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Physician Bias May Contribute to Lower Genetic Testing Rates Among Black Women, Study Suggests

NEW YORK – A survey exploring oncologists' attitudes about genetic counseling and testing for African American women showed the need to ramp up implicit bias training among doctors and implement interventions to improve access to these services.

The study, published in the Journal of Clinical Oncology on Monday, revealed that some doctors believe that Black women face more barriers to accessing genetic counseling and testing, need more education and support, and are less likely to be compliant with recommended interventions than their white counterparts.

Researchers led by Foluso Ademuyiwa, an associate professor of medical oncology at the Washington University School of Medicine in St. Louis, surveyed 277 breast oncologists around the US to determine why Black women were less likely to be referred for genetic counseling and testing than white patients. Previous research by Ademuyiwa found that while African American women may be more likely to harbor mutations in cancer risk genes, such as BRCA1/2, less than 60 percent of African American women received guideline-backed genetic testing and counseling as part of their routine care, compared to 93 percent of white patients.

In their latest survey, 90 percent of doctors said they obtain testing for all African American patients who meet guidelines and fewer than 2 percent of doctors acknowledged they were less likely to refer a Black patient for counseling and testing than a white patient. However, since this self-reported practice didn't square with earlier research showing racial differences in genetic testing referral rates, researchers dug deeper into physicians' attitudes about testing.

The survey showed that around 63 percent of surveyed doctors believed that Black patients face more barriers when trying to access genetic testing than do white patients. One in five surveyed doctors said that African American women require more education and guidance when deciding whether to get tested or receive counseling. About a quarter of doctors believed Black patients were more likely than white patients to refuse genetic counseling and testing, and 30 percent believed Black women were more likely to be noncompliant with genetic testing referrals.

Moreover, while around a third of surveyed doctors said that lack of trust in their diagnoses or referrals was a barrier to genetic counseling and testing access for all patients, 58 percent of oncologists noted lack of trust as an issue hindering access specifically for Black women. Another 46 percent of respondents believed cost was a greater barrier for Black patients compared to white patients and a potential reason not to refer them for genetic testing and counseling.

Two-thirds of oncologists surveyed were white, and nearly 60 percent were female. Female respondents were more likely than males to indicate that African Americans have lower rates of genetic testing and counseling, 90 percent versus 78 percent. Physicians in practice less than 10 years were also more likely to say that Black patients had lower rates of genetic testing than those in practice longer than 10 years.

Some doctors also had concerns about the accuracy of genetic test results for Black patients. While around a third of doctors said genetic testing has too many ambiguous results for all patients, 20 percent believed genetic testing would produce more ambiguous results for Black women than for white women.

"This study shows racial differences in how oncology physicians perceive barriers to genetic counseling and testing for patients with breast cancer. This is likely due to implicit biases physicians may have towards African American patients," Ademuyiwa said in an email. "This results in a missed opportunity for African Americans, as knowledge of a patient's genetic status can lead to improved clinical management, cascade family testing, and prevention of other malignancies in patients and their relatives."

Considering the higher breast cancer-related mortality rates among Black women and potentially higher incidence of cancer predisposing mutations in genes like BRCA1/2, improving access to genetic counseling and testing could identify more Black women at high risk for breast cancer leading to better care and outcomes. Increasing guideline-backed genetic testing rates among African American breast cancer patients could also improve their access to precision oncology drugs, the researchers suggested.

Earlier this year, the Phase III OlympiA trial showed that adjuvant treatment with the PARP inhibitor olaparib (Merck/AstraZeneca's Lynparza) significantly delayed cancer progression in germline BRCA1/2-mutated, early-stage breast cancer patients. The data caused experts to consider whether germline genetic testing should be done for all breast cancer patients.

Such a broadening of testing guidelines would certainly improve access for all breast cancer patients, but Ademuyiwa and colleagues also noted the need for more implicit bias education and awareness among oncologists, and further interventions aimed at improving testing and counseling access specifically among African American patients.