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

Pilot Trial of a Computerized Decision Aid for Breast Cancer Prevention

This study sought to evaluate a shared decision-making aid for breast cancer prevention care designed to help women make appropriate prevention decisions by presenting information about risk in context. The decision aid was implemented in a high-risk breast cancer prevention program and pilot-tested in a randomized clinical trial comparing standard consultations to use of the decision aid. Physicians completed training with the decision aid prior to enrollment. Thirty participants enrolled (15 per group) and completed measures of clinical feasibility and effectiveness prior to, immediately after, and at 9 months after their consultations. The decision aid was feasible to use during the consultations as measured by consultation duration, user satisfaction, patient knowledge, and decisional conflict. The mean consultation duration was not significantly different between groups (24 minutes for intervention group versus 21 minutes for control group, p = 0.42). The majority found the decision aid acceptable and useful and would recommend it to others. Both groups showed an improvement in breast cancer prevention knowledge postvisit, which was significant in the intervention group (p = 0.01) but not the control group (p = 0.13). However, the knowledge scores returned to baseline at follow-up in both groups. Decision preference for patients who chose chemoprevention post consultations remained constant at follow-up for the intervention group, but not for the control group. The decision framework provides access to key information during consultations and facilitates the integration of emerging biomarkers in this setting. Initial results suggest that the decision aid is feasible for use in the consultation room. The tendency for the decision choices and knowledge scores to return to baseline at follow-up suggests the need for initial and ongoing prevention decision support.

Development and Pilot Testing of Two Decision Aids for Individuals Considering Genetic Testing for Cancer Risk

Current practice in genetic counseling may not allow a full deliberation of the consequences of decisions about genetic testing for cancer risk, despite increasing demand for these services. Thus, two decision aids for individuals considering genetic testing for hereditary breast/ovarian cancer and hereditary non-polyposis colorectal cancer (HNPCC) susceptibility were developed and pilot tested with 43 individuals who had previously considered genetic testing for these cancer syndromes. A description of the decision aid development process is provided, as well as results of the pilot testing, which assessed participants' perceptions of the decision aids. All participants reported that they would recommend the decision aid to others facing the same situation, and 93% reported that the decision aid would have been relevant during their decision-making. The perceived impact of the decision aids on participants' emotions and understanding of genetic testing were assessed. Limitations of the study and future directions are discussed.

Perceived genetic knowledge, attitudes towards genetic testing, and the relationship between these among patients with a chronic disease

OBJECTIVE

Genetics increasingly permeate everyday medicine. When patients want to make informed decisions about genetic testing, they require genetic knowledge. This study examined the genetic knowledge and attitudes of patients with chronic diseases, and the relationship between both. In addition, patients were asked about their preferred source of genetic information.

METHODS

Questionnaires were mailed to participants of a nationwide representative sample of patients with chronic diseases in the Netherlands (n = 1916).

RESULTS

The response rate was 82% (n = 1496). Perceived genetic knowledge was low, particularly among older and lower educated patients. Attitudes towards genetics were rather positive, especially among younger and higher educated patients. Some concerns were also documented, mainly about the consequences of genetic testing for employment and taking insurance. Patients who perceived to have little knowledge found it difficult to formulate an opinion about genetic testing. Higher levels of genetic knowledge were associated with a more favourable attitude towards genetics. Chronic patients prefer to receive genetic information from their GP.

CONCLUSION

Chronic patients are ill prepared when they require genetic knowledge to make decisions regarding the treatment of their disease. This seems to result from a knowledge deficiency rather than from disagreement with the genetic developments.

PRACTICE IMPLICATIONS

When chronic patients are in need of information about genetics or genetic testing, their general practitioner should provide this.

Lost in transition: challenges in the expanding field of adult genetics

It is increasingly clear that medical genetics has broad relevance in adult clinical medicine. More adult patients with genetic conditions are being recognized, genetic testing for adult-onset genetic conditions is expanding, and children with genetic conditions are now more likely to survive to adulthood. While the number of patients who could benefit from medical genetic services increases, adult care providers are less well educated about clinical genetics and are not sufficiently prepared to meet the growing needs of this population. Genetics professionals may also be ill-suited for this challenge, since geneticists and genetic counselors have traditionally had greater experience in pediatric and prenatal settings. Communication between primary care physicians who treat adults and the genetics community is currently suboptimal and the identification and subsequent referral of adult patients for genetic services need improvement. Finally, published guidelines that address how to deliver genetic services to adult patients are unavailable for many genetic conditions. In this article we address the challenges of transitioning genetics services from traditional, and largely pediatric-based models to paradigms that can best address the needs of adult patients with genetic conditions. Potential solutions and the practicality of implementation of a team-based approach to adult genetic medicine, including the application of genetic counseling, are also discussed.

