Motivations and concerns of women considering genetic testing for breast cancer: a comparison between affected and at-risk probands

Since the discovery of the BRCA1 and BRCA2 genes, there has been an increasing demand for breast cancer risk assessment programs. In an effort to understand and serve the population such programs target better, several studies have identified factors influencing high-risk women to pursue breast cancer risk assessment and genetic testing services; none, however, has focused on how the motivations and concerns of at-risk women may differ from their previously affected counterparts, who are typically the initial members of their families to undergo genetic testing. The majority of both previously affected and unaffected women felt that preventative surgery decisions, surveillance practices, the assessment of children's risks, and increased breast cancer anxiety were "more important" or "very important" issues regarding their thoughts about genetic testing. Significantly more affected women deemed family members' opinions "more" or "very important" (p < 0.01). Opinions concerning insurance and employment discrimination did not vary significantly between groups; however, a larger percentage of affected women felt this issue was of importance. Although all issues above should be addressed with women seeking cancer risk assessment and genetic testing, this research may help health care providers to gain a greater understanding of how the motivators and concerns of high-risk women can differ with personal cancer status so that referral, counseling, and education can be executed optimally.

Decisional consideration of hereditary colon cancer genetic test results among Hong Kong chinese adults

This study investigated the relationship between psychosocial factors and the decisional consideration of genetic testing of hereditary colon cancer. Attitudes and beliefs about genetic testing, anxiety and depression levels, coping style, and optimism were used as psychosocial independent variables. Sixty-two registrants (61% males and 39% females) of the Hereditary Gastrointestinal Cancer Registry of the Queen Mary Hospital in Hong Kong completed a mail survey. Mean age of the respondents was 42 years (SD = 9.92 years, range: 18-68 years). Correlational analyses and regression analyses were used to examine the relationships between the dependent and independent variables. Participants were concerned about the well-being and reactions of their significant others even more than their own well-being in their decisional consideration processes. Those who had higher perceived risks of being a mutated carrier and higher depression levels tended to emphasize more on the negative consequences of learning the test results and sharing them with relatives. Besides, those who believed that having cancer was attributable to personal (e.g., stress) rather than environmental factors considered that the negative consequences were relatively more important than the positive gains in sharing their results with relatives. Our participants tended to be relational or interdependent oriented in their decisional consideration processes related to genetic testing of colon cancer. This result is consistent with the established interdependent orientation of Chinese. Participants with higher risk perception focused more on the negative consequences of genetic testing. Psychological counseling might help these patients to cope with their concerns about being diagnosed as gene carriers after genetic testing.

Developing culturally sensitive cancer genetics communication aids for African Americans

The goal of this project was to develop educational materials to communicate genetic health information in a culturally sensitive manner. These materials were designed to communicate information about cancer risk, genetic testing options, and health management options in an African American kindred with a known BRCA1 mutation. Educational materials were pilot-tested in four African American focus groups varying in socioeconomic status and gender. The audiotaped focus groups consisted of presentation of the educational materials, followed by a feedback session led by an African American facilitator. Qualitative analysis of the focus group transcripts identified important themes and the educational materials were revised in response to the participants' suggestions. The products included a booklet and a flip chart for use in educational sessions. Focus group participants recommended a substantial reduction in technical detail, and recommended that information be personalized and made relevant to the lives of the target population. Other critical themes included the importance of building trust in the medical system and avoiding words and images that have strong negative associations in the African American community. Strategies that were successful included nontechnical images to explain genetic concepts, clip art images to energize and personalize word slides, vibrant color, identifiably African American figures, and the development of themes relevant to many African Americans. The use of these materials in an ongoing study offering BRCA1 counseling and testing to a large, rural Louisiana-based kindred will provide additional feedback about the effectiveness of the culturally tailored genetic education and counseling materials.

[Preimplantation genetic diagnosis and its psychological effects]

OBJECTIVE

Report our psychoanalyst experience in clinical practice of pre-implantation genetic diagnosis (PGD).

METHODOLOGY

Between January 1999 and July 2001, 230 couples attended a multidisciplinary PGD consultation and the information meeting that preceded it. Eighty-six of these couples met the team's psychoanalyst during a private encounter (either as couples or individually, depending on their preference).

