Closing the gap: using the ECHO model to improve access to hereditary colorectal cancer risk assessment and genetic counseling in the rural setting

There is underutilization of colorectal (CRC)-related cancer genetic counseling services nationally, especially in underserved regions. Novel models of cancer genetic care in rural states like Maine are needed to narrow the practice gap, reflected in an improvement in the percentage of individuals meeting genetic testing guidelines referred for cancer genetic counseling. To lower the CRC cancer genetic counseling practice gap within a Maine-based integrated health system by building clinician capacity to identify hereditary CRC risk and facilitate provision of genetic counseling and testing services via the Project ECHO® hub-and-spoke telementoring model. MaineHealth (MH) and The Jackson Laboratory (JAX) partnered to generate tools and systems to: (1) identify baseline MH practice gaps via a gastroenterology clinician needs assessment survey; (2) promote genetic assessment of CRC patients through a standardized risk assessment tool; and (3) implement and assess Cancer Genetic ECHO (CG-ECHO) to build clinician knowledge and confidence. Clinicians had variable baseline comfort levels with aspects of cancer genetic care. Most (68%) were comfortable performing an initial risk assessment; comfort levels were lower for providing pretest counseling (28%), selecting genetic tests (23%), and managing patients with variants of uncertain significance (41%). There was interest in education about choosing tests (67%), genetic testing indications (62%), and interpreting results (62%). Spoke site engagement and participation was low; participants included healthcare providers, trainees, and support personnel. Despite institutional support, staff effort and technology demands were barriers to developing and implementing CG-ECHO. Low participant recruitment and engagement posed significant challenges to CG-ECHO, likely reflecting competing demands, to include COVID-related burdens, on clinicians and institutions. These barriers and challenges are critical to the development and sustainability of future cancer genetic ECHO programs.