Since 2014 and 2015 respectively, the National Comprehensive Cancer Network (NCCN) and the Society of Gynecologic Oncology have recommended germline genetic testing for patients with newly-diagnosed epithelial cancers of the ovary, fallopian tube, and peritoneum [[1], [2], [3], [4]]. In 2020, the American Society of Clinical Oncology joined in issuing similar recommendations [5]. Unfortunately, germline testing rates for epithelial ovarian cancer patients remain low. A systematic review and meta-analysis of studies published from 2009 to 2020 found that only 39% of ovarian cancer patients were referred for genetic counseling, and just 30% completed germline testing [6].

Completion of germline genetic testing is critical for familial cancer risk-reduction and potentially for treatment decision-making; moreover, underutilization is associated with significant disparities in cancer care delivery. For example, identifying as non-white, living farther from a tertiary care hospital, or having Medicaid insurance are associated with lower odds of germline testing [[7], [8], [9]]. Additional barriers to testing, such as out-of-pocket costs, logistics of additional appointments, travel distance, limited time off work, lack of clinician prioritization, limited patient knowledge, and incorrect assumptions about heritable cancer risk have also been identified through qualitative studies [10,11].

We identified three gaps in the existing literature on implementation of routine germline testing for patients with epithelial ovarian cancer. First, we hypothesized that a composite measure of geographical disadvantage would capture barriers to testing that are not readily apparent in patient-level data; we therefore included geographically based social deprivation alongside traditional sociodemographic variables. Second, we hypothesized that referral for germline testing might vary by treating oncologist. We therefore included treating oncologist as an independent contributor to germline testing rates. Third, we hypothesized that considering time to completion of testing might identify critical gaps in receipt of clinically important information. We therefore consider time to completion of germline testing as an independently important care delivery outcome.