'Implicit Biases' in Referrals for Genetic Testing of Breast Cancer?

Pam Harrison

October 22, 2021

A nationwide survey of breast oncology physicians has found that their self-reported practices and attitudes regarding genetic counseling and testing (GCT) for African American women with breast cancer show a disconnect with what is seen the real world.

In the survey, almost 90% of respondents said that they obtain testing for all African American patients with breast cancer who meet guidelines.

However, previous studies have shown significantly lower GCT referral rates for African American patients: they account for less than 10% of individuals undergoing genetic counseling and testing for BRCA1/2 or other breast cancer susceptibility genes, vs more than 65% of White women.

"The reasons for lower physician GCT referral rates for African American patients are unknown, but may be due to implicit biases," say the authors of the survey. "It is possible that physicians may not recognize that they are inadvertently contributing to racial inequities."

The survey also found that that 63.4% of physicians perceive that African Americans have more barriers to GCT than White patients, especially with the costs involved. In addition, 58.1% felt that lack of trust was a greater barrier for African American patients, and 30.6% felt that compliance with GCT recommendations was poorer among African American patients than it was among White patients.

"To the best of our knowledge, this is the first study to provide insights into the self-reported practices of US physicians to explore racial inequities in health care," say the authors, led by Foluso Ademuyiwa, MD, MPH, Washington University School of Medicine, St. Louis, Missouri.

The study was published online October 18 in the Journal of Clinical Oncology.

This study is "important as it shines a mirror on us all to confront our prejudices and biases," write the authors of an accompanying editorial, Sophie Sun, MD, and Karen Gelmon, MD, both from the British Columbia Cancer Agency in Vancouver, Canada.

It is a "reminder that cancer must be equitably treated with the best evidence-based medicine and [that the] guidelines are for all patients," they add.

In the short-term, updating and simplifying referral and testing criteria should help improve patient referral rates and access to GCT. "Revised guidelines should also reflect new treatment indications and include testing individuals who may not have an immediate indication but where the knowledge of a germline mutation may affect the patient or the family," the editorialists add.

"Most patients are interested in answering the question of 'Why did I get cancer'? And appropriate germline information can help answer this," they point out.

Details of the Survey Responses

The survey included responses from 277 physicians, three quarters of whom were medical oncologists and two thirds of whom were White.

Two thirds of respondents said that they refer all patients who meet the National Cancer Comprehensive Network guidelines for genetic counseling and testing, but the same proportion of respondents also indicated that Black women with breast cancer are less likely than White women to receive GCT.

Just over 37% of respondents said that every patient with breast cancer should undergo GCT, and only 1.8% of respondents indicated they were more likely to refer a White patient for GCT than an African American patient.

About 75% of respondents indicated that they have had patients refuse GCT, and 25.7% of respondents believed that African American women are more likely to refuse GCT than White women (P < .0001).

Approximately half of respondents indicated that they considered patient distress as a barrier to GCT in general, even though previous studies suggest that GCT-related cancer distress is low.

The findings "highlight the pressing need for interventions to improve rates of GCT and ultimately guideline-concordant care in African American patients with breast cancer," the authors conclude.

Given that physicians have a direct impact on the use of GCT in all women with breast cancer, "more equitable use of GCT for African Americans may represent a critical component through which we can potentially address racial disparities in breast cancer mortality," they add.

Ademuyiwa reports having received honoraria from Best Doctors and Advance Medical as well as serving as a consultant/advisor and receiving research funding from a number of pharmaceutical companies. Editorialists Sun and Gelmon also report relationships with several pharmaceutical companies, as detailed in the article.

J Clin Oncol. Published online October 18, 2021. Abstract, Editorial

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