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Turbitt E, Bourne M, McEwen A, Amor DJ. Parents' preferences for receiving and discussing prognostic genetic information regarding their children's neurodevelopmental condition: A qualitative study. Dev Med Child Neurol 2024; 66:872-881. [PMID: 38111102 DOI: 10.1111/dmcn.15830] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 11/16/2023] [Accepted: 11/20/2023] [Indexed: 12/20/2023]
Abstract
AIM To investigate parents' preferences and motivations for receiving and discussing prognostic genetic test results. METHOD We used a cross-sectional, interpretive description qualitative study design. We collected data through semi-structured interviews with Australian parents, which we analysed using reflexive thematic analysis. RESULTS Parents (n = 32) had a child or children with a genetic neurodevelopmental condition, such as fragile X syndrome, DiGeorge (22q11.2 deletion) syndrome, or Angelman syndrome. Parents of mildly impacted or older children were tolerant to prognostic uncertainty. Parents found conversations about their child's prognosis emotional and preferred to discuss their child's potential strengths and challenges. While most were enthusiastic about prognostic tests and described many motivations for testing, the potential for prognostic information to contribute to a loss of hope and stigmatizing societal views were also discussed. INTERPRETATION Parents had mixed preferences and motivations for acquiring prognostic genetic information about their child, contrasting evidence in other contexts such as cancer where parents typically have minimal tolerance of uncertainty. Health professionals should consider strength-based framing of prognostic information gained from current and emerging technologies when returning results to families. WHAT THIS PAPER ADDS Parents had varied views about receiving prognostic information on their children's neurodevelopmental condition. Some parents preferred prognostic uncertainty about their children's genetic neurodevelopmental condition.
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Affiliation(s)
- Erin Turbitt
- Discipline of Genetic Counselling, University of Technology Sydney, Ultimo, NSW, Australia
| | - Meg Bourne
- Discipline of Genetic Counselling, University of Technology Sydney, Ultimo, NSW, Australia
| | - Alison McEwen
- Discipline of Genetic Counselling, University of Technology Sydney, Ultimo, NSW, Australia
| | - David J Amor
- Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
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Pearce E, Raj H, Emezienna N, Gilkey MB, Lazard AJ, Ribisl KM, Savage SA, Han PK. The Use of Social Media to Express and Manage Medical Uncertainty in Dyskeratosis Congenita: Content Analysis. JMIR INFODEMIOLOGY 2024; 4:e46693. [PMID: 38224480 PMCID: PMC10825764 DOI: 10.2196/46693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 11/09/2023] [Accepted: 11/28/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND Social media has the potential to provide social support for rare disease communities; however, little is known about the use of social media for the expression of medical uncertainty, a common feature of rare diseases. OBJECTIVE This study aims to evaluate the expression of medical uncertainty on social media in the context of dyskeratosis congenita, a rare cancer-prone inherited bone marrow failure and telomere biology disorder (TBD). METHODS We performed a content analysis of uncertainty-related posts on Facebook and Twitter managed by Team Telomere, a patient advocacy group for this rare disease. We assessed the frequency of uncertainty-related posts, uncertainty sources, issues, and management and associations between uncertainty and social support. RESULTS Across all TBD social media platforms, 45.98% (1269/2760) of posts were uncertainty related. Uncertainty-related posts authored by Team Telomere on Twitter focused on scientific (306/434, 70.5%) or personal (230/434, 53%) issues and reflected uncertainty arising from probability, ambiguity, or complexity. Uncertainty-related posts in conversations among patients and caregivers in the Facebook community group focused on scientific (429/511, 84%), personal (157/511, 30.7%), and practical (114/511, 22.3%) issues, many of which were related to prognostic unknowns. Both platforms suggested uncertainty management strategies that focused on information sharing and community building. Posts reflecting response-focused uncertainty management strategies (eg, emotional regulation) were more frequent on Twitter compared with the Facebook community group (χ21=3.9; P=.05), whereas posts reflecting uncertainty-focused management strategies (eg, ordering information) were more frequent in the Facebook community group compared with Twitter (χ21=55.1; P<.001). In the Facebook community group, only 36% (184/511) of members created posts during the study period, and those who created posts did so with a low frequency (median 3, IQR 1-7 posts). Analysis of post creator characteristics suggested that most users of TBD social media are White, female, and parents of patients with dyskeratosis congenita. CONCLUSIONS Although uncertainty is a pervasive and multifactorial issue in TBDs, our findings suggest that the discussion of medical uncertainty on TBD social media is largely limited to brief exchanges about scientific, personal, or practical issues rather than ongoing supportive conversation. The nature of uncertainty-related conversations also varied by user group: patients and caregivers used social media primarily to discuss scientific uncertainties (eg, regarding prognosis), form social connections, or exchange advice on accessing and organizing medical care, whereas Team Telomere used social media to express scientific and personal issues of uncertainty and to address the emotional impact of uncertainty. The higher involvement of female parents on TBD social media suggests a potentially greater burden of uncertainty management among mothers compared with other groups. Further research is needed to understand the dynamics of social media engagement to manage medical uncertainty in the TBD community.
