Socioeconomic Factors Are Associated With Disparities in Germline Testing in Pancreatic Cancer

Daniel King, MD, PhD

Germline genetic testing is recommended for patients with pancreatic adenocarcinoma. However, factors such as income, race/ethnicity, and social work needs correlate with lower rates and delays in this testing, according to findings presented at the 2023 Gastrointestinal Cancers Symposium.¹

In an institutional chart review at Northwell Health, investigators obtained information from 305 patients diagnosed with pancreatic adenocarcinoma from March 2016 to February 2022 and found that only 103 patients had germline testing results.

After gathering patient information on location, race, ethnicity, insurance, primary language, and social work needs, investigators found a negative correlation between median income and delays in testing, and underserved patients were more likely to experience testing delays. Social work needs were also associated with delays in testing. Additionally, patients who obtained pre-diagnostic testing were Asian or White.

“Ultimately, we want to know what the causal factors are, because it’s not that we just want to identify the problem. We want to fix this problem. Until we understand what the causative factors are, we cannot close that gap [in germline testing],” Daniel King, MD, PhD, said in an interview with OncLive^®.

In the interview, King discussed the results of the institutional review evaluating socioeconomic factors associated with disparities for germline genetic testing in patients with pancreatic adenocarcinoma, why germline testing is necessary for this patient population, and how he is addressing gaps in germline testing in his own practice.

King is an assistant professor at the Institute of Cancer Research, Feinstein Institutes for Medical Research, Northwell Health, and an assistant professor in the Department of Internal Medicine at Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, in New Hyde Park, New York.

OncLive^®: How did you explore possible socioeconomic factors that could affect germline genetic testing in patients with pancreatic cancer?

King: We had a hypothesis that not everyone [with pancreatic cancer] is getting germline genetic testing done, and who is not getting it done may vary by certain socioeconomic or demographic factors, so we looked into that.

We completed a large chart review at our organization. We looked at [305] patients who had pancreatic cancer and reviewed their charts to see who had germline testing done. We also looked to see how long the delay was between when they were diagnosed and when they had germline testing performed. We then asked if there were any factors in these patients’ charts that could help us understand who was not getting testing done, or who was getting testing done [with] delays in how long it took to get the testing done.

Why is germline testing important for patients with pancreatic cancer?

[Delays in or lack of testing] are significant because we use some of the results in germline testing to help determine first-line chemotherapy options, for example. One of the things that we've learned is that patients who have BRCA mutations tend to have more responsiveness to platinum-based chemotherapy. If we know that someone has a BRCA mutation, we'd like to start with platinum in the first line. [Germline testing] also has implications on whether [a patient’s] family needs cascade testing to make sure that there are no BRCA malignancies in other family members. There are a lot of important values to learning about germline genetic testing status.

What were the key findings from this analysis?

When we compared how long it was taking to get germline testing done, we realized that there was a significant disparity. In patients who were African American or patients of lower socioeconomic classes, there was a much longer delay to getting germline testing done [compared with other patients].

We found that association, and then we started to mine the data more thoroughly to try to understand what other factors may be implicated. [However], it is difficult to identify what is causative. We have identified many associations. We want to know what's causative.

Some of the other associations we found were high social work needs, for example. Patients who were regularly seeing social work for transportation and patients that have fewer social contacts [were also associated with a lack of or delay in germline testing]. It does seem seem like there are other factors that are associated with the delay in having germline testing performed.

We are now submitting a grant to help us understand which of those factors are causal, and then an intervention in order to mitigate some of those factors and ensure that everybody is getting germline testing done and getting it done soon after diagnosis.

Based on the outcomes of this investigation, how can these factors that contribute to disparities be addressed?

One thing is awareness. Until you are aware that such problem is happening, you may not be attuned to trying to fix this. In my own personal practice, whenever I'm seeing a patient with pancreatic cancer, I am reflexively thinking if this is someone who is vulnerable to having delays in testing. I'm trying to change my practice so that my testing for germline genetics becomes reflex the first time I see [a patient]. It's become essentially a checkbox, so that by the end of the visit, I try to make sure that every single person has germline testing done, and if they're not getting it done, I keep it in a follow-up [note], so that I ensure that the next time I see them, I'm getting it done. That is helping ensure that there are no delays in my clinic.

The second thing [we need to do] is promote that strategy across other providers and disciplines. [Previously], if we wanted to do germline genetic testing, we first would have to make a referral to our cancer genetics group. Then the cancer genetics group would be the group who would do the germline testing. That process itself is associated with delays. It means another appointment where patients have to be seen, and sometimes patients already have difficulty making any appointments. By doing it reflexively, when we're seeing patients at diagnosis, it's going to markedly facilitate or expedite germline testing.

What other disparities need to be addressed for patients with pancreatic cancer?

We are learning about disparities in many different contexts. Another poster [presented at the 2023 Gastrointestinal Cancers Symposium identified that African American patients have more emergency department visits [compared with] White patients with pancreatic cancer.2 That also was very striking.

We learned many things as we explored this. The setting for diagnostic biopsies is 5 times more likely in an inpatient setting than an outpatient setting if you're African American. Why? Why is it that there are 4 times as many emergency department visits for patients who are African American with pancreatic cancer compared with White patients?

Studying diversity in pancreatic cancer has had ramifications into many different aspects of care received. We found that many of the same associations that we saw in our germline study were also true for patients that are having recurrent emergency department visits. We're identifying a lot of the same associations, and it behooves us to figure out which of those factors are causal and if there is anything we could do to mitigate [these disparities].

How may electronic medical records help address these disparities in pancreatic cancer care?

We're attempting to figure out how to leverage our electronic medical record system to better identify patients with pancreatic cancer. Through that effort, we now have an alert system where anyone who's African American who has an emergency department visit automatically shows up on a dashboard for us. We then have a navigator call that patient to understand what the factors were that led to that person being seen in the emergency room.

We're hoping that in real time, we can get a better sense of why patients who are African American are going to the emergency department for their care. What were the factors that led up to that visit, and what can we do to modify those factors?

References

1. Zou X, Sidiqi B, Patruni S, et al. Socioeconomic disparities causing delays in pancreatic cancer germline genetic testing. J Clin Oncol. 2023;41(suppl 4):665. doi:10.1200/JCO.2023.41.3_suppl.665
2. John KM, Dhillion HS, King D. Rates of unplanned hospital care in Black Americans with pancreatic cancer. J Clin Oncol. 2023;41(suppl 4):666. doi:10.1200/JCO.2023.41.3_suppl.666