area. The remote counseling model should be technologically advanced enough to address the language barrier as well. Effecting such a change in a country such as India, where GC is still a growing field, is especially important in the light of data that show that streamlining the process of pre- and posttest counseling and delivery of test results may be associated with an uptake of genetic testing in more than 65% of the patients with breast cancer.[70] The Indian GC model needs to evolve and adapt based on local needs and cost constraints.

With the healthcare burden of breast and/or ovarian cancers rising steadily in India, there is an urgent need for early detection, surveillance, and disease management.[16] Preemptive testing will not only ensure early detection, appropriate management, and prevention of cluster cancers but also decrease the economic burden on the family and the healthcare system of the country.[69]

In India, currently there are just four recognized GC training programs, accredited to the Board of Genetic Counselling, India (BGCI): two master's degree programs (2-year duration) and two postgraduate certificate programs (1-year duration).[71] In addition, there is a 1-week training program in Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, for those who have completed a post-medical or master's degree. It is estimated that the demand for genetic counselors in India will rise in the near future due to increase in the number of private hospitals, dedicated oncology and neo-natal facilities, and genetic testing laboratories.[19]


 » Challenges Faced in Implementing Effective GC in India Top


A general lack of awareness regarding taking up GC as a profession in India is one of the major challenges in ensuring that GC becomes a mainstream activity in oncology practice.[72]

In 2017, a report was published on the status and future directions of GC in 10 Asia-Pacific countries, and it also outlined the mission statements of the Professional Society of Genetic Counsellors in Asia that was established in 2015. The report stated that with less than 100 genetic counselors in India, the ratio of genetic counselors to general population is very low.[73] GC is not a well-recognized profession in India.[72] In addition to their primary responsibilities, genetic counselors in India are often involved in providing psychosocial support for patients, identifying appropriate tests for different patients, physician support, molecular wet laboratory work, generating laboratory reports, and administrative jobs, and thereby shifting their focus away from GC.[19]

An overview of the major challenges in implementing GC in India is given below.

Late presentation

According to data from GLOBOCAN 2018,[74] despite a lower incidence of breast cancer in India compared with the United States (162468 vs. 234087), the mortality rate was much higher (87090 vs. 41904). This indicates not just a lack of adequate diagnosis and treatment facilities but also a lack of early detection programs, resulting in high proportion of women presenting with late-stage disease. The situation is similar in ovarian cancers where late presentation is common due to a lack of screening facilities and non-specific symptoms, which considerably reduces the survival rates.[75] These data emphasize the importance of improving the breadth of GC/testing in India. With the availability of Olaparib for the treatment of BRCA 1/2 mutant cells, there is now an opportunity to use effective GC to capture BRCA 1/2 mutant cancers earlier and start treatment early for effective control.

Cultural bias

HBOC affects women, and unfortunately, most developing countries do not prioritize women's heath due to discriminatory beliefs and practices. This bias may adversely affect both clinicians' and family attitudes to GC, genetic testing, and risk management. Thus, GC/genetic testing is low on priority for most women.[76],[77],[78] It is important to make women at a high risk of having BRCA mutation to realize that genetic knowledge could prove to be means to enhance control of their lives and that they have a genetic obligation toward themselves and their family members. It is the ethical responsibility of women with a predisposition HBOCS to make an informed reproductive choice and also ensure that their children undergo GC/testing.[63]

Lack of training

As stated earlier, GC is an emerging field in India, with poor recognition of the professional status of a genetic counselor.[72] There is an urgent need to spread awareness (seminars and workshops) and sensitize Indian oncologists toward the need for mainstreaming GC. This could lead to faster detection of individuals with increased breast and ovarian cancer susceptibility. Moreover, universities need to incorporate training modules for genetic counselors into their curriculum. Currently, finding qualified mentors to teach students pursuing GC as a profession is a challenge.[19]

Lack of a multidisciplinary team approach

Currently, in India, there is a need to shift the burden of GC from the treating oncologist to a genetic counselor and involve an integrated multidisciplinary team of professionals in patients' cancer care.[13],[79]

Economic barriers

Neither GC nor genetic testing is currently covered by insurance or government funds in India.[80] Therefore, apart from the psychological burden of a positive BRCA mutation test, the economic burden of GC and genetic testing is high, especially for patients from underprivileged backgrounds. As a result, many individuals predisposed to have a BRCA mutation avoid undergoing GC/genetic testing.