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Affiliation(s)
- Emily Pearce
- Division of Cancer Epidemiology and Genetics, Clinical Genetics Branch, National Cancer Institute, National Institutes of Health, Rockville, MD, United States
| | - Hannah Raj
- Team Telomere, Coeur d'Alene, ID, United States
| | - Ngozika Emezienna
- Division of Cancer Epidemiology and Genetics, Clinical Genetics Branch, National Cancer Institute, National Institutes of Health, Rockville, MD, United States
| | - Melissa B Gilkey
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Allison J Lazard
- Hussman School of Journalism and Media, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Kurt M Ribisl
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Sharon A Savage
- Division of Cancer Epidemiology and Genetics, Clinical Genetics Branch, National Cancer Institute, National Institutes of Health, Rockville, MD, United States
| | - Paul Kj Han
- Division of Cancer Control and Population Sciences, Behavioral Research Program, National Cancer Institute, National Institutes of Health, Rockville, MD, United States
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Simonovic N, Taber JM. Effects of Construal Level on Responses to Ambiguous Health Information about Alcohol Consumption. HEALTH COMMUNICATION 2023; 38:238-251. [PMID: 34210211 DOI: 10.1080/10410236.2021.1945197] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Information about the health effects of alcohol consumption can be ambiguous (i.e., lacking in reliability, credibility, or adequacy) and thus may promote maladaptive health behavior. Guided by Construal Level Theory and a conceptual taxonomy of uncertainty in health care, we tested the hypothesis that manipulating construal level would promote adaptive responses to ambiguous health information. We examined the effects of ambiguous health information about alcohol on health cognitions, message responses, and intentions, as well as whether manipulating construal moderated these effects. Alcohol users (n = 135, Mage = 20.15, 68.9% female) were randomly assigned to either a high-level or low-level construal task and then to read either an ambiguous or unambiguous health communication about the health effects of alcohol. Participants responded similarly to ambiguous health information as they did to unambiguous health information and participants in a high-level construal did not generally report differences compared with those in a low-level construal. Findings suggest that ambiguous health information might not always lead to maladaptive effects. More research is needed to examine moderators of the relationship between ambiguous health information and health outcomes, as well as to understand how and when using construal manipulations are effective in different health contexts.
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Simonovic N, Taber JM, Scherr CL, Dean M, Hua J, Howell JL, Chaudhry BM, Wain KE, Politi MC. Uncertainty in healthcare and health decision making: Five methodological and conceptual research recommendations from an interdisciplinary team. J Behav Med 2022. [DOI: 10.1007/s10865-022-00384-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Hong SJ. Uncertainty in the Process of Communicating Cancer-related Genetic Risk Information with Patients: A Scoping Review. JOURNAL OF HEALTH COMMUNICATION 2020; 25:251-270. [PMID: 32271688 DOI: 10.1080/10810730.2020.1745963] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
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.
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Affiliation(s)
- Soo Jung Hong
- Department of Communications and New Media, Faculty of Arts and Social Sciences, National University of Singapore, Singapore
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7
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Simonovic N, Taber JM, Klein WMP, Ferrer RA. Evidence that perceptions of and tolerance for medical ambiguity are distinct constructs: An analysis of nationally representative US data. Health Expect 2020; 23:603-613. [PMID: 32097530 PMCID: PMC7321721 DOI: 10.1111/hex.13037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 01/16/2020] [Accepted: 01/31/2020] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Medical information is often conflicting and consequently perceived as ambiguous. There are individual differences both in how much people perceive ambiguity and in their tolerance for such ambiguity. Little is known about how these constructs are related to each other and with other beliefs. OBJECTIVE To examine the association between (a) perceived medical ambiguity, (b) tolerance for medical ambiguity and (c) their associations with various medical and cancer-specific judgement and decision-making correlates. METHOD AND PARTICIPANTS We conducted secondary data analyses using the cross-sectional, nationally representative Health Information National Trends Survey 4, Cycle 4 (n = 3,433, 51.0% female, Mage = 46.5). Analyses statistically controlled for age, sex, race, education and health-care coverage. MAIN VARIABLES STUDIED Perceived medical ambiguity, tolerance for medical ambiguity, cancer perceptions, health-care experiences and preferences, and information-seeking styles and beliefs. RESULTS Perceived medical ambiguity and tolerance for medical ambiguity were statistically independent. Higher perceived ambiguity was associated with lower perceived cancer preventability, lower reliance on doctors, lower perceived health and information-seeking self-efficacy, lower perceived quality of the cancer information-seeking process, and greater cancer information avoidance. Lower tolerance for ambiguity was associated with lower cancer worry, lower trust in doctors, lower likelihood of seeking health information, and lower engagement in medical research. DISCUSSION AND CONCLUSIONS Perceived medical ambiguity and tolerance for medical ambiguity seem to be distinct constructs. Findings have implications for how people make medical decisions when they perceive and prefer to avoid conflicting medical information.