Perceptions and behaviour of access of the Internet: a study of women attending a breast screening service in Sydney, Australia

OBJECTIVES

To describe the perceptions and behaviour in accessing health information from the Internet by women attending a BreastScreen, New South Wales (NSW) Service in Northern Sydney.

DESIGN

Cross-sectional study.

SETTING

A BreastScreen NSW Service in Northern Sydney.

MAIN OUTCOME MEASURES

Behaviour and perceptions of accessing of the Internet for breast health and screening information and other related health information.

PARTICIPANTS

Four hundred and fifteen women aged > or =40 years who had a screening mammogram at a BreastScreen NSW Service in Northern Sydney. Data were collected from 1 October to 22 December 2004 (study interval).

RESULTS

Four hundred and sixty-one eligible women were invited to participate in the study and of these 415 women agreed to participate in the study (participation rate=90%). Of the 415 women enrolled in the cohort, 80% (333/415) of women accessed the Internet in general and 62% (205/333) of the women who accessed the Internet also accessed health related information from the Internet, but only 7% of the total women accessed breast health and screening information from the Internet. Two hundred and eighty (70%) women in the cohort expressed their intention to access the Internet if they were diagnosed with breast cancer. Age (OR=0.94; 95% CI=0.91-0.97), marital status (OR=2.65; 95% CI=1.45-4.83), educational status (OR=3.26; 95% CI=1.77-6.02) and behavioural intention of accessing the Internet if diagnosed with breast cancer (OR=3.31; 95% CI=1.83-5.98) were found to be associated with access of Internet for general information. Furthermore, behavioural intention (OR=2.43; 95% CI=1.30-4.55), rating of computer skills as 'average' (OR=0.42; 95% CI=0.22-0.79) and 'not good to poor' (OR=0.23; 95% CI=0.11-0.49) were found to be associated with access of health related information from the Internet.

CONCLUSIONS

Information searching from the Internet is common among women having a screening mammogram. There is potential to provide guidance to women regarding accessing the BreastScreen NSW website and other reliable sources of Internet information on breast health, breast screening and cancer-related information.

The relationship of nondirectiveness to genetic counseling: report of a workshop at the 2003 NSGC Annual Education Conference

Nondirectiveness has been a guiding principle for genetic counseling since the founding of the profession. However, its efficacy and appropriateness in this role have been frequently questioned. A workshop at the 2003 Annual Education Conference of the National Society of Genetic Counselors provided audience participation in a discussion of these issues. Participants presented arguments for and against nondirectiveness as a central ethos. They described complex personal transitions in adapting what they had learned about nondirectiveness during training to the realities of the workplace. There was support for flexible approaches to genetic counseling, with varying adherence to nondirectiveness, based on client and family needs and values, clinical circumstances, and desired counseling outcomes. The discussion supports the use of clinical experience, outcomes research, and the experience of other professions to move beyond nondirectiveness and more accurately identify the theoretical bases that underlie genetic counseling in the variety of circumstances in which it is currently practiced.

A Survey of Patients’ Experiences with the Cancer Genetic Counseling Process: Recommendations for Cancer Genetics Programs

In order to promote ongoing quality improvement of not only the Penn State Cancer Genetics Program, but also other cancer risk assessment programs throughout the country, we developed, piloted and conducted a survey to explore patient expectations, experiences, and satisfaction with the cancer genetic counseling process. The comprehensive survey was mailed to 340 eligible patients, 156 (45.9%) of whom returned the completed survey within the allotted time. Responses to closed-ended questions were tallied and open-ended questions were content analyzed. Major findings show that: (1) Patients were seeking cancer-related information and support throughout the cancer risk assessment process and were interested in participating in available research studies; (2) The setting in which patients are seen for cancer risk assessment may pose potential emotional ramifications; (3) Misperceptions regarding insurance discrimination and lack of insurance coverage persist; (4) Patients view the genetic counselor as responsible for updating them about new discoveries. Specific recommendations for cancer genetics programs are included.

