Cascade Testing Barriers: How to Overcome?

Hereditary cancer syndromes account for 5%-10% of all cancers. Identifying pathogenic variants in a proband guides clinical management and enables targeted testing of at-risk relatives through cascade testing. By clarifying carrier status, relatives can adopt early surveillance and undergo risk-reducing interventions, while noncarriers are reassured. Despite clear clinical benefits and cost-effectiveness, cascade uptake remains low worldwide, averaging only ~15%-30%. This review examines facilitators and barriers to cascade testing, and outlines strategies to strengthen uptake. Barriers that exist across three interrelated levels are as follows: Individual, provider and health system. At the individual level, psychosocial concerns such as stigma, discrimination and fear of causing distress to family may limit disclosure. Limited health literacy, misconceptions and cultural norms may further reduce uptake, particularly among underserved groups. Overcoming these challenges requires culturally sensitive, patient-friendly communication to empower families to make informed choices. At the provider level, ethical dilemmas around confidentiality, confidence gaps among non-genetics professionals and shortage of genetic counsellors constrain service delivery. Embedding genetic counsellors in the wider healthcare setting, upskilling non-genetics professionals and normalising conversations about cascade testing can mitigate these barriers. At the health system level, prohibitive costs, fragmented referral pathways and administrative inefficiencies impede access, while legal gaps around genetic discrimination discourage uptake. Sustainable financing models, streamlined care pathways, legislation and international collaborations are needed to support equitable implementation of cascade testing. Cascade testing remains a powerful means for cancer prevention. Addressing individual, professional, and structural barriers through context-specific, multi-level solutions is key to realising its potential and advancing precision medicine globally.