Effect of a computer-based decision aid on knowledge, perceptions, and intentions about genetic testing for breast cancer susceptibility: a randomized controlled trial

Development of a personalized decision aid for breast cancer risk reduction and management

BACKGROUND

Breast cancer risk reduction has the potential to decrease the incidence of the disease, yet remains underused. We report on the development a web-based tool that provides automated risk assessment and personalized decision support designed for collaborative use between patients and clinicians.

METHODS

Under Institutional Review Board approval, we evaluated the decision tool through a patient focus group, usability testing, and provider interviews (including breast specialists, primary care physicians, genetic counselors). This included demonstrations and data collection at two scientific conferences (2009 International Shared Decision Making Conference, 2009 San Antonio Breast Cancer Symposium).

RESULTS

Overall, the evaluations were favorable. The patient focus group evaluations and usability testing (N = 34) provided qualitative feedback about format and design; 88% of these participants found the tool useful and 94% found it easy to use. 91% of the providers (N = 23) indicated that they would use the tool in their clinical setting.

CONCLUSION

BreastHealthDecisions.org represents a new approach to breast cancer prevention care and a framework for high quality preventive healthcare. The ability to integrate risk assessment and decision support in real time will allow for informed, value-driven, and patient-centered breast cancer prevention decisions. The tool is being further evaluated in the clinical setting.

Communication and technology in genetic counseling for familial cancer

When a cancer predisposing germline mutation is detected in an index case, the presence of the underlying syndrome is confirmed and the potential for predictive testing of at-risk relatives is established. However, the reporting of a positive family history does not routinely lead to communication of information about risk to close, much less distant relatives. This review summarizes information technology utilized to address penetration or 'reach' of knowledge of risk within extended families, including the use of telephone and video counseling to reach distant patients, and anticipate novel internet-based processes for communication between investigators and relatives.

Public trust in genomic risk assessment for type 2 diabetes mellitus

Patient trust in personal medical information is critical to increasing adherence to physician recommendations and medications. One of the anticipated benefits of learning of one's genomic risk for common diseases is the increased adoption of screening, preventive care and lifestyle changes. However, the equivocal results thus far reported of the positive impact of knowledge of genomic risk on behavior change may be due to lack of patients' trust in the results. As part of a clinical study to compare two methods of communication of genomic risk results for Type 2 diabetes mellitus (T2DM), we assessed patients' trust and preferred methods of delivery of genomic risk information. A total of 300 participants recruited from the general public in Durham, NC were randomized to receive their genomic risk for T2DM in-person from a genetic counselor or online through the testing company's web-site. Participants completed a baseline survey and three follow-up surveys after receiving results. Overall, participants reported high levels of trust in the test results. Participants who received their results in-person from the genetic counselor were significantly more likely to trust their results than those who reviewed their results on-line (p = 0.005). There was not a statistically significant difference in levels of trust among participants with increased genetic risk, as compared to other those with decreased or same as population risk (p = 0.1154). In the event they undergo genomic risk testing again, 55 % of participants overall indicated they would prefer to receive their results online compared to 28 % that would prefer to receive future results in-person. Of those participants preferring to receive results online, 77 % indicated they would prefer to have the option to speak to someone if they had questions with the online results (compared to accessing results online without the option of professional consultation). This is the first study to assess satisfaction with genomic risk testing by the method of delivery of the test result. The higher rate of trust in results delivered in-person suggests that online access reports may not result in serious consideration of results and lack of adoption of recommended preventive recommendations.

The impact of an empowering Internet-based Breast Cancer Patient Pathway program on breast cancer patients' clinical outcomes: a randomised controlled trial

AIMS AND OBJECTIVES

To evaluate the effect of the Breast Cancer Patient Pathway program on breast cancer patient's empowerment process.

BACKGROUND

The results of earlier studies indicate that the use of tailored Internet-based patient education programs increased patient's knowledge level; however, other outcome measures differed.

DESIGN

This randomised control trial studied the effect of the Internet-based patient educational program on breast cancer patients' empowerment. In this study, we measured the quality of life, anxiety and managing with treatment-related side effects as the outcomes of breast cancer patients' empowering process.

METHODS

Breast cancer patients who were Internet users in one Finnish university hospital during 2008-2010 were randomised to the control group (n=43) and the intervention group (n=47). Baseline data were collected first in the hospital and the following data seven times during the treatment process, the last time one year after breast cancer diagnosis.

RESULTS

There were no statistically significant differences in the quality of life, anxiety or side effects of treatment between the groups. The amount of treatment-related side effects was connected to both physical and psychological well-being.

CONCLUSIONS

In this study, the Breast Cancer Patient Pathway program did not decrease anxiety level or treatment-related side effects among breast cancer patients or improve subscales of quality of life when compared with controls.

RELEVANCE TO CLINICAL PRACTICE

There is a need to relieve the side effects caused by patients' care with the help of patient education. Internet-based patient education programs need more focus when developing new patient education methods.

Coaching and guidance with patient decision aids: A review of theoretical and empirical evidence

BACKGROUND

Coaching and guidance are structured approaches that can be used within or alongside patient decision aids (PtDAs) to facilitate the process of decision making. Coaching is provided by an individual, and guidance is embedded within the decision support materials. The purpose of this paper is to: a) present updated definitions of the concepts "coaching" and "guidance"; b) present an updated summary of current theoretical and empirical insights into the roles played by coaching/guidance in the context of PtDAs; and c) highlight emerging issues and research opportunities in this aspect of PtDA design.

METHODS

We identified literature published since 2003 on shared decision making theoretical frameworks inclusive of coaching or guidance. We also conducted a sub-analysis of randomized controlled trials included in the 2011 Cochrane Collaboration Review of PtDAs with search results updated to December 2010. The sub-analysis was conducted on the characteristics of coaching and/or guidance included in any trial of PtDAs and trials that allowed the impact of coaching and/or guidance with PtDA to be compared to another intervention or usual care.

RESULTS

Theoretical evidence continues to justify the use of coaching and/or guidance to better support patients in the process of thinking about a decision and in communicating their values/preferences with others. In 98 randomized controlled trials of PtDAs, 11 trials (11.2%) included coaching and 63 trials (64.3%) provided guidance. Compared to usual care, coaching provided alongside a PtDA improved knowledge and decreased mean costs. The impact on some other outcomes (e.g., participation in decision making, satisfaction, option chosen) was more variable, with some trials showing positive effects and other trials reporting no differences. For values-choice agreement, decisional conflict, adherence, and anxiety there were no differences between groups. None of these outcomes were worse when patients were exposed to decision coaching alongside a PtDA. No trials evaluated the effect of guidance provided within PtDAs.

CONCLUSIONS

Theoretical evidence continues to justify the use of coaching and/or guidance to better support patients to participate in decision making. However, there are few randomized controlled trials that have compared the effectiveness of coaching used alongside PtDAs to PtDAs without coaching, and no trials have compared the PtDAs with guidance to those without guidance.

Shared decision making and patient decision aids: knowledge, attitudes, and practices among Hawai'i physicians

As the health care field moves toward patient-centered care (PCC), increasing emphasis has been placed on the benefits of patient decision aids for promoting shared decision making (SDM). This study provides a baseline measure of knowledge, attitudes, and practices (KAP) among Hawai'i's physicians with respect to patient decision aids (DAs). Physicians throughout the State of Hawai'i were invited to complete a survey assessing their knowledge, attitudes, and practices with respect to the clinical use of DAs. One hundred and seventy four valid surveys were analyzed. Reported awareness and use of DAs were low, but recognition of the benefits of SDM and openness to the use of DAs were very high. The leading perceived barriers to the implementation of DAs were lack of awareness, lack of resources, and limited physician time to learn about DA technology. However, a significant majority of the respondents reported that DAs could empower patients by improving knowledge (88%), increasing satisfaction with the consultation process (81%), and increasing compliance (74%). Among physicians currently employing DAs, use of brochures or options matrix sheets was the most common aid tool. However, leading recommended DA formats were paper-based brochures for clinic use (75%) and interactive online website programs for outside clinic use (73.5%). Given growing emphasis on the PCC model and the recognized desire of many patients to participate in the medical decision making process, positive responses toward SDM and the use of DAs by Hawai'i physicians are promising.

