BRCA1/2 testing in hereditary breast and ovarian cancer families III: Risk perception and screening

Outcomes of a Randomized Controlled Trial of Genomic Counseling for Patients Receiving Personalized and Actionable Complex Disease Reports

There has been very limited study of patients with chronic disease receiving potentially actionable genomic based results or the utilization of genetic counselors in the online result delivery process. We conducted a randomized controlled trial on 199 patients with chronic disease each receiving eight personalized and actionable complex disease reports online. Primary study aims were to assess the impact of in-person genomic counseling on 1) causal attribution of disease risk, 2) personal awareness of disease risk, and 3) perceived risk of developing a particular disease. Of 98 intervention arm participants (mean age = 57.8; 39% female) randomized for in-person genomic counseling, 76 (78%) were seen. In contrast, control arm participants (n = 101; mean age = 58.5; 54% female) were initially not offered genomic counseling as part of the study protocol but were able to access in-person genomic counseling, if they requested it, 3-months post viewing of at least one test report and post-completion of the study-specific follow-up survey. A total of 64 intervention arm and 59 control arm participants completed follow-up survey measures. We found that participants receiving in-person genomic counseling had enhanced objective understanding of the genetic variant risk contribution for multiple complex diseases. Genomic counseling was associated with lowered participant causal beliefs in genetic influence across all eight diseases, compared to control participants. Our findings also illustrate that for the majority of diseases under study, intervention arm participants believed they knew their genetic risk status better than control arm subjects. Disease risk was modified for the majority during genomic counseling, due to the assessment of more comprehensive family history. In conclusion, for patients receiving personalized and actionable genomic results through a web portal, genomic counseling enhanced their objective understanding of the genetic variant risk contribution to multiple common diseases. These results support the development of additional genomic counseling interventions to ensure a high level of patient comprehension and improve patient-centered health outcomes.

A Rapid Systematic Review of Outcomes Studies in Genetic Counseling

As healthcare reimbursement is increasingly tied to value-of-service, it is critical for the genetic counselor (GC) profession to demonstrate the value added by GCs through outcomes research. We conducted a rapid systematic literature review to identify outcomes of genetic counseling. Web of Science (including PubMed) and CINAHL databases were systematically searched to identify articles meeting the following criteria: 1) measures were assessed before and after genetic counseling (pre-post design) or comparisons were made between a GC group vs. a non-GC group (comparative cohort design); 2) genetic counseling outcomes could be assessed independently of genetic testing outcomes, and 3) genetic counseling was conducted by masters-level genetic counselors, or non-physician providers. Twenty-three papers met the inclusion criteria. The majority of studies were in the cancer genetic setting and the most commonly measured outcomes included knowledge, anxiety or distress, satisfaction, perceived risk, genetic testing (intentions or receipt), health behaviors, and decisional conflict. Results suggest that genetic counseling can lead to increased knowledge, perceived personal control, positive health behaviors, and improved risk perception accuracy as well as decreases in anxiety, cancer-related worry, and decisional conflict. However, further studies are needed to evaluate a wider array of outcomes in more diverse genetic counseling settings.

Intuition versus cognition: a qualitative exploration of how women understand and manage their increased breast cancer risk

Risk comprehension in individuals at increased familial risk of cancer is suboptimal and little is known about how risk is understood and managed by at-risk individuals who do not undergo genetic testing. We qualitatively studied these issues in 36 unaffected women from high-risk breast cancer families, including both women who had and had not undergone genetic testing. Data were collected through semi-structured interviews and data analysis was guided by Grounded Theory. Risk comprehension and risk management were largely influenced by the individual's experience of coming from a high-risk family, with both tested and untested women relying heavily on their intuition. Although women's cognitive understanding of their risk appeared generally accurate, this objective risk information was considered of secondary value. The findings could be used to guide the development and delivery of information about risk and risk management to genetically tested and untested individuals at increased risk of hereditary cancer.