Effects of a telephone counseling intervention on sisters of young women with breast cancer

OBJECTIVE

Women that have a first-degree relative diagnosed with breast cancer at an early age are at increased risk of the disease, yet they often lack information about their personal risk of breast cancer and early detection measures. An intervention to provide objective risk information, reduce worries, and promote screening and healthy behaviors was developed.

METHOD

In 1999-2002, a randomized pre-post design was used to test a tailored telephone counseling intervention with a sample of 163 women whose sisters were diagnosed with breast cancer at age 50 or younger in the San Francisco Bay Area. Participants were interviewed by telephone regarding their breast cancer risk factors, perceived risk, worries, lifestyle factors, and screening behavior. A modified Gail model was used to compute an objective measure of individualized lifetime risk.

RESULTS

Risk overestimates averaged 25 percentage points. The intervention was effective in reducing overestimates in women age 50 and over but not in those under 50. The intervention was effective in increasing physical activity and reinforcing the conviction to maintain good breast health, but not in decreasing worries or increasing screening.

CONCLUSION

Telephone counseling appears to be a viable tool for reducing risk overestimates and promoting healthy behaviors among sisters of women with breast cancer.

Predictors of uptake of obesity genetic testing among affected adults

Given that a large number of candidate genes coding for a tendency toward obesity have been identified and some findings have been replicated, we explored characteristics of those who would be most likely to obtain future genetic testing for this tendency. During a series of focus groups, obese respondents rated their likelihood of obtaining testing under conditions in which either genetically-targeted drug treatment would be available, a positive test would be associated with a prognosis for developing diabetes, or neither of these. Interest in testing was greater given the first two scenarios than the third. Older age and belief that genetics were an important cause of obesity were associated with greater interest. For the first two scenarios, higher educational status was associated with greater interest, while for the third, respondents who said emotional issues caused overweight and those who crash-dieted intermittently were more likely to want genetic testing. Although further research is required to validate these findings, this study is the first published report of respondents' ratings of likelihood to obtain genetic testing for propensity to obesity, and suggests strong interest in genetic testing among some people, even in the absence of further treatment implications of the test.

Decision aids for familial breast cancer: exploring women's views using focus groups

BACKGROUND

There is increasing need for accessible information about familial breast cancer for those facing complex decisions around genetic testing, screening and treatment. Information currently includes leaflets and computerized decision aids, offering interactive interfaces to clarify complex choices.

OBJECTIVE

Exploration of users' views and reactions to three decision aids for genetic testing for breast cancer using focus groups.

SETTING

A regional cancer genetics service in the UK.

PARTICIPANTS

Women over 18 years of age who had been referred to Cancer Genetics Service for Wales (CGSW) and had received a risk assessment for familial breast cancer.

METHODS

Qualitative study involving one pilot and six extended focus groups with 39 women at high, moderate and population risk. Two CD-ROMs and one paper-based aid evaluated for: clarity of presentation, ease of handling, emotive response, increased knowledge and greater informed choice.

RESULTS

Women reported variable preferences for different types of decision aids and mixed emotions, indicating the sensitivity of raising issues in decision support tools, lack of consensus over the most appropriate aid and no systematic differences between risk groups. Women remarked that aids increased their knowledge, particularly about breast cancer genes and risk and wanted a decision aid designed within the context of the NHS, in both paper-based and CD-ROM formats from an authoritative source. Mixed views about presentation styles suggest decision aids would be most effective with a user-selected range of formats.

CONCLUSIONS

Decision aid development should be informed by users and should meet the needs of those concerned about their risk of breast cancer in the UK. Without such aids, patients will continue to search for information from a variety of sources of varying quality.

Development of a Population-based Questionnaire to Explore Psychosocial Determinants of Screening for Memory Loss and Alzheimer Disease

Alzheimer disease research has focused on detecting the earliest signs of cognitive decline and efforts are ongoing to develop biomarkers and cognitive measures that reliably distinguish between nondemented and demented individuals. However, little is known about factors that may directly or indirectly influence screening behavior of older community-dwelling adults. We describe an iterative process for the development and formative evaluation of a questionnaire about dementia knowledge and screening behaviors in older adults to understand the psychosocial factors underlying intention to obtain dementia screening to profile individuals manifesting intention to undergo dementia screening compared to those who will not. The Behavioral Model of Health Services Use was used as a conceptual framework for a questionnaire with constructs from the Health Belief Model, Theory of Reasoned Action and Self-Efficacy. After pretesting, we used a random dialing strategy to test our questionnaire on a final sample of 1024 older Missourians. Internal consistency and construct validity were examined. Pretesting identified several potential problems that were improved with rewording. Cronbach alpha was greater than 0.6 (range 0.62 to 0.92) in all but one construct testing dementia knowledge, suggesting good to excellent internal consistency. Convergent (construct) validity was assessed using confirmatory factor analysis. All constructs but 3 demonstrated good validity. Addressing these issues will allow researchers to identify unique characteristics based on age, race, sex, socioeconomic differences and geographic location, and characterize barriers to screening programs to more effectively develop targeted community-based interventions.

