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For patients at a safety-net hospital, referrals for prostate cancer genetic services increased after expanded guideline recommendations, but most patients still went untested, researchers reported.

Christine Gunn, PhD, of the Dartmouth Institute for Health Policy and Clinical Practice in Lebanon, New Hampshire, and colleagues retrospectively analyzed health records at an urban safety-net hospital before and after the National Comprehensive Cancer Center expanded its recommendations for germline genetic testing in 2018.

As the team explained in , the study included 1,877 patients, mean age of 65, with 44% identifying as Black, 32% as white, and 17% as Hispanic or Latino. The predominant insurance type was Medicaid (34%) followed by Medicare or private insurance (25% each).

After the expanded recommendations, 9% of patients were referred to genetic services. Of those referred, 83% attended an appointment with a genetic counselor, but just 12% completed genetic testing.

In the following interview, Gunn, who is also health equity liaison to the Community Outreach and Engagement Program of Dartmouth's Norris Cotton Cancer Center, discussed additional results and the implications.

You noted that the 9% of patients referred was an increase compared with the proportion before the guideline update. How much of an increase was it?

Gunn: We used standardized rates to measure changes over time -- the number of referrals per 1,000 diagnoses by year. This approach accounts for the fact that there are differing numbers of patients across time. Overall, 6 months after the guidelines changed, the model demonstrated an increase in referrals by 138.4% over what was expected had there been no change in the guidelines.

What were the strongest predictors of referral to genetic services?

Gunn: The strongest predictors were having metastatic disease or regional disease. This is expected, as these were the first groups (having higher risk disease) to be recommended for germline genetic testing. These are some of the clearest criteria for testing eligibility, so we expect these groups to be tested at higher rates.

Black or African-American patients also had greater odds of referral. Why do you think that was?

Gunn: This is not necessarily what we expected, but may reflect the hospital's context. Over half of the patients who are seen at the hospital identify as a racial or ethnic minority. There has also been significant attention focused on aggressive forms of prostate cancer in African-American men, which may have influenced recommendations for genetic care for this group in particular.

What are the main implications of this study?

Gunn: There are definitely opportunities to increase genetic testing for eligible patients with prostate cancer, and ensure that results are documented in the medical record. Our study may have missed some people who were tested because we relied on the medical records for documentation, which we know aren't perfect.

However, it is very important to ensure that medical records include all relevant health information. Ensuring that there are ways to document family history of cancers to identify eligible patients, and then clear ways to document that these tests were completed and their results are important issues.

We also need to learn more about why there was low uptake – whether it is that clinicians need support in identifying and referring patients, or whether it is a patient preference.

What ongoing research are you conducting to further explore this issue?

Gunn: We have also undertaken a series of qualitative interviews with patients, clinicians, and family members to learn more about the process -- how each group evaluates the need for testing, preferences, and understandings about genetic testing, experiences with the process, and areas for improvement.

Read the study here.