Research priorities for geriatric palliative care: goals, values, and preferences

Older patients and their families desire control over health decisions in serious illness. Experts recommend discussion of prognosis and goals of care prior to decisions about treatment. Having achieved longevity, older persons often prioritize other goals such as function, comfort, or family support--and skilled communication is critical to shift treatment to match these goals. Shared decision making is the ideal approach in serious illness. Older patients desire greater family involvement; higher rates of cognitive impairment mean greater dependency on surrogates to make decisions. Despite the importance of communication, fewer than half of older patients or families recall treatment discussions with clinicians, and poor quality communication adversely affects family satisfaction and patient outcomes. Direct audiorecording of clinical encounters and longitudinal studies of communication and treatment decisions have yielded important insights into the quality of clinical communication. Current clinical practice rarely meets standards for shared decision making. Innovative methods to record and use patient preferences show promise to overcome the limitations of traditional advance directives. Decision aids, intensive clinician training, and structured interpersonal communication interventions have all been shown to be effective to improve the quality of communication and decision making. Priorities for geriatric palliative care research, building on these insights, now include empirical testing of communication approaches for surrogates and for diverse populations, exploration of meaningful ways to communicate prognosis, and expansion of intervention research.

Feasibility evaluation of an online tool to guide decisions for BRCA1/2 mutation carriers

Women with BRCA1 or BRCA2 (BRCA1/2) mutations face difficult decisions about managing their high risks of breast and ovarian cancer. We developed an online tool to guide decisions about cancer risk reduction (available at: http://brcatool.stanford.edu ), and recruited patients and clinicians to test its feasibility. We developed questionnaires for women with BRCA1/2 mutations and clinicians involved in their care, incorporating the System Usability Scale (SUS) and the Center for Healthcare Evaluation Provider Satisfaction Questionnaire (CHCE-PSQ). We enrolled BRCA1/2 mutation carriers who were seen by local physicians or participating in a national advocacy organization, and we enrolled clinicians practicing at Stanford University and in the surrounding community. Forty BRCA1/2 mutation carriers and 16 clinicians participated. Both groups found the tool easy to use, with SUS scores of 82.5-85 on a scale of 1-100; we did not observe differences according to patient age or gene mutation. General satisfaction was high, with a mean score of 4.28 (standard deviation (SD) 0.96) for patients, and 4.38 (SD 0.89) for clinicians, on a scale of 1-5. Most patients (77.5 %) were comfortable using the tool at home. Both patients and clinicians agreed that the decision tool could improve patient-doctor encounters (mean scores 4.50 and 4.69, on a 1-5 scale). Patients and health care providers rated the decision tool highly on measures of usability and clinical relevance. These results will guide a larger study of the tool's impact on clinical decisions.

Incidental findings from clinical genome-wide sequencing: a review

There are several unresolved challenges associated with the clinical application of genome-wide sequencing technologies. One of the most discussed issues is incidental findings (IF), which are defined as discoveries made as a result of genetic testing that are unrelated to the indication for the test. The discussion surrounding IF began in the context of research, which we have used to frame consideration of IF in the clinical context. There is growing consensus that analytically valid and medically actionable IF should be offered to patients, but whether and to what extent clinicians should disclose other kinds of IF is debated. While others have systematically reviewed the literature concerning genetic IF, previous reviews focus on ethical and research-related issues and do not consider the implications for the genetic counseling profession specifically. This review discusses the practical considerations, ethical concerns and genetic counseling issues related to IF, with a particular focus on clinical genome-wide sequencing. To date, the bulk of the literature with respect to IF in the clinical context consists of commentaries, reviews and case reports. There is a need for more empirical studies to provide a foundation for institutional protocols and evidence-based clinical practice standards.

What is lacking in current decision aids on cancer screening?

Recent guidelines on cancer screening have provided not only more screening options but also conflicting recommendations. Thus, patients, with their clinicians' support, must decide whether to get screened, which modality to use, and how often to undergo screening. Decision aids could potentially lead to better shared decision-making regarding screening between the patient and the clinician. A total of 73 decision aids concerning screening for breast, cervical, colorectal, and prostate cancers were reviewed. The goal of this review was to assess the effectiveness of such decision aids, examine areas in need of more research, and determine how the decision aids can be currently applied in the real-world setting. Most studies used sound study designs. Significant variation existed in the setting, theoretical framework, and measured outcomes. Just over one-third of the decision aids included an explicit values clarification. Other than knowledge, little consistency was noted with regard to which patient attributes were measured as outcomes. Few studies actually measured shared decision-making. Little information was available regarding the feasibility and outcomes of integrating decision aids into practice. In this review, the implications for future research, as well as what clinicians can do now to incorporate decision aids into their practice, are discussed.

Using the pediatric emergency department to deliver tailored safety messages: results of a randomized controlled trial

OBJECTIVE

This study aimed to evaluate the impact of a computer kiosk intervention on parents' self-reported safety knowledge as well as observed child safety seat, smoke alarm use, and safe poison storage and to compare self-reported versus observed behaviors.

METHODS

A randomized controlled trial with 720 parents of young children (4 months to 5 years) was conducted in the pediatric emergency department of a level 1 pediatric trauma center. Enrolled parents received tailored safety information (intervention) or generic information (control) from a computer kiosk after completing a safety assessment. Parents were telephoned 4 to 6 months after the intervention to assess self-reported safety knowledge and behaviors; in-home observations were made 1 week after the telephone interview for a subset of 100 randomly selected participants. Positive and negative predictive values were compared between the intervention and control groups.

RESULTS

The intervention group had significantly higher smoke alarm (82% vs. 78%) and poison storage (83% vs 78%) knowledge scores. The intervention group was more likely to report correct child safety seat use (odds ratio, 1.36; 95% confidence interval, 1.05-1.77; P = 0.02). Observed safety behaviors were lower than self-reported use for both groups. No differences were found between groups for positive or negative predictive values.

CONCLUSIONS

These results add to the limited literature on the impact of computer tailoring home safety information. Knowledge gains were evident 4 months after intervention. Discrepancies between observed and self-reported behavior are concerning because the quality of a tailored intervention depends on the accuracy of participant self-reporting. Improved measures should be developed to encourage accurate reporting of safety behaviors.

The rationale for Heart Team decision-making for patients with stable, complex coronary artery disease

Stable complex coronary artery disease can be treated with coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), or medical therapy. Multidisciplinary decision-making has gained more emphasis over the recent years to select the most optimal treatment strategy for individual patients with stable complex coronary artery disease. However, the so-called 'Heart Team' concept has not been widely implemented. Yet, decision-making has shown to remain suboptimal; there is large variability in PCI-to-CABG ratios, which may predominantly be the consequence of physician-related factors that have raised concerns regarding overuse, underuse, and inappropriate selection of revascularization. In this review, we summarize these and additional data to support the statement that a multidisciplinary Heart Team consisting of at least a clinical/non-invasive cardiologist, interventional cardiologist, and cardiac surgeon, can together better analyse and interpret the available diagnostic evidence, put into context the clinical condition of the patient as well as consider individual preference and local expertise, and through shared decision-making with the patient can arrive at a most optimal joint treatment strategy recommendation for patients with stable complex coronary artery disease. In addition, other aspects of Heart Team decision-making are discussed: the organization and logistics, involvement of physicians, patients, and assisting personnel, the need for validation, and its limitations.

Coaching and guidance with patient decision aids: A review of theoretical and empirical evidence

BACKGROUND

Coaching and guidance are structured approaches that can be used within or alongside patient decision aids (PtDAs) to facilitate the process of decision making. Coaching is provided by an individual, and guidance is embedded within the decision support materials. The purpose of this paper is to: a) present updated definitions of the concepts "coaching" and "guidance"; b) present an updated summary of current theoretical and empirical insights into the roles played by coaching/guidance in the context of PtDAs; and c) highlight emerging issues and research opportunities in this aspect of PtDA design.

