Oncologist Attitudes May Factor into Underutilization of Genetic Counseling, Testing in Black Women with Breast Cancer

There may be a disconnect between oncologist’ perception of their prescribing patterns and their actual prescribing tendencies for genetic counseling and testing based on race, according to findings published in the Journal of Clinical Oncology.

Among 277 physicians surveyed, only 1.8% responded that they believed they were more likely to refer a White patient than refer a Black patient for genetic counseling and testing (GCT). A total of 66.9% of responders believed that Black women with breast cancer have lower rates of GCT than White women, although 63.4% acknowledged that Black women face more GCT barriers than White women do, and 21% agreed that Black women need more resources and guidance throughout the GCT decision-making process.

Overall, the majority of participants believed that lack of trust was a more significant barrier among Black women; 32% of physicians claimed that lack of trust was a barrier to GCT in all populations, while 58.1% stated that their barrier was felt more by Black women. Furthermore, 13.9% stated that noncompliance was an issue with all patients, while 30.6% felt that Black women are more likely than White women to be noncompliant to GCT recommendations (P = .0001).

“Physicians, being the gatekeepers of health care knowledge, have a direct impact on GCT rates in African American women with breast cancer. The role that inequitable physician referrals play in the observed racial inequities in the utilization of GCT for breast cancer has been partly elucidated,” wrote Foluso O. Ademuyiwa, MD, MPH, MSCI, Department of Medicine, Washington University School of Medicine, and colleagues in the study. “This nationwide survey will serve as a basis for understanding physicians’ determinates of GCT for African American women and highlights the necessity of education and interventions to address bias among physicians. Awareness of such inequities can enable further work to address inequities, ultimately leading to improved GCT equity for African American women with breast cancer.”

The study reminded readers that the age-adjusted US mortality rate per 100,000 for breast cancer is 28.7 in Black women vs 20.3 in White women. These statistics represent a 41% increased mortality rate for African American women. A higher percentage of biologically aggressive tumors, as well as limited scientific understanding of the genetic risk factors within this patient population, are both factors that have continued to this disparity in cancer care.

Moreover, although genetic testing has revealed that Black women and White women carry similar rates of pathogenic variants, White women are almost 5 times more likely to receive GCT than Black women.

The survey participants were 58.8% female. Seventy-five percent were medical oncologists and 61.7% were academic physicians. Overall, 67.1% were White, 23.8% were Pacific Islander, and 3.3% were Black. The survey included 49 items and queried participants about their own demographics, clinical characteristics, knowledge, attitudes, practices, and perceived barriers in referring patients with breast cancer for GCT.

Although 97.1% of participants demonstrated thorough knowledge of HBOC genetics, only 73% had a thorough understanding of the Genetic Information Nondiscrimination Act. Similarly, despite the fact that 94.2% of respondents stated that they properly understood NCCN guidelines for HBOC testing, 55.1% stated that the NCCN guidelines were complicated. Furthermore, although more than half of respondents claimed the guidelines are complicated, 94.2% still believed they were qualified to recommend GCT to their patients in clinical practice.

Only 5 people who responded to the survey thought they were more likely to refer a White patient for GCT than an African American patient.

Furthermore, only 37.7% of respondents expressed that all patients with breast cancer should undergo GCT while a significant portion (82.2%) stated that all patients with breast cancer should obtain testing only after counseling. A smaller percentage (73.8%) stated that all Black patients with breast cancer should obtain testing only after counseling.

A portion of participating oncologists shared that a consideration of the psychologic distress connected to GCT also influenced their referring decisions. According to the results, 51.6% of oncologists believe that patient distress increased if patients received genetic testing and 54.8% of oncologists believed that Black patients with breast cancer are more likely to experience an increase in psychological distress, compared with White patients. In contrast, only 32% believed that a patients’ lack of trust is a barrier to GCT for all patients with breast cancer, whereas 58.1% of oncologists felt that this barrier is more significant among Black women with breast cancer.

Researchers also assessed the oncologist’s perception of patient’s insurance and potential job discrimination. Fifty-eight percent of oncologists felt that poor insurance or job discrimination related to having a pathogenic mutation was more common among Black patients. Findings also demonstrated that 25.7% of oncologists believe that Black women are more likely to refuse to undergo GCT compared to White women.

The majority of participants (64.1%) agreed that GCT costs were a barrier for all patients, however, nearly half felt that this cost was more of a barrier among Black women (46%).

In summarizing the main findings, the study authors addressed the significance of perceived complicated NCCN testing guidelines. Racial inequities may potentially be exacerbated if complicated guidelines are being used in busy oncology clinics, they wrote. Furthermore, the study authors noted that a high percentage of oncologists believe that Black women have more GCT-related barriers than White women, believing that lack of trust and poor compliance records were more common among this population.

The study also highlighted a disconnect between physicians’ self-reported attitudes and actual practicing habits. Although studies have demonstrated that Black patients receive significantly lower GCT referral rates, merely 2% of oncologists believe that they are more likely to refer a White patient.

“There were no observed racial differences in self-reported practices regarding recommending referrals for GCT or actually obtaining testing,” concluded the study authors. “In previous studies, we and others have shown that African Americans who meet NCCN criteria are much less likely than Whites to be referred for or undergo GCT. It is possible that physicians may not recognize that they are inadvertently contributing to racial inequities. This underscores the need for programs to enhance awareness among oncologists to enable effective and guideline-concordant GCT for African Americans.”

“In this personalized medicine era, the knowledge of a patient’s germline genetic status can lead to improved clinical management, cascade family testing, and prevention of other malignancies in patients and their relatives,” they added. “Therefore, achieving appropriate use of GCT in African American patients is an essential step in minimizing on- going and future racial disparities in clinical outcomes.”

Reference

Foluso OA, Salyer P, Tao Y, et al. Genetic counseling and testing in African American patients with breast cancer: a nationwide survey of US breast oncologists. 2021; doi: 10.1200/JCO.21.01426 Journal of Clinical Oncology