Optimizing Hereditary Cancer Risk Assessment and Genetic Testing Workflow in Interprofessional Women's Health Practice: A Multicenter Survey of Advanced Practice Providers

Abstract

Introduction

Advanced practice providers (APPs), including certified nurse‐midwives (CNMs)/certified midwives and nurse practitioners, are well positioned to meet the growing demand for women's health care services. In interprofessional obstetric and gynecologic settings, APPs’ scope of practice includes performing hereditary cancer risk assessments (HCRAs) and genetic evaluations, comparable with physicians. However, time constraints, limited confidence, and inadequate resources may hinder APPs’ ability to routinely and effectively incorporate HCRA and genetic testing into practice.

Process

This prospective, single‐arm health care quality improvement initiative introduced workflow innovations and tools to improve HCRA workflow. This intervention included training on using online family history screening and virtual patient education tools within a standardized HCRA. Metrics related to genetic evaluation and testing completion and the experiences of women and APP respondents were recorded preintervention and postintervention. Data were analyzed using descriptive statistics and univariate conditional logistic regression models.

Outcomes

Following workflow standardization, APPs noted increases of 27.1 percentage points in the proportion of women offered genetic testing and 26.4 percentage points in the genetic testing completion rate (26.4%). APPs agreed or strongly agreed that the workflow modification improved their confidence in performing HCRA (91.7%) and meeting the standard of care (91.7%) and supported guideline adherence (83.3%) and ease of practice integration (66.7%).

Discussion

APPs care for women with similar risk profiles as physicians and are equally capable of implementing novel tools and processes to provide evidence‐based, personalized HCRA consistent with their scope of practice.

INTRODUCTION

Access to health care remains a persistent concern across the United States that is further exacerbated by a shrinking obstetric and gynecologic physician workforce. Encouragingly, enrollment in midwifery education programs and the number of practicing certified nurse‐midwives (CNMs) and certified midwives (CMs) continue to grow anually. ¹ American Academy of Nurse Practitioners data from 2023 noted 385,000 licensed nurse practitioners (NPs), an increase of more than 8% from the previous year, ² with advanced practice providers (APPs) projected to grow by 40% between 2023 and 2033. ³ , ⁴ Midwives and NPs are accomplished health care providers devoted to strengthening the health care system alongside their physician colleagues and other health care team members to promote good health and to optimize outcomes for women and their families. ⁵ , ⁶

QUICK POINTS

• ✦Our previously reported quality improvement findings showed that implementing an online family cancer history tool and virtual patient education in women's health settings enhanced women's understanding of cancer risk and increased genetic testing completion.
• ✦Advanced practice providers (APPs), including nurse‐midwives and nurse practitioners, are uniquely positioned to help fill gaps in comprehensive women's health care provision, particularly hereditary cancer risk assessment (HCRA).
• ✦This APP‐focused subanalysis demonstrates that well‐supported APPs effectively guide women to online family cancer history and virtual education tools and routinely incorporate HCRA processes into practice, providing guideline‐based care within their scope of practice.
• ✦The workflow changes and implementation of novel tools have important implications for the role of women's health APPs in strengthening disease prevention, enhancing early cancer detection, and optimizing clinical outcomes in women.

APPs specializing in women's health, such as CNMs/CMs and NPs, focus primarily on disease prevention and health promotion in interprofessional health care settings with many health care team members. In this setting, genetic risk evaluation often involves collaboration with and referral to genetics professionals who bring unique genetic and inherited cancer risk expertise. Within this collaborative framework, APPs oftentimes manage women who are low to moderate risk for complex health conditions, whereas their physician colleagues frequently manage women who are high risk. This could involve women at an increased risk of developing cancer, including those with hereditary cancer gene mutations. However, midwives and NPs are increasingly evaluating and managing women who are high risk, and many seek to expand their skills and knowledge related to genetic‐based care for women, including hereditary cancer risk assessment (HCRA) specifically. Existing research is limited regarding the proportion of women who are at risk and seen by APPs.

