Psychosocial predictors of BRCA counseling and testing decisions among urban African-American women

Genetic counseling and testing for mutations in XXX (BRCA)1/2 genes that increase breast cancer susceptibility potentially offer a number of benefits (e.g., more informed decision making regarding breast cancer prevention options) but also raise potential problems (e.g., issues of discrimination). However, the literature suggests that African-American women underuse genetics-related services. Therefore, the primary aim of the current study was to investigate predictors of the use of genetic counseling and testing for breast cancer susceptibility in this population. Participants were 76 African-Americans at increased risk for breast cancer attributable to their family history of the disease. Participants were recruited from an urban cancer screening clinic and completed measures assessing sociodemographic information, breast cancer knowledge, breast cancer-specific emotional distress, and perceived benefits of and barriers to BRCA testing. Free BRCA counseling and testing were offered to all interested participants, and measures were completed before counseling sessions. On the basis of their subsequent acceptance or refusal of these services, participants were described as having either: (a) declined BRCA-related genetic counseling (GC-); (b) participated in genetic counseling but refused genetic testing (GC+GT-); or (c) participated in both genetic counseling and testing (GC+GT+). Results revealed that participants who declined counseling had significantly less knowledge of breast cancer genetics than those who accepted both counseling and testing. No differences emerged among the three groups in terms of perceived benefits of testing. However, participants declining counseling demonstrated significantly higher perceived barrier scores compared with those accepting counseling and testing. Specifically, those who did not participate in counseling reported greater anticipation of negative emotional responses to testing and more concern about stigmatization, whereas those who underwent both counseling and testing had significantly lower family-related guilt. Finally, cancer-specific distress was positively associated with participation in counseling, regardless of participation in testing. The current findings underscore the need for refinement of outreach and intervention efforts that both increase awareness of BRCA counseling and testing among African-American women and provide information to those considering these options.

Evaluation of the needs of spouses of female carriers of mutations in BRCA1 and BRCA2

The process of genetic testing involves the entire family, including spouses. The objective of this study was to measure the specific needs and to describe the experiences of spouses of women who received genetic counseling for a positive BRCA1/2 result. We surveyed 59 spouses of female mutation carriers. The mean length of relationships was 26 years (range: 2.5-50 years). All were supportive of their spouses' decision to undergo genetic testing and counselling. Four respondents stated that they wished that they had received additional support at the time of test disclosure and 20% felt that their wives had received inadequate support. One-quarter of the spouses believed that their relationship had changed because of genetic testing; most felt that they had become closer to their wives. Husbands were most concerned about the risk of their wife dying of cancer (43%), followed by the risk of their spouse developing cancer (19%) and the risk that their children would test positive for the BRCA mutation (14%). Distress levels, measured by the Impact of Event scale, suggest that few spouses were experiencing clinical levels of distress.

Gender differences in psychosocial reactions to cystic fibrosis carrier testing

Gender differences involving genetic testing have become a topic of research as feminist critiques assert that women may be affected differently, and possibly more significantly, than men by genetic carrier testing information. It is possible that men and women differ in their reactions to learning whether they are or are not a carrier of a specific mutation. It is also possible that men and women may differ in their reactions to different methods of genetic testing. Data on gender differences in reactions to cystic fibrosis (CF) carrier testing in a high-risk population and to gender differences in reactions to home-based as opposed to clinic-based testing are reported. This analysis suggests that at least for CF carrier testing, men and women do differ in terms of their risk perceptions, negative psychological affect, perceptions about themselves, and the convenience of testing. However, there was only one difference between men's and women's reactions to the method of testing. A better understanding of gender differences in response to carrier testing, as well as to interactions between gender and methods of genetic testing, may inform better approaches to carrier testing and to considering alternative methods of such testing.

