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

PURPOSE: Using nationally representative data from the 2023 National Health Interview Survey (NHIS), this cross-sectional study examined whether personal cancer history and rural residence were associated with engagement in genetic cancer risk testing among U.S. adults aged 18 years or older. METHODS: Genetic testing engagement was categorized as both provider discussion and test uptake (both), discussion only, uptake only, or no engagement (neither). Multinomial logistic regression models estimated odds ratios (ORs) and 95% confidence intervals (CIs) for each engagement category relative to no engagement, adjusting for sociodemographic and health-related covariates. Overall cancer history by rurality interactions were evaluated using survey-weighted Wald tests in unadjusted and adjusted multinomial models. RESULTS: Among 27,558 adults, 90.5% reported no engagement, 3.3% reported both, 4.3% reported discussion only, and 1.9% reported uptake only. Personal cancer history was strongly associated with all engagement categories, with the largest adjusted association observed for both (OR = 5.08, 95% CI 4.19-6.15), followed by discussion only (OR = 2.66, 95% CI 2.24-3.17) and uptake only (OR = 1.57, 95% CI 1.14-2.15). Rural residence was associated with lower odds of both and uptake only in unadjusted models, but these associations attenuated after covariate adjustment. The overall cancer history by rurality interaction was statistically significant in both unadjusted (p = 0.008) and adjusted (p = 0.005) models. In stratified analyses, cancer history was associated with all engagement categories among rural adults, including uptake only. CONCLUSIONS: Personal cancer history was strongly associated with genetic cancer risk testing engagement, and this association varied by residential context. The rural uptake-only pattern should be considered hypothesis-generating because interaction tests were model-level rather than outcome-specific. Studies with richer measurement of test source, ordering context, and provider involvement are needed to clarify rural engagement pathways.