乳腺癌女性BRCA1/2检测的种族差异、医师建议与诊疗差距

　　编者按：该研究虽然开展于美国，但是仍值得中国医师深思，对于不同地域、不同社会或经济地位的中国患者，无论接受程度如何，是否应该提供一视同仁的诊疗建议？不过，目前国内医疗形势很严峻……

　　2016年5月9日，麻省总医院（马萨诸塞综合医院）、哈佛医学院、宾夕法尼亚大学佩雷尔曼医学院在美国临床肿瘤学会官方期刊《临床肿瘤学杂志》发表了国家卫生研究院国家癌症研究所赞助的人群研究：乳腺癌女性BRCA1/2检测的种族差异、医师建议与医疗差距。

　　该研究于2007年至2009年根据癌症登记数据、美国医学会医师档案、患者和医师调查，对宾夕法尼亚州和佛罗里达州18岁至64岁确诊为浸润性乳腺癌的女性开展了人群研究，入组了3016例女性（69%为白人，31%为黑人）、808位肿瘤内科医师和732位外科医师。

　　结果发现，黑人女性与白人女性相比，接受BRCA1/2检测显著较少（OR：0.40；95% CI：0.34～0.48，P＜0.001）。该差异经过校正风险突变、临床因素、社会人口学特征和检测态度后有所减少，但仍非常显著（OR：0.66；95% CI：0.53～0.81；P＜0.001）。黑人和白人女性无论至外科医师还是肿瘤专科医师，接受的诊疗存在高度差异（差异指数分别为64.1和61.9），但是经过校正医师类型或医师特征，并未改变检测差异度大小。黑人女性似乎较少报告她们收到医师建议BRCA1/2检测，即使经过校正突变风险后（OR：0.66；95% CI：0.54～0.82；P＜0.001）。经过校正医师建议，检测差异显著减少（OR：0.76; 95% CI：0.57～1.02；P=0.06）。

　　因此，虽然黑人和白人乳腺癌患者往往会看不同的外科医师和肿瘤专科医师，但是该差异与BRCA1/2检测差异无关。相反，排除患者和医生特征后，检测仍存在种族差异的主要原因在于医师建议不同。努力解决这些差异的重点，应该放在确保一视同仁的检测建议。

J Clin Oncol. 2016 May 9. [Epub ahead of print]

Health Care Segregation, Physician Recommendation, and Racial Disparities in BRCA1/2 Testing Among Women With Breast Cancer.

Anne Marie McCarthy, Mirar Bristol, Susan M. Domchek, Peter W. Groeneveld, Younji Kim, U. Nkiru Motanya, Judy A. Shea, Katrina Armstrong.

Massachusetts General Hospital; Harvard Medical School, Boston, MA; University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.

PURPOSE: Racial disparities in BRCA1/2 testing have been documented, but causes of these disparities are poorly understood. The study objective was to investigate whether the distribution of black and white patients across cancer providers contributes to disparities in BRCA1/2 testing.

PATIENTS AND METHODS: We conducted a population-based study of women in Pennsylvania and Florida who were 18 to 64 years old and diagnosed with invasive breast cancer between 2007 and 2009, linking cancer registry data, the American Medical Association Physician Masterfile, and patient and physician surveys. The study included 3,016 women (69% white, 31% black), 808 medical oncologists, and 732 surgeons.

RESULTS: Black women were less likely to undergo BRCA1/2 testing than white women (odds ratio [OR], 0.40; 95% CI, 0.34 to 0.48; P < .001). This difference was attenuated but not eliminated by adjustment for mutation risk, clinical factors, sociodemographic characteristics, and attitudes about testing (OR, 0.66; 95% CI, 0.53 to 0.81; P < .001). The care of black and white women was highly segregated across surgeons and oncologists (index of dissimilarity 64.1 and 61.9, respectively), but adjusting for clustering within physician or physician characteristics did not change the size of the testing disparity. Black women were less likely to report that they had received physician recommendation for BRCA1/2 testing even after adjusting for mutation risk (OR, 0.66; 95% CI, 0.54 to 0.82; P < .001). Adjusting for physician recommendation further attenuated the testing disparity (OR, 0.76; 95% CI, 0.57 to 1.02; P = .06).

CONCLUSION: Although black and white patients with breast cancer tend to see different surgeons and oncologists, this distribution does not contribute to disparities in BRCA1/2 testing. Instead, residual racial differences in testing after accounting for patient and physician characteristics are largely attributable to differences in physician recommendations. Efforts to address these disparities should focus on ensuring equity in testing recommendations.

Supported by Grant No. 5-R01-CA133004-3 from the National Cancer Institute, National Institutes of Health.

DOI: 10.1200/JCO.2015.66.0019