We analyzed cases of prostate adenocarcinoma diagnosed in 2016-2023 at JPS Health Network (JPS), a safety-net provider in Texas. JPS is a publicly funded and comprehensive healthcare system in Tarrant County, Texas, serving over 175,000 patients annually from a catchment population of approximately 2.1 million. In 2023, 27% of patients were uninsured, 18% qualified for the JPS financial assistance program, 36% were covered by Medicaid, Medicare, or other government programs, and 19% had private insurance. Five general medical oncologists take care of patients with prostate cancer as well as all other types of cancers at JPS Oncology and Infusion Center. Genetic counseling and hereditary cancer genetic testing are offered at JPS in collaboration with the UT Southwestern Cancer Genetics Program in Dallas, Texas. Demographic and clinical data, including genetic counseling referrals and testing results, were obtained from cancer registries and electronic health records (EHR). Statistical analysis was performed using a logistic regression model.
Among 543 patients, 46% were Black, 27% were Hispanic, and 40% had metastatic disease. Overall, 132 patients (24%) were referred for genetic counseling, of whom 102 (77%) completed the visits. Rates of referrals increased from 4% in 2017 to 9% in 2019 to 28% in 2023. A multivariate logistic regression determined that patients with stage 3 or 4 cancers were more likely than those with stage 1 to be referred (P = 0.02 and P <0.01, respectively). Genetic testing was completed for 78 patients (76%), with 8 (10%) having 9 positive results in BRCA1 (n=1), BRCA2 (n=1), CHEK2 (n=3), MSH2 (n=2), PALB2 (n=1), and PMS2 (n=1).
Following guideline changes, genetic testing referrals for patients with prostate cancer increased approximately sevenfold in a safety-net setting. Over three-fourths of referred patients completed testing, and 10% had positive results. Multiple factors contributed to a high appointment and testing completion rate as compared to previously reported studies in safety-net settings. These factors include a robust in-house genetic counseling service at JPS, availability of financial assistance for appointments and testing that reduced barriers to access, proactive rescheduling of missed appointments by referral coordinators, adoption of adaptive service delivery models such as expanded telemedicine during the pandemic, and integration of contracted genetic counselors into the EHR.
Our patient population consists of 40% with stage 4 at diagnosis as opposed 8% in the United States (US). Thirty-eight percent of stage 4 patients were referred to genetic testing, and stage 4 patients constituted 63% of all referrals. About one-fifth of all patients were stage 3, and 23% were referred. Based on NCCN guidelines, all these patients would have qualified for genetic testing, indicating that future efforts need to build on the existing framework of success. Twelve percent of all patients with stages 1 and 2 were referred, indicating these were younger patients with positive family histories. Forty-seven percent of all patients were unsured and 58% of patients referred for testing were uninsured.
This study demonstrates the feasibility and importance of genetic testing in underserved populations. While safety-net hospitals constitute approximately 25% of all US healthcare facilities, they remain significantly underrepresented in clinical research. It is imperative to bridge this gap in academic literature, ensuring that the unique challenges and successes of these institutions inform broader health policy.
Written by: Prisca Mbonu,1 Jacqueline Mersch, MS, CGC,2 Jana Heady, MS, CGC,2 Samuel Newman, MS,3 Jolonda C. Bullock, ODS-C,4 Kyle Seymour,5 David E. Gerber, MD,6,7,8 Kalyani Narra, MD1,4
- Department of Internal Medicine, Anne Burnett Marion School of Medicine at Texas Christian University, Fort Worth, Texas
- Cancer Genetics Program, Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas
- Office of Clinical Research, John Peter Smith Health Network, Fort Worth, Texas
- IT Business Intelligence, John Peter Smith Health Network, John Peter Smith Health Network, Fort Worth, Texas
- Harold C. Simmons Comprehensive Cancer Center, University of Texas Southwestern Medical Center, Dallas, Texas
- Department of Internal Medicine (Division of Hematology-Oncology), University of Texas Southwestern Medical Center, Dallas, Texas
- Peter O’Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas, USA