RESULTS

The development of this technique was capital for couples at risk who, prior to PGD, had often suffered a termination of pregnancy and who may have a child who was seriously ill. Whether they were carriers or affected by the disease, PGD gave them the possibility to react to their condition. Those who have repeatedly been subjected to a painful experience were given the opportunity to play an active part in their own medical history.

CONCLUSION

Beyond the scientific claims of this method, PGD contributes to the healing process of distressed couples and responds to their quest for recognition. We believe that this evolution in preventative medical practice, seen as a positive development, must necessarily lead to a number of ethical as well as psychoanalytical considerations, discussions and interrogations.

A social network analysis of communication about hereditary nonpolyposis colorectal cancer genetic testing and family functioning

Hereditary cancers are relational diseases. A primary focus of research in the past has been the biological relations that exist within the families and how genes are passed along family lines. However, hereditary cancers are relational in a psychosocial sense, as well. They can impact communication relationships within a family, as well as support relationships among family members. Furthermore, the familial culture can affect an individual's participation in genetic counseling and testing endeavors. Our aims are (a) to describe the composition of familial networks, (b) to characterize the patterns of family functioning within families, (c) to analyze how these patterns relate to communications about genetic counseling and testing among family members, and (d) to identify influential family members. Specifically, we asked how the relationship between mutation status, kinship ties, and family functioning constructs, e.g., communication, cohesion, affective involvement, leadership, and conflict, was associated with discussions about genetic counseling and testing. We used social network analysis and random graph techniques to examine 783 dyadic relationships in 36 members of 5 hereditary nonpolyposis colorectal cancer (HNPCC) families interviewed from 1999-2000. Results suggest that in these five HNPCC families, two family members are more likely to discuss genetic counseling and testing if either one carries the mutation, if either one is a spouse or a first-degree relative of the other, or if the relationship is defined by positive cohesion, leadership, or lack of conflict. Furthermore, the family functioning patterns suggest that mothers tend to be the most influential persons in the family network. Results of this study suggest encouraging family members who act in the mother role to take a "team approach" with the family proband when discussing HNPCC risks and management with family members.

Attitudes and psychological impact of genetic testing, genetic counseling, and breast cancer risk assessment among women at increased risk

PURPOSE/OBJECTIVES

To review research related to the psychological functioning of women with family histories of breast cancer, the impact of genetic counseling on women at increased risk, and their participation in and description of breast cancer risk evaluation programs.

DATA SOURCES

Published articles and material from the World Wide Web.

DATA SYNTHESIS

Findings from these sources suggest an underlying level of psychological distress in women with family histories of breast cancer. This may either increase or decrease their surveillance practices. With the onset of commercial genetic testing for BRCA1 and BRCA2, researchers have studied some of the initial psychosocial effects of genetic information on women at high risk.

CONCLUSIONS

Women with family histories of breast cancer have a very high interest in genetic testing for BRCA1 and BRCA2 mutations. They have an underlying level of psychological distress that is not relieved by genetic counseling. They tend to state reasons for wanting and not wanting testing that are not polar opposites. Women who attend breast cancer risk assessment programs tend to be self-referred, Caucasian, well-educated, and of middle or upper income status. Large gaps exist in the research on women of color and those who are less educated and of lower socioeconomic status.

IMPLICATIONS FOR NURSING

Nurses and other healthcare professionals should tailor care given to women at increased risk for hereditary breast cancer by using the current information related to their emotional and medical needs. Decisions regarding genetic testing, genetic counseling, and breast cancer risk assessment are highly individualized. Thus, healthcare professionals should be cautious regarding any generalizations about women at risk for breast cancer.

The role of DNA testing in breast, ovarian, and colon cancers

A proportion of cases of breast and colon cancers are caused by inherited mutations that confer a greatly increased susceptibility to malignancy. Certain clinical features may help distinguish patients with a genetic cause for their cancer from the larger number of patients with sporadic tumors. A thorough family medical history is also necessary to identify those at high risk for developing cancer. Many of the normal functions of these genes are understood, and mutation analysis for patients and their families is now available as a clinical service. Presymptomatic detection of mutations allows the patient to pursue preventive measures to reduce the probability of developing a malignancy. Evidence is now available that some prophylactic measures do reduce the incidence of cancer and reduce mortality in mutation carriers, and the standard of care is evolving rapidly. The essential elements necessary to provide accurate interpretations of molecular genetics test results to patients are described.

