Disparities in BRCA testing: when insurance coverage is not a barrier

Background: Strategies to reduce the risk of developing breast and ovarian cancer in carriers of deleterious BRCA 1 and 2 mutations are readily available. However, many people who are at high risk of having these genetic mutations are reluctant to obtain the test. We sought to identify factors associated with choice of testing. Methods: We performed a retrospective cohort review of high-risk patients referred to a multidisciplinary breast health center for BRCA testing between January 2001 and March 2008. Demographic variables were compared by using logistic regression between those who completed genetic testing and those who did not. Results: A total of 213 patients were referred for BRCA testing. The mean age was 49.2 years (range, 16-84 y). Five patients were male. The majority of individuals (63.4%) were white, 15% were Hispanic, 6.6% were black, and 4.7% were Asian. Insurance coverage for testing was available in 91.1% of patients, of whom 49.2% had private insurance, 26.7% had managed care insurance, and 24.1% had government-sponsored insurance. A total of 111 patients (52.1%) underwent testing. On multivariate analysis, patients were significantly more likely to complete testing if they had a personal history of breast cancer (73.0% of tested patients) (P = .005) and had at least some college education (61.3%) (P = .03). There were no statistically significant differences in tested versus untested groups by age, race, language, family history, parity, marital status, religion, socioeconomic status, or insurance status. Of patients whose insurance plans offered coverage for genetic testing, 51.4% underwent testing and 48.6% did not (P = not significant [NS]). Of those who had no insurance coverage for testing, 41.2% underwent testing and 58.9% did not (P = NS). Conclusions: Our data show that half of those patients at risk for carrying a BRCA mutation do not undergo testing. Insurance coverage for genetic testing does not influence the decision to test. Developing counseling instruments that explain the benefits of testing to unaffected high-risk individuals or targeted to those with a high school level education may be a strategy to improve testing rates.