The impact of multiplex genetic testing on disease risk perceptions

This study assessed the effects of multiplex genetic testing on disease risk perceptions among 216 healthy adults. Participants, aged 25-40, were recruited through the Multiplex Initiative, which offered a genetic susceptibility test for eight common diseases. Participants completed baseline telephone and web-based surveys prior to making the testing decision. Three months after the receipt of mailed test results, participants completed a follow-up telephone survey. Risk perceptions for the eight diseases were measured at baseline and follow-up, along with beliefs about genetic causation of those diseases. The main results were: (i) mean risk perceptions were considerably stable from baseline to follow-up; (ii) the best predictors of follow-up risk perceptions were the corresponding baseline perceptions and family history; and (iii) within-individuals, most participants increased or decreased their risk perceptions for specific diseases in concordance with the number of risk markers they carry, their family history and their beliefs about genetic causality of diseases. In conclusion, participants presented a vigilant approach to the interpretation of genetic test results, which provides reassurance with regard to a potential inflation of risk perceptions in the population because of multiplex genetic testing.

Patient compliance based on genetic medicine: a literature review

For this literature review, medical literature data bases were searched for studies on patient compliance after genetic risk assessment. The review focused on conditions where secondary or tertiary preventive options exist, namely cancer syndromes (BRCA-related cancer, HNPCC/colon cancer), hemochromatosis, thrombophilia, smoking cessation, and obesity. As a counterpart, patient compliance was assessed regarding medication adherence and medical advice in some of the most epidemiologically important conditions (including high blood pressure, metabolic syndrome, and coronary heart disease) after receiving medical advice based on nongenetic risk information or a combination of genetic and nongenetic risk information. In the majority of studies based on genetic risk assessments, patients were confronted with predictive rather than diagnostic genetic profiles. Most of the studies started from a knowledge base around 10 years ago when DNA testing was at an early stage, limited in scope and specificity, and costly. The major result is that overall compliance of patients after receiving a high-risk estimate from genetic testing for a given condition is high. However, significant behavior change does not take place just because the analyte is "genetic." Many more factors play a role in the complex process of behavioral tuning. Without adequate counseling and guidance, patients may interpret risk estimates of predictive genetic testing with an increase in fear and anxiety.

Cancer risk comparative perception and overscreening behaviours of non-carriers from BRCA1/2 families

Cancer-free women who are from families with an inherited form of breast and/or ovarian cancer (BRCA1/2) are referred to as 'unaffected non-carriers' when the results of genetic testing for the inherited gene are negative. Recent studies have identified overscreening behaviours (undergoing more screening tests for cancer than are medically warranted) among these women, even though they do not require specific cancer monitoring. Overscreening behaviours deserve particular attention due to their potential psychological drivers and implications. The principal objective of this study was to examine the factors, including state anxiety, feelings of self-vulnerability, and the comparative perception of cancer risk that might explain these overscreening behaviours. Unaffected non-carriers women (n = 77) were asked about these different variables. Overscreening was associated with and determined by feelings of self-vulnerability and the comparative perception of cancer risk, but was not associated with anxiety. An increase in feelings of self-vulnerability or elevated comparative pessimism (CP) was related to the participants' decision to be frequently screened. Patients' perceptions of the risk should be considered in measures or information aimed at preventing inappropriate overscreening behaviours.

Comparison of the screening practices of unaffected noncarriers under 40 and between 40 and 49 in BRCA1/2 families

This study aimed to 1) compare the cancer screening practices of unaffected noncarrier women under 40 and those aged 40 to 49, following the age-based medical screening guidelines, and 2) consider the way the patients justified their practices of screening or over-screening. For this study, 131 unaffected noncarriers-77 women under age 40 and 54 between 40 and 49, all belonging to a BRCA1/2 family-responded to a questionnaire on breast or ovarian cancer screenings they had undergone since receiving their negative genetic test results, their motives for seeking these screenings, and their intentions to pursue these screenings in the future. Unaffected noncarriers under age 40 admitted practices that could be qualified as over-screening. Apart from mammogram and breast ultrasounds, which the women under 40 reported seeking less often, these women's screening practices were comparable to those of women between 40 and 49. Cancer prevention and a family history of cancer were the two most frequently cited justifications for pursuing these screenings. We suggest that health care professionals discuss with women under 50 the ineffectiveness of breast and ovarian cancer screenings so that they will adapt their practices to conform to medical guidelines and limit their exposure to the potentially negative impacts of early cancer screening.