Genetic testing for hearing loss: different motivations for the same outcome

The recent discoveries of genes involved in deafness open new options for families and individuals with hearing loss. Our aim was to learn if parents of children with hearing loss will benefit from these new possibilities. A total of 139 parents answered questionnaires aimed at evaluating their intentions as well as their reasons to opt for or against genetic testing and prenatal diagnosis for hearing loss. A very high interest (87%) in genetic testing was found among Israeli Jewish parents of deaf and hard-of-hearing children. Although the Jewish population in Israel is very diverse in its religious beliefs, this high interest was similar across all religious sectors (secular, traditional, orthodox, and ultraorthodox); however, some of the reasons for undertaking such a test were very different between them. Reasons related to family planning and prenatal diagnosis were significantly less important to parents from the ultraorthodox sector, but the possibility to utilize genetic testing for matchmaking the children with hearing loss and their hearing siblings was an important factor in motivating them to undertake the test. Parents from all religious sectors wished testing would shed light on the cause of the hearing loss. We conclude that genetic testing would be welcomed by a wide range of communities, including those that usually do not apply for genetic counseling and testing, if it is offered in accordance with their cultural norms and beliefs.

Presymptomatic testing in Huntington's disease and autosomal dominant cerebellar ataxias

OBJECTIVE

To report a 7-year experience of presymptomatic testing in persons at risk for Huntington disease (HD) and to compare their characteristics and outcomes with those of persons at risk for a less disabling condition, autosomal dominant cerebellar ataxias (ADCA).

METHODS

The authors collected data on presymptomatic testing for HD (n = 712) and ADCA (n = 46) in 10 French centers.

RESULTS

The characteristics of applicants were similar in HD and ADCA, revealing a predominance of women, a low rate of completing the presymptomatic testing program, and a high rate of follow-up. The frequency of serious events was low (2% for HD, 5% for ADCA), but such events were also found after favorable results. Family planning was a more frequent reason for seeking presymptomatic testing in ADCA than in HD. Prenatal diagnosis was performed in only half of the pregnancies in HD carriers (n = 35) but in all of those in ADCA carriers (n = 4).

CONCLUSION

Counseling in multistep and multidisciplinary teams is important not only for presymptomatic testing in HD but also for less disabling diseases.

Application of the protection motivation theory to genetic testing for breast cancer risk

BACKGROUND

Many women, even women at low risk, are interested in genetic testing for breast cancer risk. However, the test has little to offer for women at low to moderate risk. We applied the Protection Motivation Theory (PMT) to investigate predictors of women's motivation to obtain such a test.

METHODS

Women at low to moderate risk (n = 330) were recruited through a physician network. They received an informational letter by mail and completed a telephone survey and a written baseline questionnaire.

RESULTS

Structural equation analyses with motivation to test as the outcome variable showed that the full model was not supported by the data. However, modifications to the model resulted in good model fit and explained 51% of the variance. Women with increased breast cancer worries, which were influenced by perceived risk, and women who saw more disadvantages of not getting tested showed more motivation to pursue testing. Women who saw more advantages of not getting tested showed less motivation.

CONCLUSIONS

Applying the PMT was helpful in determining factors that play a role in women's intentions to obtain genetic testing. Counseling should aim at decreasing perceived risk and breast cancer worries and include a discussion of the consequences of not getting tested.

A brief assessment of concerns associated with genetic testing for cancer: the Multidimensional Impact of Cancer Risk Assessment (MICRA) questionnaire

The Multidimensional Impact of Cancer Risk Assessment (MICRA) is a new tool to measure the specific impact of result disclosure after genetic testing. The authors compared its performance with that of questionnaires measuring general and cancer-specific distress. Participants (158 women) responded 1 month after they received genetic test results. The women were divided into 4 standard clinical test result groups: BRCA1/2 positive, BRCA1/2 negative, panel negative, and true negative. Factor analysis supported the formation of 3 subscales: Distress (6 items, alpha = .86), Uncertainty (9 items, alpha = .77), and Positive Experiences (4 items, alpha = .75). All 3 MICRA subscales differentiated participants who were BRCA1/2 positive from the other 3 groups. MICRA thus helps identify subgroups of vulnerable genetic testing participants.

