Sources of Uncertainty About Daughters’ Breast Cancer Risk that Emerge During Genetic Counseling Consultations

Information needs persist after genetic counseling and testing for BRCA1/2 and Lynch Syndrome

PURPOSE

Research has shown that cancer genetic risk is often not well understood by patients undergoing genetic testing and counseling. We describe the barriers to understanding genetic risk and the needs of high-risk persons and cancer survivors who have undergone genetic testing.

METHODS

Using data from an internet survey of adults living in the USA who responded 'yes' to having ever had a genetic test to determine cancer risk (N = 696), we conducted bivariate analyses and multivariable logistic regression models to evaluate associations between demographic, clinical, and communication-related variables by our key outcome of having vs. not having enough information about genetics and cancer to speak with family. Percentages for yes and no responses to queries about unmet informational needs were calculated. Patient satisfaction with counseling and percentage disclosure of genetic risk status to family were also calculated.

RESULTS

We found that a lack of resources provided by provider to inform family members and a lack of materials provided along with genetic test results were strongly associated with not having enough information about genetics and cancer (OR 4.54 95% CI 2.40-8.59 and OR 2.19 95% CI 1.16-4.14 respectively). Among participants undergoing genetic counseling, almost half reported needing more information on what genetic risk means for them and their family and how genetic testing results might impact future screening.

CONCLUSION

High levels of satisfaction with genetic counseling may not give a full picture of the patient-provider interaction and may miss potential unmet needs of the patient. Accessible resources and ongoing opportunities for updating family history information could reinforce knowledge about genetic risk.

Women's Metaphors About BRCA Gene Testing and How They Can Inform Health Communication Theory and Practice

Genetic testing can detect whether an individual carries a harmful variant in the BRCA1 or BRCA2 (Breast Cancer 1 or 2) gene which, if present, drastically increases a woman's risk for breast and ovarian cancer. The experience of BRCA gene testing can be an emotionally laden process yielding significant uncertainty. In this study, we examined women's experiences of BRCA gene testing by exploring how participants communicatively framed and made sense of this process through the use of metaphors. Comparing uncertain and unfamiliar experiences to familiar references through metaphor can help people in challenging health-related situations with sense-making and communicating complex emotions. Furthermore, metaphors can be employed as a therapeutic tool by health care professionals, but their use has not often been studied regarding experiences of genetic testing, including BRCA gene testing. We conducted in-depth interviews with 42 women who have undergone BRCA gene testing (regardless of results), and analyzed data using constant comparative techniques. Eight categories of metaphors that women used surrounding BRCA gene testing were evident in the data, including those related to (a) knowledge is power; (b) gambling; (c) a journey; (d) a rollercoaster; (e) battle, disaster, or wreckage; (f) Pandora's box or a can of worms; (g) doom and gloom; and (h) the release or placing of a weight. Results enhance our understanding of women's experiences related to the uncertainty-inducing process of BRCA gene testing and lead to valuable theoretical implications and practical recommendations, including regarding the potential use of metaphors in patient-provider communication about BRCA genetic risk.

Personal Health Planning in Adult-Child Former Caregivers of Parents Living With Dementia

PURPOSE

To examine how former caregivers for parents living with dementia engage in personal health planning.

DESIGN

An inductive, qualitative study.

SETTING

Virtual, audio-recorded, semi-structured interviews.

PARTICIPANTS

Thirty-two midlife former primary caregivers for parents who died following advanced dementia 3 months to 3 years prior.

METHOD

Participants responded to a series of open-ended interview prompts. Interview recordings were transcribed and evaluated by a trained, diverse team to generate Consensual Qualitative Research (CQR) domains and categories.

RESULTS

Caregivers developed health planning outlooks (ie, mindsets regarding willingness and ability to engage in personal health planning) that guided health planning activities (ie, engaging in a healthy lifestyle, initiating cognitive/genetic testing, maintaining independence and aging in place, ensuring financial and legal security). An agentic outlook involved feeling capable of engaging in health planning activities and arose when caregivers witnessed the impact and feasibility of their parents' health planning. Anxiety-inducing and present-focused outlooks arose when caregivers faced barriers (eg, low self-efficacy, lack of social support, perception that parent's health planning did not enhance quality of life) and concluded that personal health planning would not be valuable or feasible.

CONCLUSION

Caregiving for a parent living with dementia (PLWD) shapes former caregivers' personal health planning. Interventions should support former caregivers who have developed low self-efficacy or pessimistic views on healthy aging to support them in addressing health planning activities.

Understanding parents uncertainty sources and management strategies while caring for a child diagnosed with a hematologic cancer

Rationale

Parents of a child or adolescent (CA) or young adult (YA) diagnosed with a hematologic cancer often face uncertainty. Managing uncertainty is critical to reduce the psychosocial burden of illness-related stressors.

Objective

This study sought to identify: 1) sources of uncertainty among parents of a child diagnosed with a hematologic cancer, 2) strategies used by parents to manage uncertainty, and 3) clinicians' responses to parents' online information-seeking approach to managing uncertainty.

Methods

Parents of CAs/YAs diagnosed with a hematologic cancer within the past 1-18 months and living in the U.S. participated in an in-depth, semi-structured phone interview (n = 20). Data were analyzed thematically.

Results

Parents reported uncertainty about treatment (options, efficacy, and side effects or risks) and uncertainty about the future (recurrence, whether worry would subside, and how to approach the child's future). Parents managed uncertainty by seeking information online, talking to clinicians, and joining support groups. Clinicians' responses to online information-seeking were described as supportive and unsupportive.

Conclusion

Parents described struggling with uncertainty across the cancer continuum (from primary treatment to survivorship). Parents' psychosocial health may benefit from individual and systems level interventions that help address and manage uncertainty, especially interventions focusing on parent caregiver-clinician communication.

