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 χ 2 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.