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措施来降低癌症死亡率。检测乳腺癌易感基因BRCA 1和BRCA 2的突变是癌症遗传易感性检测最早的例子之一，被纳入临床实践，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BRCA 1/2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，而且在检测利用方面可能存在巨大的种族差异。了解这些差异的根本原因对于制定战略以确保基因组学的进步转化为临床护理的公平改善至关重要。基因检测利用的决定因素是复杂的，包括患者，提供者和系统因素。虽然传统上，医疗保健中的种族差异被追溯到患者特征或医生偏见的差异，但越来越多的文献表明，患者种族群体之间的供应商差异是医疗保健差异的重要且通常是根本性的。目前尚不清楚在使用遗传或基因组技术时，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。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色早发性乳腺癌妇女的BRCA 1/2检测率，并调查个体患者特征（“提供者内效应”）与提供者特征（“提供者间效应”）对利用率种族差异的相对贡献。我们将使用两个多层次模型来检查特定患者和提供者特征的贡献，并使用条件logistic回归和分解技术来确定在患者与提供者水平上解释的测试中种族差异的相对比例。基于我们之前在这方面的工作，我们将测试具体假设的贡献，医疗保健相关的不信任和保险覆盖范围在病人的水平和具体假设的贡献，对创新的态度和获得资源在供应商的水平。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BRCA 1/2检测差异的患者和提供者特征是否也会导致辅助治疗的使用差异，以及提供者对一种结果的表现是否也预测了他们对其他结果的表现。公共卫生相关性：遗传易感性测试有可能通过针对高风险个体的强化癌症风险降低干预措施来降低癌症死亡率。BRCA 1/2检测是癌症遗传易感性检测最早的例子之一，被纳入临床实践，并与多种基于证据的癌症风险降低方案相关联。该项目将增加我们对黑人和白色早发性乳腺癌妇女使用检测的理解，以及患者和提供者在使用检测方面差异的决定因素。

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.