How Veterans Feel About Genetic Testing for a Personalized Approach to Medications

Veterans’ Perspectives highlights research conducted by HSR and/or QUERI investigators, showcasing the importance of research for Veterans – and the importance of Veterans for research.

In the January-February 2025 Issue:

• Introduction: Pharmacogenomic (PGx) testing aims to increase the effectiveness — and reduce the potential harms — of medication, but patients sometimes hesitate to agree to it — including some of the Veterans at VA medical centers where PGx testing was made available through VA’s Pharmacogenomic Testing for Veterans (PHASER) program.
• The Study: This study focused on identifying barriers and facilitators to PGx testing through interviews with Veterans who accepted, declined, or were contemplating PGx testing.
• Findings: Facilitators that contributed to Veterans’ decision to undergo testing included the beliefs that PGx testing would improve their medication response and reduce the number of medications that they need to take. Providers, family members, and friends who reinforced Veterans’ autonomy also contributed to Veterans’ decision to undergo testing. Barriers to testing included the time required for testing and related travel, the belief that testing would not be beneficial, the possible negative effect on healthcare insurance coverage, privacy concerns, previous unjust research on military and minority populations, and varying resources and communications from providers about the PHASER program.

Introduction

Our genetics affect how we respond to medications. Pharmacogenomic (PGx) testing aims to increase the effectiveness — and reduce the potential harms — of medication by helping providers know which dose or type of medicine best aligns with an individual’s genetic code. Although the science behind PGx testing is complex, the testing starts with a simple cheek swab or blood draw that enables technicians to extract and analyze DNA that ultimately leads to more personalized prescriptions.

Current evidence supports PGx testing to improve therapies for cancer, and for mental health, pain, cardiovascular, and inflammatory disorders.[1] Research suggests that millions of Americans could benefit from PGx testing, but patients sometimes hesitate to agree to it — including some of the Veterans at VA medical centers where PGx testing was made available through VA’s Pharmacogenomic Testing for Veterans (PHASER) program. PHASER offers PGx testing at no cost to patients for more than 10 genes that inform the prescribing of 40-plus common medications, with continued expansion that broadens PHASER’s usefulness.

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The Study

As part of a broader effort to identify barriers and facilitators to PGx testing, researchers conducted 30-minute interviews with Veterans who accepted (n = 14), declined (n = 9), or were contemplating (n = 8) PGx testing. All groups were informed by a provider or mailed materials from a PHASER coordinator about PGx test procedures and the possible benefits of being tested.

Study Participants

Researchers recruited Veterans from 25 VA sites participating in the PHASER program who were approached about PGx testing between January and October 2022. Most participants were male, White, non-Hispanic, and had completed some college. Half of the participants were retired, and half were married. The average age was 60 years.

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Findings

Veterans’ decisions or hesitation regarding the PGx test were influenced by a range of factors, including their understanding of the test and how to get tested, experiences with medication side effects; input from providers, friends, and family; perceived ease of testing and the consequences of being tested; and trust in VA and the government in general.

Veteran Knowledge

Accepters and decliners understood that PGx testing could help their provider select medications that would improve efficacy, reduce side effects, and reduce trial and error. Accepters and decliners also had some level of knowledge about the logistics of PGx testing. Some contemplators, however, mentioned confusion about the logistics of receiving the PGx test, or didn’t know where to learn more information about the PHASER program.