METHODS

We identified literature published since 2003 on shared decision making theoretical frameworks inclusive of coaching or guidance. We also conducted a sub-analysis of randomized controlled trials included in the 2011 Cochrane Collaboration Review of PtDAs with search results updated to December 2010. The sub-analysis was conducted on the characteristics of coaching and/or guidance included in any trial of PtDAs and trials that allowed the impact of coaching and/or guidance with PtDA to be compared to another intervention or usual care.

RESULTS

Theoretical evidence continues to justify the use of coaching and/or guidance to better support patients in the process of thinking about a decision and in communicating their values/preferences with others. In 98 randomized controlled trials of PtDAs, 11 trials (11.2%) included coaching and 63 trials (64.3%) provided guidance. Compared to usual care, coaching provided alongside a PtDA improved knowledge and decreased mean costs. The impact on some other outcomes (e.g., participation in decision making, satisfaction, option chosen) was more variable, with some trials showing positive effects and other trials reporting no differences. For values-choice agreement, decisional conflict, adherence, and anxiety there were no differences between groups. None of these outcomes were worse when patients were exposed to decision coaching alongside a PtDA. No trials evaluated the effect of guidance provided within PtDAs.

CONCLUSIONS

Theoretical evidence continues to justify the use of coaching and/or guidance to better support patients to participate in decision making. However, there are few randomized controlled trials that have compared the effectiveness of coaching used alongside PtDAs to PtDAs without coaching, and no trials have compared the PtDAs with guidance to those without guidance.

Developing a comprehensive, effective patient-friendly website to enhance decision making in predictive testing for Huntington disease

PURPOSE

Predictive testing for Huntington disease is a complex decision, requiring in-depth counseling, education, and evaluation. Despite the growth in Web-based decision aids and educational resources, such tools for those considering Huntington disease testing are not available. The main objective of this project was to develop a patient-friendly, comprehensive, accessible Web-based tool to provide accurate information about testing for Huntington disease.

METHODS

A semistructured interview study was conducted to determine the informational, educational, and support needs of those considering Huntington disease testing. A dedicated predictive testing website was subsequently developed and pilot tested.

RESULTS

The interview study revealed that an effective website should include interactive diagrams, video documentaries, and personal stories of others who had considered testing. The pilot test revealed that the multidimensional site was easy to navigate and understand and provided an accurate, unbiased overview of the important factors to be considered before undergoing predictive testing.

CONCLUSION

This project demonstrates the use of a mixed-method approach to develop the first tailored website dedicated to predictive testing for Huntington disease. Such an approach enabled the development of a comprehensive, accurate, and effective educational tool that supports informed decision making for people considering predictive testing for Huntington disease in an accessible, nonthreatening manner.

Effects of informed consent for individual genome sequencing on relevant knowledge

Increasing availability of individual genomic information suggests that patients will need knowledge about genome sequencing to make informed decisions, but prior research is limited. In this study, we examined genome sequencing knowledge before and after informed consent among 311 participants enrolled in the ClinSeq™ sequencing study. An exploratory factor analysis of knowledge items yielded two factors (sequencing limitations knowledge; sequencing benefits knowledge). In multivariable analysis, high pre-consent sequencing limitations knowledge scores were significantly related to education [odds ratio (OR): 8.7, 95% confidence interval (CI): 2.45-31.10 for post-graduate education, and OR: 3.9; 95% CI: 1.05, 14.61 for college degree compared with less than college degree] and race/ethnicity (OR: 2.4, 95% CI: 1.09, 5.38 for non-Hispanic Whites compared with other racial/ethnic groups). Mean values increased significantly between pre- and post-consent for the sequencing limitations knowledge subscale (6.9-7.7, p < 0.0001) and sequencing benefits knowledge subscale (7.0-7.5, p < 0.0001); increase in knowledge did not differ by sociodemographic characteristics. This study highlights gaps in genome sequencing knowledge and underscores the need to target educational efforts toward participants with less education or from minority racial/ethnic groups. The informed consent process improved genome sequencing knowledge. Future studies could examine how genome sequencing knowledge influences informed decision making.

The impact of an empowering Internet-based Breast Cancer Patient Pathway programme on breast cancer patients' knowledge: a randomised control trial

OBJECTIVE

The aim of this study was to analyse the effect of Breast Cancer Patient Pathway program.

METHODS

In one Finnish university hospital during 2008-10 newly diagnosed breast cancer patients were randomised to the intervention (n = 50) and the control groups (n = 48). The breast cancer patient's knowledge expectations and perception of received knowledge, knowledge, the source of information and satisfaction in received patient education were measured. Baseline and one year follow up data collection was conducted.

RESULTS

No differences were found in knowledge expectations between the groups at baseline. Patients in the control group evaluated their perception of received knowledge to be higher and they were more satisfied with the patient education they received from the hospital staff. However, the Intervention group's knowledge level was higher. The most important source of information was the healthcare professionals in both groups.

CONCLUSION

The results of study indicate that when patient education increases, patients' knowledge expectations increase as well, while their perceptions of received knowledge decrease. Future research is needed to examine the relationship between patients' knowledge expectations and perception of received knowledge as patients' knowledge level increases.

PRACTICE IMPLICATIONS

Patient education has to be individually adjusted, taking patients' expectations into account.

A pre-visit tailored website enhances counselees' realistic expectations and knowledge and fulfils information needs for breast cancer genetic counselling

Counselees who are the first in their family to request breast cancer genetic counselling often don't know what to expect or have unrealistic expectations of genetic counselling. Receiving tailored information might help them to prepare for their first visit. We conducted a study of the effects of a pre-visit website providing computer-tailored information (E-info gene(ca)), on counselees' expectations, knowledge about breast cancer and heredity and information needs. Counselees were randomized to receive usual care (UC) or UC plus website. All counselees completed a baseline questionnaire and those randomized to the intervention group also completed a questionnaire after having viewed the website. After having accessed E-info gene(ca) counselees (n = 101) better knew what to expect of their first visit (χ(2) = 4.43; P = .04) and less often showed unrealistic expectations about possibilities for DNA-testing (χ(2) = 4.84; P = .03) than counselees in the UC group (n = 89). In addition, the website increased counselees' knowledge of breast cancer and heredity (B = .23; P = .003) and lowered their information needs (B = -.16; P = .000) compared to the UC group. Especially, information concerning procedural aspects and emotional consequences of genetic counselling was considered less important. This study showed that counselees know more and need less when they are provided with extended pre-visit information through a tailored website and counselees enter the visit with more realistic expectations of genetic counselling. This might facilitate and focus communication within the subsequent consultation.

Computerised decision aids: a systematic review of their effectiveness in facilitating high-quality decision-making in various health-related contexts

OBJECTIVE

To systematically review existing empirical evidence regarding the effectiveness of computerised decision aids (CDAs) in enabling high-quality decision-making in preference-sensitive health-related contexts.

METHODS

Relevant studies were identified via Medline, CINAHL, and PsycINFO databases (1990-October 2010). Only randomised controlled trials with at least one decision quality or decision process variable outcome were included.

RESULTS

Of 1467 identified articles, 28 studies met all inclusion criteria, evaluating 26 unique CDAs. CDAs performed better than standard consultations/education regarding improved knowledge and lower decisional conflict, and were found not to increase anxiety. CDAs facilitated greater satisfaction with the decision-making process than standard education. The effects on risk perceptions, value congruence with the chosen option, preferred roles in decision-making and decisional self-efficacy need further evaluation. A paucity of CDAs adhered to decision theories.

CONCLUSIONS

CDAs showed similar effects as non-computerised DAs on various outcomes. Further research into the potentially superior effects of CDAs on feeling informed, values-clarity, and decisional conflict is required.