Cancer risk assessment is a key component of disease prevention and guides the screening decisions and diagnostic examination findings as well as the subsequent plan of care. In 2024, the Women's Preventive Services Initiative published recommendations that specifically advocated that women's health care providers screen and evaluate risks for several cancers, including BRCA1/2 genetic mutations associated with breast and gynecologic cancer risk. ⁷ In addition to routine women's health care–related cancer screening, such as for cervical cancer, recommendations include screening for hereditary cancer risk. The National Association of Nurse Practitioners in Women's Health (NPWH), the American College of Obstetricians and Gynecologists (ACOG), and the US Preventive Services Task Force (USPSTF) all recommend routine HCRA. With appropriate training, ACOG and NPWH support women's health providers performing HCRA counseling and genetic testing. ⁸ , ⁹ , ¹⁰ Despite a variety of opportunities for women's health APPs to build knowledge, many still find it challenging to incorporate HCRA, genetic counseling, and testing into practice, often citing barriers such as lack of time, tools, expertise, or confidence in providing genetic education. ¹¹ , ¹²

To better support APPs’ incorporation of HCRA into women's health care, novel tools and resources have been developed. In 2018, DeFrancesco et al reported findings from a prospective process intervention study in a community obstetric and gynecologic setting that integrated a guideline‐driven, clinic‐specific HCRA process that resulted in a 4‐fold increase in genetic testing among women when compared with preintervention metrics and an 8‐fold increase compared with the prior year. The physician and APP participants reported that they would continue to incorporate the refined HCRA process in the community obstetric and gynecologic practice setting. ¹³ The data from DeFrancesco and colleagues did not distinguish between results from APPs and physicians and did not specifically address the APP experience with implementing additional supporting tools for conducting HCRA. Since DeFrancesco et al's findings, genetic testing criteria for hereditary cancer risk have continued to evolve, and new tools to improve the HCRA process have been developed and refined.

Recently, Waldman et al conducted a complementary, multicenter study in the community‐based obstetric and gynecologic practice setting with a similar design to evaluate process interventions, including an online patient screening tool and virtual patient education to improve the provision of HCRA and genetic testing. Following online patient screening and virtual patient education implementation, women eligible for HCRA and genetic testing were significantly more likely to be offered genetic testing, to submit a sample, and to complete genetic testing. Most providers also found that the online family history screening tool and virtual patient education positively impacted their practice by supporting adherence to standards of care and HCRA guidelines, facilitating easy integration, and improving time efficiently. ¹⁴

Waldman and associates’ primary results represent aggregated data from both physicians and APPs and did not provide an in‐depth analysis of the APP experience throughout process implementation. Here, we disaggregated genetic testing completion data from Waldman et al and analyzed an APP‐specific subset to assess whether workflow changes in administering HCRA and genetic testing offered additional benefits. Given the central role of women's health APPs in collaborative care, we report on their provision of HCRA within a prospective, single‐arm quality improvement initiative conducted in a community‐based, interprofessional women's health care setting.

PROCESS

A quality improvement process was conducted and evaluated at 5 community‐based obstetric and gynecologic practices between July 2021 and November 2022. The workflow intervention was previously described by Waldman et al in a prospective, multicenter, single‐arm study. ¹⁴

Patient Population

Data were collected from adult women (≥18 years) presenting for a new or a return gynecologic visit or a well‐woman examination. For the purposes of this study, women refer to individuals who were assigned female at birth. No patient randomization was conducted. Patients were not selected to see either a physician (obstetrician‐gynecologist) or APP (CNMs or women's health care–focused NPs) as part of the study. Care was provided to all women according to routine practice. Informed consent was obtained prior to conducting any genetic testing. The study was approved by an independent institutional review board (Quorum Review, 32177) and was reported in accordance with the Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0; Supporting Information: Appendix S1). ¹⁵

Workflow Change Implementation

The quality improvement process comprised 4 periods: a preintervention period (8 weeks) to observe existing practices, an intervention period (3‐4 weeks) to provide in‐person and virtual training to physicians and APPs, a practice period (4 weeks) to provide opportunities for run‐through and repetition of new workflow, and a postintervention period (4‐8 weeks) to observe new processes. The preintervention and postintervention workflow changes are summarized in Figure 1.

Figure 1.

Patient Hereditary Cancer Risk Assessment and Testing Workflow Changes from Preintervention to Postintervention

Workflow Interventions

During the training period, staff and providers were educated on the implementation of comprehensive HCRA screening via an online patient screening tool (MyGeneHistory), ¹⁶ which uses clinical and family history questions specific to current screening guidelines (National Comprehensive Cancer Network, ¹⁷ American Society of Breast Surgeon, ¹⁸ and US Preventive Services Taskforce ¹⁰ ) to identify individuals who may be candidates for hereditary cancer testing. Patients completed the online screening assessment concurrently with other routine intake processes while in the clinic waiting area prior to their appointment. APPs had access to and could review the screening results during their normal chart review procedures and prior to seeing the woman in the examination room. The accuracy and completeness of the clinical information provided by women were verified by the provider during the visit.

