“Free the Test”: A new editorial asks why BRCA testing rates still haven’t moved in over a decade

From Martinez KA & Rothberg MB. "Breaking the Genetic Counseling Bottleneck in BRCA Testing." Journal of General Internal Medicine, March 2026.

"There is no single intervention that can reduce a woman's chance of being diagnosed with breast or ovarian cancer more than BRCA testing."

A recent editorial published in the Journal of General Internal Medicine takes a look at one of the more frustrating failures in preventive cancer care: the fact that up to 80% of women eligible for BRCA genetic testing still have never received it, despite the test being cheap, non-invasive, and widely available for years.

The lead authors, Martinez and Rothberg, believe that the problem is no longer the test itself, but the system built around ordering it.

Why have testing rates for BRCA not improved in 25 years?

Martinez and Rothberg’s article is focused on the US-based population. It suggests that the problem of low BRCA testing rates is due to a standard of care that has not kept pace with how much BRCA testing has changed in the last 25 years. When the original model of BRCA testing requiring pre- and post-test genetic counselling was proposed in 2003, it was estimated to have applied to around 150,000 women per year in the US who had already been diagnosed with cancer. Today, due to increased testing scope aimed towards cancer prevention as well as treatment, more than 10 million women in the US are now eligible for BRCA testing. The genetic counsellor bookend testing model was never designed for that scale, and the numbers appear to bear that out: despite the genetic counselling workforce doubling over the past decade, testing rates did not increase at all between 2014 and 2022.

The authors of the article are direct about why they believe that to be the case: while BRCA testing is more efficient, cheaper and accessible, genetic counsellors' scope of practice has also expanded in tandem over the same period, absorbing new caseloads in whole genome sequencing, multigene panels, and pharmacogenomics. Growing the workforce has not freed up capacity in hereditary cancer testing because any new capacity is immediately consumed elsewhere.

The primary care integration argument

The article does advocate for primary care providers (PCPs) taking on greater responsibility for identifying and testing eligible individuals. The United States Preventive Services Task Force (USPSTF) has recommended since 2005 that PCPs identify women at elevated BRCA risk, and the same body has stated that trained PCPs are qualified to provide BRCA counselling directly, as they would with any other type of primary care cancer screening. Martinez and Rothberg recognize that most PCPs are unaware of this, and that the gatekeeping function of genetic counsellors is, in many cases, due to convention rather than a legal or clinical requirement.

But the article is also honest about the limitations of primary care integration. The authors cite research estimating that PCPs would, in fact, need more than 24 hours in a day currently to deliver all guideline-recommended care for their patients. This is why perhaps shifting BRCA counselling and testing onto an already overloaded PCP workforce without changing anything else is not an entirely realistic solution. Rather, the article frames PCPs as an underused resource rather than a home run fix for the shortfall.

The potential for innovative and technological solutions

What the article makes clear is that there must be a willingness to explore redesigning the testing pathway itself. The authors point to the potential of telehealth-based counselling models, AI chatbot tools for genetic cancer risk assessment, and clinical decision support systems as directions worthy of serious attention. They are careful not to oversell any of these, as clinical evidence on acceptability and feasibility is still underway for validating most technology-based options in primary healthcare.

Their concern is with models that continue to place a genetic counsellor at the centre of every testing pathway, whether in person or via telehealth. As the authors put it, this approach improves access at the margins without addressing the underlying bottleneck. The invitation is to think more ambitiously about what a genuinely different model could look like.

How does this problem apply in the Canadian healthcare context?

The arguments in the editorial must be considered differently when read from a Canadian perspective, because Canada faces versions of both bottlenecks discussed, and they are arguably more acute in a socialized healthcare model.

On the genetic counselling side, as of 2022, Canada had an estimated 484 certified genetic counsellors, according to research published in the Journal of Genetic Counselling. Demand for their skills has grown considerably faster than that small workforce. Canada's federal Job Bank currently classifies genetic counsellors as facing a strong risk of labour shortage through to 2033. Research published in the same journal found that available genetic counselling resources already fall well short of public demand, resulting in long wait lists and inequitable access across provinces and territories. 

