The research team, led by Minjee Lee of Kosin University College of Medicine in Busan, South Korea, together with Dongyu Zhang of the Medical College of Georgia at Augusta University and Meng-Han Tsai of the Georgia Cancer Center and Georgia Prevention Institute, categorized genetic testing engagement into four distinct groups. This four-way classification is methodologically important because it separates two processes that are often conflated in earlier research: the conversation in which a provider raises or discusses the possibility of genetic testing, and the actual uptake of the test itself. By treating these as separate outcomes, the investigators could detect patterns that would be invisible in a simple tested-versus-not-tested comparison. The categories were full engagement, meaning both discussion and uptake; discussion only; uptake only, meaning a test was taken without a documented provider discussion; and no engagement at all.

To quantify the associations, the researchers used multinomial logistic regression, a statistical technique suited to outcomes with more than two categories. They estimated odds ratios and 95 percent confidence intervals for each engagement category relative to no engagement, adjusting for a battery of sociodemographic and health-related covariates. Survey weights were applied throughout so that the results reflect the entire noninstitutionalized U.S. adult population rather than just the sample. The team also evaluated whether the relationship between cancer history and testing engagement differed by residential context, using survey-weighted Wald tests for the overall interaction between cancer history and rurality in both unadjusted and adjusted models. This interaction test is a key technical feature of the analysis, because it asks whether the strength of the cancer-history effect itself changes depending on where a person lives.

The results on cancer history were unambiguous. Adults with a personal history of cancer were dramatically more likely to engage with genetic testing across every category. The largest adjusted association appeared for full engagement, meaning both provider discussion and test uptake, with an odds ratio of 5.08 and a 95 percent confidence interval of 4.19 to 6.15. In other words, after accounting for age, sex, socioeconomic factors, and other health characteristics, cancer survivors had roughly five times the odds of both discussing and taking a genetic test compared with adults who had never had cancer. The association was weaker but still substantial for discussion only, at an odds ratio of 2.66, and weakest for uptake only, at an odds ratio of 1.57. This gradient makes intuitive sense: a cancer diagnosis typically brings patients into sustained contact with oncology services, where genetic counseling and testing are more likely to be offered and discussed.

The picture for rural residence was more nuanced. In unadjusted models, living in a rural area was associated with lower odds of full engagement and lower odds of uptake only, a pattern consistent with long-standing concerns about rural healthcare access. Rural Americans face documented barriers to specialty care, including shortages of genetic counselors and oncology providers, longer travel distances, and lower rates of insurance coverage. Previous studies in rural Illinois communities, cited by the authors, have documented limited knowledge and perceived barriers toward genetic testing in rural populations, and rural-urban differences in cancer incidence and mortality are well established in the epidemiological literature. Yet when the researchers adjusted for sociodemographic and health-related covariates, the rural associations attenuated, suggesting that some of the apparent rural disadvantage may reflect compositional differences, such as income, education, insurance status, or health status, rather than rurality itself.

However, the story did not end there. The overall interaction between cancer history and rurality was statistically significant in both the unadjusted model, with a p value of 0.008, and the adjusted model, with a p value of 0.005. This means the relationship between having had cancer and engaging with genetic testing genuinely differs between rural and urban residents, even after adjustment. In stratified analyses, cancer history was associated with all four engagement categories among rural adults, including the uptake-only category, whereas the pattern among urban adults differed. The authors themselves flag an important caveat here: the interaction tests were model-level rather than outcome-specific, so the rural uptake-only pattern should be considered hypothesis-generating rather than definitive. In plain terms, the statistical evidence indicates that rurality modifies the cancer-history effect somewhere in the system of outcomes, but the data cannot yet pinpoint exactly which category drives that modification with full confidence.

The uptake-only category deserves particular attention because it raises questions about how genetic testing is actually being ordered in the United States. An adult who reports taking a genetic test without a provider discussion may have received testing through a specialist who did not frame it as a discussion in the survey’s terms, may have ordered a test through an online direct-to-consumer service, or may have had a test arranged during cancer treatment without a formal counseling conversation. The survey’s measurement cannot distinguish among these pathways, and the authors explicitly call for studies with richer measurement of test source, ordering context, and provider involvement to clarify how rural residents in particular arrive at testing without a documented discussion. This matters clinically, because professional guidelines from the National Comprehensive Cancer Network and the American Society of Clinical Oncology emphasize that genetic testing for cancer susceptibility should ideally be accompanied by counseling to ensure informed consent and appropriate interpretation of results.

The findings land in a policy landscape where genetic testing capacity is unevenly distributed and where telehealth is increasingly proposed as a solution. Prior randomized research, also cited in the study, has shown that remote telehealth genetic services can outperform usual care in oncology practices that lack genetic counselors, and the National Society of Genetic Counselors has published an evidence-based practice guideline for telehealth genetic counseling. If rural residents with a cancer history are engaging with testing through atypical channels, expanding access to structured telehealth counseling could help ensure that rural testing follows guideline-concordant pathways. At the same time, the finding that 90.5 percent of all U.S. adults report no engagement with genetic cancer risk testing underscores that underuse is not exclusively a rural problem; it is a national one, affecting the vast majority of the population, including many people who might meet clinical criteria for testing based on family history.

The study’s strengths lie in its scale and representativeness. The National Health Interview Survey is conducted by the National Center for Health Statistics and is designed to produce nationally representative estimates, and the authors followed the Preferred Reporting Items for Complex Sample Survey Analysis, a checklist for transparent reporting of complex survey research. The urban-rural classification was based on the 2013 NCHS Urban-Rural Classification Scheme for counties, a standard framework in health services research. The study was supported in part by the National Cancer Institute under grant 1R21CA317745-01, with the sponsor having no role in study design, analysis, or the decision to submit. The authors declare no competing interests, and the underlying data are publicly available from the National Center for Health Statistics, allowing other researchers to verify and extend the analysis.

For clinicians, policymakers, and patients, the takeaways are concrete. A cancer diagnosis is a powerful gateway into genetic risk assessment, and health systems should treat every cancer survivorship encounter as an opportunity to evaluate whether genetic testing is appropriate, particularly in rural areas where the usual referral infrastructure may be thinner. The attenuated rural associations after adjustment suggest that improving socioeconomic and insurance-related factors could narrow part of the gap, but the significant interaction indicates that place still matters in ways that standard covariates do not capture. And for the overwhelming majority of adults with no engagement at all, the study is a reminder that genetic cancer risk testing remains an underused tool in American preventive medicine, one whose benefits, from tailored screening to cascade testing of relatives, depend first on someone starting the conversation.

Subject of Research: Genetic cancer risk testing engagement in relation to cancer history and rural residence among U.S. adults

Article Title: Cancer history, rural residence, and genetic cancer risk testing engagement among U.S. adults

Article References: Cancer history, rural residence, and genetic cancer risk testing engagement among U.S. adults. (n.d.). https://doi.org/10.1007/s10552-026-02260-y

Image Credits: AI Generated

DOI: 10.1007/s10552-026-02260-y

Keywords: genetic testing, cancer history, rural health, health disparities, National Health Interview Survey, cancer survivors, genetic counseling, patient-provider communication, healthcare access, multinomial logistic regression, cancer epidemiology, telehealth