Primary care stakeholder perspectives on clinical implementation of patient-reported hereditary cancer risk-assessment

Most individuals at increased risk of hereditary cancers are unaware of their risk status, in part due to the suboptimal implementation of evidence-based hereditary cancer screening in primary care. Identifying contextual determinants of implementation is necessary to facilitate implementation and subsequent cancer prevention. To inform these efforts, we assessed implementation determinants and needs across diverse primary care clinics. Between December 2023 and December 2024, we conducted qualitative interviews with primary care stakeholders identified through public databases and snowball sampling. Semi-structured interviews explored factors necessary to implement an evidence-based intervention: a patient‑reported family history screening tool for hereditary cancer risk assessment. We used content analysis to characterize implementation determinants according to the Consolidated Framework of Implementation Research. Nineteen stakeholders from physician offices (n = 9), outpatient clinics (n = 7) and community health centers (n = 3) completed qualitative interviews. Stakeholders viewed the intervention as feasible to implement and highlighted non-clinician-led workflows and electronic medical record integration as key facilitators. Outer setting factors such as inconsistent insurance coverage, variable patient out of pocket costs for genetic testing, and the need to align care delivery with national guidelines were key considerations. Inner setting barriers to implementation included resource constraints, competing medical priorities, and potentially low survey completion rates. Clinic leaders and primary care providers reported variable experience with cancer genetic testing, but many expressed interest and capacity to implement the intervention. Stakeholders endorsed interest and willingness to implement a patient-reported family history screening, but identified important outer and inner setting barriers that must be addressed for effective implementation. Integrating decision support tools, improving education efforts, and engaging payors to standardize recommended guidelines may improve genetic testing access for patients at-risk for hereditary cancers.