Clinician Bias and Patient Experience in Cancer Genetic Counseling

Importance: Genetic counseling helps reduce cancer burden; however, disparities exist in genetic counseling. Objective: To examine associations between genetic counselor (GC) biases (implicit and/or explicit prejudice and stereotyping) and patient-centered outcomes in cancer genetic counseling. Design, Setting, and Participants: This is a cohort study of patient-clinician communication during cancer genetic counseling focusing on hereditary cancer risk assessment. GCs and patients completed baseline surveys, video and/or audio-recorded sessions, and postencounter surveys. Data were collected at 2 comprehensive cancer centers in the South and Midwest, from August 3, 2023, to July 30, 2025. Exposure: At baseline, GCs completed measures of implicit prejudice (Race Implicit Association Test), implicit stereotyping (Medical Cooperativeness Implicit Association Test), explicit prejudice (feeling thermometer), and explicit stereotyping (general and medical-context stereotype subscales). Main Outcomes and Measures: Patients reported postencounter therapeutic alliance, satisfaction, and decisional conflicts. Differences between Black and White patients were evaluated using Welch t test for continuous variables and χ2 or Fisher exact test for categorical variables. Hypothesis testing was conducted using linear mixed-effects models with GC-specific random effects and intracluster correlation coefficients. Results: The current analysis included 185 cases with complete clinician baseline, patient baseline, and patient postencounter data. The 185 patients (mean [SD] age, 50.1 [14.0] years; 169 female [91.4%]; 16 male [8.6%]; 83 Black [44.9%]; 102 White [55.1%]) saw 1 of the 15 clinicians (mean [SD] age, 32.2 [9.5] years; 8 certified [53.3%]; 7 trainees [46.7%]). Among Black patients (mean [SD] age, 50.1 [13.6] years; 80 female [96.4%]; 3 male [3.5%]), stronger GC endorsement of explicit medical-context stereotypes favoring White over Black patients was significantly associated with poorer therapeutic alliance (b [SE], -1.40 [0.37] to -1.54 [0.46]), lower satisfaction (b [SE], -0.74 [0.27]), and greater decisional conflict (b [SE], -0.85 [0.27] to -0.91 [0.25]), after covariate adjustment. Among White patients (mean [SD] age, 50.1 [14.4] years; 89 [87.3%] female; 13 [12.7%] male), no biases were significantly associated with outcomes after adjustment (b [SE], -0.14 [0.49] to -0.48 [0.49]). Explicit medical-context stereotyping was the only factor significantly and consistently associated with racial disparities in patient-centered outcomes (b [SE], -1.35 [0.49] to -1.93 [0.61]). Conclusions and Relevance: In this cohort study of cancer genetic counseling, stronger endorsement of medical-context stereotypes favoring White over Black patients was significantly associated with poorer patient-centered outcomes among Black patients. Explicit medical-context stereotypes may contribute to racial disparities in genetic counseling. Interventions should address explicit stereotyping and its role in clinical communication.