Ethical dilemmas in testing for late onset conditions: reactions to testing and perceived impact on other family members

This paper examines some of the ethical dilemmas that arise when testing for the late onset, untreatable condition of Huntington disease (HD) specifically now that technology allows us to test younger generations of the family for the mutant gene. Drawing on interview data from families with Huntington disease, the reactions to testing and perceived impact on other family members are considered. These are discussed in the light of the possible lowering of the age of test applicants. This potentially raises problems for a younger generation as they are confronted with reproductive decisions that the older generation did not have to face. It also means that individuals have the prospect of living with knowledge of a future illness for much longer.

Psychological impact of genetic testing in women from high-risk breast cancer families

Psychological adjustment in 90 women (30 carriers and 60 non-carriers) who had undergone genetic testing for mutations in BRCA1 and BRCA2 breast/ovarian cancer susceptibility genes was compared with that of 53 women who were not offered genetic testing. Women were assessed prior to genetic testing and 7-10 days, 4 and 12 months after carrier status disclosure using self-administered questionnaires. Compared with women not offered testing, mutation carriers had significantly higher breast cancer distress 7-10 days (t=2.80, P=0.005) and 12 months (t=2.01, P=0.045) post-notification. Non-carriers showed a significant decrease in state anxiety 7-10 days post-notification (t=2.27, P=0.024) and in depression 4 months post-notification (t=2.26, P=0.024), compared with women not offered testing. These data show that non-carriers derive psychological benefits from genetic testing. Women testing positive may anticipate a sustained increase in breast cancer distress following disclosure, although no other adverse psychological outcomes were observed in this group.

No news is (not necessarily) good news: impact of preliminary results for BRCA1 mutation searches

PURPOSE

Many women who have had breast or ovarian cancer who are undergoing tests for the presence of germline mutations in the genes will receive a result that is inconclusive. As this continuing uncertainty may have a detrimental effect on their psychological well-being and it is possible that such results will be misinterpreted as indicating that no mutation is present, studying their effect is important.

METHODS

Sixty-one women undergoing such tests completed questionnaires 2 weeks after their blood was taken and at 1 week and 6 months after receiving a preliminary "inconclusive" result, i.e., indicating that two thirds of the gene had been tested and no mutation had been found so far.

RESULTS

Perceived likelihood of having a mutation and perceptions of cancer risk significantly decreased after receipt of the interim result. There were no changes in levels of psychological distress and worry about cancer, in intentions to have mammograms, to carry out breast self-examination, or to have prophylactic surgery.

CONCLUSIONS

The continuing uncertainty does not seem to have increased distress; however, it is possible that the inconclusive result is being interpreted as a "good news" result, in view of the fact that perceptions of risk decrease after receipt of the result.

Effects of risk counseling on interest in breast cancer genetic testing for lower risk women

PURPOSE

A randomized trial was conducted to test the effects of two counseling methods (genetic counseling and group counseling) against a control no-intervention condition on interest in genetic testing in lower risk women.

METHODS

After completing baseline surveys, women (N = 357) were randomized to one of three conditions: to receive individual genetic risk counseling, to receive a group psychosocial group counseling, or to serve as a control group. Participants completed follow-up questionnaires 6 months after randomization.

RESULTS

All participants had some familial history of breast cancer, but none had a family history indicative of autosomal dominant genetic mutation. At baseline over three fourths of the sample judged themselves to be appropriate candidates for testing. By the end of the survey, two thirds (70%) of the women in the counseling group still judged themselves to be appropriate candidates for testing. Findings were similar for interest in genetic testing. Changes in beliefs about genetic testing (e.g., beliefs about potential stigma associated with testing) altered the effects of counseling.

