Chicago – Young black women with breast cancer are much less likely than white or Hispanic women to undergo testing for BRCA gene mutations, which puts them also at risk for ovarian cancer. And if they carry a BRCA mutation, they are much less likely to undergo removal of their ovaries and fallopian tubes.
Carriers of BRCA mutations have a high lifetime risk of breast and ovarian cancers – up to 60%-70% risk of developing breast cancer, up to 44% risk for ovarian cancer, and a 50% or greater risk for a secondary breast cancer after a first breast cancer diagnosis. Breast cancer risk management may consist of periodic screening or prophylactic mastectomy. But because there are no reliable screening methods for ovarian cancer, the main option for risk management is surgical.At the American Society of Clinical Oncology annual meeting, Dr. Tuya Pal said, “It is very important to think about the benefits of detecting a BRCA mutation. It’s not really about getting them tested, but the health benefit arises from doing something with that information.”
For a population-based, cross-sectional study to investigate women’s receipt of BRCA testing and the uptake of preventive surgery among BRCA mutation carriers, she recruited 440 black, 284 Hispanic, and 897 non-Hispanic white breast cancer survivors through the Florida State Cancer Registry. The study included women who had been diagnosed with invasive breast cancer at up to age 50 years between 2009 and 2012, who completed a baseline survey.
“Among our black women, 36% had received BRCA testing at the time of study recruitment compared with 62% of the Hispanic women and 65% of the non-Hispanic white women,” said Dr. Pal, a clinical geneticist at the H. Lee Moffitt Cancer Center & Research Institute in Tampa, Fla. Even after controlling for meeting high-risk criteria based on national practice guidelines, socioeconomic status variables, and provider referral patterns, there were still significant disparities in BRCA testing (P = .025) for black women, compared with the other two groups.
Of the 1,621 women in the study, 917 (57%) reported BRCA testing, of whom 92 (10%) tested positive for the mutation (28 Black, 13 Hispanic, and 51 non-Hispanic White).
The pattern of ethnic disparity persisted for cancer risk management practices among women with the gene mutation, with 68% of black women opting for bilateral mastectomy vs. 85% of Hispanic women and 94% of non-Hispanic whites. Because mastectomy is not the only form of risk management, Dr. Pal also looked at the rates of breast cancer screening in these women.
“That brought us up to 86% with the black women, 100% among Hispanic women, and 98% among the white women,” she said. However, three out of four of the Black women who did not use any risk management techniques were still in treatment, so it was too early to see what they would do.
For salpingo-oophorectomy, the rates were 32% of black, 85% of Hispanic, and 71% of non-Hispanic white women. After controlling for age at enrollment, time since diagnosis, income, family medical history, and insurance status, there were still disparities between black women and Hispanic women (P = .01) and between black and white women (P = .02).
Even in light of these findings that black women are much less likely to have BRCA testing and to undergo salpingo-oophorectomy if they carry a BRCA mutation, Dr. Pal offers some caveats. First, the findings require confirmation given the limited number of mutation carriers in the study. Second, as a cross-sectional study, it is only a snapshot in time. Third, BRCA testing and the options for risk management are a choice, and many factors enter into the choice, Dr. Pal pointed out.
They include patient preference, cultural factors, information and communication, economic factors, and provider recommendations. “We really need to understand the reasons that these women are making these decisions. Are they being given the opportunity to make an informed decision, or are there other factors that are playing into it where they’re not getting information that they need?” she asked. She said the study highlights the need to design strategies to overcome the reasons for the disparities and to ensure access to testing and cancer risk management practices across all populations.
Session moderator Dr. Patricia Ganz, director of Cancer Prevention and Control Research at the Jonsson Comprehensive Cancer Center of the University of California, Los Angeles, said recruiting from a cancer registry gave the investigators a population-based snapshot of the situation at that time. But the women in the study had their cancer diagnoses between 2009 and 2012, and “a lot of things have happened since then,” she said.