Testing for PRS is increasingly being offered through commercial genetic testing companies and clinical research. Yet, to our knowledge, there is no training available for healthcare providers on the use of PRS, representing a significant barrier to implementation of this technology (21-23). To address this issue, we developed and evaluated a novel online education for program for breast and ovarian cancer PRS with 124 genetic healthcare providers across Australia. Most participants had positive reactions to the program, including that their learning needs were met, that the content was relevant to their clinical practice and the amount of information provided was about right. Completion of the training program was also associated with improved attitudes towards, and greater confidence, preparedness, and knowledge of PRS and personalized risk. However, knowledge gaps remained post-training suggesting genetic healthcare providers may require additional support applying PRS in practice.

Delivery of the education program did not alter providers thoughts regarding the potential benefits of providing PRS and personalized risk. This finding is likely due to providers having high endorsement for the benefits of PRS pre-education, including strongly agreeing that PRS can provide greater certainty about risk level and inform risk-management decisions. However, only 64% of the cohort believed that PRS would provide opportunities for reduced screening. Prior studies have identified patient and provider acceptance of reduced screening among those identified to be low risk as a potential barrier to implementation of PRS and risk-stratified screening (31-33). This issue may be exacerbated in the context of monogenic testing and familial risk, particularly in instances where PRS alters risk for family members with the same PV/LPV (16). Currently, familial cancer services primarily focus on monogenic aspects of disease risk, whereas implementation of PRS will require a shift towards personalized model of practice that involves personal evaluation of risk for each individual family member (33, 34). New genetic counselling frameworks and risk communication tools will need to be developed to facilitate discussion of personalized risk information and support patient understanding and acceptance.

In Australia, provision of genetic testing is primarily funded through public healthcare, and eligibility for publicly-funded genetic testing for breast and ovarian cancer is based on established national guidelines (30). Unsurprisingly, our study identified that pre-education most clinicians were already using personalized risk tools in their routine practice to assess eligibility for publicly-funded testing and inform risk management. This finding is of relevance given that implementation of PRS for breast and ovarian cancer risk will occur as part of personalized risk prediction tools, rather than utilizing PRS alone (35). As such, an opportunity exists to demystify and normalize the use PRS by supporting providers to identify areas of practice that they are already familiar with, such as communicating complex risk, evaluating multifactorial disease risk, and using risk prediction tools.

Providers in this study most valued the experiential components of the training i.e., role plays and case discussions with peers and field experts in supporting their learning of PRS and personalized risk. Interactive methods, such as case-based learning, are consistently rated as most preferable by adult learners, and most effective at improving learning, performance, and patient health outcomes (36-38). Benefits of case-based learning include provision of tailored education that is immediately relevant to patients, opportunity for interactions with peers and contextualization of knowledge (36-38). Such benefits are aligned with adult learning theory that posits learners are self-motivated due to a recognized need to learn educational content of perceived relevance to workplace practice (39). Despite the benefits of interactive learning, it is important to consider that this approach is resource intensive, requires administrative support to arrange learning events, expert time to develop case studies and role plays, and moderator support. As PRS availability increases, strategies are needed to upscale PRS training to reach a broader audience, while capturing the benefits of case-based learning and interactive models. One potential approach is developing a “train-the-trainer“ model, thereby creating PRS champions who can foster peer learning (38, 40).

Development of this educational program was informed by the Kolb experiential learning model and focused on developing concrete learning, reflective observation, and abstract conceptualization (26). The last item of this model, active experimentation, was not included this educational program. Active experimentation occurs when learners have an opportunity to try what they have learnt, such as seeing patients in a real world setting and discussing PRS information. Active experimentation is an important component of the learning process that involves a gradual building of experience and procedural skills over time (41). Future educational program should consider strategies to support active experimentation, such as online chat groups to provide opportunities to ask questions, identifying PRS champions who can support less experienced staff, and follow-up workshops for reflection and discussion. Additionally, our evaluation only addressed the reaction and learning levels of the Kirkpatrick model. Furthermore, the extent to which the educational program changes practice and behavior beyond the PRiMo study is not known. It is likely that additional implementation barriers, including those identified by study participants (i.e. funding models, lack of clinical practice guidelines and re-analysis over time), will need to be addressed before widespread uptake of PRS in clinical practice. These findings highlight a need for consideration of behavioral change theory to support provider uptake of PRS testing. Theoretical models such as Capability, Opportunity, Motivational model of Behavior change (COM-B) can be used to be used to identify additional barriers to provider uptake of PRS testing and inform development of targeted interventions (42).

Our educational program was targeted to genetic healthcare providers who were participating in a PRS clinical trial, and therefore, had relevant baseline genetic knowledge and were motivated to complete the training. Thus “just in time“ training was applied, which is shown to be an efficient method of education (43). To ensure continued learning and successful integration of PRS and personalized risk, a comprehensive suite of educational resources will need to be developed and adapted to different contexts and settings (23). For example, primary care providers and other non-genetic specialists will have different values, learning needs, and perceptions of PRS that will need to be considered in the development of future educational resources. Future needs assessments will need to be conducted to ensure targeted education is developed. Strategies such as point-of-care resources may need to be developed to facilitate patient communication and provider education. Similarly, access to training through other online portals, conference or professional organizations should be considered.