Beyond Genetic Testing: Preparing for the Era of Personalized Cancer Prevention

While access to genetic testing has improved substantially in recent years, significant challenges remain in ensuring patients and their families fully understand the implications of test results and receive appropriate follow-up care. Increasingly, experts are emphasizing that genetic testing is only one component of a broader cancer risk assessment strategy that incorporates family history, individualized screening recommendations, and ongoing reassessment as scientific knowledge evolves.

At the same time, emerging technologies—including multi-cancer early detection (MCED) testing—have the potential to reshape how cancer is identified and managed in the years ahead. These advances may create new opportunities for earlier detection, but they will also require community oncology practices to rethink workflows, referral pathways, and long-term management models for patients at elevated risk.

In an interview with Targeted Oncology, Ranjit Goudar, MD, director of the Hereditary Cancer Program at Virginia Oncology Associates, discussed persistent barriers to genetic testing adoption, the future role of risk assessment in oncology care, and how community practices can prepare for the next generation of cancer prevention and early detection strategies.

This is part 2 of a 2-part series. Read the first part of the interview here.

What barriers to genetic testing and hereditary cancer risk assessment still need to be addressed?

One of them is the patient’s understanding of the process. Many patients are declining testing without having a pretest consultation visit... We provide documentation, family letters to explain what is going on, and the pros and cons of testing for a particular mutation that was identified in the patient in front of us. I say, “Look, your relatives are adults; they can certainly make an adult decision not to pursue testing.” However, I prefer they make that decision after speaking about this with a genetics provider, as opposed to declining at the kitchen table, because there can be a lot of benefits to testing; there certainly can be some risks as well, [such as] anxiety, etc. So, I tell my patients clearly [that] I'm in favor of genetic testing... I don't want to have to treat a patient with chemotherapy because we detected cancer at advanced stage when we could have reduced the risk, prevented [and] detected it earlier, if we knew that patient was at high cancer risk. My patients are on board with that; it makes sense. So, I make no bones about the fact that I support the entire process of risk assessment.

Many patients and their relatives feel like a genetic test result is the end of the story. That is in fact what we used to tell patients and families with a negative test result 10 years ago. Now, we know that's not true, and we know that many individual patients, even without a family history of cancer, have a higher calculated risk of breast, colon, and pancreatic cancers. A lot of folks feel like testing is the end of the story, and it's not. We may be able to reassure some patients and say, “Well, we found a certain mutation in your family, and you tested negative for that. We recalculated your breast cancer risk, and it's close to average, so continue your regular screening.” But we need to make clear to those folks, they still could develop an unrelated cancer. Having a negative genetic test result doesn't mean you should skip your regular screening, breast exams, mammograms, and colonoscopies. So, we want to make sure that patients understand what screening we recommend. That's the key in our program; in my practice, genetic testing is a means to an end. What we really want to do is to develop a personalized cancer screening plan and make sure that our patients understand that is our recommendation at one single point of time, but many things could change. The patient's history changes, family history changes, our screening models change, or our screening technology changes. Even a patient that we feel is at average risk, we ask them to contact us. They don't need to come back to the office, but we ask them to contact us once a year to update us with new information from their side. I let my patients know, at some point in the future I may need to call them back and say, “We've discovered a new gene or a combination of genes that raise the risk of the cancers found in your family. I may ask you to come back in and talk about a re-evaluation.”

What short- and long-term advances do you anticipate in this space, and how should community oncology practices prepare?

I'm quite certain that over the next few years, we will see advances that will be difficult to predict even today… advances in screening that are coming will be very useful, specifically [MCED] testing for patients without a history of cancer. That will be revolutionary in my mind. That type of test has not been validated; they are not approved by the FDA or insurance, and I do not think that they're ready to be used at this time. The number of false positives is incredibly high, but within 2 years, my prediction is that type of multi-cancer detection test will be available and relatively standard for patients on Medicare. We have approximately 80 million Americans on Medicare at this point; over 1% of them has an undiagnosed cancer right now, so that's a very important population for us to look at. But…these MCED tests carry a 50% false positive rate, and so instead of seeing the 1% of patients with cancer, we'll need to see that 2% of patients who've had a positive result. That will be a stress on the oncology system, and I think we need to prepare for that.