CONCLUSION

These results indicate that counseling can change interest in genetic testing only slightly and that changing women's beliefs about the properties of testing might be one mechanism of doing so.

A population-based study of Ashkenazi Jewish women's attitudes toward genetic discrimination and BRCA1/2 testing

PURPOSE

The Human Genome Project continues to produce an increasing number of genetic susceptibility tests. Some of these genetic tests target social or ethnic groups who are at increased risk of developing a disease. The Ashkenazi Jewish community is one ethnic group that is an ongoing subject of genetic investigation. We assessed the attitudes of a population-based sample of Ashkenazi Jewish women toward breast-ovarian cancer susceptibility testing (BRCA 1/2). In particular, we assessed concerns about group discrimination, perceptions of the advantages and disadvantages of testing, and the relationship between concerns about discrimination and the potential benefits of genetic testing.

METHODS

A telephone survey of a population-based sample of 200 Jewish women.

RESULTS

A minority of women (17%) in this study expressed concern or discomfort with Jews being offered testing. Most women believed there were scientific reasons for testing Jews (71%), and only 5% of women felt that research that focused on Jews was bad for Jews as a group. Increased concern about genetic discrimination was associated with women who were highly educated (odds ratio 2.68). Forty percent of women surveyed were interested in testing, 40% were not interested, and 20% were uncertain about whether they would obtain testing. Increased interest in genetic testing was associated with a desire to obtain information about children's risk of disease and valuing information for its own sake.

CONCLUSIONS

The majority of a population-based sample of Jewish women did not express concerns about group discrimination resulting from genetic testing. Women who are highly educated are more concerned about genetic discrimination. There is significant variation among Jewish women's interest in breast cancer susceptibility testing.

Tailoring communication in consultations with women from high risk breast cancer families

This multicentre study examined the influence of patient demographic, disease status and psychological variables on clinical geneticists/genetic counsellors (consultants) behaviours in initial consultations with women from high-risk breast cancer families. One hundred and fifty-eight women completed a pre-clinic self-report questionnaire. The consultations were audiotaped, transcribed verbatim and coded. Consultants did not vary their behaviour according to women's expectations. However, significantly more aspects of genetic testing were discussed with women who were affected with breast cancer (P<0.001), screening and management with unaffected women (P=0.01) and breast cancer prevention with younger women (P=0.01). Prophylactic mastectomy was discussed more frequently with women with medical and allied health training (P=0.02), and prophylactic oophorectomy with women affected with breast cancer (P=0.03), those in non-professional occupations (P=0.04) and with a family history of breast and ovarian cancer (P<0.001). Consultants used significantly more behaviours to facilitate understanding with women who were in non-professional occupations (P=0.04); facilitated active patient involvement more with women affected with breast cancer (P<0.001) and used more supportive and counselling behaviours with affected women (P=0.02). This study showed that patient demographics were more likely to predict consultants' communication behaviours than the woman's psychological status. Methods to facilitate assessment of psychological morbidity are needed to allow more tailored communication.

Women's decisions regarding management of breast cancer risk

Twenty-three unaffected women with a family history of breast or ovarian cancer participated in a study to ascertain their cancer-related concerns, beliefs, and preferences for risk management. Their perceptions related to breast cancer risk management options have implications for practicing nurses.

Heart stopper genes: would you recognize a high risk patient?

Coronary artery disease (CAD) is one of the leading causes of death in the United States. Eighty percent of people having heart attacks have normal cholesterol levels. A quarter of the population have a condition called low-density lipoprotein (LDL) pattern B that has been associated with a threefold risk of myocardial infarction. Although early intervention can often prevent an otherwise fatal event, these patients often go unrecognized until after a myocardial infarction has occurred because they may not have the usual risk factors associated with cardiovascular disease. In patients with LDL pattern B, the standard lipid panel may be normal and inadequate for diagnosis and treatment of the condition. This article discusses how to identify a potentially high risk patient, available laboratory tests, management options, and the role of nurses in identifying high risk patients. The second author tells his personal story of surviving multiple cardiac arrests at a young age before being diagnosed with this condition.