Previvorship Posting: Why Breast Cancer Previvors Share Their Stories on Social Media

Research on previvors, individuals with a genetic predisposition to develop hereditary breast and ovarian cancer but who have not yet been diagnosed with breast or other cancers, examines online information gathering and community support to alleviate uncertainty. However, research exploring online content published by previvors themselves is limited. We examined content published to Instagram and TikTok to explore how breast cancer previvors discussed their lived experience which included, but was not limited to, genetic testing, diagnosis with a BRCA1/2 pathogenic (i.e. risk-increasing) variant, the decision to undergo preventative measures like surgery and/or reconstruction, and how they cope after diagnosis and surgical procedures. In the findings, we explicate how many previvors feel a responsibility to share their authentic experience on social media in order to help others and mitigate their own feelings of uncertainty. This study offers a snapshot of how women are sharing breast cancer previvorship and building social connections with each other online.

Young Adult Caregiving Daughters and Diagnosed Mothers Navigating Breast Cancer Together: Open and Avoidant Communication and Psychosocial Outcomes

For many diagnosed mothers and their daughters, breast cancer is a shared experience. However, they struggle to talk about cancer. This is particularly true when the daughter is in adolescence or young adulthood, as they tend to be more avoidant, which is associated with poorer biopsychosocial outcomes. When daughters are their mother's caregivers, daughters' burden and distress are heightened. Young adult caregiving daughters (YACDs) are the second most common family caregiver and encounter more distress and burden than other caregiver types. Yet, YACDs and their diagnosed mothers receive no guidance on how to talk about cancer. Thirty-nine mother/YACD pairs participated in an online survey to identify challenging topics and strategies for talking about cancer, and to explore associations between openness/avoidance and psychosocial outcomes. YACDs and mothers reported the same challenging topics (death, treatment-related issues, negative emotions, relational challenges, YACDs' disease risk) but differed on why they avoided the topic. YACDs and mothers identified the same helpful approaches to navigate conversations (openness, staying positive, third-party involvement, avoidance). Avoidance was correlated with more distress whereas openness was correlated with better psychosocial outcomes. These results provide a psychosocial map for a mother-YACD communication skills intervention, which is key to promoting healthy outcomes.

Feasibility, acceptability, and outcomes of a pilot intervention facilitating communication about family building between patients with inherited cancer risk and their partners

Objective

This study reports the feasibility, acceptability, and outcomes of a longitudinal, communication pilot intervention for patients with inherited cancer risk and their partners.

Methods

Couples were recruited through social media and snowball sampling. At Time 1 and 2, 15 couples completed a structured discussion task about family building concerns and decisions, followed by an online post-discussion questionnaire and dyadic interview to provide feedback about the experience. Interview data were analyzed to assess outcomes using applied thematic analysis.

Results

Participants reported the intervention created an opportunity for honest disclosure of family building goals and concerns. Participants also stated the structured nature of the discussion task was useful and did not cause additional stress. The intervention ultimately aided at-risk patients and their partners to realize their concordant concerns, discover/confront discordant concerns, and mutually agree upon next steps.

Conclusions

This pilot intervention is feasible and acceptable. Furthermore, it offers a framework to facilitate effective communication about family building between patients with inherited cancer risk and their partners.

Innovation

This intervention is the first conversational tool designed for at-risk patients and their partners.

Managing Uncertainty for and With Family: Communication Strategies and Motivations in Familial Uncertainty Management for Hereditary Cancer

The management of uncertainty is integral to health and illness. Individuals manage uncertainty about their health through communication enmeshed in family systems, but existing theorizing focuses on individuals without accounting for family processes. An iterative qualitative analysis of 42 dyadic, family interviews (N = 84) revealed (a) moments in the context of hereditary cancer that involved individual-centered and familial uncertainty appraisal and management, (b) family members' communication strategies to prompt relatives to engage familial uncertainty, and (c) the communicative (re)creation and negotiation of family models for uncertainty management. The findings illuminate tensions that individuals encounter across their lifespan as they appraise and manage uncertainty about hereditary cancer risks. This study extends uncertainty management theory to encompass familial uncertainty management and contributes insights useful for the management of hereditary cancer.

Motivating cascade testing for familial hypercholesterolemia: applying the extended parallel process model for clinician communication

Motivating at-risk relatives to undergo cascade testing for familial hypercholesterolemia (FH) is critical for diagnosis and lifesaving treatment. As credible sources of information, clinicians can assist in family communication about FH and motivate cascade testing uptake. However, there are no guidelines regarding how clinicians should effectively communicate with probands (the first person diagnosed in the family) and at-risk relatives. Individuals and families with FH can inform our understanding of the most effective communications to promote cascade testing. Guided by the extended parallel process model (EPPM), we analyzed the perspectives of individuals and families with FH for effective messaging clinicians can use to promote cascade testing uptake. We analyzed narrative data from interviews and surveys collected as part of a larger mixed-methods study. The EPPM was used to identify message features recommended by individuals and families with FH that focus on four key constructs (severity, susceptibility, response efficacy, self-efficacy) to promote cascade testing. Participants included 22 individuals from 11 dyadic interviews and 98 survey respondents. Participants described prioritizing multiple messages that address each EPPM construct to alert relatives about their risk. They illustrated strategies clinicians could use within each EPPM construct to communicate to at-risk relatives about the importance of pursuing diagnosis via cascade testing and subsequent treatment for high cholesterol due to FH. Findings provide guidance on effective messaging to motivate cascade testing uptake for FH and demonstrates how the EPPM may guide communication with at-risk relatives about genetic risk and motivate cascade testing broadly.

Patient Experiences Align with The Familial Hypercholesterolemia Global Call to Action

Objective

To explore alignment of perspectives from individuals and families with familial hypercholesterolemia (FH) to the FH Global Call to Action recommendations.