PRACTICE IMPLICATIONS

The more remarkable effects on knowledge and risk perceptions were reported when unique features of interactive computerised media were used. The potential benefit of tailored information, values-clarification, and integration of CDAs into shared decision-making consultations remains unresolved.

Getting to the point: what women newly diagnosed with breast cancer want to know about treatment-focused genetic testing

PURPOSE/OBJECTIVES

To identify young women's information preferences regarding treatment-focused genetic testing (TFGT) and to develop and evaluate a novel educational resource.

RESEARCH APPROACH

Qualitative interview study and pilot testing of a novel resource.

SETTING

Two familial cancer services and one outpatient oncology clinic in Sydney and Melbourne, Australia.

PARTICIPANTS

26 women with breast cancer aged 50 years and younger who either previously had TFGT (n = 14) or had a diagnosis of breast cancer within the previous 6-12 months.

METHODOLOGIC APPROACH

Participants were asked about their views of TFGT in semistructured interviews. A brief pamphlet on TFGT then was developed and pilot tested with 17 of the 26 women.

MAIN RESEARCH VARIABLES

Women's attitudes and preferences with regard to timing, mode of delivery, and amount and format of information regarding TFGT were explored.

FINDINGS

Most women wanted to be informed about TFGT at or around the time of their cancer diagnosis via a face-to-face consultation. No clear preference existed for which type of healthcare professional should provide information on TFGT. Brief written information about TFGT was viewed as important supporting material. The educational resource developed was well received.

CONCLUSIONS

The potential for more widespread TFGT in the future indicates a need for patient educational materials that enable women to make informed choices about TFGT. This pilot study has provided timely initial evidence on the efficacy of a brief written resource in preparing women for decision making about TFGT.

INTERPRETATION

The resource developed in this study will assist oncology nurses to make important genetic risk information available to women newly diagnosed with breast cancer at a stressful time.

Effectiveness of videos improving cancer prevention knowledge in people with profound hearing loss

Deaf persons have a poorer understanding of cancer prevention, which is felt to be partly due to communication barriers. One hundred ninety-seven d/Deaf persons completed a survey and video on cancer prevention. Half viewed a spoken English program designed for hearing persons (control group); the other half viewed an amended program that had American Sign Language, captions, and printed English options added (experimental group). Knowledge was measured before and after the video, including 1 and 6 months later. Respondents were primarily Caucasian, had low incomes, lost hearing at young ages, and had d/Deaf spouses. Although overall knowledge improved after viewing the video, the presence of culture-specific communications (American Sign Language, captions) did not improve scores compared to the control group, either immediately after the intervention or over time. Moreover, percentage correct on all pretest, and almost all post-test, questions was <50% for both experimental and control groups. For all subjects, regardless of which group they were in, a hearing spouse (p  < 0.001) and more healthcare information sources (p = 0.001) improved knowledge, while African-Americans showed a trend to lesser improvement (p = 0.06). Using culture-specific language did not improve cancer prevention knowledge in this d/Deaf population, and overall knowledge remained low. More study is needed to determine the best way to increase cancer prevention knowledge in this population.

Decision Coaching to Prepare Patients for Making Health Decisions

Background. Decision coaching is individualized, nondirective facilitation of patient preparation for shared decision making. Purpose. To explore characteristics and effectiveness of decision coaching evaluated within trials of patient decision aids (PtDAs) for health decisions. Data Sources. A subanalysis of trials included in the 2011 Cochrane Review of PtDAs. Study Selection. Eligible trials allowed the effectiveness of decision coaching to be compared with another intervention and/or usual care. Data Extraction. Two reviewers independently screened 86 trials, extracted data, and appraised quality. Data Synthesis. Ten trials were eligible. Decision coaching was provided by genetic counselors, nurses, pharmacists, physicians, psychologists, or health educators. Coaching compared with usual care ( n = 1 trial) improved knowledge. Coaching plus PtDA compared with usual care ( n = 4) improved knowledge and participation in decision making without reported dissatisfaction. Coaching compared with PtDA alone ( n = 4) increased values-choice agreement and improved satisfaction with the decision-making process without any difference in knowledge or participation in decision making. Coaching plus PtDA compared with PtDA alone ( n = 4) had no difference in knowledge, values-choice agreement, participation in decision making, or satisfaction with the process. Decision coaching plus PtDA was more cost-effective compared with PtDA alone or usual care ( n = 1). Limitations. Methodological quality, number of trials, and description of decision coaching. Conclusions. Compared with usual care, decision coaching improved knowledge. However, the improvement in knowledge was similar when coaching was compared with PtDA alone. Outcomes for other comparisons are more variable, some trials showing positive effects and other trials reporting no difference. Given the small number of trials and variability in results, further research is required to determine the effectiveness of decision coaching.

Effectiveness of a condensed protocol for disclosing APOE genotype and providing risk education for Alzheimer disease

PURPOSE

Brief, effective models of patient genetic education are needed for common, complex diseases. Using Alzheimer disease as a model, we compared participants' risk knowledge and recall in extended versus condensed education protocols.

METHODS

A four-site randomized clinical trial enrolled 280 first-degree relatives of individuals with Alzheimer disease (mean age = 58 years, 71% female); each received lifetime Alzheimer disease risk information (range: 13-74%) that incorporated apolipoprotein E genotype. In the condensed protocol, participants received an educational brochure in place of an in-person education session. Outcomes were assessed at 6 weeks and 6 months following risk disclosure.

RESULTS

The condensed protocol required less clinician time than the extended protocol (mean = 34 min vs. 77 min). The groups did not differ on recall of apolipoprotein E genotype or lifetime risk, and most participants in both groups recalled and retained this information over time. Both groups showed improvement from baseline in Alzheimer disease risk knowledge (e.g., understanding the magnitude of apolipoprotein E genotype effect on risk).

CONCLUSION

A condensed protocol for communicating genetic risk for Alzheimer disease achieved similar educational results as an extended protocol in this study. Further research should explore the efficacy of brief genetic education protocols for complex diseases in diverse populations.

Web-based tailored education program for disease-free cancer survivors with cancer-related fatigue: a randomized controlled trial

PURPOSE

To determine whether an Internet-based tailored education program is effective for disease-free cancer survivors with cancer-related fatigue (CRF).

PATIENTS AND METHODS

We randomly assigned patients who had completed primary cancer treatment within the past 24 months in any of four Korean hospitals and had reported moderate to severe fatigue for at least 1 week to participate in a 12-week, Internet-based, individually tailored CRF education program or to receive routine care. We based the program on the CRF guidelines of the National Comprehensive Cancer Network (NCCN) and incorporated the transtheoretic model (TTM). At baseline and 12 weeks, we used the Brief Fatigue Inventory (BFI) and Fatigue Severity Scale (FSS) as primary outcomes and the Hospital Anxiety and Depression Scale (HADS) and European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30) for secondary outcomes.

RESULTS

We recruited 273 participants and randomly assigned 136 to the intervention group. Compared with the control group, the intervention group had an improvement in fatigue as shown by a significantly greater decrease in BFI global score (-0.66 points; 95% CI -1.04 to -0.27) and FSS total score (-0.49; 95% CI, -0.78 to -0.21). In secondary outcomes, the intervention group experienced a significantly greater decrease in HADS anxiety score (-0.90; 95% CI, -1.51 to -0.29) as well as global quality of life (5.22; 95% CI, 0.93 to 9.50) and several functioning scores of the EORTC QLQ-C30.

CONCLUSION

An Internet-based education program based on NCCN guidelines and TTM may help patients manage CRF.

Effects of a pre-visit educational website on information recall and needs fulfilment in breast cancer genetic counselling, a randomized controlled trial

Introduction

Pre-visit education which helps counselees to prepare for their first visit for breast cancer genetic counseling might enhance information recall and needs fulfilment. This study assessed the effects of a pre-visit website with tailored information and question prompt sheet (QPS), named E-info gene^ca.

