Barriers To Genetic Testing Adoption in Oncology: A Cross-Sectional Survey from Pakistan.

Genetic testing is central to personalized cancer care, yet its routine use remains limited in low- and middle-income countries such as Pakistan. Little is known about how clinician confidence, institutional resources, and system-level barriers jointly influence its adoption in this setting. This study aimed to identify the key barriers influencing the use of genetic testing in oncology and to explore practical ways to strengthen its adoption in clinical practice. A cross-sectional survey was conducted among 49 oncology clinicians in Pakistan between August and December 2023. The questionnaire assessed clinician confidence, ordering practices, knowledge, training, and perceived barriers related to genetic testing. Two outcomes, low confidence and infrequent test ordering, were analyzed using Fisher's exact test and odds ratios to identify key associations. Open-ended responses were reviewed using an inductive thematic approach to capture context-specific implementation barriers. Among respondents, 14% reported low confidence in their knowledge of genetic testing and 18% rarely ordered tests when indicated. Limited access to a testing laboratory was strongly associated with both low confidence (odds ratio 22.0, p = 0.002) and infrequent ordering (odds ratio 14.0, p = 0.002). The absence of a genetic counsellor showed a positive but non-significant association with confidence (odds ratio 7.26, p = 0.098). Patient-level barriers, including cost (93%) and perceived stigma or irrelevance (69%), were common but did not significantly predict clinicians' behaviour. Qualitative responses highlighted three intersecting domains of barriers: system-level workflow delays and fragmented processes, clinician-level gaps in genetics training and support, and patient-level misconceptions and financial concerns. Improving infrastructure and integrating genetics education are both essential to expand equitable access to precision oncology. Our findings suggest that in Pakistan and similar LMIC settings, targeted strengthening of laboratory and referral infrastructure, together with genetics-focused education and supportive policies, may have the greatest impact on routine use of cancer genetic testing.