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Affiliation(s)
- Nicolle Simonovic
- Department of Psychological Sciences, Kent State University, Kent, OH, USA
| | - Jennifer M Taber
- Department of Psychological Sciences, Kent State University, Kent, OH, USA
| | - William M P Klein
- Behavioral Research Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Rebecca A Ferrer
- Behavioral Research Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
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Han PKJ, Babrow A, Hillen MA, Gulbrandsen P, Smets EM, Ofstad EH. Uncertainty in health care: Towards a more systematic program of research. PATIENT EDUCATION AND COUNSELING 2019; 102:1756-1766. [PMID: 31227333 DOI: 10.1016/j.pec.2019.06.012] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/08/2019] [Accepted: 06/12/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To promote a more systematic approach to research on uncertainty in health care, and to explore promising starting points and future directions for this research. METHODS We examine three fundamental aspects of medical uncertainty that a systematic research program should ideally address: its nature, effects, and communication. We summarize key insights from past empirical research and explore existing conceptual models that can help guide future research. RESULTS A diverse body of past research on medical uncertainty has produced valuable empirical insights and conceptual models that provide useful starting points for future empirical and theoretical work. However, these insights need to be more fully developed and integrated to answer remaining questions about what uncertainty is, how it affects people, and how and why it should be communicated. CONCLUSION Uncertainty in health care is an extremely important but incompletely understood phenomenon. Improving our understanding of the many important aspects of uncertainty in health care will require a more systematic program of research based upon shared, integrative conceptual models and active, collaborative engagement of the broader research community. PRACTICE IMPLICATIONS A more systematic approach to investigating uncertainty in health care can help elucidate how the clinical communication of uncertainty might be improved.
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Affiliation(s)
- Paul K J Han
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, USA; Tufts University School of Medicine, Boston, USA.
| | - Austin Babrow
- School of Communication Studies, Ohio University, Athens, USA
| | - Marij A Hillen
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Pål Gulbrandsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway; HØKH Research Center, Akershus University Hospital, Lørenskog, Norway
| | - Ellen M Smets
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Eirik H Ofstad
- Department of Medicine, Nordland Hospital Trust, Bodø, Norway; Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway
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Blanch-Hartigan D, van Eeden M, Verdam MGE, Han PKJ, Smets EMA, Hillen MA. Effects of communication about uncertainty and oncologist gender on the physician-patient relationship. PATIENT EDUCATION AND COUNSELING 2019; 102:1613-1620. [PMID: 31101428 DOI: 10.1016/j.pec.2019.05.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 04/15/2019] [Accepted: 05/01/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Physicians are increasingly expected to share uncertain information, yet there is concern about possible negative effects on patients. How uncertainty is conveyed and by whom may influence patients' response. We tested the effects of verbally and non-verbally communicating uncertainty by a male vs. female oncologist on patients' trust and intention to seek a second opinion. METHODS In an experimental video vignettes study conducted in The Netherlands, oncologist communication behavior (verbal vs. non-verbal and high vs. low uncertainty) and gender (male vs. female) were systematically manipulated. Former cancer patients viewed one video variant and reported trust, intention to seek a second opinion, and experience of uncertainty. RESULTS Non-verbal communication of high uncertainty by the oncologist led to reduced trust (β = -0.72 (SE = 0.15), p < .001) and increased intention to seek a second opinion (β = 0.67 (SE = 0.16), p < .001). These effects were partly explained by patients' increased experience of uncertainty (β = -0.48 (SE = 0.12), p < .001; and β = 0.34 (SE = 0.09), p < .001 respectively). Neither verbal uncertainty nor oncologists' gender influenced trust or intention to seek a second opinion. CONCLUSION Non-verbal communication of uncertainty by oncologists may affect patient trust and intention to seek a second-opinion more than verbal communication. PRACTICE IMPLICATIONS Further research to understand and improve oncologists' non-verbal uncertainty behavior is warranted.
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Affiliation(s)
| | - Marceline van Eeden
- Amsterdam UMC, University of Amsterdam, Department of Medical Psychology, Amsterdam Public Health, Amsterdam, The Netherlands
| | - Mathilde G E Verdam
- Amsterdam UMC, University of Amsterdam, Department of Medical Psychology, Amsterdam Public Health, Amsterdam, The Netherlands; Leiden University, Institute of Psychology, Leiden, The Netherlands
| | - Paul K J Han
- Center for Outcomes Research and Evaluation, Maine Medical Center Research Institute, Portland, USA
| | - Ellen M A Smets
- Amsterdam UMC, University of Amsterdam, Department of Medical Psychology, Amsterdam Public Health, Amsterdam, The Netherlands
| | - Marij A Hillen
- Amsterdam UMC, University of Amsterdam, Department of Medical Psychology, Amsterdam Public Health, Amsterdam, The Netherlands.
