Table 13. Predictors Associated with Uptake of Genetic Testing (GT) continued...
Reasons cited for following through with testing included a desire to learn about a child's risk, to feel relief from uncertainty, to inform screening or prophylactic surgery decisions, and to inform important life decisions such as marriage and childbearing.[24,26] Among African American women, the most important reason for testing included motivation to help other relatives decide on genetic testing.
Physician recommendation may be another motivator for testing. In a retrospective study of 335 women considering genetic testing, 77% reported that they wanted the opinion of a genetics physician about whether they should be tested, and 49% wanted the opinion of their primary care provider. However, there is some evidence of referral bias favoring those with a maternal family history of breast cancer or ovarian cancer. In a Canadian retrospective review of 315 patients, those with a maternal family history of breast cancer or ovarian cancer were 4.9 times (95% confidence interval, 3.6-6.7) more likely to be referred for a cancer genetics consultation by their physician than were those with a paternal family history (P < .001). Studies have found that physicians may not adequately assess paternal family history  or may underestimate the significance of a paternal family history for genetic risk.[29,30,31]
In May 2011, a case study examined coverage for BRCA1/2 testing using National Comprehensive Cancer Network (NCCN) clinical guidelines. The online databases included data from large private insurers (eight payers, including Aetna, Cigna, Humana, and United HealthCare) and public insurance policies, including Medicare (Washington state) and four Medicaid policies (Arizona, California, Illinois, and New York). Overall, more consistent policies were available for private than for public payers, indicating better communication of eligibility criteria and transparency of coverage. However, across all types of coverage, including private coverage, the criteria were inconsistent for coverage of genetic counseling services. Of note, the Medicare policies only covered individuals with a history of breast cancer, not those with strong family histories, as outlined by NCCN.
Conducted in 2008, another study examined coverage policies from all third-party payers in Illinois and documented relative consistency in coverage for genetic testing for breast/ovarian cancer and colorectal cancer susceptibility, but much less consistent approaches to coverage for genetic counseling services; for example, several policies would not cover genetic counseling services unless the patient ultimately decided against genetic testing. One example of success in changing coverage plans was initiated by the Michigan Department of Community Health, which used a cooperative agreement with the Centers for Disease Control and Prevention to raise awareness and provide guidance for an increase in written policies regarding BRCA1/2 testing, increasing utilization from 4 to 11 health plans. As of August 2011, 11 of 24 Michigan health plans had written BRCA1/2 genetic testing policies aligned with U.S. Preventive Services Task Force guidelines. There is evidence that concerns about genetic discrimination are decreasing. A 2007 survey of genetic counselors reported that most (94%) felt the risk of insurance discrimination resulting from genetic testing was low, and that they were confident in U.S. laws to protect against genetic discrimination.