Intention to pursue genetic testing for breast cancer among women due for screening mammography

Because few studies have addressed the intention to pursue testing for breast cancer susceptibility among women in the general population, we examined whether women due for routine mammography would want such testing and what factors might impact on their decision to pursue testing. A questionnaire was mailed to women > or =50 years of age who had undergone a screening mammogram 12 to 14 months before the study. Univariate and multivariable analyses were conducted to identify factors associated with intention to pursue genetic testing. Approximately 41% of respondents probably or definitely intended to pursue testing. In univariate analysis, the intention to undergo testing was not significantly associated with age, education, marital status, potential effects on health or life insurance, or physician recommendation. Although significant in univariate analysis, family history of breast cancer and ethnicity were not significant in multivariable analysis. In both univariate and multivariable analysis, factors significantly associated with intention to undergo testing included awareness of genetic testing, cancer worry, and insurance coverage of testing cost. Intention also was associated with the respondent wanting to know whether she possessed the susceptibility gene, even if that knowledge would not impact on options for early detection or treatment. Given the relatively high level of interest in testing among women at average risk of breast cancer, these results may help health care professionals educate and counsel women regarding the appropriate use of genetic testing as well as breast cancer risk factors.

Parents' and children's attitudes toward the enrollment of minors in genetic susceptibility research: implications for informed consent

PURPOSE

Children at high risk of future disease may be recruited for participation in disease susceptibility research involving genetic testing. This study was aimed at assessing parents' and children's reactions to such research, and their perceptions of risks and benefits of participating.

METHODS

Parents and children (ages 10-17) from families at increased risk for breast cancer (n = 16 dyads) and heart disease (n = 21 dyads) participated in separate audiotaped interviews and a follow-up family interview one year later. We asked about reactions, risks and benefits, and informational needs regarding participation in hypothetical research involving genetic testing on a saliva sample. Audiotape transcripts were analyzed qualitatively.

RESULTS

All children would initially participate because they viewed the research as low risk. When thinking about learning their test result and sharing it with others, or the uncertainties of testing, many children became hesitant about participating. Many parents thought their child might worry about a positive result, making them unlikely to enroll their child, or to choose not to tell the child test results. Both children and parents thought the benefits of participating included early detection or treatment (breast cancer families), prevention (heart disease families) and helping others. Children's questions about research participation centered on details of the study design and purpose, while parents' questions related to the genetic test itself.

CONCLUSIONS

Children's first reaction to participating in research involving genetic susceptibility testing research may not indicate an adequate appreciation of risks and benefits; if encouraged to personalize the impact of genetic testing, children are able to engage in a more informed decision-making process.

Testing the test--why pursue a better test for Huntington disease?

In 1993, the gene mutation for Huntington disease (HD) was identified and testing became possible with a reliability of >99%, without the need for co-operation of relatives. In 1997, a systematic information program offered the mutation retest to individuals who had earlier received a linkage test result for HD, which has a residual uncertainty of 1-9%. The characteristics of 129 individuals tested by linkage analysis for HD are reported on, as well as the reasons for their reassessment by mutation testing. Three groups were compared: (1) people who were retested between 1993 and 1997, before this study had started, (2) people who were retested after we provided information, and (3) persons who refrained from retesting. Nearly half of the linkage-tested individuals were retested, with the exception of noncarriers with a residual risk of 1 or 2%. Of them, less than one out of five were retested. Carriers with a hopeful view on the future (BHS) and a better sense of well-being (GHQ) were more likely to have the retest. Female carriers were also more likely to have the retest before we contacted them. Noncarriers who were retested were more anxious (HADS) than noncarriers who refrained from the retest. Retestees were younger at the time of testing. No risk reversals were revealed by this study.