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Hamilton JG, Robson ME. Psychosocial Effects of Multigene Panel Testing in the Context of Cancer Genomics. Hastings Cent Rep 2019; 49 Suppl 1:S44-S52. [PMID: 31268573 PMCID: PMC7430497 DOI: 10.1002/hast.1016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In recent years, with both the development of next-generation sequencing approaches and the Supreme Court decision invalidating gene patents, declining costs have contributed to the emergence of a new model of hereditary cancer genetic testing. Multigene panel testing (or multiplex testing) involves using next-generation sequencing technology to determine the sequence of multiple cancer-susceptibility genes. In addition to high-penetrance cancer-susceptibility genes, multigene panels frequently include genes that are less robustly associated with cancer predisposition. Scientific understanding about associations between many specific moderate-penetrance gene variants and cancer risks is incomplete. The emergence of multigene panel tests has created unique challenges that may have meaningful psychosocial implications. Contrasted with the serial testing process, wherein patients consider the personal and clinical implications of each evaluated gene, with multigene panel testing, patients provide broad consent to whichever genes are included in a particular panel and then, after the test, receive in-depth genetic counseling to clarify the distinct implications of their specific results. Consequently, patients undergoing multigene panel testing may have a less nuanced understanding of the test and its implications, and they may have fewer opportunities to self-select against the receipt of particular types of genetic-risk information. Evidence is conflicting regarding the emotional effects of this testing.
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Affiliation(s)
- Jada G. Hamilton
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan Kettering Cancer Center
- Department of Medicine, Memorial Sloan Kettering Cancer Center
- Weill Cornell Medical College
| | - Mark E. Robson
- Department of Medicine, Memorial Sloan Kettering Cancer Center
- Weill Cornell Medical College
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11
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Esteban I, Lopez-Fernandez A, Balmaña J. A narrative overview of the patients' outcomes after multigene cancer panel testing, and a thorough evaluation of its implications for genetic counselling. Eur J Med Genet 2018; 62:342-349. [PMID: 30476626 DOI: 10.1016/j.ejmg.2018.11.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 11/08/2018] [Accepted: 11/22/2018] [Indexed: 01/07/2023]
Abstract
Massively parallel sequencing is being implemented in clinical practice through the use of multigene panel testing, whole exome sequencing and whole genome sequencing. In this manuscript we explore how the use of massively parallel sequencing, and in particular multigene cancer panel testing, is potentially changing the process of genetic counselling and how patients cope with pre-test genetic counselling and results. We found that the main challenges are around uncertainty, hopes and expectations and the amount and complexity of information that needs to be discussed. This may impact the process of genetic counselling, although genetic counsellors can still use their core skills and enhance some of them in order to evolve and meet patients' needs in the genomics era. Available data suggests that patients can cope with multigene cancer panels although more research is needed to fully understand the psychosocial implications of multigene cancer panels for patients, especially for those who have variants of unknown significance or moderate penetrance variants. Research is also needed to explore and develop communication models that maximize patients' understanding and empower them to make informed decisions.
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Affiliation(s)
- I Esteban
- Department of Clinical Genetics, Ninewells Hospital, Dundee, Scotland, UK.
| | - A Lopez-Fernandez
- High Risk and Cancer Prevention Unit, Vall D'Hebron Institute of Oncology, Barcelona, Spain
| | - J Balmaña
- High Risk and Cancer Prevention Unit, Vall D'Hebron Institute of Oncology, Barcelona, Spain; Medical Oncology Department, Vall D'Hebron Hospital, Barcelona, Spain
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Schulz GL, Kelly KP, Holtmann M, Doering MM, Armer JM. Decision making in pediatric hematopoietic cell transplantation: Influential factors vary among diseases. Pediatr Blood Cancer 2018; 65. [PMID: 29218777 DOI: 10.1002/pbc.26890] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 10/09/2017] [Accepted: 10/10/2017] [Indexed: 12/31/2022]
Abstract
Hematopoietic cell transplantation (HCT) is not a trivial treatment decision in pediatrics. We sought to understand what influences this decision-making process from the perspectives of the pediatric patients, their family, and physicians. Using integrative review methods, we identified 19 relevant studies: six qualitative, ten quantitative, and three mixed methods. Synthesis of the results revealed six themes describing patient, family, and provider decision-making processes with distinct subthemes contrasting influential factors among malignant and nonmalignant diseases. Identification of what influences HCT decision making will aid in development of decision support, education, and communication strategies. The child/adolescent voice and provider perspective warrant more attention.