Internet design preferences of patients with cancer

PURPOSE/OBJECTIVES

To describe computer experience and preferences for multimedia design.

DESIGN

Prospective, descriptive.

SETTING

Physician office and outpatient cancer centers in an urban area in the southeastern United States.

SAMPLE

Convenience sample of 22 volunteer patients with cancer from four racial groups.

METHODS

A questionnaire on computer experiences was followed by a hands-on computer session with questions regarding preferences for seven interface items. Data termination occurred when sample size was obtained.

MAIN RESEARCH VARIABLES

Design of Internet education site for patients. Variables include preferences, computer, cancer, multimedia, and education.

FINDINGS

Eighty-two percent had personal computers, 41% used a computer daily, and 95% believed that computers would be a good avenue for learning about cancer care. Preferences included display colors in blue and green hues; colored buttons; easy-to-read text; graphics with a simple design and large, clear pictures; serif font in dark type; light-colored background; and larger photo size in a rectangle shape. Most popular graphic icons as metaphors were 911 for emergency, picture of skull and crossbones for danger, and a picture of a string on an index finger representing reminder. The simple layout most preferred for appearances was one that included text and pictures, read from left to right, and was symmetrical in its placement of pictures and text on the page.

CONCLUSIONS

Preferences are necessary to maintain interest and support navigation through computer designs to enhance the translation of knowledge to patients.

IMPLICATIONS FOR NURSING

Development of multimedia based on patient preferences will enhance education, learning, and, ultimately, quality patient care.

An evaluation of the Decisional Conflict Scale for measuring the quality of end-of-life decision making

OBJECTIVE

Researchers and clinicians acknowledge the complexity of planning for future medical treatment desired in the event of incapacitation. Unfortunately, many attempts to evaluate the quality of such difficult planning have been stymied by the lack of measures that can be shown to have validity. This study examines the psychometric characteristics of the Decisional Conflict Scale (DCS) when used as a measure of patients' evaluation of their end-of-life decision-making process.

METHODS

This evaluation used the combined data from two independent samples in which 59 outpatients with a life-threatening illness and their surrogate decision makers were assigned to receive, a decision aid intervention, the patient-centered advance care planning (PcACP), or usual care only.

RESULTS

Internal consistency for the DCS in the end-of-life decision-making context was high. The DCS demonstrated convergent, construct, and discriminant validity based on the total scale scores.

CONCLUSION

The DCS appears to be a viable research instrument for measuring the quality of end-of-life decision making. However, the uncertainty subscale showed a weak discriminating ability and lack of association with the two other subscales, the modifiable factors contributing to uncertainty and the effectiveness of the decision making.

PRACTICE IMPLICATIONS

The findings of the study can be useful for measuring decisional conflict in individuals with serious illness facing end-of-life decision making.

Evaluation of a decision aid for families considering p53 genetic counseling and testing

PURPOSE

Li-Fraumeni syndrome (LFS) is associated with p53 germline mutations, and carriers are at increased risk for multiple primary cancers. We evaluated outcomes following the administration of a video-based decision aid (DA) prior to clinical p53 genetic counseling and testing among persons who had previously participated in cancer genetics research.

METHODS

Fifty-seven individuals at risk for a known p53 mutation completed baseline and post-DA measures of psychological outcomes, plus knowledge and attitudes regarding p53 genetic testing. Counseling and testing uptake also was recorded.

RESULTS

At baseline, multivariate analysis showed that greater testing intention was associated with lower decisional conflict (P < 0.01). Compared with baseline data, multivariate analyses of post-DA outcomes showed that knowledge about LFS and genetic testing increased and decisional conflict related to testing decreased (P < 0.001). Mean cancer worries scores decreased among all participants (P < 0.001), and mean depression scores decreased for males (P < 0.05). Thirty-nine (68%) completed pre-test genetic counseling and 23 (40%) subsequently gave a blood sample for clinical genetic testing.