Methods

Interviews and focus groups were conducted with individuals and families with FH from multiple U.S. health systems and the Family Heart Foundation community to capture lived experiences and to identify barriers to diagnosis, cascade testing, and treatment. Participant perspectives were examined and classified, according to their alignment to recommendations of the FH Global Call to Action.

Results

A total of 75 lived experiences were analyzed. Participants were majority female, mostly white, older, and well-educated. Participants most frequently mentioned recommendations were family-based care (84%) and screening, testing, & diagnosis (84%), followed by treatment (69%), advocacy (60%), cost & value (59%), awareness (56%), research & registries (43%), and severe & homozygous FH (11%). An average of 4.65 (SD 1.76) recommendations were mentioned.

Conclusions

The FH Global Call to Action was driven by the persistent unmet needs of those living with FH in receiving a timely diagnosis, appropriate care, and support to prevent early morbidity and mortality. Patient- and family-centric perspectives suggest the FH Global Call to Action captures these concerns. Acting on recommendations, particularly improvements in screening and family-based care, will address patient, and public health, concerns.

The explanation of a complex problem: A content analysis of causality in cancer news

Understanding causality is a critical part of developing preventive and treatment actions against cancer. Three main causality models-necessary, sufficient-component, and probabilistic causality have been commonly used to explain the causation between causal factors and risks in health science. However, news media do not usually follow a strict protocol to report the causality of health risks. The purpose of this study was to describe and understand how the causation of cancer was articulated on news media. A content analysis of 471 newspaper articles published in the United States during two time-frames (2007-2008 and 2017-2018) was conducted. The analysis showed that probabilistic causality was most frequently used to explain the causal relationship between risk factors and cancer. The findings also uncovered other important details of news framing, including types and characteristics of risk factors, intervention measures, and sources of evidence. The results provided theoretical and practical implications for public understanding and assessment of cancer risks.

A Content Analysis of Social Support Messages about Environmental Breast Cancer Risk within Blogs for Mothers

Bloggers can help stimulate online conversations among their readers about a variety of health topics, including breast cancer. However, in previous studies, researchers have not specifically examined supportive messages within an online blogger community that stem from an intervention where bloggers were provided with evidence-based information about breast cancer risk that they could tailor and disseminate to their readers. In the current study, we content analyzed 282 supportive messages within online conversations from participants in blogger communities over a 2-month period immediately following an intervention where the authors provided 74 bloggers who write about motherhood issues with an infographic based on evidence-based information from the Breast Cancer and the Environment Research Program (BCERP) about environmental breast cancer risk/prevention. Bloggers who shared information about their personal breast cancer risk generated a significantly higher number of blog reader comments than bloggers who did not share information about their personal breast cancer risk. Bloggers who cited breast cancer statistics in posts were more likely to draw esteem and emotional support from their readers. Bloggers' repetition of information from blog intervention messages was more likely to elicit esteem, informational, and emotional support from readers. Disclosure of a personal breast cancer diagnosis was associated with mixed types of social support messages. The theoretical and practical implications are discussed along with key limitations of the study and future directions for research in this area.

The communication of uncertainty in health: A scoping review

OBJECTIVE

To conduct a scoping review of existing studies that examine communication strategies that address uncertainty in health and categorize them using the taxonomy of uncertainty.

METHODS

Relevant articles retrieved from ten databases were categorized according to the dimensions of the taxonomy of uncertainty, and study characteristics were extracted from each article.

RESULTS

All articles (n = 63) explored uncertainty in the context of probabilistic risk and related to scientific issues (n = 63; 100%). The majority focused on complexity (n = 24; 38.1%) and uncertainty experienced by patients (n = 52; 82.5%). Most utilized quantitative methods (n = 46; 73.0%), hypothetical scenarios (n = 49; 77.8%), and focused on cancer (n = 20; 31.7%). Theory guided messages and study design in fewer than half (n = 27; 42.9%).

CONCLUSIONS

Heterogeneity in terminology used to refer to different types of uncertainties preclude a unified research agenda on uncertainty communication. Research predominately focuses on probability as the source of uncertainty, uncertainties related to scientific issues, and uncertainty experienced by patients.

PRACTICE IMPLICATIONS

Additional efforts are needed to understand providers' experience of uncertainty, and to identify strategies to address ambiguity. Future studies should use consistent terminology to allow for coherence and advancement of uncertainty communication scholarship. Continued efforts to refine the existing taxonomy should be undertaken.

Blood cancer caregiving during COVID-19: understanding caregivers' needs

The COVID-19 pandemic likely exacerbated caregiving challenges for caregivers of parents diagnosed with a blood cancer. Providing care during a public health crisis presents a complex web of uncertainties regarding cancer care, personal health, and COVID-19 risk. Identifying caregivers’ uncertainty experiences during the COVID-19 pandemic can be a first step in learning where to direct resources or alter policies to ensure that they can not only perform their caregiver role but also cope in health-promoting ways. Using uncertainty management theory, this study explored how the pandemic has impacted adult child caregivers’ experiences caring for a parent diagnosed with a blood cancer, as well as their experiences of uncertainty and uncertainty management. As part of a larger study on blood cancer caregivers’ needs, a survey was administered from March 30 to June 1, 2020, to recruit caregivers through the Leukemia and Lymphoma Society. A qualitative and quantitative content analysis was conducted on open-ended responses from 84 caregivers. Caregivers described changes illustrating the complexity of providing care during a pandemic: (a) increased fears and uncertainty-related distress, b) reduced in-person care opportunities, (c) increased isolation, and (d) enhanced family communication. Caregivers with parents diagnosed with acute blood cancers used significantly more uncertainty management strategies and had more sources of uncertainty than caregivers with parents living with chronic blood cancer types. Findings highlight the need for supportive services to help caregivers manage uncertainty and improve their capacity to provide care in an unpredictable global health crisis. Such support may reduce poor psychosocial outcomes.