Methods

A total of 197 counselees were randomized to receive usual care (UC) or UC plus E-info gene^ca. All counselees completed a pre- and post-visit questionnaire and visits were videotaped. We studied effects on counselees' information recall, knowledge about breast cancer and heredity, fulfillment of needs, risk perception alignment, anxiety and perceived personal control, using multilevel regression analyses.

Results

Intent-to-treat analysis showed that counselees in the intervention group (n = 103) had higher levels of recall of information from the consultation (β = .32; confidence interval (CI): .04 to .60; P = .02; d = .17) and post-visit knowledge of breast cancer and heredity (β = .30; CI: .03 to .57; P = .03) than counselees in the UC group (n = 94). Also, intervention group counselees reported better fulfilment of information needs (β = .31; CI: .03 to .60; P = .03). The effects of the intervention were strongest for those counselees who did not receive an indication for DNA testing. Their recall scores showed a larger increase (β = .95; CI: .32 to 1.59; P = .003; d = .30) and their anxiety levels dropped more in the intervention compared to the UC group (β = -.60; CI: -1.12 to -.09; P = .02). No intervention effects were found after the first visit on risk perception alignment or perceived personal control.

Conclusions

This study shows that pre-counseling education, using tailored information technology, leads to more effective first visits for breast cancer genetic counseling, in particular for counselees who received no indication for DNA testing and, therefore, had no indication for a second visit. Future study should focus on the effects of a pre-visit website on the outcomes after a complete series of visits.

Trial registration

Dutch Trial Register ISRCTN82643064.

Cancer genetic risk assessment for individuals at risk of familial breast cancer

BACKGROUND

The recognition of an inherited component to breast cancer has led to an increase in demand for information, reassurance, and genetic testing, which has resulted in the creation of genetic clinics for familial cancer. The first step for patients referred to a cancer genetic clinic is a risk assessment.

OBJECTIVES

To evaluate the impact of cancer genetic risk-assessment services on patients at risk of familial breast cancer.

SEARCH METHODS

The specialised register maintained by the Cochrane Breast Cancer Group was searched on 16th February 2005. We also searched MEDLINE, EMBASE, CINAHL, PsycLIT, CENTRAL, DARE, ASSIA, Web of Science, SIGLE and LILACS. The original searches covered the period 1985 to February 2005. We also handsearched relevant journals. For this review update the search was repeated through to April 2011.

SELECTION CRITERIA

We considered trials looking at interventions for cancer genetic risk-assessment services for familial breast cancer for inclusion. Trials assessed outcomes such as understanding of risk, satisfaction and psychological well-being. We excluded studies if they concerned cancers other than breast cancer or if participants were not at risk of inherited breast cancer. We also excluded trials concerning the provision of general cancer genetic information or education as this review was concerned with the delivery of genetic risk assessment. Participants could be individuals of any age or gender, with or without a known BRCA mutation, but without a previous history of breast cancer or any other serious illness.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. Additional information was sought from investigators as necessary. Due to the heterogeneity of both the interventions and outcomes, we reported data descriptively.

MAIN RESULTS

In this review update, we included five new trials, bringing the total number of included studies to eight. The included trials (pertaining to 10 papers), provided data on 1973 participants and assessed the impact of cancer genetic risk assessment on outcomes including perceived risk of inherited cancer, and psychological distress. This review suggests that cancer genetic risk-assessment services help to reduce distress, improve the accuracy of the perceived risk of breast cancer, and increase knowledge about breast cancer and genetics. The health professional delivering the risk assessment does not appear to have a significant impact on these outcomes.

AUTHORS' CONCLUSIONS

This review found favourable outcomes for patients after risk assessment for familial breast cancer. However, there were too few papers to make any significant conclusions about how best to deliver cancer genetic risk-assessment services. Further research is needed assessing the best means of delivering cancer risk assessment, by different health professionals, in different ways and in alternative locations.

Breast cancer genetic testing awareness, attitudes and intentions of Latinas living along the US-Mexico border: a qualitative study

BACKGROUND

Genetic testing for breast cancer may facilitate better-informed decisions regarding cancer prevention, risk reduction, more effective early detection, and better determination of risk for family members. Despite these potential benefits, significant portions of the US population-particularly Latinas-lack awareness of genetic testing for breast cancer susceptibility. Among women who are tested, less than 4% are Latina. To uncover reasons for Latinas' low participation, this study explores awareness, attitudes and behavioral intentions to undergo genetic testing among average-risk Latinas along the Texas-Mexico border.

METHODS

Eight focus groups were conducted with 58 Latinas aged 19-69 living in Hidalgo County, a largely Latino region of South Texas. Focus group discussions were digitally recorded, transcribed and analyzed using qualitative content analysis to assess, categorize and interpret them. Two experienced study team members analyzed transcripts to identify major concepts grouped into theme categories.

RESULTS

Participants mostly had less than a high-school education (43%), spoke primarily Spanish (52%), were of Mexican-American origin (90%) and had a family income of $30,000 or less (75%). Focus groups found that most participants had positive attitudes and strong interest in genetic testing, yet lacked general awareness and knowledge about genetic testing, its risks, benefits, and limitations. Participants also identified several key cultural-based influencers, such as family, religious beliefs and fear of testing.

CONCLUSION

The delivery of culturally adapted risk information is needed to increase and ensure Latinas' understanding of breast cancer genetic testing during their decision-making processes. Key Latino values-religiosity, importance of family and the influential role of health care providers in health decisions-should also be considered when designing interventions targeting this specific group. Further research is needed to identify effective ways to communicate genetic risk susceptibility information to Latinas to help them make informed testing decisions.

Psychometric testing of the decisional conflict scale: genetic testing hereditary breast and ovarian cancer

BACKGROUND

: Hereditary breast and ovarian cancer (HBOC) syndrome is attributed mostly to mutations in the Breast Cancer 1 and Breast Cancer 2 genes (BRCA1/2). Mutation carriers of BRCA1/2 genes have significantly higher risk for developing breast cancer compared with the general population (55%-85% vs. 12%) and for developing ovarian cancer (20%-60% vs. 1.5%). The availability of genetic testing enables mutation carriers to make informed decisions about managing their cancer risk (e.g., risk-reducing surgery). However, uptake of testing for HBOC among high-risk individuals is low, indicating the need to better understand and measure the decisional conflict associated with this process.

OBJECTIVE

: The aim of this study was to evaluate the reliability and validity of the modified Decisional Conflict Scale for use in decisions associated with genetic testing for HBOC.

METHODS

: This cross-sectional cohort study, recruited women who pursued genetic testing for HBOC in two genetic risk assessment clinics affiliated with a large comprehensive cancer center and one of their female relatives who did not pursue testing. The final sample consisted of 342 women who completed all 16 items of the Decisional Conflict Scale. The psychometric properties of the scale were assessed using tests of reliability and validity, including face, content, construct, contrast, convergent, divergent, and predictive validity.

RESULTS

: Factor analysis using principal axis factoring with oblimin rotation elicited a three-factor structure: (a) Lack of Knowledge About the Decision (α = .97), (b) Lack of Autonomy in Decision Making (α = .94), and (c) Lack of Confidence in Decision Making (α = .87). These factors explained 82% of the variance in decisional conflict about genetic testing. Cronbach's alpha coefficient was .96.

DISCUSSION

: The instrument is an important tool for researchers and healthcare providers working with women at risk for HBOC who are deciding whether genetic testing is the right choice for them.