CONCLUSION

This intervention was useful as an initial outreach and educational method for families considering p53 genetic testing, and may improve knowledge about LFS as well as psychological outcomes.

Impact of an information booklet on satisfaction and decision-making about BRCA genetic testing

The aim of this study was to assess the impact of a standardized patient information booklet on decisions women make about genetic testing. This French national multi-centre survey included all women with cancer to whom genetic testing for BRCA1/2 mutation had been proposed. The control group was surveyed before the booklet became available (n = 263), and the experimental group, after being given it personally (n = 297). After multivariate adjustment, the booklet had a positive impact on satisfaction with the information provided (Odds ratio (OR) = 2.9; 99% confidence interval (CI) = 1.7-5.0; P = 0.001), decreased the decisional conflicts due to lack of information (OR = 1.9; 99% CI = 1.1-3.3; P = 0.002), and had a marginal impact on knowledge (R2-gain = 3%; P = 0.001). The women in the experimental group decided more frequently to undergo testing (99% vs. 95%; P = 0.009). In addition to a consultation providing more tailored information, a standardized written document improved the decision-making process involved in giving informed consent to genetic testing.

Communication in genetic counselling for breast/ovarian cancer

Cancer genetic counselling represents a very special situation of interaction between the geneticist and the counselee, marked by a number of specificities that account for its complexity. Cancer genetic counselling has multiple repercussions, such as identification of a deleterious genetic mutation associated with a high probability of developing breast and/or ovarian cancer, the implementation of preventive measures ranging from close surveillance to the decision to perform mutilating prophylactic surgical procedures, or the impact of the information on the other members of the counselee's family also concerned by the genetic risk. This chapter is based on a review of the literature that has been rapidly growing over recent years and on our clinical expertise as psycho-oncologists and geneticists. We will first present the reasons that make the information so critical. These reasons are both objective (complexity of the genetic information per se, difficulties of understanding the concept of risk) and subjective (information given to people with an emotionally charged family history and a perception of risks closely linked to their representation of cancer). At the same time, the counsellees are charged with the transmission of this information to members of their own family. We will then discuss the various modalities of communication in this setting. While unidirectional transfer of information from the geneticist to the counselee has been the preferred method in cancer genetics for a long time, a model based on patient-centered communication is more adequate in predictive medicine and allows shared decision making. In all cases, the different professionals involved in the process have to learn how to work in a performing cohesion. We also present the main guidelines on the subject and the various underlying objectives with regard to information delivery and the subject's personal experience. Although the psychological impact of genetic counselling consultations raises a number of questions, the results of preliminary studies are reassuring, demonstrating psychological benefits. However, a number of aspects concerning communication in predictive medicine remain to be investigated and improved.

Rethinking informed consent: the case for shared medical decision-making

In law, with rare exception such as legislative action, change is evolutionary and methodical. Unlike biomedical science where a breakthrough can quickly lead to dramatic changes in medical practice, legal precedent is more adherent and must evolve either through the legislative process or on a court by court basis in case law. Nevertheless, compelling evidence will pave the road to change within the law. Health care research conducted over the last three decades has produced a body of empirical evidence that suggests an overhaul of our current legal standards of informed consent is overdue.

This article uses health services research to examine the fundamental assumptions of our current informed consent laws and propose legal reform. Much has been written on how to bring the law to bear on medical practice in order to improve patient rights and protect physicians, but far less has been done to bring the practice of medicine to inform our legal standards. Prior legal scholarship on informed consent has made arguments regarding reform from both ethical and legal perspectives; however, only a small few have incorporated clinical and health services research as well as ethical and legal principles to analyze informed consent.

The role of health education and behavior in public health genetics

This article highlights the important role of health behavior and health education (HBHE) research in public health genetics. Broadly defined, public health genetics is the integration of genetic advancements and technologies in the study and practice of public health. The potential role of HBHE within this area is presented across two intersecting continua--namely, the continuum between research and practice and the continuum between individual/personalized medicine and population health. The authors begin this article with an overview of current issues arising from the use of genetic information to improve the public's health and provide a framework for understanding the multidimensional role of HBHE research in translating genetic research into medical and public health practice. An introduction to the nine articles and two practice notes included in this special issue is also provided to draw attention to the crosscutting themes and issues presented.

Individualized Survival Curves Improve Satisfaction With Cancer Risk Management Decisions in Women With BRCA1/2 Mutations

Purpose

Women with BRCA1/2 mutations are faced with complex decisions about breast and ovarian cancer risk management. This study was conducted to determine the effect of a tailored decision support system (DSS) that provides individualized survival and cancer incidence curves specific to expected outcomes of alternative management strategies.

