African-Americans Are Less Frequently Accessed for Hereditary Colon Cancer

Anuja Chitre, MS, CGC - CGA-IGC Communications Committee Member

Colorectal cancer (CRC) is the third most common cancer in the United States, and thus it is important to identify individuals at increased risk for CRC so that initiation, frequency, and method of screening can be appropriately determined.

To identify individuals at higher risk for CRC, it is recommended to obtain a detailed family history (a three-generation cancer pedigree, including age at diagnosis) during the initial cancer risk assessment visit in the outpatient gastroenterology and procedural setting.  However, prior studies show that detailed family histories are not always obtained, and referral rates are often low for individuals at high risk. [i]^{, [ii], [iii], [iv]}.

However, is this trend more pronounced among African Americans (AA) and other minority patients?

This study investigated the rate of hereditary CRC risk assessment and genetic counselling referrals in patients at a university gastroenterology clinic and explored differences between African American and White patients.[i]

A 3-month retrospective chart review of all patients referred for colon cancer screening in 2018 was performed where each chart was assessed for documentation of a three generational family history and referral to genetics was examined.

Key Findings:

The key findings of this study were:

1.      Overall rate of documenting a three-generation family history was only 16.4%.

2.      Rate of documenting a three-generation family history was significantly lower for Black/AA individuals compared to White individuals, 13.7% verse 22.1%, respectively.

3.      Among the total patients who qualified for genetic counseling (65 total), there was no significant difference in eligibility for genetic counseling between Black/AAs and Whites (36 AA and 29 White).

4.      There was also no significant difference in the rates of referral for genetic testing between AA and White patients

Insights:

Although the importance of an individual’s family history in CRC decision making is well-established, this study made a concerning finding that providers in a gastroenterology clinic are rarely documenting family histories. Furthermore, the lower rate of documenting family histories in AA patients is especially troubling given the higher incidence, higher rate of late-stage diagnosis and increased mortality from CRC in AAs.

On the positive side, the rate of referral to genetic counseling was similar between AA and White patients in this study, in contrast to prior studies that had shown disparities in genetic referrals between the two patient groups.[i]^{, [ii], [iii], [iv]} However, the rate of referrals was surprisingly still low for both groups.

The authors provide a detailed discussion about possible reasons for poor rates of family history documentation, such as gaps in provider knowledge and provider assumptions that another specialty is responsible for placing the genetic referral.[i]

Additionally, the authors highlight that implicit bias about patient’s knowledge of family history, willingness to undergo genetic testing and probability to follow-up with a genetic provider may also limit family history documentation.[i].

The authors also explore patient factors that may limit communication of family history information by patients to providers. These include avoidance of conversations with family about cancer history among African Americans, low understanding and knowledge of genetic counseling and testing among ethnic minorities and perceived financial barriers.[i]^{, [ii]}

The results from this study offer valuable insights, but, being a single-institution design over a short period of three months, further exploration of these findings is warranted. Additionally, it is difficult to account for instances when a provider may have elicited a three-generation family history but did not fully document it.

Overall, this study shows a need for providers to improve family history taking and documentation, particularly for minority patients. It also emphasizes the need for better communication between patient and provider about the role of family history in CRC.

See the article HERE

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[i] Wood, M. E., Kadlubek, P., Pham, T. H., et al. (2014). Quality of cancer family history and referral for genetic counseling and testing among oncology practices: a pilot test of quality measures as part of the American society of clinical oncology quality oncology practice initiative. J Clin Oncol, 32, 824.

[ii] Grover, S., Stoffel, E. M., Bussone, L., Tschoegl, E., & Syngal, S. (2004). Physician assessment of family cancer history and referral for genetic evaluation in colorectal cancer patients. Clin Gastroenterol Hepatol, 2, 813-819.

[iii] Sweet, K. M., Bradley, T. L., & Westman, J. A. (2002). Identification and referral of families at high risk for cancer susceptibility. J Clin Oncol, 20, 528-537.

[iv] Han, J., & Spigelman, A. D. (2019). Adherence to guidelines for the referral of patients with colorectal cancer and abnormal tumour tissue testing for assessment of lynch syndrome. ANZ J Surg, 89, 1281-1285.

[i] Garland, V., Cioffi, J., Kirelik, D., Pascual, L., & Borum, M. L. (2021). African-Americans Are Less Frequently Assessed For Hereditary Colon Cancer. Journal of the National Medical Association, 113(3), 336–341.

[i] Underhill, M. L., Jones, T., & Habin, K. (2016). Disparities in cancer genetic risk assessment and testing. Oncol Nurs Forum, 43(4), 519-523.

[ii] Muller, C., Lee, S. M., Barge, W., et al. (2018). Low referral rate for genetic testing in racially and ethnically diverse patients despite universal colorectal cancer screening. Clin Gastroenterol Hepatol, 16(12), 1911-1918.e2.

[iii] Peterson, J. M., Pepin, A., Thomas, R., et al. (2020). Racial disparities in breast cancer hereditary risk assessment referrals. J Genet Couns, 29(4), 587-593.

[iv] . Manrriquez, E., Chapman, J. S., Mak, J., Blanco, A. M., & Chen, L. M. (2018). Disparities in genetics assessment for women with ovarian cancer: can we do better? Gynecol Oncol, 149(1), 84-88

[i] Noll, A., Parekh, P. J., Zhou, M., et al. (2018). Barriers to lynch syndrome testing and preoperative result availability in early onset colorectal cancer: a national physician survey study. Clin Transl Gastroenterol, 9.

[i] Prochniak, C. F., Martin, L. J., Miller, E. M., et al. (2012). Barriers to and motivations for physician referral of patients to cancer genetics clinics. J Genet Couns, 21, 305-325.

[i] Allen, C. G., Escoffery, C., Haardörfer, R., & McBride, C. M. (2018). Factors influencing not perceiving family health history assessments as important: opportunities to improve dissemination of evidence-based population screening for cancer. Public Health Genomics, 21, 144-153.

[ii] Hann, K. E. J., Freeman, M., Fraser, L., et al. (2017). Awareness, knowledge, perceptions, and attitudes towards genetic testing for cancer risk among ethnic minority groups: a systematic review. BMC Public Health, 17(1), 503.