E-genetics: exploring the acceptability and feasibility of using technology in cancer genetics services

The use of information and communication technologies (ICTs) in the delivery of cancer genetics services could improve equality of access in rural areas and help meet the increasing demand for specialist genetics services. An online patient survey and focus groups with patients and staff from the Cancer Genetics Service for Wales (CGSW) were used to explore the acceptability and feasibility of utilizing ICTs within genetics services, which we have termed e-genetics. A total of 225 patients completed the online survey. Many aspects of e-genetics proposed in the survey were highly acceptable to patients, including an electronic version of the family history questionnaire, an email facility for cancer genetic queries, and a computerized decision-aid. Participants in the focus groups emphasized the importance of patient choice when developing new models of service delivery. For example, the use of genetic counselling via telemedicine was not considered to be preferable to face-to-face clinic appointments but could benefit those unable to travel. This article highlights the fact that e-genetics initiatives may not be appropriate for all cancer genetics service users. However, user-friendly developments that can be easily implemented and attend to individual needs could improve efficiency and cost-effectiveness, whilst providing high-quality services to remote areas.

Temporal lobe epilepsy surgery: what do patients want to know?

Patients with pharmacoresistant temporal lobe epilepsy (TLE) contemplating brain surgery must make a complex treatment decision involving trade-offs. Patient decision aids, containing information on the risks and benefits of treatment interventions, increase patient knowledge and facilitate shared decision making between patients and physicians. We conducted five focus groups to describe the information patients need to make informed decisions about TLE surgery. Twenty patients who had undergone TLE surgery described the information used in their decision-making process, and evaluated the potential for a patient decision aid to assist other patients who are considering surgery. Thematic analysis revealed information needs that were both experiential (i.e., learning about other patients' experiences through testimonials) and factual (i.e., individualized statistical information). Patients also made suggestions on how this information should be delivered to patients. These data will accelerate the development of a patient decision aid designed to assist TLE patients in their decision making about epilepsy surgery.

Decision aids for people facing health treatment or screening decisions

BACKGROUND

Decision aids prepare people to participate in decisions that involve weighing benefits, harms, and scientific uncertainty.

OBJECTIVES

To evaluate the effectiveness of decision aids for people facing treatment or screening decisions.

SEARCH STRATEGY

For this update, we searched from January 2006 to December 2009 in MEDLINE (Ovid); Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, issue 4 2009); CINAHL (Ovid) (to September 2008 only); EMBASE (Ovid); PsycINFO (Ovid); and grey literature. Cumulatively, we have searched each database since its start date.

SELECTION CRITERIA

We included published randomised controlled trials (RCTs) of decision aids, which are interventions designed to support patients' decision making by providing information about treatment or screening options and their associated outcomes, compared to usual care and/or alternative interventions. We excluded studies in which participants were not making an active treatment or screening decision.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened abstracts for inclusion, extracted data, and assessed potential risk of bias. The primary outcomes, based on the International Patient Decision Aid Standards, were:A) decision attributes;B) decision making process attributes.Secondary outcomes were behavioral, health, and health system effects. We pooled results of RCTs using mean differences (MD) and relative risks (RR), applying a random effects model.

MAIN RESULTS

Of 34,316 unique citations, 86 studies involving 20,209 participants met the eligibility criteria and were included. Thirty-one of these studies are new in this update. Twenty-nine trials are ongoing. There was variability in potential risk of bias across studies. The two criteria that were most problematic were lack of blinding and the potential for selective outcome reporting, given that most of the earlier trials were not registered.Of 86 included studies, 63 (73%) used at least one measure that mapped onto an IPDAS effectiveness criterion: A) criteria involving decision attributes: knowledge scores (51 studies); accurate risk perceptions (16 studies); and informed value-based choice (12 studies); and B) criteria involving decision process attributes: feeling informed (30 studies) and feeling clear about values (18 studies).A) Criteria involving decision attributes:Decision aids performed better than usual care interventions by increasing knowledge (MD 13.77 out of 100; 95% confidence interval (CI) 11.40 to 16.15; n = 26). When more detailed decision aids were compared to simpler decision aids, the relative improvement in knowledge was significant (MD 4.97 out of 100; 95% CI 3.22 to 6.72; n = 15). Exposure to a decision aid with expressed probabilities resulted in a higher proportion of people with accurate risk perceptions (RR 1.74; 95% CI 1.46 to 2.08; n = 14). The effect was stronger when probabilities were expressed in numbers (RR 1.93; 95% CI 1.58 to 2.37; n = 11) rather than words (RR 1.27; 95% CI 1.09 to 1.48; n = 3). Exposure to a decision aid with explicit values clarification compared to those without explicit values clarification resulted in a higher proportion of patients achieving decisions that were informed and consistent with their values (RR 1.25; 95% CI 1.03 to 1.52; n = 8).B) Criteria involving decision process attributes:Decision aids compared to usual care interventions resulted in: a) lower decisional conflict related to feeling uninformed (MD -6.43 of 100; 95% CI -9.16 to -3.70; n = 17); b) lower decisional conflict related to feeling unclear about personal values (MD -4.81; 95% CI -7.23 to -2.40; n = 14); c) reduced the proportions of people who were passive in decision making (RR 0.61; 95% CI 0.49 to 0.77; n = 11); and d) reduced proportions of people who remained undecided post-intervention (RR 0.57; 95% CI 0.44 to 0.74; n = 9). Decision aids appear to have a positive effect on patient-practitioner communication in the four studies that measured this outcome. For satisfaction with the decision (n = 12) and/or the decision making process (n = 12), those exposed to a decision aid were either more satisfied or there was no difference between the decision aid versus comparison interventions. There were no studies evaluating the decision process attributes relating to helping patients to recognize that a decision needs to be made or understand that values affect the choice.C) Secondary outcomesExposure to decision aids compared to usual care continued to demonstrate reduced choice of: major elective invasive surgery in favour of conservative options (RR 0.80; 95% CI 0.64 to 1.00; n = 11). Exposure to decision aids compared to usual care also resulted in reduced choice of PSA screening (RR 0.85; 95% CI 0.74 to 0.98; n = 7). When detailed compared to simple decision aids were used, there was reduced choice of menopausal hormones (RR 0.73; 95% CI 0.55 to 0.98; n = 3). For other decisions, the effect on choices was variable. The effect of decision aids on length of consultation varied from -8 minutes to +23 minutes (median 2.5 minutes). Decision aids do not appear to be different from comparisons in terms of anxiety (n = 20), and general health outcomes (n = 7), and condition specific health outcomes (n = 9). The effects of decision aids on other outcomes (adherence to the decision, costs/resource use) were inconclusive.

AUTHORS' CONCLUSIONS

New for this updated review is evidence that: decision aids with explicit values clarification exercises improve informed values-based choices; decision aids appear to have a positive effect on patient-practitioner communication; and decision aids have a variable effect on length of consultation.Consistent with findings from the previous review, which had included studies up to 2006: decision aids increase people's involvement, and improve knowledge and realistic perception of outcomes; however, the size of the effect varies across studies. Decision aids have a variable effect on choices. They reduce the choice of discretionary surgery and have no apparent adverse effects on health outcomes or satisfaction. The effects on adherence with the chosen option, patient-practitioner communication, cost-effectiveness, and use with developing and/or lower literacy populations need further evaluation. Little is known about the degree of detail that decision aids need in order to have positive effects on attributes of the decision or decision-making process.

Educational needs about cancer family history and genetic counseling for cancer risk among frontline healthcare clinicians in New York City

PURPOSE

This study investigated the educational needs of frontline healthcare clinicians about cancer family history and genetic counseling for cancer risk.

METHODS

We conducted a voluntary, anonymous survey among (1) general medicine clinicians, (2) obstetrics/gynecology clinicians, and (3) nurse practitioners at Mount Sinai School of Medicine in New York City.

RESULTS

A total of 143 clinicians completed the survey (response rate 81%). The majority of clinicians (77.5%) reported regularly completing family histories on cancer risk for their patients, but only 1.7% considered themselves "experts" in interpreting risk to make prevention, screening, and treatment recommendations. Numerous barriers to cancer family history collection were noted. More than half (55.8%) reported referring patients to genetic counseling, although only 14.3% reported confidence in their ability to make appropriate referrals. The majority reported that they would apply genetic counseling for cancer risk in their practice if they had the skills (84.9%). There was some variability found regarding specialty.

