Racial Differences in BRCA1/2 Testing: Patients or Providers?

描述（由申请人提供）：癌症易感性的基因检测有可能通过针对高风险个体的强化癌症风险降低干预来降低癌症死亡率。乳腺癌易感基因brca1和BRCA2的突变检测是最早将癌症遗传易感检测纳入临床实践的例子之一，并与多种基于证据的癌症风险降低方案相关联。尽管在高危人群中考虑BRCA1/2检测的建议已经存在了近十年，但有证据表明，检测的接受程度有限，并且在检测使用方面可能存在实质性的种族差异。了解这些差异的潜在原因对于制定策略至关重要，以确保基因组学的进步转化为临床护理的公平改善。利用基因检测的决定因素是复杂的，包括病人，提供者和系统的因素。虽然医疗保健中的种族差异传统上被追溯到患者特征的差异或医生的偏见，但越来越多的文献表明，不同患者种族群体之间提供者的差异是医疗保健差异的一个重要且往往是根本的因素。在使用基因或基因组技术方面，不同种族的患者在不同提供者之间的分类是否是种族差异的重要决定因素，目前尚不清楚。在本提案中，我们概述了一项基于人群的前瞻性队列研究，该研究将确定黑人和白人早发性乳腺癌女性的BRCA1/2检测率，并调查个体患者特征（“提供者内部效应”）与提供者特征（“提供者之间效应”）对使用中的种族差异的相对贡献。我们将使用多级模型来检查特定患者和提供者特征的贡献，并使用条件逻辑回归和分解技术来确定在患者和提供者水平上解释的测试中种族差异的相对比例。在我们之前在这一领域的工作的基础上，我们将测试关于在患者层面上与医疗保健相关的不信任和保险覆盖的贡献的具体假设，以及关于在提供者层面上对创新和获取资源的态度的贡献的具体假设。我们将这些结果与相同因素对乳腺癌管理中其他已知种族差异的贡献进行比较，询问导致BRCA1/2检测差异的患者和提供者特征是否也导致使用辅助治疗的差异，以及提供者在一个结果上的表现是否也预测了他们在其他结果上的表现。公共卫生相关性：遗传易感性试验有可能通过针对高危人群的强化癌症风险降低干预措施来降低癌症死亡率。BRCA1/2检测是最早将癌症遗传易感性检测纳入临床实践的例子之一，并与多种基于证据的癌症风险降低方案相关联。这个项目将增加我们对黑人和白人早发乳腺癌妇女检测使用情况的了解，以及患者和提供者使用差异的决定因素。

DESCRIPTION (provided by applicant): Genetic tests for cancer susceptibility have the potential to reduce cancer mortality by targeting intensive cancer risk reduction interventions to high risk individuals. Testing for mutations in the breast cancer susceptibility genes, BRCA1and BRCA2, is one of the earliest examples of cancer genetic susceptibility testing to become incorporated into clinical practice and be linked to multiple evidence based options for cancer risk reduction. Although recommendations for consideration of BRCA1/2 testing among high risk groups have existed for nearly ten years, evidence suggests that testing uptake has been limited and that substantial racial disparities in testing utilization may exist. Understanding the underlying causes of these disparities is critical for the development of strategies to ensure that advances in genomics are translated into equitable improvements in clinical care. The determinants of utilization of genetic testing are complex and encompass patient, provider and system factors. Although racial disparities in health care have traditionally been traced to differences in patient characteristics or physician bias, a growing body of literature indicates that differences in providers across patient racial groups are an important and often fundamental of health care disparities. Whether the sorting of patients of different races across different providers is an important determinant of racial differences in the use of genetic or genomic technologies is currently not known. In this proposal, we outline a population based, prospective cohort study that will determine the rates of BRCA1/2 testing among Black and White women with early onset breast cancer and investigate the relative contribution of individual patient characteristics ("within provider effects") vs. provider characteristics ("between provider effects") to racial differences in utilization. We will use both multi-level models to examine the contribution of specific patient and provider characteristics and conditional logistic regression and decompositional techniques to determine the relative proportion of the racial difference in testing explained at the patient vs. the provider level. Building on our prior work in this area, we will test specific hypotheses about the contribution of health care related distrust and insurance coverage at the patient level and specific hypotheses about the contribution of attitudes towards innovation and access to resources at the provider level. We will compare these results to the contribution of the same factors to other known racial disparities in breast cancer management, asking whether the patient and provider characteristics that lead to disparities in BRCA1/2 testing also lead to disparities in use of adjuvant therapy and whether a provider's performance on one outcome also predicts their performance on the other outcomes. Public Health Relevance: Genetic susceptibility tests have the potential to reduce cancer mortality by targeting intensive cancer risk reduction interventions to high risk individuals. BRCA1/2 testing is one of the earliest examples of cancer genetic susceptibility testing to become incorporated into clinical practice and be linked to multiple evidence based options for cancer risk reduction. This project will increase our understanding of the use of testing among Black and White women with early onset breast cancer and the patient and provider determinants of disparities in that use.