Social vulnerability and genetic service utilization among unaffected BRIDGE trial patients with inherited cancer susceptibility
Authors: Bather Jemar R. , Goodman Melody S. , Harris Adrian , Del Fiol Guilherme , Hess Rachel , Wetter David W. , Chavez-Yenter Daniel , Zhong Lingzi , Kaiser-Jackson Lauren , Chambers Rachelle , Bradshaw Richard , Kohlmann Wendy , Colonna Sarah , Espinel Whitney , Monahan Rachel , Buys Saundra S. , Ginsburg Ophira , Kawamoto Kensaku , Kaphingst Kimberly A. ,   on behalf of the BRIDGE research team
Published: January 2025

Abstract

Background
Research on social determinants of genetic testing uptake is limited, particularly among unaffected patients with inherited cancer susceptibility.

Methods
We conducted a secondary analysis of the Broadening the Reach, Impact, and Delivery of Genetic Services (BRIDGE) trial at University of Utah Health and NYU Langone Health, involving 2,760 unaffected patients meeting genetic testing criteria for inherited cancer susceptibility and who were initially randomized to either an automated chatbot or an enhanced standard of care (SOC) genetic services delivery model. We used encounters from the electronic health record (EHR) to measure the uptake of genetic counseling and testing, including dichotomous measures of (1) whether participants initiated pre-test cancer genetic services, (2) completed pre-test cancer genetic services, (3) had genetic testing ordered, and (4) completed genetic testing. We merged zip codes from the EHR to construct census tract-weighted social measures of the Social Vulnerability Index. Multilevel models estimated associations between social vulnerability and genetic services utilization. We tested whether intervention condition (i.e., chatbot vs. SOC) moderated the association of social vulnerability with genetic service utilization. Covariates included study arm, study site, age, sex, race/ethnicity, language preference, rural residence, having a recorded primary care provider, and number of algorithm criteria met.

Results
Patients living in areas of medium socioeconomic status (SES) vulnerability had lower odds of initiating pre-test genetic services (adjusted OR [aOR] = 0.81, 95% CI: 0.67, 0.98) compared to patients living in low SES vulnerability areas. Patients in medium household vulnerability areas had a lower likelihood of completing pre-test genetic services (aOR = 0.80, 95% CI: 0.66–0.97) and having genetic testing ordered (aOR = 0.79, 95% CI: 0.63–0.99) relative to patients in low household vulnerability areas. We did not find that social vulnerability associations varied by intervention condition.

Conclusions
These results underscore the importance of investigating social and structural mechanisms as potential pathways to increasing genetic testing uptake among patients with increased inherited risk of cancer. Census information is publicly available but seldom used to assess social determinants of genetic testing uptake among unaffected populations. Existing and future cohort studies can incorporate census data to derive analytic insights for clinical scientists.

Trial registration
BRIDGE was registered as NCT03985852 on June 6, 2019 at clinicaltrials.gov.