CONCLUSION

Despite widespread use of family histories for cancer risk, barriers remain to appropriate cancer risk management among frontline healthcare clinicians. Development of educational training programs to assist clinicians with collection of cancer family history information, interpretation, and appropriate referral along with teaching direct application of a modified form of genetic counseling for low-medium risk patients and referral of patients at genetic risk is warranted.

Effect of pre-test genetic counseling for deaf adults on knowledge of genetic testing

Empirical data on genetic counseling outcomes in the deaf population are needed to better serve this population. This study was an examination of genetics knowledge before and after culturally and linguistically appropriate pre-test genetic counseling in a diverse deaf adult sample. Individuals ≥18 years old with early-onset sensorineural deafness were offered connexin-26/30 testing and genetic counseling. Participants completed questionnaires containing 10 genetics knowledge items at baseline and following pre-test genetic counseling. The effects of genetic counseling, prior beliefs about etiology, and participant’s preferred language on genetics knowledge scores were assessed (n = 244). Pre-test genetic counseling (p = .0007), language (p < .0001), prior beliefs (p < .0001), and the interaction between counseling and beliefs (p = .035) were predictors of genetics knowledge. American Sign Language (ASL)-users and participants with “non-genetic/unknown” prior beliefs had lower knowledge scores than English-users and participants with “genetic” prior beliefs, respectively. Genetics knowledge improved after genetic counseling regardless of participants’ language; knowledge change was greater for the “non-genetic/unknown” beliefs group than the “genetic” beliefs group. ASL-users’ lower knowledge scores are consistent with evidence that ethnic and cultural minority groups have less genetics knowledge, perhaps from exposure and access disparities. Culturally and linguistically appropriate pre-test genetic counseling significantly improved deaf individuals’ genetics knowledge. Assessing deaf individuals’ prior beliefs is important for enhancing genetics knowledge.

Multimedia computerized smoking awareness education for low-literacy Hispanics

To meet the needs of low-literacy, underserved, Mexican-American patients, this transdisciplinary team created a freestanding computer kiosk. Smoking awareness and cessation were the topic chosen. Focus groups were used to inform the design and creation of each screen to include appropriate culturally based images and messages. A kiosk was placed in a primary care clinic in a West Texas city. User feedback was collected, showing that this method of patient education is acceptable.

An exploration of the communication preferences regarding genetic testing in individuals from families with identified breast/ovarian cancer mutations

The responsibility for informing at-risk relatives of the availability of genetic testing for breast/ovarian cancer gene (BRCA1 or BRCA2) mutations currently falls on the probands. This study explored the support needs of individuals from families with identified BRCA1 or BRCA2 mutations when communicating about genetic risk and genetic testing with at-risk family members. Thirty-nine semi-structured telephone interviews were conducted with individuals from families with identified BRCA mutations. Interview responses were cross-tabulated by sample characteristics using the qualitative research analysis software NVivo8. The development of educational materials, which individuals could use when communicating the risks of carrying a BRCA gene mutation with their relatives, was identified as a specific need. Many participants expressed a preference for a staged approach, where relatives are notified of their increased risk and the availability of genetic testing risk either face-to-face or via a letter, with additional educational sources, including brief written information or access to a website, made available for those wishing to access more in-depth information. This research identified a need for the development of educational/informational resources to support individuals with identified breast/ovarian cancer mutations to communicate with their at-risk relatives about genetic risk and genetic testing availability.

Mediated decision support in prostate cancer screening: a randomized controlled trial of decision counseling

OBJECTIVE

This randomized trial was conducted to assess the impact of a mediated decision support intervention on primary care patient prostate cancer screening knowledge, decisional conflict, informed decision making (IDM), and screening.

METHODS

Before a routine office visit, 313 male patients eligible for prostate cancer screening completed a baseline telephone survey and received a mailed brochure on prostate cancer screening. At the visit, participants were randomized to either an enhanced intervention (EI) or a standard intervention (SI) group. Before meeting with their physician, EI Group men had a nurse-led "decision counseling" session, while SI Group men completed a practice satisfaction survey. An endpoint survey was administered. Survey data, encounter audio-recordings, and chart audit data were used to assess study outcomes.

RESULTS

Knowledge increased in the EI Group (mean difference of +0.8 on a 10-point scale, p=0.001), but decisional conflict did not change (mean difference of -0.02 on a 4-point scale, p=0.620). The EI Group had higher IDM (rate ratio=1.30, p=0.029) and lower screening (odds ratio=0.67, p=0.102).

CONCLUSION

Nurse-mediated decision counseling increased participant prostate cancer screening knowledge, and influenced informed decision making and screening.

PRACTICE IMPLICATIONS

Nurses trained in decision counseling can facilitate shared decision making about screening.

Direct-to-consumer genetic testing: an assessment of genetic counselors' knowledge and beliefs

PURPOSE

Direct-to-consumer genetic testing is a new means of obtaining genetic testing outside of a traditional clinical setting. This study assesses genetic counselors' experience, knowledge, and beliefs regarding direct-to-consumer genetic testing for tests that would currently be offered in genetics clinics.

METHODS

Members of the National Society of Genetic Counselors completed a web-administered survey in February 2008.

RESULTS

Response rate was 36%; the final data analysis included 312 respondents. Eighty-three percent of respondents had two or fewer inquiries about direct-to-consumer genetic testing, and 14% had received requests for test interpretation or discussion. Respondents believed that genetic counselors have a professional obligation to be knowledgeable about direct-to-consumer genetic testing (55%) and interpret results (48%). Fifty-one percent of respondents thought genetic testing should be limited to a clinical setting; 56% agreed direct-to-consumer genetic testing is acceptable if genetic counseling is provided. More than 70% of respondents would definitely or possibly consider direct-to-consumer testing for patients who (1) have concerns about genetic discrimination, (2) want anonymous testing, or (3) have geographic constraints.

CONCLUSIONS

Results indicate that genetic counselors have limited patient experiences with direct-to-consumer genetic testing and are cautiously considering if and under what circumstances this approach should be used.

Multimedia computerized smoking awareness education for low-literacy Hispanics

To meet the needs of low-literacy, underserved, Mexican-American patients, this transdisciplinary team created a freestanding computer kiosk. Smoking awareness and cessation were the topic chosen. Focus groups were used to inform the design and creation of each screen to include appropriate culturally based images and messages. A kiosk was placed in a primary care clinic in a West Texas city. User feedback was collected, showing that this method of patient education is acceptable.

Genetic testing and counseling for hereditary neurological diseases in Mali

As genetic advances become incorporated into health care delivery, disparities between developing and developed countries may become greater. By addressing genetic health care needs and specific differences of developing countries, these disparities may be mitigated. We sought to describe the attitudes and knowledge of subjects with hereditary neurological diseases in Mali before and after receiving genetic testing and counseling for the first time. A questionnaire of attitudes and knowledge items was adapted and piloted for use in Mali. We found that the majority of subjects had positive attitudes toward genetic testing and counseling, both before and afterwards. Subjects responded to approximately half of the knowledge questions regarding hereditary transmission correctly before and after genetic testing and counseling. Neither overall attitudes nor knowledge scores changed significantly from baseline. Concerns about confidentiality were expressed by the majority of subjects. These findings indicate that, despite limited knowledge of patterns of inheritance, Malians understood the sensitive nature of this information and were favorable toward receiving genetic testing and counseling for diagnostic and prognostic purposes.

Effects of a decision support intervention on decisional conflict associated with microsatellite instability testing

BACKGROUND

Decision support to facilitate informed consent is increasingly important for complicated medical tests. Here, we test a theoretical model of factors influencing decisional conflict in a study examining the effects of a decision support aid that was designed to assist patients at high risk for hereditary nonpolyposis colorectal cancer (CRC) deciding whether to pursue the microsatellite instability (MSI) test.

METHODS

Participants were 239 CRC patients at high familial risk for a genetic mutation who completed surveys before and after exposure to the intervention. Half of the sample was assigned to the CD-ROM aid and half received a brief description of the test. Structural equation modeling was employed to examine associations among the intervention, knowledge, pros and cons to having MSI testing, self-efficacy, preparedness, and decisional conflict.

