Men with cancer history often do not receive recommended genetic testing
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Only a small percentage of men recommended to undergo genetic testing due to personal or family history of cancer actually received it, according to findings published in Journal of the National Comprehensive Cancer Network.
A retrospective cohort study evaluated 7,894 men with incident pancreatic, breast or metastatic prostate cancers. All men had commercial insurance or received care through the Veterans Health Administration.
Researchers found 1-year testing rates of 18% (95% CI, 16.8%-19.2%) among commercially insured men and 14.2% (95% CI, 11.5%-15%) among those treated in the VA system.
Results also revealed an association between Black race and lower likelihood for testing among commercially insured men (adjusted HR = 0.73; 95% CI, 0.58-0.91); however, this finding did not persist among veterans.
“My hope is that our study motivates providers in both oncology and survivorship practices caring for men with a current or past history of prostate cancer, male breast cancer and/or pancreatic cancer to introduce genetic testing to their patients,” researcher Kara N. Maxwell, MD, PhD, assistant professor of medicine and genetics at University of Pennsylvania’s Perelman School of Medicine and director of the Men and BRCA Program at Penn’s Basser Center for BRCA, told Healio. “As there will always be some patients who decline genetic testing, my hope is to obtain closer to 80% genetic testing rates among all men with these cancer diagnoses.”
Healio spoke with Maxwell about the findings and what can be done to increase rates of genetic testing among men with a personal or family history of cancer.
Healio: What prompted you to conduct this study?
Maxwell: Most of the research on the uptake of genetic testing has evaluated testing of women for genes associated with breast or ovarian cancer, such as BRCA1/BRCA2, in predominantly self-identified white populations. This research has shown suboptimal rates of genetic testing, even for patients with indications such as ovarian cancer for whom indications have been in guidelines for many years. We, therefore, wished to study uptake of genetic testing of men with newly diagnosed metastatic prostate, breast or pancreatic cancers in racially diverse cohorts. In addition, studies of women have raised concerns for racial disparities in genetic testing, so we also wished to compare genetic testing uptake between self-identified white and Black males with cancer.
Healio: How did you conduct the study?
Maxwell: Using electronic phenotyping algorithms, we identified men newly diagnosed with metastatic prostate, breast or pancreatic cancers in two nationwide cohorts. We tested the association between race and genetic testing completion, adjusting for age, cancer type, census region, diagnosis year and Elixhauser comorbidity index among the entire cohort, as well as Agent Orange exposure among veterans.
Healio: What did you find?
Maxwell: Across the entire cohort, genetic testing rates were highest among male patients with breast cancer — at approximately 50% — and lowest in patients with metastatic prostate cancer, at approximately 10%. Black race was associated with lower genetic testing completion rates only in the commercially insured population, not in the equal-access VA health care system.
Healio: What might explain your findings?
Maxwell: Low rates of genetic testing may be a result of an inadequate genetics workforce to carry out testing, a lack of perceived benefit by physicians, and/or a lack of perceived utility by patients. A causal mediation analysis of the racial disparity seen in the commercially insured population suggests that income and net worth — but not other factors, such as education — may explain racial disparities in the commercially insured population.
HealioWhat racial disparities did your study identify in terms of underuse of genetic testing among men with commercial insurance?
Among self-identified white and Black patients in the commercially insured cohort, 1-year testing rates were 10.1% for white patients vs. 7.2% for Black patients with metastatic prostate cancer, 23.8% for white patients vs. 21% for Black patients with pancreatic cancer, and 50.8% for white patients vs. 37.5% for Black patients with breast cancer.
Healio: What strategies can be implemented to address this problem?
Maxwell: Given that disparities in genetic testing did not occur in an equal-access VA health care system, this would suggest that addressing insurance coverage and reducing estimated out-of-pocket costs for genetic testing could reduce disparities in testing. In addition, genetic testing may have hidden costs in the requirements to find childcare or elder care or take off work when the process is cumbersome — for example, multiple in-person visits that are not coordinated with oncology visits. Streamlining point-of-care genetic testing at an oncology visit and increasing access to telegenetics services may help reduce disparities in testing as well.
References:
- Basser Center for BRCA. BRCA in men. Available at: https://www.basser.org/brca/brca-men.
- Shevach JW, et al. J Natl Compr Canc Netw. 2024;doi:10.6004/jnccn.2023.7105.
For more information:
Kara N. Maxwell, MD, PhD, can be reached at kara.maxwell@pennmedicine.upenn.edu.
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