Unconscious Bias Among Physicians Creates Obstacles to Genetic Counseling and Testing For Black Women with Breast Cancer

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June 28, 2022

Unconscious Bias Among Physicians Creates Obstacles to Genetic Counseling and Testing For Black Women with Breast Cancer

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The latest data from an ECOG-ACRIN Cancer Research Group (ECOG-ACRIN) clinical trial reinforces that cancer health disparities are prevalent in the United States. An analysis of 9,719 participants in the TAILORx trial for women with early breast cancer found that Black women had significantly shorter survival rates than white women. Researchers say several social, behavioral, and environmental factors are contributing to this disparity—and a perspective recently published in the New England Journal of Medicine considers the disparity’s origin. Additionally, Black women have a higher-risk genetic profile than white women.

For many years, other research has shown that, despite this higher genetic risk, Black women with breast cancer are far less likely than their white counterparts to undergo genetic counseling and testing. It is crucial to recognize this disparity and find ways to address it because genetic testing can identify patients at high risk of developing cancer. In addition, testing can guide women and their doctors to select both prevention and treatment approaches that are right for them.

One reason that helps explain this discrepancy in genetic testing is unconscious bias, i.e. the stereotypes that affect a person’s understanding, actions, and decisions in an unconscious way. Researchers found that, in general, doctors are less likely to refer Black patients for genetic testing than white patients. One researcher at Washington University in St. Louis, Dr. Foluso O. Ademuyiwa, set out to learn why.

Late last year, Dr. Ademuyiwa and her colleagues published the results of a nationwide survey they conducted. Their goal was to find out if doctors’ beliefs and practices regarding genetic counseling and testing varied by race for patients with breast cancer. The short answer? A resounding ‘yes.’

A few of the highlights:

  • Very few respondents said they were more likely to refer a white patient for genetic testing than a Black patient, yet over 60% said they believed Black women face more obstacles to completing genetic testing
  • A significant number (over 20%) said they felt that Black women require more information and guidance than white women related to genetic testing and counseling
  • More than half of respondents said lack of trust was a greater issue for Black women than other women
  • About 30% believed Black women are more likely than white women not to follow their doctor’s plans and recommendations

“We demonstrated that racial differences exist in oncology physicians’ perceived barriers to genetic counseling and testing for patients with breast cancer,” said Dr. Ademuyiwa and study co-authors.

Dr. Ademuyiwa’s work is an essential step toward acknowledging and addressing unconscious bias. It may also encourage doctors to make more equitable future recommendations about genetic testing and counseling.

"There are major consequences of unconscious bias and it affects us all,” said Carmen E. Guerra, MD, MSCE, vice chair of diversity, equity, and inclusion for the department of medicine and associate director of Diversity and Outreach at the Abramson Cancer Center of the University of Pennsylvania. "An overwhelming majority of the scientific literature shows that unconscious bias impacts patient care, and this study adds to that body of work."

"Prior clinical trial equity research has shown that unconscious bias leads providers to perceive minority patients as challenging and not ideal research study candidates. These negative attitudes, combined with clinic‐level barriers, lead to providers withholding clinical trial opportunities from potential minority participants," said Dr. Guerra. "Similar negative perceptions by providers may be leading them to withhold recommendations for genetic counseling and testing."

Of note, however, recent research presented at the 2022 ASCO Annual Meeting by the Metastatic Breast Cancer Alliance found that Black people living with metastatic breast cancer are interested in clinical trials—more than 80% of them would consider participating in a research study.

ECOG-ACRIN is taking steps to conduct more equitable clinical trials by encouraging diverse participation. For example, over 20% of the participants in the TMIST breast cancer screening trial are Black, compared to the average of about 9% for National Cancer Institute-funded clinical trials.

Learn more about ECOG-ACRIN’s TMIST trial—and how it is helping to eliminate health disparities in breast cancer in this issue.

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