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Affiliation(s)
- Ginny L Schulz
- Sinclair School of Nursing, University of Missouri, Columbia, Missouri.,Siteman Kids at St, Louis Children's Hospital, St. Louis, Missouri.,Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Katherine P Kelly
- Children's National Health System, Washington, District of Columbia.,Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - Megan Holtmann
- Siteman Kids at St, Louis Children's Hospital, St. Louis, Missouri
| | - Michelle M Doering
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Jane M Armer
- Sinclair School of Nursing, University of Missouri, Columbia, Missouri.,American Lymphedema Framework Project, Columbia, Missouri
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Gramling R, Stanek S, Han PK, Duberstein P, Quill TE, Temel JS, Alexander SC, Anderson WG, Ladwig S, Norton SA. Distress Due to Prognostic Uncertainty in Palliative Care: Frequency, Distribution, and Outcomes among Hospitalized Patients with Advanced Cancer. J Palliat Med 2018; 21:315-321. [DOI: 10.1089/jpm.2017.0285] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Robert Gramling
- Division of Palliative Medicine, Department of Family Medicine, University of Vermont Medical Center, Burlington, Vermont
| | - Susan Stanek
- School of Nursing, University of Rochester, Rochester, New York
| | - Paul K.J. Han
- Maine Medical Center Research Institute, Scarborough, Maine
| | - Paul Duberstein
- Department of Psychiatry, University of Rochester, Rochester, New York
| | - Tim E. Quill
- School of Nursing, University of Rochester, Rochester, New York
| | - Jennifer S. Temel
- Department of Medicine, Harvard University, Cambridge, Massachusetts
| | - Stewart C. Alexander
- Department of Consumer Science, Department of Medicine, Purdue University, West Lafayette, Indiana
| | | | - Susan Ladwig
- Division of Palliative Care, University of Rochester, Rochester, New York
| | - Sally A. Norton
- School of Nursing, University of Rochester, Rochester, New York
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Hillen MA, Gutheil CM, Strout TD, Smets EM, Han PK. Tolerance of uncertainty: Conceptual analysis, integrative model, and implications for healthcare. Soc Sci Med 2017; 180:62-75. [DOI: 10.1016/j.socscimed.2017.03.024] [Citation(s) in RCA: 161] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 02/27/2017] [Accepted: 03/12/2017] [Indexed: 11/29/2022]
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McMahon MA, Dluhy NM. Ambiguity Within Nursing Practice: An Evolutionary Concept Analysis. Res Theory Nurs Pract 2017; 31:56-74. [DOI: 10.1891/1541-6577.31.1.56] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Purpose:To analyze the concept of ambiguity in a nursing context.Background:Ambiguity is inherent within nursing practice. As health care becomes increasingly complex, nurses must continue to successfully deal with greater amounts of clinical ambiguity. Although ambiguity is discussed in nursing, minimal concept refinement exists to capture the contextual intricacies from a nursing lens. Nurse perception of an ambiguous clinical event, in combination with nurse tolerance level for ambiguity, can impact nurse response. Yet, little is known about what constitutes ambiguity within nursing practice (AWNP).Method:Rodgers evolutionary method was used to explore AWNP, with emphasis on nurse thinking during ambiguous clinical situations. Literature searches across multiple databases yielded 38 articles for analysis.Results:Attributesof AWNP include (a) variations in cues/available information, (b) multiple interpretations, (c) novel/nonroutine presentations, and (d) unpredictable.Antecedentsinclude (a) a context-specific, clinical situation with ambiguous features needing evaluation and (b) an individual to sense a knowledge gap or perceive ambiguity.Consequencesinclude ranges of (a) emotional, (b) behavioral, and (c) cognitive clinician responses.Conclusion:Preliminary findings support AWNP as a distinct concept in which ambiguity perceived by the nurse likely affects judgment, decision making, and clinical interventions. AWNP is a clinically relevant concept requiring continued development.
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Khan NE, Rosenberg PS, Alter BP. Preemptive Bone Marrow Transplantation and Event-Free Survival in Fanconi Anemia. Biol Blood Marrow Transplant 2016; 22:1888-1892. [PMID: 27345141 DOI: 10.1016/j.bbmt.2016.06.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 06/17/2016] [Indexed: 11/25/2022]
Abstract
Fanconi anemia (FA) is a rare inherited bone marrow failure syndrome associated with high risks of severe bone marrow failure (BMF), acute myeloid leukemia (AML), and solid tumors (ST). Bone marrow transplantation (BMT) provides a theoretical cure for hematologic risks (BMF, AML), but it introduces uncertain risks of transplantation-related mortality (TRM) and carcinogenicity. We developed a mathematical (Markov) decision model to estimate event-free survival (EFS) conditional on age based on per-year cause-specific hazard rates. We assumed that preemptive (PE) BMT eliminates the risks of BMF and AML, but it may introduce independent risks of TRM or influence the trajectory to ST. Our model suggested that the expected mean EFS in FA is higher for PE-BMT at young ages, with minimal risk of TRM and with little carcinogenicity. PE-BMT in adults decreased expected EFS because of the greater competing risk of ST in adulthood. Estimates of EFS conditioned on attained age may be used in shared decision-making when clinicians must counsel patients using limited data. Our methods may be used to model early transplantation in other blood disorders for which hematopoietic stem cell transplantation mitigates some but not all of the risks.
