Universal testing - Should it be that hard? Probably. If you're doing it right.

In their article “Improving genetic testing following abnormal mismatch repair immunohistochemistry results in endometrial cancer”, Karpel et al. describe an intervention aimed at solving a recurrent problem in our practices and in the literature– patients who may benefit from widely-available genetic testing are not being tested as routinely as would be medically-indicated [ [1] Karpel H.C. Smith M. Brodsky A. Pothuri B. Improving genetic testing following abnormal mismatch repair immunohistochemistry results in endometrial cancer. Gynecol. Oncol. 2023 Jun 6; 175 (Epub ahead of print. PMID: 37290248): 20-24https://doi.org/10.1016/j.ygyno.2023.04.013 Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar ]. Their findings, while encouraging, are not surprising. Having a genetic counselor follow up with patients directly when pathology identifies mismatch repair deficient (MMRd) tumors results in a significantly improved genetics referral rate. This type of quality improvement initiative is clinically powerful and also practical given that these data are often collected by hospital accreditation bodies, as well. However, this leaves the unanswered question, “Why is this additional step necessary when the pathology report clearly indicates that referral to genetics is already indicated?” In many settings, expending genetic counselor effort in this capacity simply would not be feasible due to lack of reimbursement for genetic counseling services in both clinical and non-clinical settings. In other words, there would be little justification for paying a genetic counselor to do what a pathology report already does. We seem to have figured out that the key to having the MMR immunohistochemistry (IHC) performed universally is to automate the system. Pathologists are not waiting for a provider to recognize when the MMR IHC should be performed and to formally place an order. Unquestionably, we need to both lean on available technology and work collaboratively within the multidisciplinary team to build automated clinical support tools (ideally within the electronic health record system), if we truly aim for any service to be delivered universally and equitably.