Clinical staff were also trained to offer virtual patient education to women who met guideline criteria for genetic testing. This education consisted of either a prerecorded video containing information on genetic testing or the prerecorded video combined with a phone call with a patient education genetic counselor from the testing laboratory (Myriad Genetics). The telephone call with a genetic counselor included the collection of personal health information, a detailed family tree, and education on genetic testing and its impact on the woman and family. During the postintervention period, data related to HCRA, patient education, and genetic testing completion rates were collected. The criteria for completing virtual patient education varied by site resources: Women either (1) watched the patient education video at sites only offering the video or (2) completed a phone call with a genetic counselor, with or without viewing the video, at sites offering both modes of education. ¹⁴

Data Collection

HCRA data were collected by provider type at 2 of 5 sites during the preintervention period and at 4 of 5 sites during the postintervention period. The remaining sites reported aggregated data that combined both provider types. Site‐reported HCRA and patient survey response data from sites that reported provider type, along with provider responses from all 5 sites, are described.

Patient Survey

Nonclinician staff offered women a satisfaction survey after their appointment during the postintervention period. The patient satisfaction survey was offered to all women who met the testing criteria. Surveys collected data on the self‐reported metrics of virtual patient education completion and women's initial decision to complete genetic testing. Women who received the survey could self‐report completing patient education even if they partially completed the tasks required to meet guideline‐defined end points (eg, completing the video but not the telephone call with the counselor at sites offering both modes).

Provider Survey

APPs also completed a satisfaction survey following the postintervention period. Questions assessed APP satisfaction with the implemented workflow solutions and tools, including the online family history assessment tool and virtual patient education. The evaluation consisted of 4 statements scored on a 5‐point Likert‐type scale (1, strongly disagree; 2, disagree; 3, neutral; 4, agree; 5, strongly agree).

Data Analysis

Univariate conditional logistic regression models, stratified by site, were used to compare postintervention completion rates for the various steps of the HCRA process across provider types. The results of the logistic regression models are reported with odds ratios, 95% profile‐likelihood CIs, and P values from partial likelihood ratio tests.

OUTCOMES

Of the 39 health care providers who participated in the original quality improvement study, 13 (33.3%) were APPs (4 NPs and 9 CNMs), and 26 (66.7%) were physicians (obstetricians‐gynecologists). For sites wherein the type of health care provider was known, the total women seen across the clinics was 2188 and 4040 during the preintervention and postintervention periods, respectively.

To evaluate the impact of process changes and tools on APP practice, the success rate for each process step was evaluated preintervention and postintervention. When comparing the preintervention and postintervention periods, the percentage of women who were eligible and offered genetic testing increased by 27.1%, and the percentage of women were eligible and completed genetic testing increased by 26.4% for APPs (Figure 2).

Figure 2.

Comparison of Preintervention and Postintervention Showed an Increase in the Percentage of Patients Meeting Guidelines Who Went on to Complete Genetic Testing

Abbreviations: HCRA, hereditary cancer risk assessment; vPE, virtual patient education.

We closely examined the APP practice performance during the postintervention period. Women seen by an APP who met eligibility criteria were offered genetic testing 97.3% of the time. Among women who met testing guidelines, 41.0% of those who were offered testing completed it. When considering all women who were guideline eligible, including those not offered testing, the overall completion rate was slightly lower, at 39.9%. During the postintervention period, APPs effectively connected women with online screening and virtual patient education. Among women who met testing guidelines, 88.5% were offered virtual patient education, and 38.9% of those offered completed it (Table 1).

Table 1.

Comparison of HCRA Process Completion Metrics in the Postintervention Period

Postintervention HCRA Metrics	Patients Seen With a Known Provider Type (APP or Physician) n/n (%)	Patients Seen by an APP n/n (%)
Patients meeting genetic testing guidelines among those who provided family cancer history	957/3456 (27.7)	296/1115 (26.5)
Patients offered genetic testing out of those who met genetic testing guidelines	900/957 (94.0)	288/296 (97.3)
Patients offered virtual patient education out of those who met testing guidelines	825/957 (86.2)	262/296 (88.5)
Patients who completed virtual patient education when were offered	360/825 (43.6)	102/262 (38.9)
Patients who completed genetic testing out of those offered genetic testing	349/900 (38.8)	118/288 (41.0)
Patients who completed genetic testing out of those who met genetic testing guidelines	349/957 (36.5)	118/296 (39.9)

Abbreviation: APP, advanced practice provider.

