Does financial subsidy equalise cancer genetic testing uptake across socioeconomic groups? A retrospective observational study in Singapore.

Abstract

To examine the association between socioeconomic status (SES), financial subsidies and awareness-related factors such as age, cancer stage and family history, and the uptake of cancer genetic testing, with a focus on equitable access to care. Retrospective cohort study. Tertiary care cancer genetics service in Singapore. The study population included 2687 individuals of all ages, genders and ethnicities who attended pretest counselling between 2014 and 2020 and were eligible for genetic testing for hereditary cancer syndromes. The primary outcome was the uptake of genetic testing. The main explanatory variables were SES (proxied by Housing Index), subsidy status, age, cancer stage and family history. Analyses examined whether associations varied across SES and age subgroups. Receipt of financial subsidies was strongly associated with testing uptake (adjusted OR 9.15, 95% CI 2.68 to 31.20). Uptake exceeded 90% among subsidised individuals across all socioeconomic strata, compared with 56-68% among non-subsidised individuals, with the largest gains in the lowest SES group (43 vs 28 percentage points (pp) in the highest). The level of subsidy was not associated with uptake. Younger patients (18-39 years) had higher uptake than those aged 60+ (66% vs 57%); patients with advanced cancer (stage IV) had the highest uptake (82% vs 57-66% in earlier stages); and family history was associated with increased uptake, strongest for having a child with cancer (+28 pp). Interaction analysis suggested that the additive effects of subsidies were greatest in lower SES groups and in older adults. Financial subsidies were strongly associated with higher genetic testing uptake. Awareness indicators like age, cancer stage and family history were associated with higher uptake. The association between subsidies and uptake varied by SES and age, suggesting that subsidies may help reduce disparities and improve equitable access to genetic testing services.