Engaging Men With BRCA-Related Cancer Risks: Practical Advice for BRCA Risk Management From Male Stakeholders

Men are at risk for developing hereditary cancers such as breast, prostate, pancreatic, and melanoma due to a pathogenic germline variant in either the BRCA1 or BRCA2 gene. The purpose of this study was to identify and provide practical advice for men managing their BRCA-related cancer risks based on men's real-life experiences. Semistructured interviews were conducted with 25 men who either tested positive for a pathogenic variant in BRCA1/2 gene or who had an immediate family member who had tested positive for a pathogenic variant in BRCA1/2. A thematic analysis of the interview transcripts was completed utilizing the constant comparison method. Qualitative analysis produced three categories of participant advice for men who recently learned of their hereditary cancer risk. Specifically, participants advised the following: (a) know the basics, (b) engage in the family narrative, and (c) advocate for yourself. Results showed the need for men to know and understand their BRCA cancer risks and communicate that genetic risk information to their family members and practitioners. In particular, the findings stress the importance of addressing men's risks and medical management from a family-focused approach. Overall, because men are historically undereducated about their BRCA-related cancer risks, this practical advice serves as a first step for men managing BRCA-related cancer risks and may ultimately assist them in making preventive and screening health behaviors.

Sharing genetic test results with family members of BRCA, PALB2, CHEK2, and ATM carriers

OBJECTIVE

This study explored motivators and challenges/barriers to sharing personal genetic test results (GTR) with family members (FM).

METHODS

Semi-structured, in-depth interviews were conducted with 62 women who had a pathogenic or likely pathogenic (P/LP) variant in aBRCA, PALB2, CHEK2, or ATM gene. Selective qualitative data analysis focused on eliciting motivators and challenges/barriers identified by participants when sharing their GTR with FM.

RESULTS

Motivators to sharing personal GTR with FM included: health protection and prevention; moral obligation; decisional empowerment; familial ties; written resources; and contextualization for a familial cause for cancer. Challenges/barriers to family sharing included: concern for FM reactions; complexities of information; lack of closeness; perceived relevance; and emotional impact.

CONCLUSIONS

All motivators and challenges/barriers were identified across BRCA and non-BRCA carriers, demonstrating commonalities in family sharing of GTR among high- to moderate-penetrance hereditary BC (breast cancer) genes. Despite challenges/barriers, participants disclosed their GTR with most close FM, yet restrictions in communication and/or strain on the timing, manner of disclosing, and strategies used varied across certain FM.

PRACTICE IMPLICATIONS

These findings offer healthcare providers and researchers preliminary practical implications for broadly improving family sharing interventions across P/LP variants in BC risk genes by demonstrating important elements to include in family sharing letters.

PGx in psychiatry: Patients' knowledge, interest, and uncertainty management preferences in the context of pharmacogenomic testing

OBJECTIVE

Pharmacogenomic testing (PGx) is expanding into psychiatric care. PGx could potentially offer a unique benefit to psychiatric patients, providing information about patients' reaction to medications that could reduce the time and financial burdens of drug optimization. The aims of this study were to: (1) examine psychiatry patients' familiarity and interest in PGx, and (2) explore how Uncertainty Management Theory relates to PGx testing in psychiatry.

METHOD

We surveyed psychiatric patients, measuring their PGx familiarity and interest, attitudes toward PGx testing, and preference for managing illness uncertainty.

RESULTS

We analyzed data from 598 patients. Patients' familiarity of PGx was low, but interest was high. Thirty percent of patients were familiar with the test from communication with their healthcare provider or their own online health information seeking. A preference for seeking information was a significant positive predictor of testing interest (p < .001).

CONCLUSION

Psychiatric patients were interested in PGx testing, regardless of their uncertainty management preferences.

PRACTICE IMPLICATIONS

This study is one of the first to examine psychiatric patients' perspectives on PGx testing in mental health care. Our findings show that psychiatric patients are interested in the test and are familiar enough with PGx to be included in future research on the topic.

Referencing BRCA in hereditary cancer risk discussions: In search of an anchor in a sea of uncertainty

As panel testing and exome sequencing are increasingly incorporated into clinical care, clinicians must grapple with how to communicate the risks and treatment decisions surrounding breast cancer genes beyond BRCA1 and BRCA2. In this paper, we examine clinicians' practice of employing BRCA1 and BRCA2 to help contextualize less certain genetic information regarding cancer risk and the possible implications of this practice for patients within the context of an exome sequencing study, NCGENES. We audio-recorded return of results appointments for 14 women who participated in NCGENES, previously had breast cancer, and were suspected of having a hereditary cancer predisposition. These patients were also interviewed four weeks later regarding their understanding of their results. We found that BRCA1 and BRCA2 were held as the gold standard, where clinicians compared what is known about BRCA to the limited understanding of other breast cancer-related genes. BRCA1 and BRCA2 were used as anchors to shape patients' understandings of genetic knowledge, risk, and management, illustrating how the information clinicians provide to patients may work as an external anchor. Yet, presenting BRCA1 and BRCA2 as a means of scientific reassurance can run the risk of patients conflating knowledge about certainty of risk with degree of risk after receiving a result for a moderate penetrance gene. This can be further complicated by misperceptions of the precision of cancer predictability attributed to these or other described 'cancer genes' in public media.

How does genetic testing influence anxiety, depression, and quality of life? A hereditary breast and ovarian cancer syndrome suspects trial

BACKGROUND

Emotional distress associated with genetic testing for hereditary breast and ovarian cancer syndrome (HBOC) is reported to interfere with adherence to treatment and prophylactic measures and compromise quality of life.

OBJECTIVES

To determine levels of anxiety, depression, and quality of life in patients tested for pathogenic BRCA1/2 mutations and identify risk factors for the development of adverse psycho-emotional effects.