Patients and Methods

This was a double-blind, randomized controlled trial of 32 women with BRCA1/2 mutations. Primary outcome measures were decision satisfaction, cancer anxiety, perceptions of cancer risk given alternative management strategies, and management decisions.

Results

Twenty-seven women completed a 6-week follow-up. Women in the intervention arm (n = 13) reported significantly higher decision satisfaction at follow-up than women in the control arm (n = 14; adjusted mean difference, 9.7; P < .0005). The effect of the DSS was greater among women with low cancer anxiety at baseline than women with high cancer anxiety at baseline (P = .01 for interaction). However, the DSS did not significantly alter cancer anxiety at follow-up, perceptions of cancer risk given alternative management strategies, or management decisions.

Conclusion

The presentation of individualized survival and incidence curves for alternative management options improves satisfaction about cancer risk management decisions among women with BRCA1/2 mutations without increasing anxiety or changing management decisions. The benefit of the DSS is greatest among women with relatively low cancer-related anxiety at baseline.

How to establish a high-risk cancer genetics clinic: Limitations and successes

The development of technology to locate and isolate cancer susceptibility genes has brought together the fields of oncology, cancer control, genetics, and genetic counseling to create a new specialty of cancer risk counseling with the goal to communicate more accurate information about personal cancer risk profiles based on personal and family histories. As cancer risk assessment and counseling services become standard of care in medical practice, their availability is increasingly moving from comprehensive cancer centers and academic institutions to community settings. High-risk cancer genetics clinics in the community face several challenges, including staffing, time commitment, costs, and unique quality control issues. The societal benefits include a more educated public armed with the information needed to make health decisions appropriate for the individual level of risk.

Decision making and decision support for hereditary breast-ovarian cancer susceptibility

Genetic testing for disease susceptibility has the potential to revolutionize health care by allowing for individually tailored disease prevention strategies. To achieve this promise, patients and physicians must use the information obtained through genetic testing to make medical decisions that are consistent with patient preferences and that lead to reduced disease morbidity and mortality. However, decisions associated with genetic testing can be complex. In this article, the authors review decision making associated with genetic testing and the medical management of hereditary breast-ovarian cancer susceptibility. They focus on decisions regarding BRCA1/2 testing and prophylactic surgery among BRCA1 and BRCA2 mutation carriers. They highlight the role of patient preferences and decision support in this population. The studies reviewed indicate that although patients' preferences do predict genetic testing and management decisions, other factors also influence their decision making. In particular, the authors discuss the role of anxiety and worry in relation to testing and surgery decisions.

Use of an educational computer program before genetic counseling for breast cancer susceptibility: effects on duration and content of counseling sessions

PURPOSE

Patients seeking genetic testing for inherited breast cancer risk are typically educated by genetic counselors; however, the growing demand for cancer genetic testing will likely exceed the availability of counselors trained in this area. We compared the effectiveness of counseling alone versus counseling preceded by use of a computer-based decision aid among women referred to genetic counseling for a family or personal history of breast cancer.

METHODS

We developed and evaluated an interactive computer program that educates women about breast cancer, heredity, and genetic testing. Between May 2000 and September 2002, women at six study sites were randomized into either: Counselor Group (n = 105), who received standard genetic counseling, or Computer Group (n = 106), who used the interactive computer program before counseling. Clients and counselors both evaluated the effectiveness of counseling sessions, and counselors completed additional measures for the Computer Group. Counselors also recorded the duration of each session.

RESULTS

Baseline characteristics did not differ significantly between groups. Participants and counselors both rated the counseling sessions as highly effective, whether or not the sessions were preceded by computer use. Computer use resulted in significantly shorter counseling sessions among women at low risk for carrying BRCA1/2 mutations. In approximately half of the sessions preceded by clients' computer use, counselors indicated that clients' use of the computer program affected the way they used the time, shifting the focus away from basic education toward personal risk and decision-making.

CONCLUSION

This study shows that the interactive computer program "Breast Cancer Risk and Genetic Testing" is a valuable adjunct to genetic counseling. Its use before counseling can shorten counseling sessions and allow counselors to focus more on the clients' individual risks and specific psychological concerns. As the demand for counseling services increases, a program such as this can play a valuable role in enhancing counseling efficiency.