A patient satisfaction survey was offered to women who met the guidelines for genetic testing. Of the women seen by an APP in the postintervention period who met genetic testing criteria, 68.9% (204/296) provided a response to questions about completing virtual patient education. Of those 204 responses, 149 (73.0%) reported completing virtual patient education. This rate is higher than the 102/296 (34.5%) observed in the site‐reported HCRA metrics because women may have self‐reported completing patient education with partial, rather than full, completion of the guideline‐defined education services. The 149 women who self‐reported completing virtual patient education were also surveyed about their experience. Nearly all respondents agreed or strongly agreed that watching the prerecorded education video with or without the phone call with a genetic counselor helped them better understand the purpose of testing (93.1%, 134/144), that they are an appropriate candidate for testing (89.5%, 128/143), and what the impact of the results could mean for them and their family (92.3%, 132/143). Among the 55 of 204 women seen by an APP who reported not completing virtual patient education, 44 respondents provided reasons for not completing it. Reasons included feeling they could make an informed decision without education (27.3%), lack of time (29.5%), preference for receiving information directly from their health care provider (6.8%), or having already undergone genetic testing (9.1%). Of the women seen by an APP in the postintervention period who met genetic testing criteria, 68.6% (203/296) responded to the question about their initial decision regarding genetic testing. Among these 203 respondents, 118 (58.1%) reported that they initially chose to undergo genetic testing, even if they later changed their decision.

In a provider satisfaction survey, APP respondents “agreed” or “strongly agreed” that access to an online screening tool and virtual patient education improved their ability to meet the standard of care (91.7%) and improved their confidence in performing HCRA (91.7%). Additionally, APPs reported that access to the online screening tool supported their adherence to guidelines (83.3%) and was easy to incorporate into their practice (66.7%) (Table 2).

Table 2.

APP Respondents’ Satisfaction on Postintervention Workflow

Questions	Agreed or Strongly Agreed %
Having access to an online patient screening tool and virtual patient education improved my ability to meet standard of care.	91.7
Having access to an online patient screening tool and virtual patient education improved my confidence in performing HCRA.	91.7
Having access to an online patient screening tool helped me adhere to professional society guidelines recommending HCRA.	83.3
The online patient screening tool was easy to incorporate into my routine practice.	66.7

Abbreviations: APP, advanced practice provider; HCRA, hereditary cancer risk assessment.

DISCUSSION

APPs are committed to providing guideline‐driven, evidence‐based health care. ⁵ , ⁶ Here, we disaggregated genetic screening and testing data from Waldman et al and reanalyzed it to reveal potential benefits to women's health APPs through the enhancement of the HCRA workflow and genetic testing by incorporating an online patient screening tool and virtual patient education. Contrasting the disaggregated preintervention and postintervention period data to isolate APP's contribution within an interprofessional women's health care practice offered a more complete picture of how APPs, adequately equipped with novel tools and resources, may help to optimize the HCRA and genetic testing workflow for women. These results demonstrated that APPs care for a similar at‐risk population of women as their physician colleagues. The data further support APPs as providers of high‐quality, evidence‐based, personalized care enhanced by novel tools, educational resources, and improved processes. APPs were also particularly effective at connecting women to the online video and virtual patient education tools. Among women meeting testing criteria, sites reported that 88.5% were offered virtual patient education, and 34.5% completed it. For both APPs and physicians, we observed a significant increase in the percentage of women meeting guidelines who also completed genetic testing—26.4% and 13.6%, respectively—highlighting the value of all women's health care providers having access to HCRA tools, resources to implement HCRA, and supporting education.

APPs routinely perform cancer risk assessment for a variety of cancers affecting women, such as breast and cervical cancers, and identify women who may benefit from additional screening and preventive care services. HCRA and genetic evaluation of appropriate individuals are within the scope of APP practice and should be included in the care they provide to the women they serve. Based on this study's results, APPs provide HCRA as effectively as their physician colleagues. In the quality improvement initiative described by Waldman et al and in the present APP‐focused study, comprehensive HCRA screening used an online patient screening tool that queried women on their health and familial histories in accordance with American Society of Breast Surgeons, National Comprehensive Cancer Network, and USPSTF guidelines. More than one‐quarter of women (n = 296; 26.5%) who were seen by an APP met genetic testing guidelines after providing family cancer history. ¹⁴  This aligns with previous studies that show approximately one in every 4 women in an obstetric and gynecologic setting qualify for genetic testing. ¹³ , ¹⁹  Other studies have evaluated the utility of online family cancer history questionnaires, suggesting improvement in patient identification and testing completion. ²⁰ , ²¹  Frey et al showed that when compared to non–web‐based family history collection methods, a web‐based cancer family history collection tool resulted in more comprehensive family history collection and greater patient completion of genetic education (31% vs 14%) and testing (18% vs 8%). ²⁰

