USPSTF just released the draft guidance, for public comment, today on February 19, 2019. While USPSTF accepts comments on draft guidances, changes between draft and final are usually fairly small.
Comment Period Until March 18
Find the draft guidance page here. The comment period for BRCA related testing is open until March 18, 2019. There are separate comment channels for "evidence analysis" and "recommendation."
Basic Recommendations Unchanged
The headline news is that the basic recommendation is that women should be screened for high risk family histories, and, if positive, referred to genetic counseling, and, if desired, BRCA testing. This is unchanged. There is an insertion that uses ethnicity/ancestry as a trigger point, in addition to having relatives with cancer.
 |
| click to enlarge |
Also unchanged is the recommendation against routine screening and testing for women without a familial or personal cancer history. In contrast, a range of articles and opinions have advocated for broader use of BRCA genetic screening (e.g. Beitsch et al., 2019, here, and Yang et al., 2018, here.)
Some USPSTF recommendations have age brackets (e.g. mammography) but the BRCA guidance has no remarks on patient age.
Medicare vs USPSTF vs NCCN Guidelines (!)
Note that these recommendations are dysjunct with Medicare coverage. Medicare coverage for BRCA (and related) testing is currently only in women with a personal history of cancer. Medicare coverage follows the first of two tracks of NCCN recommendations; NCCN recommendations have one track for personal history of cancer, and one track for family history of cancer. USPSTF offers preventive services, so it focuses on care of women without a personal history of cancer.
The summary report at USPSTF contains a lengthy section on guidelines of other bodies - NCCN, ESMO, ACMG, ASCO, etc. Too late for inclusion, the American Society of Breast Surgeons guideline was just updated in early February (here), recommending testing in all women with breast cancer (CNN here). (Women with breast cancer wouldn't be part of the USPSTF prevention guidance.)
The USPSTF guidance refers in passing to the multiplicity of testing - multigene panels are available - but these aren't highlighted any further in the recommendation document. There are a few remarks around page 39 of the 440-page evidence review document.
For Affordable Care Act Preventive Services, HHS Has Coupled Genetic Counseling with Testing
Based on an HHS ruling shortly after the Affordable Care Act was passed, the ACA preventive benefit for commercial plans must include both genetic counseling and BRCA testing without copay (not only counseling). Here (archive here).
 |
| click to enlarge |
