Can Health System Engagement Facilitate Greater Utilization of Genetic Tests to Predict Cancer Risk? A Health Disparities Exploration of National Survey Data

Objective: To estimate the effect health system engagement on a woman's awareness of and decision to complete a genetic test to predict cancer risk. Background: Young African American women face a higher risk of breast cancer mortality than white women. To mitigate this disparity, clinicians have developed predictive risk assessment and stratified screening protocols based on genetic tests. However, African American women have historically been underrepresented in genetic test utilization. If the trend of low genetic test participation continues, potential health gains from precision medicine will be limited or unrealized, further expanding the Black/White breast cancer mortality disparity. Significance: While previous investigators have made numerous attempts to better understand the Black/White disparity in genetic testing, this study directly analyzes racial disparities in genetic test exposure and utilization through health system engagement using the latest population-level survey dataset. Methods: Data was obtained from the nationally representative, cross-sectional National Health Interview Surveys for years 2000, 2005, 2010, and 2015. Outcomes included: 1) awareness of a genetic test; 2) genetic test utilization, conditional on awareness; 3) discussing a genetic test with a medical provider; and 4) unconditional genetic test utilization. Weighted odds ratios were calculated by a series of multivariate logistic regression models. Independent variables included various socioeconomic and demographic indicators, as well as health system factors. Results: White women with a usual place of medical care held significantly higher odds of genetic test awareness and of discussing a genetic test with a medical provider (OR = 2.16, p < .001; OR = 5.34, p < .05). Conversely, a usual place of medical care was not found to heighten awareness or facilitate greater discussion with a medical provider for African American women. Consistent with this trend, only among white women did a consistent place of medical care yield a positive effect on genetic test utilization (OR = 2.53, p <.001). No such protective factor existed for black women at a significant level. Conclusion: There still exists a stark disparity in genetic test awareness and utilization between black and white women. But this study identified another disparity, that white women were more likely to discuss genetic tests with a medical provider than black women. These results support the idea that health system engagement promotes greater awareness of genetic tests to predict cancer risk. However, the limited impact a usual place of medical care had on actual utilization warrants further exploration into the drivers of genetic test decision making both across and within racial groups. The continued commitment to addressing cancer disparities requires not only policy-makers and oncologists, but explicit engagement from genetic counselors and providers across the care continuum.