As a hereditary cancer genetic counselor and a self-proclaimed math geek, I often mull over a challenging math problem: how can “X” number of cancer genetic counselors see “Y” number of cancer patients for genetic testing?

Let’s use breast cancer as an example. In 2022, there were 339,250 new diagnoses of breast cancer*. Recent NSGC Professional Status Survey data reported that 660 adult cancer GCs provide direct patient care, with an average of 9.6 new patients a week. With these numbers, our current workforce could see ~97% of breast cancer patients**. At first glance, it’s a profound impact! However, when we begin to add up the patients with other cancer types and unaffected patients with a family history, the effect of the GC workforce decreases. As guidelines continue to expand, what exactly IS the answer when the number of qualifying patients steadily increases?

I’m certainly not claiming to have the answer, but I think it’s an arithmetic puzzle worth discussing. My experience allows me to view this equation from multiple angles. I previously worked with a small GC team to establish a hereditary cancer clinic in a mid-sized community practice and have served as a field-based GC for a genetic testing laboratory. Since then, I’ve joined the GC team at Texas Oncology, supporting an alternative service delivery model. This journey has offered me different workflows and partnerships with GCs trying to grapple with this same big math problem.

Texas Oncology’s GREAT (Genetic Risk Evaluation and Testing) Program began in 2004 with an MD and two nurse practitioners. In 2012, they hired their first GC and the team has now grown to include 5 GCs, a data coordinator and over 130 NPs and PAs across Texas. GREAT providers undergo hands-on training with a GC and then meet with patients to provide thorough genetic risk assessments and offer appropriate genetic testing. In total, over 11,000 patients in 84 different clinics were seen through the GREAT program last year, with the overall patient count of the program reaching 62,000.

I like to tell new providers that they’re entering this field at a phenomenal time. Criteria are more encompassing, testing is affordable and the major hereditary cancer labs have stepped up their client and clinical support. Most major labs have regional lab GCs who can help with workflow support and GCs with expertise in variant interpretation and gene curation — all just a call or email away. Perhaps I'm viewing things through rose-colored glasses, but my experiences have demonstrated a true sense of camaraderie in these professional relationships. Compared to a decade ago, it’s easier to see labs as partners in our patient care and another variable to help us solve our equation.   

Working with APPs (Advanced Practice Providers) has been a highlight of my career. They have an incredible knowledge of oncology and a long-standing rapport with patients requiring counseling and testing. It’s wonderful to observe interactions with patients who already feel comfortable with the APPs — it helps them grasp the complexity of genetics and remain open in their questions and thoughts about the testing process.

While I often identify new variables to incorporate into alternative service delivery models, collaborating with APPs and other healthcare providers feels like a crucial piece of the puzzle, especially when it can further our mission to support patients with genetic information. MK Schoolcraft, DNP, shared, “When I began my journey in oncology, I never imagined genetics would be a part of my practice. The GREAT program has given me the tools to help patients improve their awareness of the importance of healthcare screenings and reduce stress levels among patients and families with genetic diseases. In general, I find the genetic counselors I have encountered more than willing to share their knowledge and passion for genetics. It must be in their DNA! Their support and positivity have been so great, that I was encouraged to seek further education and applied for the City of Hope Program. I recently completed my certification, and cannot thank our GREAT team enough for their help in opening my eyes to a new practice!”

We need to be flexible in how we provide services to continue addressing the integration of genetic data into cancer care for MANY, if not ALL, patients. By encouraging other providers to perform risk assessments and order testing, our role is not devalued — it instead positions us as expert consultants. Alternative service delivery models can enhance our reach and keep us working at the top of our scope.

In college calculus, we learned about Fermat’s Last Theorem. It is an incredibly challenging problem that mathematicians finally proved after over 350 years! How did they do that? By successively building on each other’s work. They collaborated with other bright minds, critiqued solutions and identified processes that had potential. I hope it won’t take us quite as long to find our solution, and realistically, there may not be one answer. But, by breaking the mold, partnering with our lab allies and trying alternative ways to help our patients, I’m confident we’ll find innovative solutions for the future.

*American Cancer Society
** 660 Cancer GCs x 9.6 patients per week x 52 weeks per year = 329,472 patients per year. 329,472 divided by 339,250 new breast cancers = 97.11%

Sara Mokhtary, MS, CGC is currently the President of the Texas Society of Genetic Counselors and the phone-a-friend GC for the Texas Oncology APPs in the San Antonio area. Her excitement for the lab space led her to join the Myriad Genetics’s Steering Committee. And while she doesn’t usually read math books, she’s still a self-proclaimed bookworm!