Prenatal genetic screening

This article presents a discussion of screening principles and techniques available to screen for common birth defects during pregnancy. Sixty-five to 70% of women have serum screening and /or ultrasound during pregnancy to evaluate the health and well-being of the developing fetus. The most common birth defects identified by screening include neural tube defects and chromosome abnormalities. Nurses employed in prenatal care settings need to have accurate information they can provide to women so they understand the benefits and limitations of screening. Timely presentation of information and identification of available resources will help nurses minimize confusion and provide support for women as they proceed with pregnancy screening.

Genetic screening for Alzheimer's disease: what factors predict intentions to take a test?

The authors investigated factors that predict intention to take a genetic test for Alzheimer's disease (AD). The 449 men and women were surveyed in two groups: (a) those told that a positive result meant a 90% chance of developing AD (increased certainty) and (b) those told that a positive result meant a 50% chance of developing AD (decreased certainty). Participants completed measures of the Theory of Planned Behavior (TPB), anticipated regret, risk perception, likelihood of taking a genetic test for cancer, and AD risk factors. Just over 50% of the variance in intentions was related to TPB variables, likelihood of taking a genetic test for cancer, number of people the participants knew who had AD, experimental condition, and anticipated regret. The subjective norm was the strongest predictor of intention in the increased certainty group, whereas positive belief was the strongest predictor in the decreased certainty group.

Worry and attitude of men in at-risk families for prostate cancer about genetic susceptibility and genetic testing

BACKGROUND

The aim of this study was to evaluate worry about genetic susceptibility and the attitude of men with family history of prostate cancer (CaP) toward genetic testing.

METHODS

Three hundred seventy-five eligible first-degree relatives (FDR) of men with CaP, were asked to participate in a screening and to fill out a survey covering the worry about genetic susceptibility and interest in genetic testing.

RESULTS

Of the 375 candidates contacted, 277 completed the survey, and had undergone PSA measurement. Sixty-four percent worried a little or not at all about inherited predisposition to CaP, while the remainder worried a lot or extremely. The candidates who worried a lot or extremely were men with high levels of durable anxiety disposition (STAI trait), who had undergone a previous screening procedure and men with sons. Ninety-eight percent of men expressed their interest in undergoing genetic testing. The most motivated candidates to have the test done were men with several relatives with CaP.

CONCLUSIONS

The level of worry about genetic susceptibility was low and there was a concrete interest in genetic testing in FDR of men with CaP. This interest increased with the number of CaP in the family.

Factors influencing intention to obtain a genetic test for colon cancer risk: a population-based study

BACKGROUND

The availability of genetic testing for cancer risk has prompted an examination of the intention of the general public to undergo testing. This study expands a previous psychosocial model of factors influencing intention to undergo genetic testing for cancer in general to the context of colon cancer.

METHODS

A sample of 1,836 adult residents of Vermont, New Hampshire, and Maine were interviewed via telephone. The survey instrument included measures derived from the Health Belief Model and additional psychosocial measures adapted from the literature. Structural Equation Modeling techniques were used to examine factors associated with the likelihood to undergo genetic testing.

RESULTS

Perceived barriers and benefits of testing, and perceived susceptibility to colon cancer had direct associations with likelihood. Optimism and pessimism had both direct and indirect effects. Age, socioeconomic status, family history, and awareness of genetic testing had indirect effects, and acted through the other factors. The model explained 22% of the variance in likelihood.

CONCLUSIONS

Perceived barriers, benefits, susceptibility, optimism, and pessimism directly influenced likelihood, and may also mediate the effect of background factors examined in this study. These findings suggest effective educational strategies to improve decision-making concerning genetic testing for colon cancer risk in the general population.