Where You Get Tested Matters More Than How You’re Asked: Workflow Beats Outreach in Cancer Genetic Testing Study

When it comes to convincing high-risk patients to undergo genetic testing for hereditary cancer, the message matters far less than the moment. A large real-world study published in Frontiers in Cancer Control and Society has found that three different outreach methods—mailed brochures, email, and SMS text messages—produced virtually identical and disappointingly low uptake of genetic testing, while the physical location where testing was offered made a dramatic difference in whether patients followed through.

The research, conducted across eight Providence Health and Services clinics in California, examined two critical questions in the rapidly expanding field of population-scale genetic testing: which outreach method best reconnects patients with testing opportunities they declined or deferred, and whether requiring patients to travel to a different building for sample collection suppresses participation. The answers carry significant implications for health systems attempting to scale genetic services beyond specialty clinics.

The scale of unmet need is substantial. Despite established national guidelines from the National Comprehensive Cancer Network, fewer than 20 percent of eligible US patients with a personal or family history of breast or ovarian cancer undergo genetic testing. That gap translates to an estimated 1.2 to 1.3 million women in the United States who qualify for testing but have not received it. Among women with a family history of breast or ovarian cancer but no prior diagnosis, only about 3.6 percent have completed testing. These shortfalls are compounded by well-documented disparities tied to race, age, education, and insurance coverage—disparities that the Centers for Disease Control and Prevention has called a public health imperative to address before precision medicine widens existing health inequities.

Providence’s population-scale cancer risk assessment program offered an ideal testing ground. The program uses the Ambry CARE platform to deliver electronic risk assessments aligned with NCCN guidelines to patients before their mammogram appointments. Patients flagged as high risk for hereditary cancer are informed of their eligibility for a multigene pan-cancer hereditary panel and offered genetic counseling. At the mammogram encounter itself, mammography technicians hand eligible patients informational materials and confirm their decision about testing. For the outreach experiment, 7,112 patients who had not formally agreed to testing at their visit were randomized to receive one of three follow-up contacts: a mailed brochure, an email, or an SMS text message, each reminding them of their high-risk status and inviting them to call and pursue testing.

The results were sobering. Fewer than 3 percent of patients who received any outreach went on to have a genetic test ordered, and the rate did not differ meaningfully by method. Brochures yielded a 3.2 percent order rate, while email and SMS each produced 2.7 percent—differences that vanished statistically. The one factor that did correlate with uptake was timing: patients who received outreach closer to their mammogram appointment were somewhat more likely to order a test, averaging 98 days between appointment and outreach compared with 107 days for those who did not order. Younger patients, those aged 45 and under, also responded at higher rates of roughly 4.4 to 4.5 percent compared with less than 2.5 percent for older groups.

The workflow analysis told a far more compelling story. Drawing on 16,965 high-risk patients seen between 2023 and 2024, the researchers compared clinics where genetic testing was offered in the same building—and sometimes the same room—as the mammogram against clinics that required patients to travel to a different building for sample collection. The overall order rate in this high-risk population was 11.7 percent, but the same-building workflow achieved 13 percent versus 9 percent for the different-building approach. After adjusting for age, language, race and ethnicity, and insurance payor using modified Poisson regression, patients in the different-building group had a 28 percent lower rate of test orders, with an incidence rate ratio of 0.72 and a 95 percent confidence interval of 0.65 to 0.80.

The stratified analysis revealed something more troubling than a simple convenience effect. In clinics requiring patients to go elsewhere for testing, disparities by patient characteristics widened dramatically. Not a single patient who completed their risk assessment in a language other than English had a test ordered at a different-building clinic—a 0 percent order rate among 35 patients—while the same-building clinics showed no language-based difference. Black patients at different-building clinics had an order rate of just 2.3 percent and Asian patients 6.5 percent, compared with rates within a percentage point or two of White and Hispanic patients at same-building clinics. Younger patients aged 18 to 39 also fared worse when sent elsewhere, ordering at 11 percent versus 15 percent for the 40-to-45 group, a reversal of the pattern seen at same-building sites.

These findings align with prior research showing that point-of-care testing models can double participation compared with referral-based approaches. Studies by Wang and colleagues and Brabender and colleagues documented genetic testing completion rates of 35 percent and 50.1 percent respectively in high-risk populations offered same-day testing—figures well above the 13 percent seen in Providence’s same-building group, though the researchers note that differences in patient demographics, provider capacity, and the fact that their different-building patients did not need to schedule a separate appointment may have attenuated the gap. The Providence order rates instead track more closely with the roughly 15 percent observed in other Southern California populations and national survey data.

The modest outreach results also contrast instructively with the Geno4ME population-scale whole genome sequencing program, which achieved 7.5 percent enrollment using similar outreach methods. The researchers suggest several explanations: Geno4ME was free of charge, whereas clinical genetic testing involves insurance billing and potential out-of-pocket costs; Geno4ME used multiple outreach attempts rather than a single contact; and qualitative research has shown that repetition helps patients reconsider testing they initially declined. Notably, the finding that no single outreach channel outperformed the others suggests health systems can simply choose whichever method is cheapest and most feasible—email being the obvious candidate—without sacrificing effectiveness.

The study’s limitations warrant consideration. The workflow variable served as a proxy for convenience but could not capture unmeasured differences in how clinics implemented the program, such as staff capacity to discuss testing during appointments. With only eight clinics, facility-level variation could not be fully modeled, and the analysis relied on electronic health records that might have missed testing done at other health systems, potentially inflating the denominator. Personal cancer history, which could strongly influence a patient’s decision, was not visible in the data. Still, the core message is difficult to escape: outreach alone, however delivered, moves only a small fraction of eligible patients, while embedding testing directly into the care patients are already receiving—same building, same day—substantially raises participation and, critically, does so more equitably across language and racial groups. As health systems invest in scaling genetic services beyond specialty clinics, the evidence suggests that dollars spent on provider capacity and point-of-care access will yield far greater returns than any brochure, email, or text message ever could.

Subject of Research: Effectiveness of outreach methods and testing workflows on genetic testing participation among high-risk mammography patients

Article Title: Evaluating the effectiveness of outreach efforts and testing workflow on genetic testing participation in a high-risk population

Article References: Dickey, L., Bryce, E., Rinaldi, J. B., Emery, K., Childers, K., Brown, S., Gordon, O., & Vartanian, K. (2026). Evaluating the effectiveness of outreach efforts and testing workflow on genetic testing participation in a high-risk population. Frontiers in Cancer Control and Society, 4, Article 1765262. https://doi.org/10.3389/fcacs.2026.1765262

Image Credits: AI Generated

DOI: 10.3389/fcacs.2026.1765262

Keywords: genetic testing, hereditary cancer, outreach methods, point-of-care testing, health equity, mammography, precision medicine, NCCN guidelines, health disparities, patient participation, clinical workflow, cancer prevention