Notwithstanding, the expertise of APPs in providing personalized care, time constraints, and a lack of confidence and resources may present barriers to women comprehending HCRA screening and genetic testing during routine practice. In this APP‐focused investigation, 39.9% of women who met testing guidelines completed genetic testing. This is substantially higher than previous publications reporting that patient completion of hereditary cancer testing is typically low, with only 15% to 18% of respondents completing it when offered. These studies cite a lack of patient understanding as a major barrier, which may be due, in part, to limited access to genetic education. ¹³ , ²² Access to clinical genetic services and education may be impeded by the absence of in‐person genetic counseling services in geographic areas outside of metropolitan areas. Virtual patient education may help to address the lack of women's access to in‐person genetic counseling services across the United States. Across the 5 institutions in our study, virtual patient education consisted solely of prerecorded videos at 2 sites, whereas 3 locations provided video education supplemented by telephone exchanges with a genetic counselor. The self‐reported rate for completing virtual patient education was nearly twice the proportion reported by sites, reflecting that some women may have only completed part of the guideline‐defined education offerings. Although a majority of women who met testing guidelines did not complete genetic testing, potential opportunities exist to identify how to effectively shift attitudes on the utility of virtual patient education and increase accessibility.

Virtual counseling, including both prerecorded video education and telephone genetic counseling services, has been evaluated as an alternative to in‐person hereditary cancer pretest counseling. For instance, Schneider et al found that patients who watched an informative video compared with waiting for an in‐person genetic consultation were more likely to complete genetic testing (90.95% vs 77.8%), and Chavarri‐Guerra et al saw no significant difference between testing completion in patients watching an education video compared with in‐person counseling (P = 1.0), concluding that video education is a viable option for patients prior to pursual of hereditary cancer testing. ²³ , ²⁴ In a systematic review and meta‐analysis by Bracke and colleagues, patients who received telephone genetic counseling for BRCA1/2 testing exhibited genetic knowledge comparable with that of their in‐person counseling counterparts and reported equal levels of satisfaction. Telephone counseling was deemed an acceptable situationally preferred alternative to in‐person genetic counseling. ²⁵ We report that APPs effectively connected women with virtual education, possibly contributing to improved testing completion rates. Consistent with this interpretation, a majority of women concurred that the patient education methods helped facilitate comprehension of testing aims and their testing eligibility.

Although the APPs in our study were not genetics specialists, the postintervention period demonstrated that modifying the workflow to include an online family cancer history tool and virtual patient education resources enhanced their ability to support patients. Most APP respondents expressed greater confidence and faculty in administering HCRA following workflow modification. Many APP respondents were resolved that implementing the online screening tool was straightforward and aided in regular guideline adherence. Our results support that, in totality, these process interventions empower APPs to confidently provide standard of care evaluation and treatment for all women.

Limitations

The sample size of APP respondents was relatively small. Additional limitations include those associated with prospective studies, such as attrition bias from women who did not successfully complete patient education activities, or response bias. The risk assessment data were reported by individual practice sites and clinicians, resulting in a strict definition of the “completion” for virtual patient education for site‐level metrics to avoid inconsistencies across sites. Having participated in DeFrancesco et al's study, 2 sites received prior HCRA education and had already implemented HCRA procedures. However, only one site provided HCRA data metrics by provider type. Two sites in the preintervention period and 4 sites in the postintervention period reported HCRA metrics by provider type, limiting the data available for our analyses. Finally, these results from only a few community‐based practices may not be generalizable to obstetrics and gynecology practices across the United States or globally.

CONCLUSION

These results demonstrated that APPs, given effective tools and processes, successfully incorporated HCRA into practice and identified women at increased risk for hereditary cancer. The benefits of cancer prevention, early detection, and appropriate management have all been shown to improve women's health care outcomes and prevent cancer deaths. ²⁶ Effectively identifying hereditary cancer risks may benefit the individual by guiding risk modification and a change in medical management and providing crucial information for family members because genetic risk may be inherited. Equipping APPs to confidently incorporate HCRA processes into practice has benefits that extend well beyond the individual, with the ultimate goal of helping women and their families thrive.

CONFLICT OF INTEREST

H.B., E.S., A.S., L.S., and L.L. were employees of Myriad Genetics at the time of the study and received salary and stock options. R.T.A. and D.K. were paid consultants for Myriad Genetics. D.K. became a Myriad employee in September 2025 but was not an employee when this work was conducted. E.M. has no conflicts of interest to disclose.

Supporting information

Appendix S1. Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) September 15, 2015