Disparities in genetic testing for women with ovarian cancer: a systematic review

Objectives: Despite the recommendation for genetic assessment for all women with ovarian cancer, the limited available data suggest significant disparities in referral and uptake of genetic services in minority populations. Additionally, the COVID-19 pandemic has exacerbated many existing health care disparities, making it even more critical that inequalities be identified and addressed. We sought to evaluate differences in genetic counseling and genetic testing among women with ovarian cancer based on race and insurance status. Methods: A complete systematic search of online databases (PubMed, EMBASE, MEDLINE, and the Cochrane Library) for studies reporting on genetic testing in ovarian cancer without date restriction was performed. Random effects pooled proportions were calculated using the logit transformation and 95% confidence intervals for individual study proportions were calculated using the Clopper-Pearson exact method. Results: The comprehensive search produced 3026 studies, among which 38 met inclusion criteria. Eight studies included analysis by self-reported race/ethnicity and 6 included analysis by insurance status. Among studies listing mean age of diagnosis, stage, and histology data, the median of the mean age of diagnoses across the studies was 63.3 years. The median proportion of patients with early stage (I/II) ovarian cancer was 14.7%, late stage (III/IV) 68.6%, and unknown stage 9.3%. The median proportion of patients with serous histology was 81.8%, endometrioid 12.6%, mucinous 5%, clear cell 5.8%, mixed 3.7%, carcinosarcoma 3%, and other/unknown histology 81.8%. Among 7,862 patients, 6,469 reported being White, 599 Black, and 794 Asian. Random-effects pooled proportions by race/ethnicity to follow: Among White patients, 43% [CI 26-62%] were referred for genetic counseling and 40% [CI 25-57%] completed testing, and for Black patients, 24% [CI 13-42%] were referred for counseling and 26% [CI 17-38%] completed testing. For Asian patients, 23% [CI 2-83%] were referred for counseling and 14% [CI 2-51%] completed testing, although only two studies included referral and testing proportions in Asian patients, with the majority of patient data coming from one study with referral proportion of 39% and another study with testing proportion of 31%. Among 7,681 patients, 5,320 (69%) had private insurance, 2,078 (27%) had Medicare/Medicaid, and 283 (4%) were uninsured. Random-effects pooled proportions by insurance status to follow: Among patients with private insurance, 39% [CI 26-54%] were referred for genetic counseling and 47% [CI 30-64%] completed testing. Among patients with Medicare/Medicaid, 27% [CI 18-38%] were referred for counseling and 26% [CI 16-40%] completed testing, and among uninsured patients, 24% [CI 13-41%] were referred for counseling and 23% [CI 18-28%] completed testing. Small sample and high study heterogeneity observed in the race and insurance data resulted in large confidence intervals in the pooled proportions of interest. Conclusions: Rates of genetic counseling and genetic testing are below national guidelines for all women with ovarian cancer. Our systematic review of the existing literature on this topic suggests that minority women and patients without private insurance may be disproportionally affected by lower referral rates and more limited access to genetic testing. This disparity is concerning as it can have significant impact on the health of the affected patient and her at-risk relatives. Download : Download high-res image (212KB) Download : Download full-size image