METHODS

Cross-sectional observational trial involving 178 breast or ovarian cancer patients from a referral cancer hospital in Northeastern Brazil. Information was collected with the Hospital Anxiety and Depression Scale (HADS) and the World Health Organization (WHO) Quality of Life (QoL) questionnaire (WHOQOL-BREF).

RESULTS

Patients suspected of HBOC had higher levels of anxiety than depression. The presence of (probably) pathogenic BRCA1/2 mutations did not affect levels of anxiety and depression. High schooling, history of psychiatric disease, and use of psychotropic drugs were directly associated with high anxiety. High schooling was too inversely associated with QoL as such a breast tumor. Anxiety and depression were directly correlated and both reduced significantly QoL.

CONCLUSION

Our results highlight the importance of psychological support and screening of risk factors for anxiety and depression and low QoL in HBOC patients at the time of testing.

Helping Mothers and Daughters Talk about Environmental Breast Cancer Risk and Risk-Reducing Lifestyle Behaviors

Background: Mothers and daughters struggle to talk about breast cancer risk. Even less attention is paid to environmental determinants of cancer. Third-party online approaches can be helpful navigating these conversations. The aim of this study was to obtain feedback from mothers exposed to a social media intervention (“mommy bloggers”) and identify their preferences for message-design approaches that could help them talk to their daughter(s) about environmental breast cancer risk. Methods: We conducted semi-structured interviews with 50 mothers. A thematic analysis was conducted using the constant comparative method. Results: Mothers identified four approaches to message design that could help facilitate mother–daughter communication about environmental breast cancer risk. These included two action-oriented approaches that centered on getting the conversation started and keeping the conversation going and two approaches based on lifespan factors to promote daughters’ engagement by using age-appropriate language and visuals and focusing on developmentally specific lifestyle behaviors. Mothers also provided recommended strategies within each approach. Conclusions: Mothers identified various approaches interventionists can utilize to overcome barriers to talking to daughters about environmental breast cancer risk. To promote mother–daughter communication, the messages should be action-oriented to facilitate interaction, but also developed with lifespan and developmental considerations in mind to engage daughters.

Uncertainty in the Process of Communicating Cancer-related Genetic Risk Information with Patients: A Scoping Review

In the era of precision medicine, patients must manage the uncertainty caused by ambiguous genetic information. To aid health practitioners in effectively communicating genetic information, this study classified the types of uncertainty involved in these communication processes. A search of recent literature turned up 64 articles that measured and/or discussed patients' perceptions and/or feelings of uncertainty related to the communication process of cancer-related genetic information. In reviewing these papers, six types of uncertainty regarding cancer-related genetic information were identified: (1) uncertainty about understanding genetic information (n = 25; 39.1%); (2) uncertainty about future cancer risks (n = 34; 53.1%); (3) uncertainty about managing known genetic information or mutation status (n = 33; 51.6%); (4) uncertainty about the utility of genetic information (n = 5; 7.8%); (5) uncertainty about genetic test results before undergoing testing or receiving the results (n = 10; 15.6%); and (6) uncertainty about the impact of genetic results on family and life (n = 11; 17.2%). These six types of uncertainty serve as a helpful taxonomy for developing, validating, and utilizing future measures of uncertainty in the context of cancer-related genetic risk communication.

Partnering With Mommy Bloggers to Disseminate Breast Cancer Risk Information: Social Media Intervention

BACKGROUND

Women are concerned about reducing their breast cancer risk, particularly if they have daughters. Social media platforms, such as blogs written by mothers, are increasingly being recognized as a channel that women use to make personal and family health-related decisions. Government initiatives (eg, Interagency Breast Cancer and Environmental Research Coordinating Committee) and researchers have called for scientists and the community to partner and disseminate scientifically and community-informed environmental risk information.

OBJECTIVE

We developed and evaluated a blog intervention to disseminate breast cancer and environmental risk information to mothers. We teamed with mommy bloggers to disseminate a message that we developed and tailored for mothers and daughters based on scientific evidence from the Breast Cancer and the Environment Research Program (BCERP). We posited that the intervention would influence women's exposure to, acceptance of, and beliefs about environmental risks while promoting their intention to adopt risk-reducing behaviors.

METHODS

Using a quasi-experimental design, we recruited 75 mommy bloggers to disseminate the breast cancer risk message on their respective blogs and examined the impact of the intervention on (1) readers exposed to the intervention (n=445) and (2) readers not exposed to the intervention (comparison group; n=353).

RESULTS

Following the intervention, blog reader scores indicating exposure to the breast cancer risk and prevention information were greater than scores of blog readers who were not exposed (or did not recall seeing the message; mean 3.92, SD 0.85 and mean 3.45, SD 0.92, respectively; P<.001). Readers who recalled the intervention messages also had higher breast cancer risk and prevention information satisfaction scores compared with readers who did not see (or recall) the messages (mean 3.97, SD 0.75 and mean 3.57, SD 0.94, respectively; P<.001). Blog readers who recalled seeing the intervention messages were significantly more likely to share the breast cancer risk and prevention information they read, with their daughters specifically, than readers who did not recall seeing them (χ²₁=8.1; P=.004). Those who recalled seeing the intervention messages reported significantly higher breast cancer risk and prevention information influence scores, indicative of behavioral intentions, than participants who did not recall seeing them (mean 11.22, SD 2.93 and mean 10.14, SD 3.24, respectively; P=.003). Most women ranked Facebook as their first choice for receiving breast cancer risk information.

CONCLUSIONS

Results indicated that blog readers who were exposed to (and specifically recalled) the BCERP-adapted intervention messages from mommy bloggers had higher breast cancer risk and prevention information exposure scores and higher breast cancer risk and prevention information satisfaction and influence scores than those who did not see (or recall) them. Mommy bloggers may be important opinion leaders for some women and key to enhancing the messaging, delivery, and impact of environmental breast cancer risk information on mothers.