What do ratings of cancer-specific distress mean among women at high risk of breast and ovarian cancer?

Women recruited from a hereditary cancer registry provided ratings of distress associated with different aspects of high-risk status and genetic testing and completed measures of general psychological distress, emotional and social health, and role functioning. Overall, high-risk status was rated as more distressing than undergoing genetic testing. Women without a personal history of cancer rated the level of distress associated with a positive test result to be greater than that associated with high-risk status. In contrast, level of distress associated with a positive test result was not significantly different from that associated with high-risk status for women with a personal history of cancer. Furthermore, women with a personal cancer history also anticipated that if they had an altered gene associated with increased risk of cancer, it would be less distressing than their diagnosis of cancer had been. Women with the highest ratings of cancer-related stress were less inclined to obtain testing, but were not more generally distressed or maladjusted. The need to interpret psychological distress and the stressfulness of genetic testing among high-risk women with respect to relevant comparison data is discussed.

Psychological outcomes and risk perception after genetic testing and counselling in breast cancer: a systematic review

OBJECTIVES

To conduct a systematic review of the effects of genetic counselling and testing for familial breast cancer on women's perception of risk and psychological morbidity.

DATA SOURCES

MEDLINE, PsychLIT and EMBASE were searched for the period 1980-2001.

STUDY SELECTION

Studies were eligible if published in a peer-reviewed journal in English, included women with a family history of breast cancer who underwent genetic counselling or testing and had either a randomised controlled trial or prospective design, with a pre- and at least one post-counselling assessment.

DATA SYNTHESIS

As there was considerable heterogeneity in populations and measures, results were summarised rather than subjected to meta-analysis.

RESULTS

Overall, genetic counselling and testing appear to produce psychological benefits and to improve accuracy of risk perception. Carriers of mutations in cancer predisposition genes did not experience significant increases in depression and anxiety after disclosure of their mutation status, while non-carriers experienced significant relief. Women who were tested but declined to learn their results seemed to be at greater risk of a worse psychological outcome.

CONCLUSIONS

To date, the data on psychological outcomes after genetic counselling and testing are reassuring. However, few studies used a randomised trial design, limiting the strength of the conclusions. Follow-up to date has been short, and we know little about the long-term impact of testing on patient behaviours, perceptions and psychological state.

Genetic testing for hereditary colorectal cancer in children: long-term psychological effects

Children who carry a gene mutation for familial adenomatous polyposis are virtually certain to develop colorectal cancer without annual endoscopic screening and a colectomy when polyps appear. Predictive genetic testing can identify children who need regular surveillance. While the medical benefits of genetic testing are clear, the psychological effects have not been well studied. We evaluated the long-term psychological effects of genetic testing in 48 children and their parents. In each family, one parent was a known APC gene mutation carrier. Before genetic testing, and three times afterward, participants completed measures of psychological functioning, which, for children, included depression and anxiety symptoms, and behavior problems and competencies. Parents completed a measure of depression symptoms. Data were collected at 3-, 12-, and 23-55 months after disclosure. Twenty-two children tested positive; 26 children tested negative. Mean length of follow-up was 38 months. There were no clinically significant changes in mean psychological test scores in children or parents, regardless of the children's test results or the sex of the affected parent. However, the group of children who tested positive and had a mutation-positive sibling showed significant, but subclinical, increases in depression symptoms. Furthermore, several individual mutation-negative children with a positive sibling had clinical elevations in anxiety symptoms at one or more follow-up. Behavior problems declined for all groups, and behavior competence scores remained unchanged. We conclude that most children do not suffer clinically significant psychological distress after testing. However, because some children showed clinically significant anxiety symptoms, long-term psychological support should be available to those families with both mutation-positive and mutation-negative children, and with multiple mutation-positive children. Our findings should call for a multidisciplinary approach to genetic testing for children.

Teaching clinical management skills for genetic testing of hereditary nonpolyposis colorectal cancer using a Web-based tutorial

PURPOSE

To pilot and evaluate an interactive Web-based continuing medical education tutorial on clinical management of hereditary nonpolyposis colon cancer (HNPCC) and genetic testing.