Genetic counseling forBRCA1/2: A randomized controlled trial of two strategies to facilitate the education and counseling process

Due to the complexity of information surrounding BRCA1/2 counseling and testing and its time consuming nature, efforts to facilitate the genetic counseling and education process are needed. Using a 2 x 2 factorial design, two strategies were examined: a CD-ROM program for patients and a feedback checklist to the genetic counselor on patients' prior misconceptions. A total of 197 women attending a breast and ovarian cancer risk evaluation clinic for BRCA1/2 counseling were randomized into one of four conditions: standard care, CD-ROM only, feedback to counselor only, and both CD-ROM and feedback. Counseling outcomes included face-to-face time with the genetics team, knowledge acquisition, changes in worry about having a gene mutation, and genetic testing decisions. Overall, women who viewed the CD-ROM spent less time with the genetic counselor and were less likely to undergo genetic testing compared to women who did not view the CD-ROM. Feedback to the genetic counselor resulted in greater gains in knowledge of genetics and breast cancer. Among women less worried at baseline, those who viewed the CD-ROM showed no changes in worry following genetic counseling, in contrast to those who did not view the CD-ROM who increased in worry over time. This latter finding raises concerns about the impact of the increased worry on genetic testing decisions. No interaction effects of the two intervention arms were found. The study results support the importance of both strategies as valuable supplements to clinical BRCA1/2 counseling.

Promoting an ethical approach to unproven screening imaging tests

The use of screening imaging technology such as electron beam computed tomography and computed tomographic scans for the early detection of coronary artery disease, lung cancer, and other diseases is rising, even though they have not been proven to reduce disease-specific mortality. Until randomized, controlled trials assess the efficacy of these tests as screening tests, they will remain controversial. It is unclear whether the potential benefits of these screening tests outweigh the risks. In a practice environment in which public demand and enthusiasm for screening is high, radiologists can recognize the ethical issues associated with unproven screening imaging tests; understand current national policies toward professionalism and informed and shared decision making for screening; draw on the lessons learned from the proliferation of another unproven screening test, the prostate-specific antigen blood test for prostate cancer; and work with others in the health care system to promote an ethical approach to screening imaging tests.

Preferences for different methods of communicating information regarding adjuvant chemotherapy for breast cancer

Many patients play an active role in determining their cancer treatments, and the communication of medical information influences patient decision-making. This study examined participants' preferences between various methods of communicating quantitative risks and benefits of adjuvant chemotherapy. Using clinical vignettes, participants were first asked to decide whether or not to endorse chemotherapy and were subsequently asked about their preferences for the methods used to communicate the risks and benefits. Participants preferred the absolute survival benefit method over negatively framed methods, such as relative or absolute risk reduction. We also present analysis of qualitative data which supports the conclusions drawn from quantitative analyses. In summary, the absolute survival benefit was shown to be the superior method of communicating quantitative risks and benefits of chemotherapy. Failure to use clear and concise methods of communicating quantitative risk and benefit information may compromise efforts to obtain informed consent for treatment.

Development of an audit tool for genetic services

Rapid growth in demand and altered professional roles have produced changes in the delivery of genetic services over the past decade, but these have not been rigorously evaluated because of the paucity of appropriate audit tools. The aim of this study was to use clients' accounts and factor analysis to develop a robust assessment and audit tool. Qualitative data abstracted from several published studies were used to generate a number of statements related to outcomes of genetic services. A total of 57 statements were incorporated into a questionnaire. The questionnaire was mailed to clients of the Wales genetic service (n = 133) who had completed their episode of care. Respondents were asked to rank each statement on a seven-point Likert type scale. Responses were subjected to factor analysis. A total of 97 anonymized responses were received (73% response rate). Six main factors were found to contribute to the outcome of the service from the client's perspective. These were labeled (i) enhanced understanding, (ii) positive psychological change, (iii) respect for autonomy, (iv) adaptation, (v) disequilibirium, and (vi) value of contact. The audit tool has now been refined for use in evaluating genetic services. Questions are included to investigate the six outcome areas shown to be relevant from the client's perspective. Data from the next phase of the study will be analyzed to validate the tool for use in both clinical audit and research contexts.

Development of a risk assessment tool for women with a family history of breast cancer

BACKGROUND

Innovative technologies that enable the collection of family history information and the assessment of breast cancer risk have a potential to enhance the quality of preventive care. We developed a computerized tool that supports stratification of breast cancer risk, genetic risk assessment in the clinical environment (GRACE).

