Establishing a Cancer Genetics Programme in Asia - the Singapore Experience

Abstract

Cancer genetics is now an established oncology subspecialty with the primary prevention role of identifying high-risk individuals through genetic information for enrolment into screening and preventive programmes. Integrated into major Western centres since the late 1990s, such a programme has been established in Singapore since 2001. Our programme has evaluated 367 index patients comprising mainly breast and colorectal cancer cases. Cancer patients were receptive to genetic counselling, but cost posed a major barrier to genetic testing. However, when the cost barrier was removed through government subsidy plans, more than half of high-risk patients still declined testing. The major barriers were reluctance to involve family members, perception that the information would not change management, and fears of negative feelings. Confirmed mutation carriers were compliant to screening and receptive to prophylactic surgery. Uptake of predictive testing among cancer-free family members has been low, possibly arising from the stigma associated with cancer in our Asian culture. These potential barriers are being addressed through government subsidy plans, continuing education to increase awareness, and being culturally sensitive when dealing with the Asian family.

Impact of subsidies on cancer genetic testing uptake in Singapore

“…Unfortunately, our FDR predictive testing rate of 6% in our service is disappointing, far below the reported ratios in other established services 23. The low uptake of predictive testing is contrary to survey findings of high interest in predictive screening of unaffected family members in Singapore 3 7 25. Patients who declined predictive testing in other studies have cited fear of emotional burden and stress associated with genetic information on themselves as reasons for not availing themselves to genetic testing 3 7 26.…”

“…The low uptake of predictive testing is contrary to survey findings of high interest in predictive screening of unaffected family members in Singapore 3 7 25. Patients who declined predictive testing in other studies have cited fear of emotional burden and stress associated with genetic information on themselves as reasons for not availing themselves to genetic testing 3 7 26. This is an area in critical need for further research so as to best understand how we can improve FDR testing rates to optimise health impact.…”

“…Cancer is the leading causing of mortality in Singapore1 2 with a conservative 5%–10% of cancers having an inherited nature. Clinical cancer genetic testing was first introduced in Singapore in 20013 but did not service a comprehensive range of cancers owing to limited resources at that time. Since 2014, the Cancer Genetics Service (CGS) at the National Cancer Centre Singapore (NCCS) has systematically addressed the manpower shortage with the introduction of formally trained genetic counsellors to the clinical team led by a clinical cancer geneticist 4.…”

“…Notwithstanding the growing accessibility of clinical genetic testing in Singapore through improved manpower and infrastructure for genetic testing, previous3 and recent reports5–7 from Asia continue to report low uptake of genetic testing in the population identified at risk for inherited cancer. Reasons cited as the main barriers to uptake are high costs of genetic tests to patients and exclusion of clinical genetic testing services from national healthcare systems, with the consequent a lack of government subsidies.…”

“…However, the reports cited are largely outdated, as the cost of genetic testing has dropped tremendously over the last 2 years. The price of testing BRCA1/2 genes previously cited to be ∼S$5058 (US$3667) in 20063 has since dropped sharply with the entry of many clinical molecular laboratories into local and global genetic testing marketplace. At present, clinical genetic testing for known cancer predisposition syndromes costs ∼S$1414 (US$1025).…”