“What I understood from this test was it basically measures the metabolism of your liver enzymes and how they work with certain medications. But the test also isn’t specific enough to say, I guess, which ones work and don’t. Just maybe how you would process it if it did work, if that makes sense.”—An Accepter

“I don’t really know much about the genetic testing. I never done it. I know that they prescribe different medications for me, and they try to find the best ones for me, the most effective medicine for me. But as far as the genetic testing, I don’t know much about it.”—A Contemplator

“I wasn’t exactly sure what I would have to do.”—A Contemplator

“I think this is the program to see what drugs that I would be amicable [with] based on a genetic, you know, on my genotype as far as how I am receptive to certain drugs to help me for whatever malady that I may have. It is a valid thing, except there are so many things wrong with me that I don’t see what the purpose is for me.”—A Decliner

Decision Processes

Accepters and decliners weighed the benefits and drawbacks of PGx testing differently. Accepters considered the opinions of others and focused on the potential health benefits of testing, while decliners were driven by perceived negative consequences such as the disclosure of personal information or the negative impacts on their healthcare benefits. Contemplators reported not feeling knowledgeable enough to consider the benefits and drawbacks to make a decision. Some study participants considered whether getting tested might help other Veterans.

Accepters stated that easy-to-follow instructions on how to undergo PGx testing allowed them to complete the genetic test during their routine bloodwork. Several decliners and one contemplator anticipated the procedures would be time-consuming, citing time to set up the appointment, travel to and from the VA hospital, and the time to complete the PGx test.

“I had to go in for regular lab work anyway, so they just lumped it in with the rest of my lab work.”—An Accepter

“My PCP is like 25 minutes away, so yeah, I mean, timing does have a little bit to do with it. And the VA hospital is about a 30-minute drive away. So, if I had, you know, something 15 minutes away or 10 minutes away, it would be much easier to go over on a lunch break or something like that and get things taken care of.”—A Contemplator

“In a way, I just thought it was a waste of time. I mean, it is testing me, taking blood from me. How is that going to help the next Veteran? It’s just for that, the individual person, right?”—A Decliner

Accepters generally thought that only licensed professionals would have access to their PGx test results and that their results would be stored safely. Two accepters were pleased that the results could be accessed by providers they do not normally see, such as when they travel and need to see a provider at another VA hospital. Some decliners raised concerns about the safekeeping of their genetic information. Some contemplators also mentioned worries about the storage of their private health information. One decliner felt that test results could negatively affect their private healthcare and long-term insurance.

“I have no problem with [the results being part of my medical record]. I’ve had tests done before, and it was confidential, and they kept the information between me and the VA physicians and [the results] stayed in my medical records. So no, I’m not worried about it.”—A Contemplator

“With technology the way it is, you know, your genetic DNA could get misused on other things that it’s not meant for. . . . It could be put in the wrong hands and used for something negative.”—A Decliner

“If I do [it], there could be possibilities of something coming up negatively in the future of my DNA used for this, my DNA used for that. . . . The government has tested people without their knowledge and done things to people without their knowledge — and [we] find out later there was something negative that the government [has] done to people.”—A Decliner

Social Influence

Accepters mentioned that clear communication with a provider encouraged them to undergo PGx testing. They directly asked providers about how the PGx test could benefit their care and what procedures they should follow to receive the test. In contrast, several decliners indicated that providers did not influence their decision. A few decliners mentioned that their past education and personal research on the topic allowed them to feel secure in deciding to decline the test. Two contemplators stated that they would like to talk to a provider about the PHASER program to help them make a decision.

In several cases, family and friends also influenced participants’ decisions. Some accepters said that family and friends emphasized the possible benefits of testing, and two said the opportunity to help other Veterans supported their decision to undergo PGx testing. Several decliners and contemplators indicated that family and friends did not influence their decision.

“[A friend] told me about [PGx testing] when her mental health team first suggested it. And so we were kind of like, eh, she’s going to try this, and we’re going to kind of sit back and watch and see what happens. And her test results came back, and she sat down with her doctor and went over the test results. And they immediately switched her meds around. It was such immediate improvement, such a quick improvement after going over the results with her.”—An Accepter

“I was in a negative frame of mind, and I still am regarding medicine. The prescriptions they have given me have done nothing. . . . And so, I don’t know that genetic testing is going to help that at all. I doubt it.”—A Decliner

Beliefs About Consequences

Nearly all participants believed that PGx testing could reduce trial and error to find the right medication. Accepters and some decliners hoped that PGx testing would result in them taking fewer medications and believed that testing could result in fewer side effects, an optimal dose, and living better. One decliner believed PGx testing would not benefit her because she has no children, while another felt that they were too old to benefit. Other decliners explained that they did not see the benefits extending beyond their current healthcare goals to their long-term goals. Two contemplators said they were unsure about how PGx testing could benefit them.