Lack of bias redressal in case of a positive test for BRCA1/2

Currently, there is no Genetic Information Non-discrimination act in India, similar to that of the United States,[62] which is another deterrent for Indian patients to undergo GC and subsequent genetic testing. If diagnosed with a BRCA mutation, patients might have to face discrimination by insurance companies and employers. Therefore, there is a need to provide legal protection to at-risk individuals who want to undergo GC and genetic testing, so that they do not feel intimidated by the possibility of a positive diagnosis.


 » Elements of an Effective GC Model for India Top


Since GC in India is evolving, salient features of various international models (discussed in the previous sections) can be extrapolated into the Indian context. Apart from pretest phone-based counseling by trained non-geneticist counselors, use of educational material, and post-test phone counseling, the Indian GC counseling model may also incorporate elements from the following:

Technology models

  • Telegenetics: GC provided remotely by live video-conferencing, with visual and audio access, can play a very important role in a vast country like India, for both pre- and posttest GC. By exploiting the recent telecom boom in India, low-cost Internet can allow counselors at an urban healthcare facility to advise patients who visit a rural healthcare facility in local language
  • A recent study analyzed evidence to determine whether remotely delivered GC through telephone or telemedicine is an effective alternative to in-person counseling for individuals who are at high risk for HBOC and found that both modes of counseling have equivalent efficacy in ensuring patients' BRCA knowledge acquisition and reducing their anxiety and depression. Importantly, GC delivered remotely was more convenient and less expensive.[41]Identifying probands, and informing relatives directly, using phone-based counseling tools, in families with a strong germline predisposition for cancer: In India, the social structure is still quite close-knit. It has been shown that informing relatives directly nearly doubles the number of relatives tested, is psychologically safe, and may be implemented effectively in India.[81]


Visit models

  • Group counseling: When multiple individuals have pretest GC together, it is categorized as group counseling, which has been shown to have similar benefits as traditional individual counseling sessions.[82] Given the large population of India, group counseling can prove to be quite effective in simultaneously counseling relatives and family members of individuals with a predisposition for BRCA 1/2mutations
  • Non-Genetics Clinician Counseling: Like the Royal Marsden model where non-geneticists are provided online courses and trained for GC, a similar model adapted for Indian needs could prove to be effective.



 » GC Case Study from India Top


Several case studies across the world have shown that GC increases patient's knowledge of cancer, improves acceptance, and is beneficial for patient and family tested positive for BRCA genes.[83],[84] Although case studies from India are few, available information does highlight the importance of BRCA counseling and testing.

A recent study was published on pedigree and BRCA gene analysis in patients with breast cancer to identify HBOCS to prevent morbidity and mortality of disease in Indian population. Of the 127 patients with breast cancer evaluated, 24 (18.89%) met HBOC criteria and consented for BRCA1 and BRCA2 sequence analysis after pretest GC.[69] Posttest counseling recommended targeted mutation analysis for 64 high-risk family members in the 13 families where pathogenic mutations were detected in the index cases. Mutation carriers were put on age-appropriate surveillance to reduce morbidity, mortality, and emotional and financial burden. In India where the cost of treatment is borne either by the patient or by the government (for individuals below the poverty line), offering the genetic test to identified cases/families after a simple effective GC session will help in healthcare management of this vulnerable group. Including a genetic counselor in the health management faculty of oncology units is a simple cost-effective way of preventive management of breast cancer. It can be recommended that all oncology units should have a GC service for providing appropriate support to oncologists, patients, and families to prevent unnecessary testing.[69]


 » GC Recommendations for India Top


The traditional model of providing GC is changing. Given a choice, a majority of patients eligible for testing would opt for a simplified mode of GC and delivery of test results.[85]

Based on the current knowledge of BRCA behavior in HBOC and available guidelines, the following recommendations can be made for GC in BRCA testing in a developing country like India:

  • There is not sufficient number of genetic counselors in India, and there is an urgent need to train more non-geneticists in this field. Incorporation of GC training within university curriculums might prove useful
  • Educating patients about the need for genetic testing and the role of genetic counselor in medical care
  • Building national guidelines for GC and genetic testing in oncology with special reference to BRCA testing and counseling
  • Building multidisciplinary teams and mainstreaming the process of GC into oncology settings
  • Insurance coverage of BRCA and other genetic testing.


Acknowledgements

The authors thank AstraZeneca Pharma India Ltd for providing medical writing assistance in the development of this manuscript, in collaboration with Turacoz Healthcare Solutions, Gurugram.

Financial support and sponsorship

Financial support to authors - Nil.

The supplement issue in which this article has been published has been sponsored by AstraZeneca Pharma India Ltd.

Conflicts of interest

There are no conflicts of interest.



 
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