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Purpose:As genetic counseling and testing become more fully integrated into clinical care, alternative delivery models are increasingly prominent. This study examines predictors of genetic testing for hereditary breast/ovarian cancer among high-risk women in a randomized trial of in-person versus telephone-based genetic counseling.Methods:Methods include multivariable logistic regression and interaction analyses.Results:Of the 669 participants, 600 completed counseling and 523 received test results. As previously reported, participants randomized to telephone counseling were significantly less likely to be tested. In intention-to-treat analyses, completion of counseling and testing was associated with: race/ethnicity (odds ratio (OR) = 1.96, 95% confidence interval (CI): 1.20–3.20), perceived stress (OR = 0.89, 95% CI: 0.81–0.98), knowledge (OR = 1.12, 95% CI: 1.02–1.23), and randomization group (OR = 1.48, 95% CI: 1.01–2.16). Further, race/ethnicity moderated the association between randomization group and testing; minority women receiving telephone counseling were least likely to complete testing.Conclusion:Evidence for logistical and communication-based explanations for this interaction is presented. The overall increased access made possible with telephone genetic counseling should be considered in light of the possibility that this may also lead to lower rates of testing among high-risk minority women. Additional care should be taken to assess and address potential barriers when services are delivered by telephone.Genet Med 17 6, 467–475.

Genetic counseling via telephone (TC) has emerged as a potential avenue of care for women at risk of breast and ovarian cancers and open to BRCA1and BRCA2genetic testing. However, although TC has been shown to be on level with usual care (UC) methods in terms of knowledge, satisfaction, decisional quality, quality of life, and distress, all while yielding high cost savings to the patient and increasing patient accessibility, studies have also shown that patients randomized to TC are less like to complete the genetic testing process. In order to determine the factors leading to lower rates of genetic testing uptake after TC, the authors of this study examined sociodemographic, medical, and psychosocial predictors of genetic testing uptake and evaluated patient-related moderators (knowledge, numeracy, race/ethnicity, education level, etc) in a large cohort of women.In this noninferiority trial, 669 women (21–85 years old) seeking BRCA1/2genetic testing, with no history of counseling or testing, were randomized into 2 groups, a TC group (n = 335) and an in-person counseling or UC group (n = 334). Measures included sociodemographics, medical history, intentions for risk-reducing surgery, perceived risk of BRCAmutation, perceived risk of breast and ovarian cancer, knowledge, numeracy, decisional conflict, cancer-specific distress, and quality of life. Analysis, logistic regression with backward elimination, was conducted within an intention-to-treat (ITT) sample, which included all randomized participants regardless of genetic counseling session completion, and with a per-protocol (PP) sample, limited to participants who completed genetic counseling as assigned.Within both the ITT and PP samples, genetic testing uptake was lower in the TC group than in the UC group (ITT: 74.9% vs 81.4%, P= 0.04; PP: 84.2% vs 90.1%, P= 0.03). In the ITT population, independently associated significant predictors of completing genetic testing were non-Hispanic white race/ethnicity (odds ratio [OR], 1.96; P= 0.007), randomization to UC (OR, 1.48; P= 0.045), higher knowledge (OR, 1.12; P =0.018), and lower perceived stress (OR, 0.89; P= 0.017). In the PP sample, independently associated predictors were marital status (OR, 1.85; P= 0.017), objective mutation risk (OR, 1.22; P =0.007), knowledge (OR, 1.13; P =0.050), and randomization to UC (OR, 1.65; P=0.050). Considering both ITT and PP analyses, it is of note that knowledge, perceived stress, and objective risk did not interact with group assignment in either analysis (marital status was not tested). In regard to potential moderator variables, the only variable that reached statistical and clinical significance in both samples was race/ethnicity (ITT: P =0.054; PP: P =0.028).Overall, the strongest moderator affecting genetic testing uptake after TC was race/ethnicity. When randomized to TC, minority women were less likely to complete BRCA1/2genetic testing. Despite these lower rates, which may be due in part to practical barriers (unlike UC patients, TC patients need to travel to an alternate location to provide a DNA sample), this finding needs to be balanced with the possibility that TC may increase access in the first place. Further studies on availability of TC and its effect on overall rates should be conducted as other modes of delivery emerge for genetic counseling and testing.