METHODS

In a preliminary evaluation of the tool's impact, we randomized women with a family history of breast cancer (n=72) to either use the GRACE tool or undergo risk counseling by a nurse specialist.

RESULTS

There was no statistically significant differences between the GRACE and nurse counselling groups in risk perceptions (F=.03, P>.05) and cancer-related worries (F=.80, P>.05). However, patients reported more positive attitudes toward working with the nurse.

CONCLUSION

It was feasible to use GRACE in a Clinic. Additional research is required to identify solutions for providing emotional support in conjunction with the tool.

Facilitating informed decision making about breast cancer risk and genetic counseling among women calling the NCI's Cancer Information Service

Despite increased interest among the public in breast cancer genetic risk and genetic testing, there are limited services to help women make informed decisions about genetic testing. This study, conducted with female callers (N = 279) to the National Cancer Institute's (NCI's) Atlantic Region Cancer Information Service (CIS), developed and evaluated a theory-based, educational intervention designed to increase callers' understanding of the following: (a) the kinds of information required to determine inherited risk; (b) their own personal family history of cancer; and (c) the benefits and limitations of genetic testing. Callers requesting information about breast/ovarian cancer risk, risk assessment services, and genetic testing were randomized to either: (1) standard care or (2) an educational intervention. Results show that the educational intervention reduced intention to obtain genetic testing among women at average risk and increased intention among high-risk women at 6 months. In addition, high monitors, who typically attend to and seek information, demonstrated greater increases in knowledge and perceived risk over the 6-month interval than low monitors, who typically are distracted from information. These findings suggest that theoretically designed interventions can be effective in helping women understand their cancer risk and appropriate risk assessment options and can be implemented successfully within a service program like the CIS.

Decision aids for people facing health treatment or screening decisions

BACKGROUND

Decision aids prepare people to participate in preference-sensitive decisions.

OBJECTIVES

1. Create a comprehensive inventory of patient decision aids focused on healthcare options. 2. Review randomized controlled trials (RCT) of decision aids, for people facing healthcare decisions.

SEARCH STRATEGY

Studies were identified through databases and contact with researchers active in the field.

SELECTION CRITERIA

Two independent reviewers screened abstracts for interventions designed to aid patients' decision making by providing information about treatment or screening options and their associated outcomes. Information about the decision aids was compiled in an inventory; those that had been evaluated in a RCT were reviewed in detail.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data using standardized forms. Results of RCTs were pooled using weighted mean differences (WMD) and relative risks (RR) using a random effects model.

MAIN RESULTS

Over 200 decision aids were identified. Of the 131 available decision aids, most are intended for use before counselling. Using the CREDIBLE criteria to evaluate the quality of the decision aids: a) most included potential harms and benefits, credentials of the developers, description of their development process, update policy, and were free of perceived conflict of interest; b) many included reference to relevant literature; c) few included a description of the level of uncertainty regarding the evidence; and d) few were evaluated. Thirty of these decision aids were evaluated in 34 RCTs and another trial evaluated a suite of eight decision aids. An additional 30 trials are yet to be published. Among the trials comparing decision aids to usual care, decision aids performed better in terms of: a) greater knowledge (WMD 19 out of 100, 95% CI: 13 to 24; b) more realistic expectations (RR 1.4, 95%CI: 1.1 to 1.9); c) lower decisional conflict related to feeling informed (WMD -9.1 of 100, 95%CI: -12 to -6); d) increased proportion of people active in decision making (RR 1.4, 95% CI: 1.0 to 2.3); and e) reduced proportion of people who remained undecided post intervention (RR 0.43, 95% CI: 0.3 to 0.7). When simpler were compared to more detailed decision aids, the relative improvement was significant in: a) knowledge (WMD 4 out of 100, 95% CI: 3 to 6); b) more realistic expectations (RR 1.5, 95% CI: 1.3 to 1.7); and c) greater agreement between values and choice. Decision aids appeared to do no better than comparisons in affecting satisfaction with decision making, anxiety, and health outcomes. Decision aids had a variable effect on which healthcare options were selected.

REVIEWER'S CONCLUSIONS

The availability of decision aids is expanding with many on the Internet; however few have been evaluated. Trials indicate that decision aids improve knowledge and realistic expectations; enhance active participation in decision making; lower decisional conflict; decrease the proportion of people remaining undecided, and improve agreement between values and choice. The effects on persistence with chosen therapies and cost-effectiveness require further evaluation. Finally, optimal strategies for dissemination need to be explored.