Previvors' Uncertainty Management Strategies for Hereditary Breast and Ovarian Cancer

Individuals with a genetic predisposition to develop hereditary breast and ovarian cancer (HBOC), but who have not been diagnosed with cancer, are referred to as previvors. Although genetic testing may reduce previvors' worries about whether or not they have a high genetic cancer risk, testing positive produces negative emotions and long-term uncertainty-thus requiring the management of uncertainty. Existing research indicates family, friends, and social support networks are limited in their assistance for previvors' uncertainty management. Therefore, this study examined how health care providers may assist previvors in uncertainty management by asking: What strategies do BRCA-positive previvors enact with their health care providers to help manage their uncertainty about HBOC? Purposive sampling was employed to recruit participants via online social media. The final sample consisted of 34 BRCA-positive women. Interviews revealed four uncertainty management strategies-seeking health care providers as informational sources, seeking health care providers as partners for decision making, seeking health care providers for supportive communication, and seeking referrals from health care providers for social support networks. Findings indicate that health care providers who are knowledgeable about BRCA, provide information, answer questions, check understanding, and provide additional resources assist previvors in managing their uncertainties by distinguishing options and fostering meaning.

Communicating with Daughters About Familial Risk of Breast Cancer: Individual, Family, and Provider Influences on Women's Knowledge of Cancer Risk

INTRODUCTION

Women facing complex and uncertain situations such as cancer in their families may seek information from a variety of sources to gain knowledge about cancer risk and reduce uncertainty. We describe and assess the relative importance of information sources about familial breast cancer at the individual, family, and healthcare provider levels influencing women's reporting they had enough information to speak with daughters about breast cancer. This outcome we refer to as being informed about breast cancer.

MATERIALS AND METHODS

Sister Study participants, a cohort of women with a family history of breast cancer, were surveyed on family cancer history, family communication, social support, and interactions with healthcare providers (n = 11,766). Adjusted percentages and 95% confidence intervals for being informed about breast cancer versus not being informed were computed for individual-, family-, and provider-level characteristics in three steps using multivariate logistic regression models.

RESULTS

We found 65% of women reported being informed about breast cancer while 35% did not. Having a trusted person with whom to discuss cancer concerns, having a lower versus higher perceived risk of breast cancer, having undergone genetic counseling, and being satisfied with physician discussions about breast cancer in their families were predictors of being informed about breast cancer.

CONCLUSIONS

Although acquiring objective risk information, such as through genetic counseling, may contribute to a basic level of understanding, communication with providers and within other trusted relationships appears to be an essential component in women's reporting they had all the information they need to talk with their daughters about breast cancer.

Investigating Uncertainty in Genetic Counseling Encounters: Managing Information About Genetic Cancer Risk

The Theory of Motivated Information Management (TMIM) was used to investigate how individuals at increased risk of developing hereditary cancer seek information from genetic counselors. Results show the TMIM model fit the data well in predicting participants' intentions to seek information from genetic counselors. Participants felt an uncertainty discrepancy that elicited feelings of anxiety, which in turn negatively predicted both outcome expectancies and efficacy assessments. Efficacy assessments, but not anxiety, significantly predicted participants' intentions to seek information from a genetic counselor in the future. Findings showed no significant relationship between outcome expectancies and efficacy assessments. One implication for genetic counselors is the need to more closely monitor emotional response to genetic disease risk-whether that emotional response be positive or negative-as that response may influence information-seeking intentions. Further, genetic counselors might also pay more attention to building efficacy for themselves (making patients feel the counselor is more credible) and their patients (increasing patient ability to communicate effectively about genetic disease risk). Analysis also extends TMIM theory by showing that in a relationship where information exchange is the primary function the model still showed good fit. However, outcome expectancies functioned differently than in previous tests of the model.

"It's not if I get cancer, it's when I get cancer": BRCA-positive patients' (un)certain health experiences regarding hereditary breast and ovarian cancer risk

RATIONALE

Women with a harmful mutation in the BReast CAncer (BRCA) gene are at significantly increased risk of developing hereditary breast and ovarian cancer (HBOC) during their lifetime, compared to those without. Such patients-with a genetic predisposition to develop cancer but who have not yet been diagnosed with cancer-live in a constant state of uncertainty and wonder not if they might get cancer but when.

OBJECTIVE

Framed by uncertainty management theory, the purpose of this study was to explore BRCA-positive patients' health experiences after testing positive for the BRCA genetic mutation, specifically identifying their sources of uncertainty.

METHODS

Thirty-four, qualitative interviews were conducted with female patients. Participants responded to online research postings on the non-profit organization Facing Our Risk of Cancer Empowered's (FORCE) message board and social media pages as well as HBOC-specific Facebook groups. The interview data were coded using the constant comparison method.

RESULTS

Two major themes representing BRCA-positive patients' sources of uncertainty regarding their genetic predisposition and health experiences emerged from the data. Medical uncertainty included the following three subthemes: the unknown future, medical appointments, and personal cancer scares. Familial uncertainty encompassed the subthemes traumatic family cancer memories and motherhood.

CONCLUSIONS

Overall, the study supports and extends existing research on uncertainty-revealing uncertainty is inherent in BRCA-positive patients' health experiences-and offers new insight regarding uncertainty management and HBOC risk.

Using communication to manage uncertainty about cervical cancer screening guideline adherence among Appalachian women

Changes to the United States Preventive Services Task Force (USPSTF) recommendations for cervical cancer preventive services have led to patient confusion, especially in medically underserved populations. We investigated how patient uncertainty concerning cervical cancer screening guidelines is appraised and managed through communication with healthcare providers by conducting in-depth, face-to-face interviews with 24 adult women between the ages of 24 and 65 (m = 41, SD = 14) living in Appalachia Kentucky. In general, participants expressed a high degree of uncertainty about the updated cervical cancer screening guidelines and appraised this uncertainty as both a danger and an opportunity. Communication with healthcare providers served both to exacerbate and to mitigate patient uncertainty. The study identifies how health care providers may use the change in USPSTF guidelines as a 'teachable moment' to productively counsel patients on the importance of timely screening, the typical progression of certain types of high-risk HPV infection to cervical cancer, and the importance of follow-up care.

