Racial disparities in cancer genetic counseling encounters in the naturalistic clinical setting

尽管几十年来一直在努力减少种族癌症差异，但黑人的死亡率仍然较高， 比美国任何其他种族都多。因为预防是关键的成本效益和长期的 控制癌症，癌症遗传咨询在减少种族癌症方面发挥核心作用的潜力 差距很大。然而，遗传咨询的好处在种族之间并不公平。总体 这项研究的目的是比较和对比遗传咨询的性质， 在自然主义临床环境中，黑人和白色患者之间以患者为中心的结局。只有2%的 遗传咨询师自我认同为黑人/非裔美国人，因此大多数遗传咨询遇到黑人 患者种族不一致。在种族不和谐的医疗互动中， 患者-提供者沟通，并收到次优的临床建议。一个主要因素是， 造成这些种族医疗差异的原因是种族偏见。根据先前的研究结果，我们 假设遗传咨询师提供者更大的隐性种族偏见将与更贫穷的人相关， 患者-提供者沟通，而提供者明确的负面种族刻板印象将与 对黑人（对比白色）患者的癌症风险和基因检测的临床讨论不够全面。这些 就诊的差异将进一步与较差的以患者为中心的结果相关。我们将测试我们的 通过解决四个具体目标的假设：目标1）比较/对比患者-提供者的性质 按患者种族（黑人或白色）进行沟通;目的2）通过以下方式比较/对比临床讨论内容 患者种族;目标3），以量化的作用，每种类型的咨询师偏见的病人提供者的沟通（目标 1)和临床讨论内容（目标2）;和目标4）量化患者-提供者沟通的作用/ 以患者为中心的临床讨论内容（信任，满意度，治疗联盟， 基因检测（Genetic Testing）。这些目标将通过一项观察性研究来实现， 收敛混合方法研究设计。我们将分析记录的癌症遗传咨询遭遇 定性和定量地将这些数据与遭遇前和遭遇后调查的数据联系起来， 医疗图表评论。随着COVID-19，许多遗传咨询已经转移到远程医疗， 预计远程保健在大流行病之后将继续蓬勃发展。拟议的研究将包括这一点 独特的，过渡性的机会，并通过以下方式解决自然主义临床环境中的总体目标： 多种模式（面对面、远程保健）。这项多中心研究的结果将突出以下几个方面： 癌症遗传咨询遭遇（患者-提供者沟通和临床建议）， 与以患者为中心的结果直接相关。患者-提供者沟通和临床 建议是可修改的因素，它们已经在遗传咨询培训中教授 因此，研究结果可以对遗传咨询培训和实践产生直接影响。

Despite decades of effort to reduce racial cancer disparities, Black people continue to die at higher rates from cancer than any other U.S. racial group. Because prevention is the key to the cost-effective and long-term control of cancer, the potential for cancer genetic counseling to play a central role in reducing racial cancer disparities is high. However, the benefits of genetic counseling are not equitable across race. The overarching goal of this proposed research is to compare and contrast the nature of genetic counseling encounters and patient-centered outcomes between Black and White patients in the naturalistic clinical setting. Only 2% of genetic counselors self-identify as Black/African American, so most genetic counseling encounters with Black patients are racially discordant. Patients in racially discordant medical interactions tend to have poorer quality patient-provider communication and receive suboptimal clinical recommendations. One major factor that contribute to these racial healthcare disparities is racial bias. Drawing on findings from prior research, we hypothesize that genetic counselor providers' greater implicit racial prejudice will be associated with poorer patient-provider communication, while providers' explicit negative racial stereotypes will be associated with less comprehensive clinical discussion of cancer risk and genetic testing for Black (vs. White) patients. These disparities in encounters will be further associated with poorer patient-centered outcomes. We will test our hypotheses by addressing four specific aims: Aim 1) to compare/contrast the nature of patient-provider communication by patient race (Black or White); Aim 2) to compare/contrast the clinical discussion content by patient race; Aim 3) to quantify the role of each type of counselor bias in patient-provider communication (Aim 1) and clinical discussion content (Aim 2); and Aim 4) to quantify the role of patient-provider communication/ clinical discussion content with patient-centered outcomes (trust, satisfaction, therapeutic alliance, empowerment, genetic testing uptake). These aims will be achieved through an observational study with a convergent mixed methods research design. We will analyze recorded cancer genetic counseling encounters both qualitatively and quantitatively, linking those data to data from pre- and post-encounter surveys and medical chart reviews. With COVID-19, many genetic counseling encounters have moved to telehealth, and telehealth is expected to continue to thrive beyond the pandemic. The proposed study will embrace this unique, transitional opportunity and addresses the overarching goal in the naturalistic clinical setting through multiple modalities (in-person, telehealth). Findings from this multi-center study will highlight specific aspects of cancer genetic counseling encounters (patient-provider communication and clinical recommendations) that are directly associated with patient-centered outcomes. Patient-provider communication and clinical recommendations are modifiable factors, and they are already being taught in genetic counseling training programs; thus, the findings can have immediate impact on genetic counseling training and practice.