Table 1.

Genetic referral barriers.

Barrier (coded to TDF domain)	Barrier descriptions
Knowledge	Provider lack of knowledge about genetics and/or referral criteria [3, 33, 35–38, 42–44, 48, 55, 58, 60, 61, 73]
	Provider lack of knowledge about the genetic counseling referral process [3, 34]
	Patient lack of knowledge about the availability of genetic services [35]
	Provider lack of knowledge about the availability of genetic services [34, 37, 73]
	Patient lack of knowledge about genetic testing and potential benefits [37]
	Provider lack of knowledge about criteria for pathology tests to guide genetic risk assessment [3]
	Lack of provider knowledge about the genetic counseling referral process [3, 34]
Skills	Difficulties communicating genetic information to patient [35]
	Limited exploration and/or documentation of patient family history [36, 44, 48, 54, 58]
	Incomplete ordering of pathology tests (e.g., mismatch repair immunohistochemistry) [3]
	Difficulties applying referral guidelines/criteria to identify patients at increased genetic risk [3, 55, 58]
	Training provided on an ad hoc basis, resulting in unfamiliarity with referral processes [3]
Environmental context & resources	Lack of on-site genetic counselors [34, 56]
	Limited availability of genetic counselors (due to clinical demands, limited resources) and subsequent long waitlists [34, 49, 56, 57]
	Lack of geographical access to genetic services [42, 49, 50]
	Patient financial constraints preventing access to genetic counseling and testing [50]
	Time required to collect a complete family history to assess genetic risk [51]
	Administrative referral barriers (e.g., referral forms not always available in clinic, faxing process can be fraught; multiple electronic management systems and departments with limited connectivity) [3]
	Delayed implementation of genetic screening tests (e.g., mismatch repair immunohistochemistry) [3]
	Lack of availability among genetic staff to attend multidisciplinary team meetings [3]
	Genetic risk assessment guidelines may be complex to interpret and unsuited to occasional use in a busy setting [38]
	Limited access to genetic services (reason not specified) [55]
	Time constraints and absence of primarily responsible pathologist act as a barrier to appropriate ordering of genetic screening tests [62]
	Limited integration of genetic testing into the cancer treatment workflow [56]
Memory, attention, & decision processes	Inconsistent documentation of referral recommendations [34]
	Difficulty deciding which patients were eligible for genetic screening tests (e.g., mismatch repair immunohistochemistry) [33]
	Difficulty deciding which patients warrant genetic referral [36, 43, 48, 55]
	Genetic risk assessment guidelines may be complex to interpret and unsuited to occasional use in a busy setting [38]
	Clinicians can easily forget to refer cases for genetic screening tests (e.g., microsatellite instability testing) [62]
	Interpreting pathology results can be difficult, making the decision-making process more difficult and less routine [3]
	Genetic referrals can be overlooked due to competing clinical priorities [3]
	Clinicians may not have the necessary information (e.g., immunohistochemistry reports) to make a decision about genetic referral [3]
Beliefs about consequences	Perception of limited clinical utility of genetic testing among providers [50]
	Lack of patient awareness about the potential benefits of genetic testing [37]
Beliefs about capabilities	Lack of confidence in ability to assess patients’ genetic risk or in providing genetic services [38, 42, 46]
	Terminology in the pathology reports can be confusing, generating the perception that it is hard to make an appropriate referral [3]
Emotion	Patient fear about the potential outcomes of genetic testing [37]
Social/professional role & identity	Lack of clarity about clinician roles in the genetic risk assessment process [33, 34]

TDF Theoretical Domains Framework.