METHODS

Gastroenterology fellows and genetic counseling trainees were asked to read standard written materials before taking the tutorial. A pretest/post-test assessment was used to measure change in subjects' clinical management skills.

RESULTS

Subjects made the correct management decision 63.9% of the time before the tutorial and 81.1% of the time after the tutorial (P < 0.001).

CONCLUSIONS

Supplementing written materials with an interactive program may assist medical professionals in integrating their knowledge of HNPCC and genetic testing into clinical practice.

Primary care physicians' attitudes and practices regarding cancer genetics: a comparison of 2001 with 1996 survey results

BACKGROUND

To determine whether Texas primary care physicians' attitudes and practices regarding cancer genetics changed over a five-year period, a follow-up survey was conducted and the results obtained in 1996 were compared with those obtained in 2001.

METHODS

A survey was mailed in 2001 to a random sample of 350 primary care physicians in Texas.

RESULTS

More primary care physicians in 2001 were discussing the subject of genetic screening with their patients and more physicians were referring their patients for genetic evaluations and testing for cancer risk, compared with 1996. Cost of genetic testing continues to be the most frequently cited barrier to using genetic testing for cancer susceptibility.

CONCLUSION

Results suggest a continuing need for more educational programs for physicians regarding genetic testing for cancer susceptibility.

Communication with close and distant relatives in the context of genetic testing for hereditary breast and ovarian cancer in cancer patients

The psychological aspects of genetic testing for hereditary breast and ovarian cancer (HBOC) in cancer patients (diagnostic genetic testing) have so far received less attention than predictive genetic testing in unaffected persons. Our study is aimed at gaining insight into the psychological aspects of diagnostic genetic testing and at formulating practical recommendations for counseling. Cancer patients often play a key role in the communication of information to relatives because they were the first individuals to be tested in the family. The present article focuses on the communication to close and distant relatives about the hereditary cancer, the genetic test and its result. Participants previously diagnosed with breast and/or ovarian cancer, with a family history of these cancers and who requested DNA-testing, were eligible for the study. Of the 83 eligible patients who could be contacted, 63 participated (response rate = 76%). Twenty-six participants were members of a family where a BRCA1 or BRCA2 mutation was detected. The DNA-analysis in the family of 37 participants had not revealed any mutation. Data were collected by semi-structured interviews and psychological tests and questionnaires. The dissemination of information was largely focused on first-degree relatives. Communication to distant relatives about the genetic test and its result was problematic. Other than the genetic test result and age as "objective" predictors of informing distant relatives, little and/or superficial contact seemed to be the major subjective barrier to informing distant relatives. Furthermore, the knowledge about HBOC of these messengers reveals several shortcomings. Communication within the family should receive special attention during counseling.

Attitudes of African American premedical students toward genetic testing and screening

PURPOSE

Genetic research is progressing at a rapid rate. While most view genetic advances favorably, concerns regarding eugenics and discrimination based on genetic test results have been raised. These concerns have been found among all groups studied; however, they have particular relevance for members of the African American community. Studies have shown that because of a long history of negative experiences, African Americans have a general mistrust of the medical establishment. It is unclear whether these negative attitudes encompass genetic advances. Because there is little empiric data in the literature, it is not known whether African Americans have a positive view of genetic advances or whether they have the same level of mistrust as is seen in their attitudes toward other forms of biomedical research.

METHODS

This study was conducted as an initial effort to examine the attitudes of African Americans toward recent genetic advances and, specifically, genetic testing. A cohort of 97 college-age minority students, including 78 African Americans, participating in the Health Career Enhancement for Minorities Program (HCEM) at Case Western Reserve University were surveyed. Surveys were made available before and after the summer long course, which included five lectures on basic genetic principles and medical genetics.

RESULTS

Both African American students and other minority students initially (questionnaire prior to HCEM course) had an overall positive view of genetic testing. The vast majority supported genetic testing for preventive care (95%) and presymptomatic detection of disease (88%) and agreed that it should be easily available (83%). However, several concerns were expressed as well, including fears about discrimination (68%), privacy (68%), that abortions will become more common (51%), and eugenics (37%). It is interesting that in the postcourse questionnaire, the percentages of positive views remained similar to those of the precourse survey, but the number of respondents expressing concerns increased.