Communication Between Breast Cancer Patients Who Received Inconclusive Genetic Test Results and Their Daughters and Sisters Years After Testing

Inconclusive genetic test results including screening recommendations for the breast cancer patients and their first-degree relatives are the most common outcomes of BRCA 1/2 testing. Patients themselves should communicate these results to their relatives. Our aim was to explore communication of breast cancer genetic counseling results with daughters and sisters over a long period of time. Breast cancer patients, who had received an inconclusive DNA test result 7-14 years earlier, completed a self-report questionnaire. Additionally, in-depth interviews were conducted and analysed thematically. Of the 93 respondents, 85 (91 %) considered themselves responsible for communicating genetic test results to relatives. In-depth interviews (n = 14) showed, that counselees wanted 'to hand over' their responsibilities to communicate the test results and screening recommendations to their sisters. Although most patients had informed their daughters and sisters about the genetic test results, usually little is spoken about genetic test results and screening recommendations once the duty of informing is completed. We recommend that, similar to the procedure for BRCA1/2-mutation carriers, a separate letter for first-degree relatives of patients with an inconclusive test result should be provided. In this way information about risks and screening recommendations can be verified by family members years after genetic testing has been completed.

Information Seeking in Uncertainty Management Theory: Exposure to Information About Medical Uncertainty and Information-Processing Orientation as Predictors of Uncertainty Management Success

Uncertainty management theory outlines the processes through which individuals cope with health-related uncertainty. Information seeking has been frequently documented as an important uncertainty management strategy. The reported study investigates exposure to specific types of medical information during a search, and one's information-processing orientation as predictors of successful uncertainty management (i.e., a reduction in the discrepancy between the level of uncertainty one feels and the level one desires). A lab study was conducted in which participants were primed to feel more or less certain about skin cancer and then were allowed to search the World Wide Web for skin cancer information. Participants' search behavior was recorded and content analyzed. The results indicate that exposure to two health communication constructs that pervade medical forms of uncertainty (i.e., severity and susceptibility) and information-processing orientation predicted uncertainty management success.

More breast cancer patients prefer BRCA-mutation testing without prior face-to-face genetic counseling

Currently, most breast cancer (BC) patients receive face-to-face genetic counseling (DNA-intake) prior to BRCA-mutation testing, with generic information regarding hereditary BC and BRCA-mutation testing. This prospective study evaluated a novel format: replacing the intake consultation with telephone, written and digital information sent home, and face-to-face contact following BRCA-mutation testing (DNA-direct). From August 2011 to February 2012, 161 of 233 eligible BC patients referred to our Human Genetics department chose between DNA-direct (intervention) or DNA-intake (control). Exclusion criteria were psychological problems (n = 33), difficulty with Dutch text (n = 5), known BRCA-family (n = 3), non-BRCA-referral (n = 1). 30 declined genetic counseling or study participation. Participants received questionnaires including satisfaction and psychological distress. 59 % chose DNA-direct (p = 0.03), of whom 90 % were satisfied and would choose DNA-direct again (including 6/8 BRCA-mutation carriers); although 27 % hesitated to recommend DNA-direct to other patients. General distress (GHQ-12, p = 0.001) and heredity-specific distress (IES, p = 0.02) scored lower in DNA-direct than DNA-intake, both at baseline and follow-up 2 weeks after BRCA-result disclosure; all scores remained below clinical relevance. DNA-direct participants reported higher website use (53 vs. 32 %, p = 0.01), more referrer information about personal consequences (41 vs. 20 %, p = 0.004) and lower decisional conflict (median 20 [0-88] vs. 25 [0-50], p = 0.01). Processing time in DNA-direct was reduced by 1 month. Mutation detection rate was 8 % in both groups. All BRCA-mutation carriers fulfilled current testing criteria. In conclusion, more BC patients preferred DNA-direct over intake consultation prior to BRCA-mutation testing, the majority being strongly to moderately satisfied with the procedure followed, without increased distress.

An examination of the relationships among uncertainty, appraisal, and information-seeking behavior proposed in uncertainty management theory

Uncertainty management theory (UMT; Brashers, 2001, 2007) is rooted in the assumption that, as opposed to being inherently negative, health-related uncertainty is appraised for its meaning. Appraisals influence subsequent behaviors intended to manage uncertainty, such as information seeking. This study explores the connections among uncertainty, appraisal, and information-seeking behavior proposed in UMT. A laboratory study was conducted in which participants (N = 157) were primed to feel and desire more or less uncertainty about skin cancer and were given the opportunity to search for skin cancer information using the World Wide Web. The results show that desired uncertainty level predicted appraisal intensity, and appraisal intensity predicted information-seeking depth-although the latter relationship was in the opposite direction of what was expected.

Talking about familial breast cancer risk: topics and strategies to enhance mother-daughter interactions

A hereditary cancer predisposition can rattle families, creating dysfunctional interactions. Families need assistance navigating conversations about risk. Because mothers and daughters uniquely share breast cancer experiences and risk, there is a particular need for practitioners to assist them with communication. Three focus groups were conducted with 11 mothers with an elevated cancer risk (with adolescent daughters) receiving genetic counseling. We explored three inquiries to capture mother-daughter communication: emergent challenging topics (e.g., health-promotion behavior, daughter's risk, mother's risk of death), factors complicating discussions (e.g., balancing what to share and when, guilt and blaming, confusion about risk and prevention), and strategies enhancing conversations initiated by mothers (e.g., paying attention to daughter's cues) or practitioners (e.g., inviting daughters to appointments). Findings suggested that mothers struggle to balance eliciting daughters' concerns, providing them with support, and imparting knowledge without overwhelming them. We offer mothers and practitioners guidance to help facilitate these conversations.

