Study: Surgeon attitude impacts rate of genetic testing after a breast cancer diagnosis


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Young women diagnosed with breast cancer who have not yet had genetic testing

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Checked Breast cancer survivors


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A study in JAMA Surgery this year examined the factors that impact genetic testing after a breast cancer diagnosis. This study suggests that the attitudes of attending surgeons about genetic testing have the most impact on whether patients receive testing. (10/6/18)

Contents

At a glance In-depth                            
Findings     Limitations               
Guidelines Resources
Questions for your doctor  


STUDY AT A GLANCE

This study is about:

How surgeons’ attitudes impact genetic testing in women with breast cancer.

Why is this study important?

This study is important because knowledge of a mutation in a gene that increases cancer risk may alter treatment and risk reduction decisions for a woman and her family members.

Study findings: 

Of 3,910 women with breast cancer in this study:

  • 34% met national standard-of-care guidelines (NCCN)  for genetic testing.
  • 27% had genetic testing.

Researchers surveyed attending surgeons to determine what impacted genetic testing rates in various hypothetical clinical scenarios.

  • About one-third of the variation in genetic testing recommendations is due to surgeon attitude and patient volume.
    • A surgeon’s attitude most impacted genetic testing rates. Some surgeons’ recommendations differ from national guidelines.
    • Surgeons with larger patient volumes were more likely to recommend genetic testing.
       
  • Socioeconomic status and insurance coverage had a small impact, but this did not track with surgeons’ recommendations.
  • Patients with no insurance or public insurance were less likely to get genetic testing.
  • Genetic testing rates differed by ethnicity:
    • Black women were 51% less likely to have genetic testing than white women.
    • Latina women were 16% less likely to have genetic testing than white women.
    • Asian women were as likely to have genetic testing as white women.

What does this mean for me?

Surgeons’ attitudes about genetic testing may affect their recommendations for you. You may consider getting a second opinion about whether genetic testing might be helpful given your family history and breast tumor characteristics. It may be useful to ask if you can consult with a genetic counselor about your risk of carrying a gene mutation associated with hereditary breast cancer.

Surgeons who treat more than 50 patients per year are more likely to recommend genetic testing when appropriate. You may want to ask how many breast cancer patients your surgeon treats annually.

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Expert Guidelines

The National Comprehensive Cancer Network is a consortium of experts in cancer and genetics. They publish consensus guidelines for genetic testing for inherited mutations that increase cancer risk. Their guidelines for genetic testing for people diagnosed with breast cancer include:

  • breast cancer of any type (including ductal carcinoma in situ or DCIS) diagnosed before age 50 
  • breast cancer in both breasts or a second breast cancer in the same breast
  • triple-negative (ER-/PR-/Her2-) breast cancer before age 60
  • Ashkenazi (Eastern European) Jewish ethnicity
  • relatives with breast, ovarian, pancreatic, prostate or melanoma cancer
  • men with breast cancer

For people with HER2-negative, metastatic breast cancer, NCCN recommends BRCA testing before starting on chemotherapy to see if there may be benefit from treatment with a PARP inhibitor.

According to NCCN, cancer risk assessment and genetic counseling is highly recommended before genetic testing is offered (pre-test counseling) and after results are disclosed (post-test counseling). A genetic counselor, medical geneticist, oncologist, surgeon, oncology nurse, or other health professional with expertise and experience in cancer genetics should be involved early in the counseling of patients.

Questions To Ask Your Health Care Provider

  • Am I at elevated risk for carrying a mutation in a breast cancer gene given my family history and tumor characteristics?
  • Should I consult with a genetic counselor?
  • If I have a mutation in a breast cancer gene, how might that alter my treatment or risk-reduction recommendations?

 

IN-DEPTH REVIEW OF RESEARCH
Study background:

Surgeons guide clinical management of their patients‘ treatment. Genetic testing can inform those decisions. Almost all patients see a surgeon after diagnosis, but only about one-third of eligible patients have genetic testing. Current National Comprehensive Cancer Network (NCCN) guidelines recommend genetic testing for women diagnosed with breast cancer who have risk of carrying a pathogenic mutation in a breast cancer gene based on family history and her own tumor characteristic.

Variability in surgeons’ attitudes about genetic testing are documented. The researchers for this study wanted to know how surgeons’ recommendations differed when faced with patients with similar clinical indications. If variability in genetic testing is due to surgeons rather than clinical findings, it suggests greater efforts be made to educate surgeons about genetic testing or to encourage patients to get a second opinion.

Researchers of this study wanted to know:

How surgeons impact genetic testing in women with breast cancer.

Populations looked at in this study:

Participants were 5,080 women from the iCanCare study ages 20 to 79. Each woman was diagnosed with either ductal carcinoma in situ (DCIS) or invasive cancer (stage 0 to II) between July 1, 2013 and August 31, 2015 that was reported to SEER registries in Georgia or Los Angeles County, California.

98% of patients identified their attending surgeon. Of these, 377 of 488 attending surgeons responded to a survey about their likelihood to order genetic testing or genetic counseling in different hypothetical clinical scenarios. These surgeons treated 3,910 patient-participants.

Study findings:  

Of 3,910 women with breast cancer in this study:

  • 34% (1,350 of 3,910 women) had elevated risk of having a breast cancer gene mutation as determined by NCCN guidelines (i.e.,these women are candidates for genetic testing based on personal and family history).
  • 27% (1,056 of 3,910 women) had genetic testing.

Researchers surveyed the attending surgeons to determine what factors impacted genetic testing rates in various hypothetical clinical scenarios. In these scenarios, elevated risk was based on NCCN testing guidelines:

  • 20% of variation in genetic testing recommendations reflects variation in pretest genetic risk among the patients.
  • About one-third of the variation in genetic testing recommendations is due to surgeon attitude and patient volume.
     
    • Surgeons’ attitudes most impacted genetic testing rates. Some surgeon's recommendations differ from national guidelines.
       
      • Surgeons who were most likely to recommend genetic testing (top 5%) recommended testing for 72% of patients with an elevated chance of carrying a mutation.
         
      • Surgeons who were least likely to recommend testing (bottom 5%) recommended testing for 26% of patients with an elevated chance of carrying a mutation.
         
    • Surgeons who see greater patient volumes (50 or more cases per year) were more likely to recommend genetic testing.
       
  • Socioeconomic status and insurance coverage impacted genetic testing but did not track with surgeon's recommendation.
    • Patients with no insurance or public insurance were less likely to get genetic testing.
       
    • Genetic testing rates differed by ethnicity:
       
      • Black women were 51% less likely to have genetic testing than white women.
         
      • Latina women were 16% less likely to have genetic testing than white women.
         
      • Asian women were as likely to have genetic testing as white women.

Limitations:

Because participating women with breast cancer were identified from SEER registries, some information about their family history may not be available. Given the data available, it was not possible to directly determine whether attending surgeons recommended genetic testing for women who were later shown to have mutations and did not recommend genetic testing for women who were later shown to not have mutations. Some women and some surgeons did not participate in the surveys and that may have skewed the data. The study was based on participants in Georgia and California only; nationwide results may vary. 

Conclusions:

Recommendations for genetic testing after a breast cancer diagnosis can be strongly impacted by surgeon attitudes. The results of this study suggest that patients should be aware that some surgeons’ recommendations may differ from national guidelines and vary given similar situations. These results suggest greater efforts be made to educate surgeons about genetic testing and to encourage patients to get a second opinion. It also highlights the need for greater consensus among surgeons about genetic testing and genetic counseling needs.

Share your thoughts on this XRAYS article by taking our brief survey.

Posted 10/6/18

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