Impact of race on referral for genetics assessment for women with ovarian cancer in a large health care system

Abstract

<h3>Objectives:</h3> To identify racial and health factors associated with referral, assessment and genetic testing patterns for women with ovarian cancer. <h3>Methods:</h3> Women were identified with a new diagnosis of ovarian cancer in a large integrated health care system in Northern California between 8/1/2013 and 12/31/2018. Women were excluded if they had undergone genetic testing prior to the diagnosis of ovarian cancer. Standardized guidelines of the health system at the time of diagnosis were used for genetics referral criteria: from 8/2013 until 4/2015, the guidelines limited referral to ovarian cancer diagnosed under age ≤70 years and non-mucinous histology; from 4/2015-4/2017, ovarian cancer diagnoses of all ages became eligible; and starting in 4/2017, all ovarian cancer histologies were eligible for referral. Demographic variables including race, ethnicity, primary language and personal cancer history were retrieved from the electronic medical record. The primary outcome was referral to genetics for assessment within 12 months of ovarian cancer diagnosis. Secondary outcomes were completion of genetics contact and testing, as well as testing result. <h3>Results:</h3> We identified 1,414 women, newly diagnosed with ovarian cancer between 8/1/2013 and 12/31/2018, who were eligible for testing based on the health system criteria. Most of these women, 941 (66.5%) were referred to genetics in the first 12 months after diagnosis with a mean time from diagnosis to referral of 2.3 months. Referral rates varied by race and ethnicity: White 65.9%, Hispanic 69.7%, Black 58.2%, Asian 70.3%. Overall rates of referral to Genetics, seen by a genetic counselor, and tested for genetic mutations were lower for Black women compared to non-Black women although the difference was not significant (p-value = 0.07, 0.06, 0.07, respectively). Over the three time periods of genetics referral criteria, referrals for all races increased, the rate in Blacks increased from 45.8 % to 67.6% from the first period to the last (p-value = 0.09). Overall, 919/941 (65%) were seen by Genetics and 842 (59.5%) completed genetic testing, 796 had a multigene panel test, and the remainder had <i>BRCA</i> or single gene testing, with 161 (20%) with a positive test and 228 with variants of unknown significance. Only 6% (6/98) of Black women had a pathogenic mutation. <h3>Conclusions:</h3> In a large integrated health system with comprehensive health services, access to medical records for all tests and care, and a uniform cost structure for genetic services, Black women had lower referral and genetic testing rates than women of other races but the difference was not significant. While academic centers have shown significant differences in referral to genetic services of ovarian cancer patients by race, primary language and insurance types, these differences may be mitigated in systems with universal cost structures, integrated referrals and systemwide access for counseling, but more work still needs to be done to reach Black women.