Improving Timeliness of Genomic Testing Results Through Nurse Navigation

Background: Early-stage and hormone receptor–positive breast cancers may need additional genomic testing to determine which patients need chemotherapy in addition to endocrine therapy.^1,2

The National Comprehensive Cancer Network (NCCN) recommends genomic testing with the 21-gene assay using reverse transcription polymerase chain reaction (RT-PCR) to predict who is most likely to respond to systemic chemotherapy.³ If women need chemotherapy, it is vital that it is initiated as soon as possible since chemotherapy initiated within 30 days after surgery has improved outcomes in survival.⁴ Studies have shown that delays in obtaining genomic testing can lead to delays in initiating adjuvant chemotherapy.^5,6 Previous research has examined the role of oncology nurse navigators (ONNs) in improving the timeliness in receiving breast cancer treatment.⁷ One study demonstrated that nurse navigators can develop an intervention and tracking tool to improve timeliness in genomic testing for breast cancer.⁸

Baseline data at Jersey City Medical Center (JCMC) from 3/2017 to 3/2018 revealed significant delays in ordering (27 days) and in reporting of the 21-gene RT-PCR assay results (45 days).

Objectives: Improve timeliness by: (1) decreasing days to ordering 21 gene RT-PCR assay, and (2) decreasing days to reporting 21 gene RT-PCR assay

Methods:

Inclusion criteria

• Surgery completed at JCMC and revealed breast cancer on final pathology
• Must meet all NCCN 2018 Guidelines for 21-gene RT-PCR assay
• • Receptor status: Estrogen receptor–positive and HER2-negative
  • Histology: Ductal, lobular, mixed, metaplastic
  • Tumor size: >0.5 cm and either pT1, pT2, or pT3
  • Node status: pN0, pN1mi (≤2 mm axillary node metastasis), or 1 to 3 positive lymph nodes

Exclusion criteria

• Patients undergoing breast surgery outside JCMC
• Patients who already received preoperative chemotherapy
• Patients who have already received the 21-gene RT-PCR assay score on the same invasive specimen with the same histology

Intervention:

• The ONN tracked patients who are eligible for testing
• ONN followed up with the multidisciplinary team to expedite the order/results
• Created policy for 21-gene RT-PCR assay ordering via ONN and Pathology Department
• Tracked ONN interventions to expedite testing in database

Results: Analysis at 1 year postintervention revealed significant improvements: (1) decreased days to ordering genomic testing from 27 days at baseline to 10 days in the intervention period (a 63% reduction), and (2) decreased days to reporting genomic testing results from 45 days at baseline to 21 days in the intervention period (a 53% reduction).

Conclusions: This performance improvement project demonstrates that an ONN intervention can improve timeliness in genomic testing ordering and reporting of results.

ONNs are in a unique position to improve timeliness of care as they work with patients across the cancer continuum. Genomic testing is an expanding field in cancer treatment, and future research can explore how ONNs can be part of the multidisciplinary team improving timeliness of care.

References

1. Albain KS, Barlow WE, Shak S, et al. Prognostic and predictive value of the 21-gene recurrence score assay in postmenopausal women with node-positive, oestrogen-receptor-positive breast cancer on chemotherapy: a retrospective analysis of a randomised trial. Lancet Oncol. 2010;11:55-65.
2. Liedtke C, Kolberg HC. Breast cancer and genomic testing. Br J Surg. 2017;104:799-801.
3. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). Breast Cancer. Version 4.2017. www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Accessed February 7, 2018.
4. Gagliato DM, Gonzalez-Angulo AM, Lei X, et al. Clinical impact of delaying initiation of adjuvant chemotherapy in patients with breast cancer. J Clin Oncol. 2014;32:735-744.
5. Vandergrift JL, Niland JC, Theriault RL, et al. Time to adjuvant chemotherapy for breast cancer in National Comprehensive Cancer Network institutions. J Natl Cancer Inst. 2013;105:104-112.
6. Losk K, Vaz-Luis I, Camuso K, et al. Factors associated with delays in chemotherapy initiation among patients with breast cancer at a comprehensive cancer center. J Natl Compr Cancer Netw. 2016;14:1519-1526.
7. Basu M, Linebarger J, Gabram SGA, et al. The effect of nurse navigation on timeliness of breast cancer care at an academic comprehensive cancer center. Cancer. 2013;119:2524-2531.
8. McAllister KA, Schmitt ML. Impact of a nurse navigator on genomic testing and timely treatment decision making in patients with breast cancer. Clin J Oncol Nurs. 2015;19:510-512.