In the Journals Plus

Genetic testing low among medically underserved women with breast, ovarian cancers

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August 14, 2018

Only 8% of older or disabled women with breast or ovarian cancer who had Medicare and met eligibility criteria underwent testing for BRCA1 and BRCA2 mutations between 2000 and 2014, according to a research letter published in JAMA.

“Women who carry one of these mutations but don’t know their mutation status are not able to take advantage of preventive or early detection interventions that we have available, so they miss out on the opportunity to reduce their risk for these cancers and potentially reduce their overall mortality,” Amy Gross, PhD, epidemiologist at Vanderbilt Institute for Clinical and Translational Research, said in a press release. “They are also not able to inform family members who might be affected.”

Identifying pathogenic germline mutations in BRCA1 and BRCA2 genes can lead to potential life-saving therapeutic and preventive recommendations among patients with cancer and their family members.

Whether medically underserved Medicare beneficiaries are given the option to undergo testing for BRCA1 and BRCA2 mutations has remained unknown. Medicare coverage for BRCA1 and BRCA2 testing is based on personal and family history of cancer.

Gross and colleagues evaluated medical records from 49,642 women (66% black) enrolled in the Southern Community Cohort Study, which included individuals seen at various community health centers across 12 Southeastern states between 2002 and 2009.

Investigators linked state cancer registry data with Medicare claims between 2000 and 2014 to identify women diagnosed with breast or ovarian cancer while enrolled in Medicare Part B.

Among all study participants, 2,002 had a diagnosis of breast cancer, ovarian cancer or both between 2000 and 2014, of whom 751 had Medicare Part B coverage at diagnosis.

Thirty-three women died within 6 months of diagnosis, and therefore were excluded from the final analysis.

The final cohort included 718 women (62% black). The mean age at diagnosis was 64 years among 689 women diagnosed with breast cancer and 62.5 years among 30 women with ovarian cancer.

Sixty-two percent of women had an annual income of less than $15,000, and 30% had less than a high school education.

Ninety-two women (12.8%) met Medicare criteria for coverage of BRCA1 and BRCA2 testing, of whom eight (8.7%) underwent testing over a median follow-up of 4.9 years after diagnosis.

“We were surprised at how low the test rate was, although we didn’t expect it to be very high,” Gross said.

Although concerning, Gross noted that not all patients were aged 65 years and older, and some had Medicare due to a disability.

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“In fact, more than half of them were [younger than] 65,” Gross said.

Researchers observed a median time between diagnosis and test claim date of 117 days (interquartile range, 34-415).

None of the Southeastern states outpaced a 25% testing rate; Arkansas, Louisiana, Tennessee, Virginia and West Virginia had a 0% testing rate.

Testing rates increased from 0% of eligible women between 2000 and 2004 to 5% (95% CI, 0.6-17) of women between 2005 and 2009 and to 15.8% (95% CI, 6-31.3) between 2010 and 2014 (P for trend = .04).

“This testing rate is lower than what I have seen reported in terms of any other study with the same time and eligibility constraints,” Gross said.

For instance, a study conducted in Georgia and Los Angeles County reported a 52.9% testing rate among eligible women from 2013 to 2014.

Gross noted that several factors could be responsible for the low testing rate, including lack of patient interest or physician recommendations.

Researchers found that fewer than 10% of physicians who treated the 92 women eligible for screening documented a need for genetic services, and none included referral to genetic counseling.

“Novel strategies are needed to ensure that medically underserved women with cancer receive appropriate referral and access to genetic testing,” the researchers wrote. – by Melinda Stevens

Disclosures: The authors report no relevant financial disclosures.