Young adult daughters of BRCA1/2 positive mothers: what do they know about hereditary cancer and how much do they worry?

OBJECTIVE

The objectives of this study are to determine (i) what daughters, ages 18-24 years, of BRCA1/2 mutation carriers understand about their 50% chance of carrying a BRCA1/2 mutation and about risk reduction or management options for mutation carriers, (ii) the extent and nature of daughters' cancer-related distress, and (iii) the effects of knowing mother's mutation status on daughters' future plans.

METHODS

A total of 40 daughters, currently aged 18-24 years, of mothers who tested positive for a mutation in BRCA1/2 were invited by mail to participate (with contact information supplied by their mothers). Daughters participated in a qualitative telephone interview about the impact of learning their mother's mutation status on their understanding of their own cancer risks and their cancer-related distress, and their knowledge of screening strategies, risk-reducing surgery, current health status, and future plans. Participants also completed study-specific demographic and family history questionnaires, the Brief Symptom Inventory-18, Impact of Event Scale (with hereditary predisposition to breast/ovarian cancer as the event), and the Breast Cancer Genetic Counseling Knowledge Questionnaire.

RESULTS

Daughters' genetic knowledge is suboptimal; gaps and misconceptions were common. Over 1/3 of the daughters reported high cancer-related distress, despite normal levels of general distress. Disclosed genetic information raised future concerns, especially regarding childbearing.

CONCLUSION

Targeted professional attention to this high-risk cohort of young women is critical to inform the next generation of daughters of BRCA1/2 mutation carriers and encourage recommended screening by age 25 years. Improved uptake of screening and risk reduction options could improve survival, and psychoeducation could reduce cancer-related distress.

Genetic counseling does not fulfill the counselees' need for certainty in hereditary breast/ovarian cancer families: an explorative assessment

BACKGROUND

Many cancer-patients undergo DNA testing in the BRCA1/2 genes to receive information about the likelihood that cancer is heritable. Previous nonsystematic studies suggested that DNA testing often does not fulfill the counselees' needs for certainty. We explored the balance between the counselees' need for certainty and perceived certainty (NfC-PC, i.e., level of fulfillment of NfC) regarding the specific domains of DNA test result, heredity and cancer. We also examined relationships of NfC-PC with coping styles and distress.

METHOD

Before disclosure of BRCA1/2 test results for hereditary breast/ovarian cancer (T1), questionnaires were filled in by 467 cancer-patients. Another questionnaire (T2) was filled in after disclosure of pathogenic mutation results (n = 30), uninformative results (n = 202) or unclassified-variants (n = 16).

RESULTS

Before and after DNA test result disclosure, overall 58-94% of all counselees experienced unfulfilled NfC regarding the DNA test result, heredity and cancer. Compared with T1, the communication of pathogenic mutations (T2) caused more fulfillment of the NfC about the DNA test result, but less about cancer and heredity (p < .01). Compared with T1, unclassified variants (T2) did not significantly change the extent of fulfillment of all counselees' needs for certainty (NfC > PC). Compared with T1, uninformative results (T2) caused more fulfillments of all needs than before disclosure (p < 0.01). Counselees differentiated NfC and PC between the domains of DNA-test result, heredity and cancer (p < 0.01). The unfulfilled needs for certainty (NfC-PC) were uncorrelated with cognitive understanding of the DNA test result.

CONCLUSION

The counselees' NfC needs more attention in research and practice, for example, when the potential uncertainties of testing are discussed. The counselees' NfC may be assessed and used in tailored, mutual communication of DNA test results.

DNA-testing for BRCA1/2 prior to genetic counselling in patients with breast cancer: design of an intervention study, DNA-direct

Background

Current practice for patients with breast cancer referred for genetic counseling, includes face-to-face consultations with a genetic counselor prior to and following DNA-testing. This is based on guidelines regarding Huntington’s disease in anticipation of high psychosocial impact of DNA-testing for mutations in BRCA1/2 genes. The initial consultation covers generic information regarding hereditary breast cancer and the (im)possibilities of DNA-testing, prior to such testing. Patients with breast cancer may see this information as irrelevant or unnecessary because individual genetic advice depends on DNA-test results. Also, verbal information is not always remembered well by patients. A different format for this information prior to DNA-testing is possible: replacing initial face-to-face genetic counseling (DNA-intake procedure) by telephone, written and digital information sent to patients’ homes (DNA-direct procedure).

Methods/design

In this intervention study, 150 patients with breast cancer referred to the department of Clinical Genetics of the Radboud University Nijmegen Medical Centre are given the choice between two procedures, DNA-direct (intervention group) or DNA-intake (usual care, control group). During a triage telephone call, patients are excluded if they have problems with Dutch text, family communication, or of psychological or psychiatric nature. Primary outcome measures are satisfaction and psychological distress. Secondary outcome measures are determinants for the participant’s choice of procedure, waiting and processing times, and family characteristics. Data are collected by self-report questionnaires at baseline and following completion of genetic counseling. A minority of participants will receive an invitation for a 30 min semi-structured telephone interview, e.g. confirmed carriers of a BRCA1/2 mutation, and those who report problems with the procedure.

Discussion

This study compares current practice of an intake consultation (DNA-intake) to a home informational package of telephone, written and digital information (DNA-direct) prior to DNA-testing in patients with breast cancer. The aim is to determine whether DNA-direct is an acceptable procedure for BRCA1/2 testing, in order to provide customized care to patients with breast cancer, cutting down on the period of uncertainty during this diagnostic process.

Trial registration

The study is registered at the Dutch Trial Registry http://www.trialregister.nl (NTR3018).