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Affiliation(s)
- Nicholas E Khan
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Philip S Rosenberg
- Biostatistics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland
| | - Blanche P Alter
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland.
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17
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Patient hopes for diagnostic genomic sequencing: roles of uncertainty and social status. Eur J Hum Genet 2015; 24:803-8. [PMID: 26395557 DOI: 10.1038/ejhg.2015.204] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 07/12/2015] [Accepted: 08/14/2015] [Indexed: 11/08/2022] Open
Abstract
For patients with unexplained or undiagnosed conditions, genomic sequencing offers the hope of resolving unanswered questions. With the growth of clinical genomic sequencing, understanding factors that shape patients' hope for information could have important implications for developing patient education guidelines. Based on the goal-directed theory of hope, we investigated illness uncertainty as a form of motivation and subjective social status as a form of perceived resources to predict the amount and kinds of information that adult patients (N=191) and parents of pediatric patients (N=79) hoped to receive from diagnostic sequencing results. Participants were part of a larger longitudinal study on clinical genomic sequencing, but the current study focuses on their hopes for diagnostic sequencing results. Hopes for information were assessed through close-ended and open-ended responses. Findings from mixed methods analyses indicated that although patients and parents hoped to learn multiple kinds of information from diagnostic sequencing results, their hopes appeared to be influenced by their illness uncertainty and perceptions of their social and economic resources. These findings suggest that patients' illness uncertainty and perceived resources could be useful avenues for discussing patient hopes and educating patients about strengths and limitations of genomic sequencing.
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Taber JM, Klein WMP, Ferrer RA, Han PKJ, Lewis KL, Biesecker LG, Biesecker BB. Perceived ambiguity as a barrier to intentions to learn genome sequencing results. J Behav Med 2015; 38:715-26. [PMID: 26003053 DOI: 10.1007/s10865-015-9642-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 04/28/2015] [Indexed: 10/23/2022]
Abstract
Many variants that could be returned from genome sequencing may be perceived as ambiguous-lacking reliability, credibility, or adequacy. Little is known about how perceived ambiguity influences thoughts about sequencing results. Participants (n = 494) in an NIH genome sequencing study completed a baseline survey before sequencing results were available. We examined how perceived ambiguity regarding sequencing results and individual differences in medical ambiguity aversion and tolerance for uncertainty were associated with cognitions and intentions concerning sequencing results. Perceiving sequencing results as more ambiguous was associated with less favorable cognitions about results and lower intentions to learn and share results. Among participants low in tolerance for uncertainty or optimism, greater perceived ambiguity was associated with lower intentions to learn results for non-medically actionable diseases; medical ambiguity aversion did not moderate any associations. Results are consistent with the phenomenon of "ambiguity aversion" and may influence whether people learn and communicate genomic information.
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Affiliation(s)
- Jennifer M Taber
- National Cancer Institute, 9609 Medical Center Drive, Bethesda, MD, 20892-9761, USA.
| | - William M P Klein
- National Cancer Institute, 9609 Medical Center Drive, Bethesda, MD, 20892-9761, USA
| | - Rebecca A Ferrer
- National Cancer Institute, 9609 Medical Center Drive, Bethesda, MD, 20892-9761, USA
| | | | - Katie L Lewis
- National Human Genome Research Institute, Bethesda, MD, USA
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Khan CM, Rini C, Bernhardt BA, Roberts JS, Christensen KD, Evans JP, Brothers KB, Roche MI, Berg JS, Henderson GE. How can psychological science inform research about genetic counseling for clinical genomic sequencing? J Genet Couns 2015; 24:193-204. [PMID: 25488723 PMCID: PMC4777349 DOI: 10.1007/s10897-014-9804-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 11/25/2014] [Indexed: 01/02/2023]
Abstract
Next generation genomic sequencing technologies (including whole genome or whole exome sequencing) are being increasingly applied to clinical care. Yet, the breadth and complexity of sequencing information raise questions about how best to communicate and return sequencing information to patients and families in ways that facilitate comprehension and optimal health decisions. Obtaining answers to such questions will require multidisciplinary research. In this paper, we focus on how psychological science research can address questions related to clinical genomic sequencing by explaining emotional, cognitive, and behavioral processes in response to different types of genomic sequencing information (e.g., diagnostic results and incidental findings). We highlight examples of psychological science that can be applied to genetic counseling research to inform the following questions: (1) What factors influence patients' and providers' informational needs for developing an accurate understanding of what genomic sequencing results do and do not mean?; (2) How and by whom should genomic sequencing results be communicated to patients and their family members?; and (3) How do patients and their families respond to uncertainties related to genomic information?