Retrospective comparison of patient outcomes after in-person and telephone results disclosure counseling for BRCA1/2 genetic testing

Telephone disclosure of BRCA1/2 molecular genetic test results has been proposed as a feasible alternative to traditional in-person results disclosure. The purpose of this study was to investigate the relationship between method of result disclosure with the patient outcome variables of knowledge, cancer worry, cancer risk perception, satisfaction, and cancer screening and prophylactic surgery behaviors. Study participants included 228 women who completed retrospective, self-administered, mailed surveys regarding their pre-test genetic counseling and results disclosure. No significant relationships were found between result disclosure method and the outcome variables investigated. A majority (90%) of individuals who received positive results by telephone returned for follow up visits. Factors which genetic counselors believed influenced their clinical decision to offer telephone disclosure, such as history of breast cancer, a priori risk of genetic mutation and family history of known mutation were not shown to significantly impact the actual disclosure method. This study suggests that telephone results disclosure is clinically appropriate when counselors utilize their clinical judgment to determine which patients are appropriate candidates.

Women's decision making about risk-reducing strategies in the context of hereditary breast and ovarian cancer: a systematic review

Women who have a mutation in the BRCA1 or BRCA2 genes have up to an 87% lifetime risk of breast cancer and up to a 40% lifetime risk of ovarian cancer. Cancer prevention and early detection strategies are often considered by these women to address this heightened risk. Risk-reducing strategies include risk-reducing mastectomy and oophorectomy, breast and ovarian cancer screening, and chemoprevention. This systematic literature review summarizes the factors and contexts that influence decision making related to cancer risk-reducing strategies among women at high-risk for hereditary breast and ovarian cancer. In the 43 published research articles reviewed, three main types of factors are identified that influence high-risk women's decisions about risk-reducing strategies: a) medical and physical factors, b) psychological factors and c) social context factors. How these factors operate in women's lives over time remains unknown, and would best be elucidated through prospective, longitudinal research, as well as qualitative research.

Sisters in hereditary breast and ovarian cancer families: communal coping, social integration, and psychological well-being

OBJECTIVE

We investigated the association between psychological distress and indices of social integration and communal coping among sisters from hereditary breast and ovarian cancer (HBOC) families.

SAMPLE AND METHODS

Sixty-five sisters from 31 HBOC families completed the Brief Symptom Inventory-18 and the Colored Eco-Genetic Relationship Map, which identified members of participants' social support networks. Hierarchical linear models were used for all analyses to account for the clustering of sisters within families.

RESULTS

Intra-family correlation coefficients suggested that sisters shared perceptions of breast cancer risk and worry, but not ovarian cancer risk and worry. Further, sisters demonstrated shared levels of anxiety and somatization, but not depressive symptoms. Communal coping indices quantifying shared support resources were negatively related to anxiety and somatization. The number of persons with whom cancer risk information was shared exhibited a positive trend with somatization. Social integration, as measured by the size of participants' emotional support network, was negatively associated with anxiety. Lower depression scores were observed among participants with more persons playing multiple support roles and fewer persons providing tangible assistance.

CONCLUSION

Understanding how support relationships impact well-being among persons adjusting to HBOC risk, and the particular role of family in that process, will facilitate developing appropriate management approaches to help cancer-prone families adjust to their cancer risk.

BRCA1 and BRCA2 risk perceptions among African American women at increased risk for hereditary breast-ovarian cancer

OBJECTIVES

To describe BRCA1 or BRCA2 (BRCA1/2) risk perceptions among African American women at increased risk for hereditary breast-ovarian cancer and to identify factors having independent associations with these perceptions.

METHODS

Risk perceptions were evaluated by self-report during a structured telephone interview among African American women (n = 162) at increased risk for hereditary cancer who were recruited from oncology clinics, general medical practices, and community oncology resources.

RESULTS

The majority of women (75%) believed that it was likely that they had a BRCA1/2 mutation. Women ages 50 and younger and those with greater cancer-specific worry were most likely to believe that they had a BRCA1/2 mutation.

CONCLUSIONS

Although BRCA1/2 risk perceptions may be consistent with objective risk levels among African American women, discussion about the basis of risk perceptions may enhance provision of genetic counseling and testing in this population.

Subjective and objective risk of ovarian cancer in Ashkenazi Jewish women testing for BRCA1/2 mutations

OBJECTIVE

Ovarian cancer is the leading cause of gynecological death in the United States, and 14% of ovarian cancer cases are attributed to BRCA1/2 hereditary mutations. This study examined (1) change in subjective ovarian cancer risk in response to genetic counseling and testing, (2) accuracy of subjective ovarian cancer risk estimates, and (3) new methods for conceptualizing subjective ovarian cancer risk based on Leventhal's Common Sense Model, in women at increased risk to carry BRCA1/2 mutations.

