1. DiGiulio, Sarah

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Given disparities in breast cancer outcomes among Black women with breast cancer compared with White women and given the fact that White women are significantly more likely to undergo genetic counseling and testing for gene mutations that heighten breast cancer risk, oncologists set out to better understand physician attitudes and potential biases that might contribute to these disparities. The data showed that racial differences indeed exist in physicians' perceived barriers to genetic counseling and testing for patients with breast cancer.

Foluso Ademuyiwa, MD... - Click to enlarge in new windowFoluso Ademuyiwa, MD, MPH, MSCI. Foluso Ademuyiwa, MD, MPH, MSCI

For the new study published in the Journal of Clinical Oncology, researchers surveyed 277 physicians: 58.8 percent were female; 75.1 percent were medical oncologists; 61.7 percent were academic physicians; and 67.1 percent were White (2021; doi: 10.1200/JCO.21.01426). Only 1.8 percent reported being more likely to refer a White patient for genetic counseling and testing than an African-American patient. But 66.9 percent believed that African-American women with breast cancer have lower rates of genetic counseling and testing than White women.


Other findings included the following: 1) 63.4 percent of respondents indicated that African-American women face more barriers to genetic counseling and testing than White women; 2) 21 percent felt that African-American women require more information and guidance during the genetic counseling and testing decision-making process than White women; 3) although 32 percent of respondents indicated that lack of trust was a barrier to genetic counseling and testing in all patients, 58.1 percent felt that this was a greater barrier for African-American women; and 4) 13.9 percent believed that noncompliance with genetic counseling and testing is a barrier for all patients, whereas 30.6 percent believed that African-American women are more likely than White women to be noncompliant.


In an interview with Oncology Times, the study's lead author, Foluso Ademuyiwa, MD, MPH, MSCI, Associate Professor of Medicine in the Division of Oncology's Section of Breast Oncology at Washington University School of Medicine, explained that these survey findings suggest some clinicians may hold implicit biases. Here's why she says the findings are significant and what's important for practicing cancer care providers to know.


1 Why did you and your colleagues decide to conduct this research now?

"Genetic testing for gene mutations (BRCA1 or BRCA2) is able to identify individuals at high-risk for developing diseases such as breast cancer. If such mutations are detected, enhanced screening with both mammograms and MRIs are offered, rather than mammograms alone. This strategy is then able to detect breast cancer at the very earliest stages when most curable. Preventive medications or surgeries are also options to reduce the risk of developing breast cancer in those with mutations-and family members also have the option of getting tested for the same genes. In addition, for those who do develop breast cancer due to gene mutations, targeted therapies are now approved and improve outcomes.


"The specific reason for conducting this research now is that, over the last few years, we and others have shown that doctors do not refer Black patients for genetic counseling and testing at the same frequency as White patients, even though they have similar rates of mutations. Therefore, Black patients (and their families) miss out on these important health benefits. As such, we decided to do a national survey where we asked doctors from all over the United States about their practices regrading genetic counseling and testing for patients with breast cancer to determine if there is any inequity in how Black patients are managed."


2 What were the key findings and do they differ from what was previously known about these types of disparities?

"Only less than 2 percent of doctors who responded to the survey stated that they refer White patients for genetic counseling and testing more frequently than Black patients. This is not consistent with the literature that shows that, even when eligible, doctors refer less than 60 percent of Black patients versus over 90 percent of eligible White patients (Breast Cancer Res Treat 2019; doi: 10.1007/s10549-019-05359-w).


"Doctors also felt that Black patients have more barriers to getting genetic counseling and testing, require more education about the process, and are more likely to be non-compliant with following through with testing recommendations. These responses likely represent implicit biases towards Black patients."


3 What is most important to know about how these disparities might affect patient care?

"If Black patients have less testing rates, they (and their families) miss out on the precision medicine that comes with knowing your risks. They also miss out on the targeted medications for individuals with certain mutations. As physicians, we need to make sure we are providing equitable care to all patients. The genetic counseling and testing referral process needs to be simplified, access needs to improve, and testing criteria needs to be expanded. The medical community also needs to enhance training of oncologists and improve diversity in the oncology workforce.


"[Gaps in the research include] understanding how to implement clinic-based interventions to help increase genetic counseling and referral rates for Black patients, and understanding specific barriers faced by doctors in clinic so that we can design interventions to mitigate those. Genetic testing has the ability to detect individuals and family members at high-risk for breast cancer, and can lead to preventative options, early detection, targeted treatment, and saved lives. All races need equitable medical care."