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Affiliation(s)
- Cynthia M Khan
- Department of Health Behavior, University of North Carolina-Chapel Hill, 312 Rosenau Hall, CB#7440, Chapel Hill, NC, 27599-7440, USA,
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20
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Hay JL, Orom H, Kiviniemi MT, Waters EA. "I don't know" my cancer risk: exploring deficits in cancer knowledge and information-seeking skills to explain an often-overlooked participant response. Med Decis Making 2015; 35:436-45. [PMID: 25810268 DOI: 10.1177/0272989x15572827] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Accepted: 01/19/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Perceived risk is a central theoretical construct in health behavior research. Participants' "don't know" responses to perceived-risk items (DKPR) are usually excluded from analyses. Yet those who provide such responses may have unique cancer information needs. OBJECTIVE The hypotheses that DKPR responding may be due to cancer knowledge deficits or behavioral, skill, and attitudinal antecedents to knowledge deficits (information seeking, numeracy, and self-efficacy, respectively) were explored. METHODS Data from the 2005 Health Information National Trends Survey (HINTS; N = 1789), a US population-based survey, and an urban, minority, primary care clinic survey (N = 590) were analyzed. Multivariable logistic regressions were conducted to examine knowledge deficit explanations for responding DKPR to colon cancer risk perception questions (adjusting for demographics and family colorectal cancer history). MEASURES Comparative (HINTS) and absolute verbal perceived risk of colon cancer (HINTS, clinic survey), knowledge of colon cancer risks and screening, cancer/health information-seeking behavior and self-efficacy (HINTS), and numeracy (clinic survey). RESULTS Greater knowledge of colon cancer prevention and screening, cancer and health information seeking, and numeracy were each associated with lower odds of providing a DKPR response. LIMITATIONS The study was cross-sectional, which limits the ability to infer causal direction. The use of existing data sets limited our variable choices. Other plausible hypotheses may also explain DKPR responding. CONCLUSIONS People who report that they don't know their colon cancer risk may have low cancer knowledge and reduced knowledge acquisition behaviors and skills. Health behavior research could benefit from including data concerning DKPR responses to risk perception questions, because individuals who respond in this way may require interventions to address potential cancer risk knowledge deficits.
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Affiliation(s)
- Jennifer L Hay
- Department of Psychiatry & Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, NY, USA (JLH)
| | - Heather Orom
- Department of Community Health & Health Behavior, School of Public Health and Health Professions, University at Buffalo, SUNY, New York, NY, USA (HO, MTK)
| | - Marc T Kiviniemi
- Department of Community Health & Health Behavior, School of Public Health and Health Professions, University at Buffalo, SUNY, New York, NY, USA (HO, MTK)
| | - Erika A Waters
- Department of Surgery, Division of Public Health Sciences, Washington University in St. Louis, St. Louis, MO, USA (EAW)
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Klein WMP, Hamilton JG, Harris PR, Han PKJ. Health messaging to individuals who perceive ambiguity in health communications: the promise of self-affirmation. JOURNAL OF HEALTH COMMUNICATION 2015; 20:566-72. [PMID: 25806652 DOI: 10.1080/10810730.2014.999892] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
The perception that extant health messages about risk factors for a disease are ambiguous can be associated with greater anxiety and reduced interest in taking precautionary action. In this experiment, 247 female alcohol consumers who perceived varying degrees of ambiguity in current cancer prevention messages read an unambiguous article about the documented link between alcohol consumption and breast cancer. Before reading the article, half were given the opportunity to self-affirm by reflecting on an important value-a technique previously shown to enhance receptivity to threatening messages. The authors found that self-affirmation increased message acceptance among those who perceived relatively higher levels of ambiguity in cancer communications. Also, the relation between perceived ambiguity and risk perception became positive among self-affirmed participants, suggesting they had become less defensive. Self-affirmation may be an effective technique to use when delivering health communications to audiences who perceive a lack of consistency in prevention messages.
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Affiliation(s)
- William M P Klein
- a Behavioral Research Program, Division of Cancer Control and Population Sciences , National Cancer Institute, National Institutes of Health , Bethesda , Maryland , USA
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22
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Genetic Information-Seeking Behaviors and Knowledge among Family Members and Patients with Inherited Bone Marrow Failure Syndromes. J Genet Couns 2014; 24:760-70. [PMID: 25540896 DOI: 10.1007/s10897-014-9807-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 12/09/2014] [Indexed: 10/24/2022]
Abstract
Inherited bone marrow failure syndromes (IBMFS) including Fanconi anemia, dyskeratosis congenita, Diamond-Blackfan anemia, and Shwachman-Diamond syndrome are rare genetic disorders characterized by hematologic complications and increased risk of cancer. Patients and their families likely experience obstacles in obtaining sufficient health information given their disorders' rarity. To investigate this possibility, we examined information-seeking behaviors and levels of general and disorder-specific genetic knowledge among 315 members of 174 families with an IBMFS, and how information-seeking behaviors and socio-demographic factors may be associated with their genetic knowledge. Cross-sectional survey data indicated that participants were most likely to have ever used the Internet or healthcare providers for genetic information. On average, participants correctly answered 57 % of items assessing general genetic knowledge and 49-59 % of disorder-specific knowledge items. Greater knowledge was associated with greater education and ever experiencing genetic counseling, attending a scientific meeting, and seeking information from the Internet and scientific literature. Among families with Fanconi anemia (whose family support organization has the longest history of providing information), greater disorder-specific genetic knowledge was also associated with seeking information from support groups and other affected families. Results suggest that families with IBMFS have uncertainty regarding genetic aspects of their disorder, and highlight potential channels for delivering educational resources.