METHODS

Women (n=78) were asked their subjective risk of ovarian cancer (in terms of a percentage, estimated survival time, and projected age of onset) at pre-counseling, post-counseling, 1 week post-result, and 6 months post-result.

RESULTS

Women with a personal history of breast cancer were most inaccurate at pre- but improved post-counseling. Subjective survival time increased post-counseling. Accuracy of subjective risk improved at post-result for those with uninformative negative results. Subjective percentage risk and subjective survival time decreased at 6 months.

CONCLUSIONS

Subjective risk changed in response to genetic counseling and testing. Common Sense Model-derived assessments of risk may be useful for understanding the impact of genetic counseling and testing.

PRACTICE IMPLICATIONS

Genetic counseling can assist women at risk of carrying BRCA1/2 mutations to understand their risk of ovarian cancer, and genetic testing further refines their risk.

Distress and Family Functioning in Oncogenetic Counselling for Hereditary and Familial Breast and/or Ovarian Cancers

We conducted a psychological assessment during oncogenetic counseling for hereditary breast/ovarian cancer. Anxiety and depression were assessed with the HAD scale, and family functioning and satisfaction with FACES III. HAD was administered at baseline (t(1)), at risk communication (t(2)), at genetic test result communication, or at first surveillance in not tested subjects (t(3)); FACES III was administered at baseline only. We analysed a total of 185 questionnaires administered to the 37 subjects studied. Although not pathological, distress was significantly higher at t(2) and t(3) (p = 0.027 and p = 0.039, respectively). Health and marital status were significantly associated with distress. In a disease-free condition, anxiety was higher (p = 0.027) at t(2), and for single status, depression increased from t(1) to t(2) (p = 0.026). Families were perceived to be well functioning, and subjects were satisfied with their families. The data collected in this analysis could help to improve the quality of oncogenetic counselling in clinical practice.

The impact of breast cancer genetic risk assessment on intentions to perform cancer surveillance behaviors

One hundred and fifty-four women undergoing breast/ovarian cancer genetic risk assessment completed questionnaires at entry into the Cancer Genetic Service for Wales (CGSW) assessment program and following risk provision, mapping the strength of intentions to engage in a number of preventive/surveillance behaviors, including seeing specialists, breast self-examination, and involvement in screening programs, including mammography. A number of potential predictors of intentions were also assessed, including participants' mood and emotional response to receiving risk information, the perceived benefits (in terms of reassurance and early disease detection) of engaging in each preventive behavior, and the perceived desires of their family and General Practitioner. Intentions to self-examine did not change following risk provision, although strength of intentions to engage in some other preventive behaviors did lessen. Family and General Practitioners appeared to be strong social influences on behavioral intentions, as were the perceived benefits of gaining reassurance and/or early detection of disease.

Sociocultural predictors of breast cancer risk perceptions in African American breast cancer survivors

Although African American breast cancer survivors are at increased risk for developing breast cancer again, empirical data are not available on breast cancer risk perceptions in these women. This study characterized perceived risk of developing breast cancer in African American breast cancer survivors at risk for having a BRCA1 or BRCA1 (BRCA1/2) mutation and identified factors having significant independent associations with risk perceptions. Participants were 95 African American breast cancer survivors at an increased risk for having a BRCA1/2 mutation. Risk perceptions and sociodemographic, clinical, treatment, and sociocultural factors were collected during a structured telephone interview. Most women reported that they had the same or lower risk of developing breast cancer again compared with other women (53%); however, a substantial minority of women (47%) reported that they had a higher or much higher risk. Factors having significant independent associations with heightened risk perceptions included having a >or=10% prior probability of having a BRCA1/2 mutation [odds ratio (OR), 2.91; 95% confidence interval (95% CI), 1.09-7.72; P = 0.03] and more years of formal education (OR, 2.74; 95% CI, 1.02-7.36; P = 0.05). In addition, women who thought about the past a lot were three times more likely to report heightened risk perceptions compared with those who did not think about the past a lot (OR, 3.72; 95% CI, 1.45-9.57; P = 0.01). These results suggest that it may be important to ensure adequate risk comprehension among African American women as part of genetic counseling for inherited breast-ovarian cancer risk. Discussion of risk perceptions within the context of existing beliefs and values may facilitate this process.