Community oncologists are busy…again, because the average patient presents with a relatively advanced stage, the patient may be ill from underlying symptoms: losing weight related to pancreatic cancer, having a mass related to breast cancer. We need to deal with creating a treatment plan while simultaneously treating the patient's symptoms. If a patient has significant weight loss, we need to avoid significant nausea from chemotherapy. There may [also] be a complex situation that may extend to social situations and insurance issues.

Now, we need to start thinking about what we will do in terms of workflow: in terms of training providers, in terms of patient flow through the office, how we will move towards seeing patients who are currently healthy but are at higher risk. We do, of course, have primary providers, gynecologists, and gastroenterologists; they are very busy as well. In our area, even with a large number of doctors, it may take more than a year to have a new appointment with a new primary doctor. We [oncologists] don't have that luxury; our patients need to be seen quite quickly. So, this is another thing that we will need to take on in the next few years. We are likely a generation away from moving towards seeing healthier patients to prevent and detect cancer at earlier stages. We have a generation of Americans who have cancer or are at high risk and have not been evaluated yet. My opinion is that within 10 years, we will offer some panel of genetic testing to all Americans. That's not the issue; the issue is who will take us up on that. Even in our high-volume center, our last set of numbers was from 2024—we saw 80% women and 20% men, and we should see 50/50; that is something that we need to work on from our end. There are significant cancer disparities, and there are certainly significant genetic testing disparities, but we need to lay out a plan in each office in each community practice across the country [for] how we will intake these patients, identify those at high risk, plan out their risk assessment, lay out which other specialists that may entail, and how to follow these patients over time. Especially [among] those who carry a mutation, their management guidelines may change as often as once or twice a year. We do follow those patients long term, because in my opinion, oncologists, especially those in the community, are best equipped to do so.

Beyond genetic testing itself, what opportunities exist to improve cancer risk assessment, screening, and referral pathways for high-risk patients and their families?

The next larger issue at the top of the funnel… is trying to make sure that outside referring providers have a better sense of how to identify these patients at higher risk and where to refer them. Many of us in our middle age were trained that oncologists do not want to see patients unless they have a tissue diagnosis of cancer. We need to move away from that, and our gynecologists and gastroenterologists here in the area are well versed in these issues now, and they see our practice as a referral point, as they should. The bigger thing in my mind is expanding screening to those patients we identify at higher risk who test negative for a mutation, and the implications for their families.

As an example, [for] patients who have more than 20 precancerous polyps over their whole life, which [represents] a high number of Americans… patients with over 10 polyps qualify for genetic testing. Patients with over 20 with a negative test fall into a category called colon polyposis of unknown etiology, and the name says it all, but close relatives of those patients would qualify for colonoscopies in some cases as often as every 1 to 2 years, and the vast majority of them do not know.

Up to 10% of American women would qualify for discussion on high-risk breast cancer screening, specifically with breast MRIs. Over the last few years, the Mammogram Quality Safety Act now requires reporting of mammogram breast density on the radiology report, but the vast majority of women don't know what that means, how that relates to breast cancer risk, what to do or where to go with that information, or how to have that evaluated. Mammogram density is rated from A through D, D being the most dense. The newest set of guidelines from 2026 tells us that [for] women with extremely dense breast tissue—category D—if they have category D density at age 50 or [older], they are automatically qualified for screening with mammogram annually, and 6 months later, breast MRI annually. We need to make sure that patients, and then unaffected relatives, and then general Americans are aware that community oncologists want to see them… We need to stop talking about genetic testing and test results. We need to move towards a complete process of risk assessment, and to watch that information, identify those patients, and keep them and ourselves updated, because this risk assessment space, in my immediate experience, changes even more rapidly than treatments for [cancer], because we are talking about panel testing as opposed to treating or screening for 1 individual tumor type.