The picture on primary care is equally challenging. The OurCare survey, published in late 2025 in partnership with the Canadian Medical Association, found that nearly 5.9 million Canadians (roughly 15% of Canada’s current population) still lack reliable access to a regular family doctor or nurse practitioner. That figure has improved slightly since 2022, but it means that for a significant portion of the population, the question of who orders a BRCA test is somewhat academic when the more immediate problem is having no consistent access to primary care at all. Research published in Frontiers in Medicine in 2025 also noted that the average number of patients seen per family physician fell from 1,746 in 2013 to 1,353 in 2021, reflecting growing workload complexity rather than shrinking effort. Canadian family physicians are not an untapped reserve.

This is also why the editorial's broader argument resonates particularly well in Canada. The call is not simply to hand responsibility to PCPs. It is to stop treating the current counsellor-gated model as fixed, and to take seriously the question of what genuinely different pathways, whether through digital tools, risk-stratified triage, or new scopes of practice, might look like at scale. 

One could argue that in a system where both the genetic counselling workforce and the primary care workforce are under significant strain, compromises in the level of hands-on case oversight should be considered where the trade-off is meaningfully increased testing accessibility. Healthcare systems are always considering the calculus of benefit versus harm, and BRCA care is no exception. Adjusting models of care to reflect changes in technological development and the relative cost of BRCA testing is essential as healthcare evolves.  Rather than fixating on ‘best practice’ and convention, we should be ensuring that more patients have the opportunity to prevent their BRCA-driven cancers rather than bear the consequences of decisions based on outdated models.

REFERENCES

1. Martinez KA, Rothberg MB. Breaking the genetic counseling bottleneck in BRCA testing. Journal of General Internal Medicine. Published 10 March 2026. doi:10.1007/s11606-026-09456-5

2. Finch APM, Lubinski J, Møller P, et al. Impact of oophorectomy on cancer incidence and mortality in women with a BRCA1 or BRCA2 mutation. J Clin Oncol. 2014;32(15). doi:10.1200/JCO.2013.53.2820

3. Owens DK, Davidson KW, Krist AH, et al. Risk assessment, genetic counseling, and genetic testing for BRCA-related cancer: US Preventive Services Task Force recommendation statement. JAMA. 2019;322(7):652–665. doi:10.1001/JAMA.2019.10987

4. Chen Z, Kolor K, Grosse SD, et al. Trends in utilization and costs of BRCA testing among women aged 18–64 years in the United States, 2003–2014. Genet Med. 2018;20(4):428–434. doi:10.1038/gim.2017.118

5. Porter J, Boyd C, Skandari MR, Laiteerapong N. Revisiting the time needed to provide adult primary care. J Gen Intern Med. 2023;38(1). doi:10.1007/s11606-022-07707-x

6. Webster EM, Ahsan MD, Perez L, et al. Chatbot artificial intelligence for genetic cancer risk assessment and counseling: A systematic review and meta-analysis. JCO Clin Cancer Inform. 2023;(7). doi:10.1200/CCI.23.00123

7. Kukafka R, Pan S, Silverman T, et al. Effects of patient and clinician decision support for BRCA1/2 genetic testing vs standard education. JAMA Network Open. 2022;5(7). doi:10.1001/jamanetworkopen.2022.22092

8. Knoppers T, Haley CE, Patrinos D, Zawati MH. "Protection for the public, better use of resources and clearer lines": Interviews with genetic counselors and their colleagues on the need for regulation in Quebec. J Genet Couns. 2025;34(2):e1960. doi:10.1002/jgc4.1960

9. Costa T, Gillies B, Oh T, Scott J. The Canadian genetic counseling workforce: Perspectives from employers and recent graduates. J Genet Couns. 2021;30:406–417. doi:10.1002/jgc4.1326

10. Government of Canada. Job Bank: Genetic counsellor — outlook. Updated December 2024. Available at: https://www.jobbank.gc.ca/marketreport/outlook-occupation/25171/ca

11. Kiran T, Canadian Medical Association. OurCare Survey 2025: Access to primary care in Canada. Published December 2025. Available at: https://www.cma.ca

12. Najafizada M. Beyond headcount: Four dimensions of Canada's primary care access crisis and a three-level agenda for action. Front Med (Lausanne). 2025;12:1695409. doi:10.3389/fmed.2025.1695409

This blog post is intended for general informational purposes and does not constitute medical advice. Please speak with a healthcare provider about your personal risk.