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Biesecker BB, Klein W, Lewis KL, Fisher TC, Wright MF, Biesecker LG, Han PK. How do research participants perceive "uncertainty" in genome sequencing? Genet Med 2014; 16:977-80. [PMID: 24875302 PMCID: PMC4247806 DOI: 10.1038/gim.2014.57] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Accepted: 04/21/2014] [Indexed: 11/18/2022] Open
Abstract
PURPOSE The scope of uncertainty in genome sequence information has no rival in health-care delivery. We present data from adults participating in a National Institutes of Health study using this technology, in which perceptions of uncertainty are hypothesized to be key in predicting decisions to learn and act on genome health information. METHODS We conducted six professionally moderated focus groups with 39 randomly selected ClinSeq participants varying on whether they had coronary heart disease and had received prior sequence results. We elicited perceptions of the uncertainties associated with genome sequencing using written prompts. RESULTS Participants perceived uncertainty as a quality of genome information. The majority of participants characterized uncertainty of sequencing information as "changing, fluid, developing, or ground breaking." These responses led to anticipation of more optimistic future outcomes. Fewer participants described uncertainty as "questionable, less accurate, limited, or poorly understood." These perceptions seemed to undermine participants' faith in genome information, leading to feelings of disillusionment. CONCLUSION Our findings suggest that perceptions of uncertainty are related to epistemological beliefs that inform expectations for the information. Interventions that promote realistic expectations of genome sequencing may mitigate negative responses to uncertainty.
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Affiliation(s)
- Barbara B Biesecker
- Social and Behavioral Research Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland 20892
| | - William Klein
- Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892
| | - Katie L Lewis
- Genetics Disease Research Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland 20892
| | - Tyler C Fisher
- Social and Behavioral Research Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland 20892
| | - Martha Frances Wright
- Genetics Disease Research Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland 20892
| | - Leslie G Biesecker
- Genetics Disease Research Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, Maryland 20892
| | - Paul K Han
- Maine Medical Center Research Institute, Center for Outcomes Research and Evaluation, 81 Research Dr Scarborough, ME 04074
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Abstract
Fanconi anemia (FA) is a rare autosomal recessive cancer-prone inherited bone marrow failure syndrome, due to mutations in 16 genes, whose protein products collaborate in a DNA repair pathway. The major complications are aplastic anemia, acute myeloid leukemia (AML), myelodysplastic syndrome (MDS), and specific solid tumors. A severe subset, due to mutations in FANCD1/BRCA2, has a cumulative incidence of cancer of 97% by age 7 years; the cancers are AML, brain tumors, and Wilms tumor; several patients have multiple events. Patients with the other genotypes (FANCA through FANCQ) have cumulative risks of more than 50% of marrow failure, 20% of AML, and 30% of solid tumors (usually head and neck or gynecologic squamous cell carcinoma), by age 40, and they too are at risk of multiple adverse events. Hematopoietic stem cell transplant may cure AML and MDS, and preemptive transplant may be appropriate, but its use is a complicated decision.
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Affiliation(s)
- Blanche P Alter
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, USA.
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Hooker GW, Ormond KE, Sweet K, Biesecker BB. Teaching genomic counseling: preparing the genetic counseling workforce for the genomic era. J Genet Couns 2014; 23:445-51. [PMID: 24504939 PMCID: PMC4096068 DOI: 10.1007/s10897-014-9689-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2013] [Accepted: 01/09/2014] [Indexed: 12/13/2022]
Abstract
Genetic counselors have a long-standing history of working on the clinical forefront of implementing new genetic technology. Genomic sequencing is no exception. The rapid advancement of genomic sequencing technologies, including but not limited to next generation sequencing approaches, across all subspecialties of genetic counseling mandates attention to genetic counselor training at both the graduate and continuing education levels. The current era provides a tremendous opportunity for counselors to become actively involved in making genomics more accessible, engaging the population in decisions to undergo sequencing and effectively translating genomic information to promote health and well-being. In this commentary, we explore reasons why genomic sequencing warrants particular consideration and put forward strategies for training program curricula and continuing education programs to meet this need.
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Affiliation(s)
- Gillian W Hooker
- Social and Behavioral Research Branch, Genetic Counseling Training Program, The Johns Hopkins School of Public Health, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA,
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