Germline BRCA testing underused for women with ovarian cancer and commercial insurance
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About one-third of women with commercial insurance underwent genetic testing for ovarian cancer between 2008 and 2018 despite unequivocal recommendations for universal testing, according to research in JAMA Network Open.
“Our study shows that we desperately need to increase genetic testing in women with ovarian cancer,” Alexi A. Wright, MD, MPH, associate professor at Harvard Medical School and director of gynecologic oncology outcomes research at Dana-Farber Cancer Institute, told Healio. “Every woman with ovarian cancer should have access to genetic testing because the results guide treatment decisions and can help prevent cancers in family members. Yet, despite unequivocal recommendations, fewer than half of women received testing in most years between 2008 and 2018.”
Background
Wright and colleagues pursued the research because testing rates reportedly have remained low despite new guidelines in 2010 recommending universal testing. They noted that 15% of patients with ovarian cancer have a germline BRCA variation and that testing first-degree relatives is a cost-effective cancer prevention measure.
“We wanted to examine a commercially insured population because women who have germline genetic mutations such as BRCA are often diagnosed with ovarian cancer at a younger age than patients who do not have these mutations,” Wright said. “We worried that if we examined Medicare data — mostly of women over 65 years of age — that we would miss the group of women whom physicians would be most likely to test if they are not already doing universal testing.”
Methodology
The analysis included 3,603 women (mean age, 57 years; standard deviation, 11.3) with claims through a large national commercial insurer for ovarian cancer and a biopsy or surgery between 2008 and 2018.
Wright and colleagues analyzed patient, physician and practice characteristics associated with outcomes. Germline BRCA testing, using gene-specific and methodology-based procedure codes, served as the primary outcome. Secondary outcomes included timeliness (6 months or less from biopsy/surgery) and median time from first chemotherapy claim to testing.
Key findings
Results showed 1,220 women (33.9%) received germline BRCA testing. Testing rates increased during the study period, from 14.7% (55 of 375 patients) in 2008 to 46.4% (96 of 207 patients) in 2018, with the median time to testing decreasing from 280 days to 72.5 days.
Adjusted analysis revealed lower testing rates among older women (aged 65 years vs. < 50 years: adjusted difference, 20.8 percentage points) and women with more comorbidities (Charlson Comorbidity Index score 2 vs. 0: adjusted difference, 4.6 percentage points); similar testing among oncologists (medical vs. gynecologic oncologist: adjusted difference, 1.5 percentage points) but lower rates among other physicians (other vs. gynecologic oncologist: adjusted difference, 5.9 percentage points); and higher testing rates at academic and NCI cancer centers compared with community practices (academic vs. NCI: adjusted difference, 0.5 percentage points; community vs NCI: adjusted difference, 4.5 percentage points).
Although rates remained below 50% for most years, expect for 2016 (54.1%) and 2017 (52.5%), analyses revealed a statistically significant increase in testing over time (2018 vs. 2008: adjusted difference, 32 percentage points; 95% CI, 24.4-39.7), researchers wrote. They reported similar results for analyses of timeliness of germline BRCA testing, which significantly improved from 2010 to 2018.
Implications
The low overall rates of testing despite all women in the study having insurance that covers genetic testing and access to genetic counselors surprised Wright.
Wright and colleagues called for future work examining barriers to timely testing, as well as strategies targeting clinicians — as the absence of physician recommendations remains the biggest hurdle to increased testing.
“I would love to see scalable strategies to increase genetic testing in community oncology practices,” Wright said.
For more information:
Alexi A. Wright, MD, MPH, can be reached at Division of Population Sciences, Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Ave., Boston, MA 02215; email: alexi_wright@dfci.harvard.edu.
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