Social Determinants of Health and Genetic Testing in Triple-Negative Breast Cancer With Barb Kunz, MS, LCGC

Oncology Data Advisor: Welcome to Oncology Data Advisor. Today, we're here at the ASCO Annual Meeting, and I'm joined by Barb Kunz. Thanks so much for coming on today.

Barb Kunz: Thanks for having us.

Oncology Data Advisor: Would you like to introduce yourself and share what your work and your research focus on?

Ms. Kunz: My name is Barb Kunz, and I'm a genetic counselor with the US Oncology Network. I was part of a study that Ontada sponsored, that six of our practices that have genetics programs contributed information to. Data was collected on about 1,300 patients who had triple-negative breast cancers. Our goal was to see how many of them had germline testing for BRCA1 and 2, and it was women who were 60 and younger because that used to be the guideline for that testing. Now it's everyone with triple-negative breast cancers. So, we were looking for the exact germline testing rate, but we also wanted to understand the social determinants of health that we saw in that population of who got tested and who didn't get tested.

Oncology Data Advisor: So, just for some background for this study, what is some background about the impact of social determinants of health and why you decided to investigate it in this setting?

Ms. Kunz: Well, triple-negative breast cancers are typically more dangerous cancers. Because there are less types of treatments that you can use for them—those breast cancers don't have estrogen progesterone receptors or human epidermal growth factor receptor 2 (HER2) receptors—those kinds of options aren't there. Also, there is an underlying increased chance of inherited cancer in that population. There are a lot of reasons why you'd want to look and see if those people are being offered it.

For one, if they needed treatment that could be guided by the result of that test, that be one important reason. Or if they recurred and needed treatment to be guided by that, that would be another reason. And then women who have an increased inherited risk for breast cancer also have a risk for other cancers. You want to guide their care going forward in the best way to prevent cancers and detect them early. Then lastly, if you find a hereditary cause for cancer, you want those individuals' relatives to be able to take advantage of that knowledge and prevent cancers and get better surveillance. So, there are a lot of reasons to focus on that population.

Oncology Data Advisor: Definitely. So, how did you and your team go about designing this study and carrying it out?

Ms. Kunz: So, this was a study that was done in collaboration with Ontada. They had the ability to pull from our electronic medical records (EMR) the data to identify among these patients, in a period of about four and a half years, who'd had triple-negative breast cancer. We really wanted to understand what the social determinants of health were so that we can later target and increase rates if we found a discrepancy. Our study was paired with another study that looked at triple-negative breast cancers and looked at whether neoadjuvant chemo was done, and they didn't see a disparity, but we did find a disparity. So, that's how we went about it. We have a subcommittee in our genetics group, it's called The Great Program, which is the collaboration across the practices. We put forward this proposal because we really wanted to understand this population and how well we were serving them.

Oncology Data Advisor: Absolutely. So, what were the results that you found?

Ms. Kunz: So, we did find that, overall, the testing rates were very good. They were around 75%, 74.4% overall. But we did see that among women who were Black, they were lower, about 67%. That's concerning, because it means that the population of patients who have a higher rate of triple-negative breast cancer than White patients are not getting the care that they need. We don't know enough about whether they were identified or whether they were referred. Did they follow through? If they were referred, why did they choose not to test? We also found that there was a difference in the insurance type in the population who got tested. Not surprisingly, individuals who had private pay insurance had the highest rate of testing, and self-pay was the lowest. In between, there was Medicaid and Medicare, but it was about 75% for private insurance and 60% for self-pay.

So, that coverage of testing is also a really important piece, especially in a population that's burdened with a cancer diagnosis and has a lot of other costs. And there was a difference in age in the population who was tested and not tested, but it was only a few years' difference. Then when they looked at the mean area of deprivation index for the population that was tested versus not, there was about a five-point difference in the score. So, we are seeing those other pieces that relate to the area in which people live, which gives us some sense of lower income and other issues that contribute. We really need to understand that better and hopefully address it. And one of the things I think about is doing a better systematic approach to it across practice to really make sure that we are following up. I think there's going to be a lot of quality work that's done on the back end of this, looking at those individuals and what happened.

Oncology Data Advisor: Definitely, yes. So, having these results in this knowledge, how do you recommend that it can be used to improve genetic testing in light of social determinants of health?

Ms. Kunz: For one, I think there's an effort across our network to do, like I said, some systemic approach, identifying and flagging individuals who have triple-negative breast cancer at any age now, and having those guidelines to recommend to the providers so that they don't overlook that option for patients. So, better identification, and then really, better paths towards genetic services. When someone doesn't choose genetic testing, the question is how good of an education did they get? Was it really an informed consent to decline testing, or did they just say, "No, I'm not interested"? Providing good education and having a good discussion about it, in many studies, has shown that that increases the use of genetic services. I think there will be a work towards that. And then I think there are some policy things that we really need to do, which is better coverage for genetic testing. It varies in different populations, but it's important as well.

Oncology Data Advisor: Absolutely. One last question I'll ask you, since the theme of ASCO this year is "Partnering With Patients," which was discussed in the opening session today, what is your perspective as a genetic counselor on how this is important and how you can partner with patients?