DISCUSSION

These results suggest that the minority students surveyed view many aspects of genetic testing and other advances favorably. However, these students expressed concerns about discrimination, privacy, and eugenics. These concerns were increased, not lessened, by exposure to genetics education. One possible explanation for this observation is that the students had a greater understanding of the issues regarding genetic testing after the HCEM lectures and discussion. Of note, there was a greater negative response toward genetic screening programs among the African American students compared with the non-African American minority students. This suggests that the negative attitudes of African Americans toward biomedical research do extend to some aspects of genetics and that educational programs must be designed and implemented if this community is going to receive the maximum benefits of this advancing technology.

Psychological distress in the 5-year period after predictive testing for Huntington's disease

The paper reports on a 5-year longitudinal study on psychological distress after predictive testing for Huntington's disease (HD) and on correlates of post-test distress. Psychometric tests and questionnaires were used. The tested persons were invited to participate in the follow-up study; the uptake rate was 75% (24 carriers, 33 non-carriers). Three time points were included: baseline, 1 year and 5 years post-test. Five years after the test, mean distress scores of both carriers and non-carriers were within the normal range. Carriers did not differ from non-carriers with regard to mean general distress. Compared to non-carriers, however, carriers had significantly less positive feelings (P<0.001) and were more consciously avoiding HD-related situations and thoughts (P<0.01). These findings reflect the carriers' conscious and unconscious attempt to escape from pessimism and to minimise negative consequences of the test result. Psychological distress 5 years post-test was significantly associated with ego-strength (P<0.05 to P<0.001). Except for intrusion and avoidance, distress was also associated with test motivation (P<0.05 to P<0.01). Compared with baseline level, mean depression, general and specific anxiety had significantly decreased 1 year and 5 years post-test (P<0.05 to 0.01). This evolution was independent of the test result. However, based on test motivation, a subgroup of tested persons having long lasting psychological distress could be identified, also irrespective of test result. Persons who asked the test to get rid of the uncertainty, without being able to specify implications for substantial life areas, had more psychological distress before and after the test than those who wanted the test for specific reasons (P<0.001 to P<0.0001). Moreover, the pattern of post-test anxiety differed over time, depending on the test motivation (P<0.05). The findings suggest that pre- and post-test counselling should pay special attention to persons with lower ego-strength and with an unspecified test motivation, because they are at higher risk for long-term psychological distress, independently of the test result.

[Psychosocial factors associated with genetic testing for certain hereditary types of neoplasms]

Mutations in predisposing genes for some of the hereditary forms of cancer exhibit autosomal dominant mode of inheritance. Introduction of genetic tests for these mutations to the clinical practice initiated studies focused on the psychosocial factors associated with genetic testing. Undergoing the genetic testing is a stressful experience for both the healthy individuals in risk and the patients already affected with cancer. The psychosocial characteristics of the tested individual influence not only the psychological functioning during the testing but also the acceptance of the test, and generally his life style and health practices. Psychological support during the genetic testing process is mostly provided by the genetic counsellor. The findings of psychosocial studies might be therefore helpful for the focusing of the genetic consultation, and fulfilling the client needs and expectations towards testing. Factors of motivation, psychological state, influence of family situation and support, and optionally the involvement of a psychologist into the process of genetic testing are observed.

A cancer genetics education campaign: delivering parallel messages to clinicians and the public

BACKGROUND

Up to 10% of all cancers are thought to have a familial basis through complex interactions between genes and environment.

METHODS

A community-wide education campaign was conducted that included several elements: a five part television news series; an educational newsletter; web site pages and links to educational materials; a Continuing Medical Education (CME) program for professionals; and an evaluation survey.

RESULTS

Survey estimates revealed that 39000 households recalled seeing the series; 14800 households changed their views about the risks of hereditary cancers; and about 9900 households were made more aware/informed about cancer and hereditary risk.

CONCLUSION

This awareness campaign broadened public knowledge about the myths and realities associated with genetic factors and cancer risk. It reinforced the importance of early screening for persons at high risk of cancer due to hereditary factors.