RESULTS

The goodness of fit for the model was acceptable [FIML, full information maximum likelihood, χ(2) (df = 280) = 392.24; P = 0.00]. As expected, the paths to decisional conflict were significant for postintervention pros of MSI testing (t = -2.43; P < 0.05), cons of MSI testing (t = 2.78; P < 0.05), and preparedness (t = -7.27; P < 0.01). The intervention impacted decisional conflict by increasing knowledge about the MSI test and knowledge exerted its effects on decisional conflict by increasing preparedness to make a decision about the test and by increases in perceived benefits of having the test.

CONCLUSION

Increasing knowledge, preparedness, and perceived benefits of undergoing the MSI test facilitate informed decision making for this test.

IMPACT

Understanding mechanisms underlying health decisions is critical for improving decisional support. Individuals with Lynch syndrome have an elevated lifetime risk of CRC. Risk of Lynch syndrome may be assessed with a tumor-based screening test (MSI testing or immunohistochemical tissue staining).

Evaluation of phone-based genetic counselling in African American women using culturally tailored visual aids

Genetic counselling (GC) services for inherited breast and ovarian cancer (HBOC) are underutilized by African American (AA) women. We sought to evaluate factors associated with knowledge gain in a sample of AA women diagnosed with early-onset breast cancer, in whom GC for HBOC was provided, using a culturally targeted genetic counselling aid (GCA). Through a cancer registry-based study, phone-based GC for HBOC was offered to AA women with breast cancer < or =50. A questionnaire to assess knowledge about HBOC was completed prior to GC. All women were provided a GCA about HBOC developed by the investigative team for use during the GC session. Following GC, a personalized summary letter was mailed to all study participants and the same knowledge questionnaire was completed. A total of 37 study participants completed the pre- and post-GC knowledge questionnaires with significant gains in knowledge following the GC process (p < 0.0001). Statistically significant factors associated with knowledge gain included earlier stage of diagnosis of breast cancer and education level. Our results indicate that phone-based GC supplemented by a culturally targeted visual aid is an effective means of improving knowledge about HBOC in young AA women with invasive breast cancer.

Longitudinal changes in patient distress following interactive decision aid use among BRCA1/2 carriers: a randomized trial

BACKGROUND

Increasingly, women with a strong family history of breast cancer are seeking genetic testing as a starting point to making significant decisions regarding management of their cancer risks. Individuals who are found to be carriers of a BRCA1 or BRCA2 mutation have a substantially elevated risk for breast cancer and are frequently faced with the decision of whether to undergo risk-reducing mastectomy.

OBJECTIVE

In order to provide BRCA1/2 carriers with ongoing decision support for breast cancer risk management, a computer-based interactive decision aid was developed and tested against usual care in a randomized controlled trial.

DESIGN

. Following genetic counseling, 214 female (aged 21-75 years) BRCA1/2 mutation carriers were randomized to usual care (UC; n = 114) or usual care plus decision aid (DA; n = 100) arms. UC participants received no further intervention; DA participants were sent the CD-ROM-based decision aid to view at home.

MAIN OUTCOME MEASURES

The authors measured general distress, cancer-specific distress, and genetic testing-specific distress at 1-, 6-, and 12-month follow-up time points postrandomization.

RESULTS

Longitudinal analyses revealed a significant longitudinal impact of the DA on cancer-specific distress (B = 5.67, z = 2.81, P = 0.005), which varied over time (DA group by time; B = -2.19, z = -2.47, P = 0.01), and on genetic testing-specific distress (B = 5.55, z = 2.46, P = 0.01), which also varied over time (DA group by time; B = -2.46, z = -2.51, P = 0.01). Individuals randomized to UC reported significantly decreased distress in the month following randomization, whereas individuals randomized to the DA maintained their postdisclosure distress over the short term. By 12 months, the overall decrease in distress between the 2 groups was similar.

CONCLUSION

This report provides new insight into the long-term longitudinal effects of DAs.

Communication of BRCA results and family testing in 1,103 high-risk women

BACKGROUND

Genetic testing for hereditary cancer risk has implications for individuals and families. This study of women at risk of hereditary breast and ovarian cancer examines communication of BRCA results and subsequent genetic testing in the family.

METHODS

We surveyed 1,103 female BRCA testers at two hospitals, querying for communication of results and testing in relatives.

RESULTS

Ninety-seven percent of participants communicated BRCA results with at least one relative. Communication was negatively associated with older age [odds ratio (OR), 0.66 per decade; 95% confidence interval, (95% CI), 0.4-0.9], Asian race (OR, 0.18; 95% CI, 0.06-0.5), and testing at the public hospital versus the cancer center (OR, 0.19; 95% CI, 0.07-0.5). Communication was positively associated with increased knowledge of hereditary breast and ovarian cancer screening and risk reduction recommendations (OR, 1.9; 95% CI, 1.1-3.4) and increased satisfaction with the decision to BRCA test (OR, 2.6; 95% CI, 1.6-4.0). Seventy-five percent of BRCA-positive participants reported that at least one relative pursued genetic testing. Family testing was negatively associated with Asian race (OR, 0.15; 95% CI, 0.02-0.8) and positively associated with increased socioeconomic status (OR, 1.4; 95% CI, 1.1-1.7) and increased satisfaction with decision (OR, 2.1; 95% CI, 1.1-4.1).

CONCLUSION

Despite high overall rates of communicating BRCA results, underserved and some minority women seem less likely to inform relatives of their BRCA status or have relatives test for a known family mutation. Satisfaction with the decision to BRCA test is positively associated with both outcomes.

IMPACT

This study identified several novel predictors of family communication and family genetic testing in a large population of high-risk women. This work can inform clinicians interested in improving family communication regarding cancer predisposition testing.

Patient responses to genetic information: studies of patients with hereditary cancer syndromes identify issues for use of genetic testing in nephrology practice

Advances in the genetic basis of kidney disease may mean that genetic testing is increasingly important in reducing disease morbidity and mortality among patients. However, there is little research examining patient responses to genetic information for Mendelian and common kidney diseases. Existing research on kidney and other hereditary cancer syndromes can inform three major issues relevant to the nephrology context as follows: (1) how patients understand their risk of disease after genetic counseling and testing, (2) their emotional responses to the information, and (3) their uptake of recommended risk-reducing strategies. Prior research suggests that genetic counseling and testing may improve patient understanding of genetics, but patients still might not fully understand the meaning of their results for disease risk. Genetic counseling and testing does not appear to result in long-term negative emotional effects among patients who carry mutations or those who do not. Finally, although genetic counseling and testing may improve adherence to recommended screening strategies, adherence varies substantially across different risk-reduction options. Previous research also suggests that computer-based interventions might be a useful adjunct to genetic counseling approaches. Examining whether and how these prior findings relate to the context of hereditary kidney disease is an important area for future research.

Enhanced counselling for women undergoing BRCA1/2 testing: Impact on knowledge and psychological distress-results from a randomised clinical trial

This randomised controlled trial evaluated the impact of an enhanced counselling (EC) intervention on knowledge about the heritability of breast and ovarian cancer and distress, as a function of BRCA test result, among high-risk women. Before deciding about whether or not to undergo genetic testing, participants were randomly assigned to the EC intervention (N = 69), designed to promote cognitive and affective processing of cancer risk information (following the standard individualised counselling session), or to the control condition (N = 65), which involved standard individualised counselling followed by a general health information session to control for time and attention. Women in the EC group exhibited greater knowledge than women in the control group, 1 week after the intervention. Further, at the affective level, the intervention was found to be the most beneficial for women testing positive: specifically 1 week after test result disclosure, women in the intervention group who tested positive experienced lower levels of distress than women in the control group who tested positive. The findings suggest that the design of counselling aids should include a component that explicitly activates the individual's cognitive-affective processing system.