9/19/2014. Conflict of Interest Disclosures In relation to this presentation, I declare the following, real or perceived conflict(s) of interest:

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1 9/9/0 Cancer Genetic Counseling and Testing in an Era of Rapid Change Gillian W. Hooker, Adam H. Buchanan, Keelia Rhoads, Kristen Vogel Postula, John Quillin, Pia Summerour, Sara Knapke, Rebecca Nagy Conflict of Interest Disclosures In relation to this presentation, I declare the following, real or perceived conflict(s) of interest: Gillian W. Hooker Paid employee of NextGxDx Co-authors Pia Summerour is a paid employee of Ambry Genetics Kristen Postula is a paid employee of GeneDx These conflicts did not exist at the time this study was conceptualized A Rapidly Changing Landscape First expanded cancer panels launched AMP v. Myriad decision that NSGC Cancer naturally occurring DNA segments SIG Survey are not patentable and launching Launched of several new BRCA tests 0 0 Angelina Jolie CIGNA requires discloses her involvement of BRCA status and genetics decision to professionals in undergo a supporting genetic preventive testing decisions mastectomy

9/9/0 Study Aims To describe the short term impact of 0/0 events on cancer genetic counseling and testing Assess genetic testing preferences and practices Assess impact on clinical practice GC

2 9/9/0 Study Aims To describe the short term impact of 0/0 events on cancer genetic counseling and testing Assess genetic testing preferences and practices Assess impact on clinical practice GC Demographics and Practice Characteristics Age % of Total (n = ) Gender 8-8% (89) Female 98% () Years in Practice < years 0% (6) Work Setting University Medical Center 8% (9) Number of BRCA/ Tests /month (including panels) -0 % (67) Italian Ancestry Breast 0 Newly diagnosed No other known cancers in family Referred for surgical decision making Excellent insurance coverage for testing [Before / Currently] What would be your first line test for a patient like this? 7 y Breast 7 If that were negative, what reflex testing might you consider?

% of Respondents % of Respondents 9/9/0 BC @ 0 BC @ 7 First-line testing 00% 80% Before Currently 60% 0% 0% 0% B/seq+ B/seq+, Breast Panel General Panel Breast Panel General Panel No Testing ref DD

3 % of Respondents % of Respondents 9/9/0 0 7 First-line testing 00% 80% Before Currently 60% 0% 0% 0% B/seq+ B/seq+, Breast Panel General Panel Breast Panel General Panel No Testing ref DD (w. B/) (w.b/) (no B/) (no B/) Other 0 7 Reflex Testing 00% 80% Before Currently 60% 0% 0% 0% No Further Testing B/seq+ B/ DD Breast Panel General Panel Breast Panel General Panel (w. B/) (w.b/) (no B/) (no B/) Other Northern European Ancestry OvCa@0 BrCa@8 OvCa@0 0 y Classic HBOC 97.% BRCA/ before 9% BRCA/ before, BRCA/ seq neg 89% BRCA/ del/dup before 8% BRCA/ currently 6.% BRCA/ currently 0% Br. Panel 0% Gen. Ca Panel % del/dup currently

4 9/9/0 Northern European Ancestry 0 y Classic HBOC 97.% BRCA/ before 9% BRCA/ before, BRCA/ seq neg 89% BRCA/ del/dup before 8% BRCA/ currently 6.% BRCA/ currently 0% Br. Panel 0% Gen. Ca Panel % del/dup currently Northern European Ancestry OvCa@0 BrCa@8 OvCa@0 0 y Classic HBOC 97.% BRCA/ before 9% BRCA/ before, BRCA/ seq neg 89% BRCA/ del/dup before 8% BRCA/ currently 6.% BRCA/ currently 0% Br. Panel 0% Gen. Ca Panel % del/dup currently Changes to Testing Practices Have you changed the type of tests that you are ordering for hereditary breast and/or ovarian cancer risk assessment in the last months? Yes (9%) No (7%) What is the most important factor for you in choosing a laboratory for genetic testing? Lab Reputation (7%) Insurance Preauth (%) OOP Cost to Patient (0%) Testing Platform (8%) TAT (7%) Variant Rates (%) Customer Support (%) Cost to Insurance Co (%)

Percent of Respondents 9/9/0 Changes to Counseling Practice Do you feel like your genetic counseling practice has changed in any way in the past months?

Myriad (%) Angelina Jolie Op Ed (9%) Changes Billing Ability (%) In what ways has your practice changed in the last year?

5 Percent of Respondents 9/9/0 Changes to Counseling Practice Do you feel like your genetic counseling practice has changed in any way in the past months? Which of the following events had the greatest impact on your clinical practice? Yes (99%) No (%) Expanded Panels (%) AMP vs. Myriad (%) Angelina Jolie Op Ed (9%) Changes Billing Ability (%) In what ways has your practice changed in the last year? Changes in content and length of session Changes in tests offered/discussed More consideration given to lab choice Increased patient volume More counseling done by phone Increased wait time Increased workload.modifications to pre-test counseling session; learning how to counsel about testing for a multitude of genes by using a few genes as an example but not going into great detail about each gene; spending a little more time on the idea of results leading to some level of uncertainty either due to a variant or a deleterious mutations in a newer gene. What predicts change? No significant effects: Age Years in practice Practice setting Practice size Volume of patients Volume of tests Number of Changes by Region Number 60% Region 0% Region 0% Region 6 0% 0% 0% 0% 0 Number of Changed Tests Before vs Currently 6 F=., p = 0.0

6 Mean Reported Degree of Change 9/9/0 What predicts change? No significant effects: Age Years in practice Practice setting Practice size Volume of patients Volume of tests Mean Reported Change by Region Number (Error Bars: 9% Confidence Interval) NSGC Region Number F=6., p < 0.00 Conclusions and Future Directions BIG changes to genetic counseling and testing practices Uniformity Variability More options for testing and different values weighed in decision making Watch for the follow up survey anticipated November 0!!! Data is intended to be a resource Open to requests for data Open to suggestions for future surveys Contact us! Acknowledgements Cancer SIG Members Cancer SIG Leadership Adam H. Buchanan, Keelia Rhoads, Kristen Vogel Postula, John Quillin, Pia Summerour, Sara Knapke, Rebecca Nagy 6

BRCAnowTM It s Your Decision

Hereditary Breast and Ovarian Cancer BRCAnowTM It s Your Decision Patient & Physician Information What is BRCA? The breast cancer genes BRCA1 and BRCA2 are found within an individual s normal genetic makeup;