Outcomes of Testing and Veterans’ Future Intentions

A few of the accepters were not certain if anything came of the testing because their providers did not mention changes to their medications or confirm that their current medication and dosages were consistent with the test results. Two accepters who did not know how the testing had affected their healthcare reported that they would not undergo testing again. Several decliners stated that they do not intend to receive the PGx test until there is clarity regarding how VHA stores and secures genetic information.

“I would do anything to help myself and to help other Veterans, of course. I would do another genetic testing if it was more . . . specific to the medication that would work.”—An Accepter

“[I feel] good, very good, because there’s not a question in the back of my mind if I’m going to keep trying medications, which I’m not. So that’s, for me, that’s a big thing I can check off the boxes. I’m not going to be playing around, trying to figure out what concoction of chemicals works or doesn’t work.”—An Accepter

“There’s a possibility. I have a lot of medical issues going on right now. So now that I have a little more information on it, if the opportunity presented itself again, then there’s a possibility that I might go ahead and do it.”—A Contemplator

“Well, I can’t predict the future, and I know that I’m always subject to changing my mind. That’s, the older I get, the more I learn every day from my own mistakes. And it may happen that I see this as a mistake. It hasn’t yet.”—A Decliner

Suggestions for PHASER Improvement

Participant suggestions to improve the PHASER program centered around improving education for Veterans about testing procedures, possible outcomes, the safekeeping of data, and access. One accepter requested more education aimed at medical providers regarding the PHASER program. A few accepters mentioned that the test needs to be more accessible. One accepter felt that the test should cover additional medications. Two decliners noted that VA should provide more information about PGx testing via different communication methods such as in-person discussions and mailed letters. Two contemplators mentioned that VA should make sure patients receive appropriate information and follow-up to improve participants’ understanding. Some contemplators preferred discussion with a provider to learn about the pros and cons of PGx testing, while others preferred a letter that clearly explains PGx testing.

“I think it needs to be more readily available to everybody right now.”—An Accepter

“I think maybe if I was provided a pamphlet with information, what the testing would be used for exactly, who would have that information, [and] what exactly they’re looking for, [that would help].”—A Contemplator

“Maybe more information just because, and it’s like when you say we’re going to use your DNA to test, to, say, test to see if we use the right medication for the right people. It’s like, when they say it like that, it’s like a more clinical thing. Like it’s not personal. You understand? . . . Maybe make it a little bit more personal instead of like more cut-and-dry clinical.”—A Decliner

Implications

Information about PGx testing for Veterans should emphasize how the test can benefit their care and what the test cannot do. It should also highlight how VA safeguards participants’ private health information. Additionally, there is a need to find other ways to offer PGx testing, such as through mobile phlebotomy.

Corrine Voils, PhD, is an HSR Research Career Scientist and Principal Investigator of PHASER QUERI.

Study Publication

Melendez K, Gutierrez-Meza D, Gavin KL, Alagoz E, Sperber N, Wu RR, Silva A, Pati B, Voora D, Hung A, Roberts MC, Voils CI. Patient Perspectives of Barriers and Facilitators for the Uptake of Pharmacogenomic Testing in Veterans Affairs’ Pharmacogenomic Testing for the Veterans (PHASER) Program. Journal of Personalized Medicine. September 9, 2023;13(9):1367.

^[1] Genophenotypic Factors and Pharmacogenomics in Adverse Drug Reactions - PubMed

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