Inequities in genetic testing for hereditary breast cancer: implications for public health practice

Development and early-stage evaluation of a patient portal to enhance familial communication about hereditary cancer susceptibility testing: A patient-driven approach

INTRODUCTION

Genetic testing for hereditary cancer syndromes (HCSs) can improve health outcomes through cancer risk mitigation strategies. Effective communication between tested individuals and their family members is key to reducing the hereditary cancer burden. Our objective was to develop a patient portal to improve familial communication for patients undergoing HCS genetic testing, followed by an early-phase evaluation.

METHODS

The portal was developed following the completion of 25 semistructured interviews with individuals having undergone HCS susceptibility testing at BC Cancer. Following initial development, we recruited patients and healthcare providers to provide critical feedback informing portal refinement. Quantitative feedback was summarized using descriptive statistics, and qualitative feedback was synthesized by two reviewers who engaged in iterative discussion within the research team to prioritize recommendations for integration.

RESULTS

The patient portal includes four key components consisting of (a) targeted educational information about hereditary cancer and HBOC syndrome associated risks and testing process overview, (b) a general frequently asked questions 'FAQ' page informed by the qualitative interviews, patient partner feedback, and consultation with the HCP, (c) guidance to support familial communication including a video developed with a patient partner describing their lived experience navigating the communication process and (d) a series of lay summaries of genetic test findings to support information transfer among family members. Thirteen healthcare providers and seven patients participated in user testing. Domains within which participant recommendations were provided included presentation, educational content and process clarification.

CONCLUSIONS

This investigation demonstrates the value of continual integration of patient and provider preferences through the development of tools endeavouring to assist with complex genomics-informed decision-making. Our work aims to broaden the population-wide impact of HCS testing programs by improving communication processes between probands and their potentially affected family members.

PATIENT OR PUBLIC CONTRIBUTION

This work involved a patient partner who was actively engaged in all aspects of the research investigation including protocol development, review and editing of all study documentation (including that of the previously published qualitative investigation), interpretation of results, as well as reviewing and editing the manuscript. Patient partners and healthcare professionals were recruited as research participants to provide critical feedback on the patient portal.

Health and healthcare equity within the Canadian cancer care sector: a rapid scoping review

BACKGROUND

Despite a publicly-funded healthcare system, alarming cancer-related health and healthcare inequities persist in Canada. However, it remains unclear how equity is being understood and taken up within the Canadian cancer context. Our objective was to identify how health and healthcare equity are being discussed as goals or aims within the cancer care sector in Canada.

METHODS

A rapid scoping review was conducted; five biomedical databases, 30 multidisciplinary websites, and Google were searched. We included English-language documents published between 2008 and 2021 that discussed health or healthcare equity in the Canadian cancer context.

RESULTS

Of 3860 identified documents, 83 were included for full-text analysis. The prevalence of published and grey equity-oriented literature has increased over time (2008-2014 [n = 20]; 2015-2021 [n = 62]). Only 25% of documents (n = 21) included a definition of health equity. Concepts such as inequity, inequality and disparity were frequently used interchangeably, resulting in conceptual muddling. Only 43% of documents (n = 36) included an explicit health equity goal. Although a suite of actions were described across the cancer control continuum to address equity goals, most were framed as recommendations rather than direct interventions.

CONCLUSION

Health and healthcare equity is a growing priority in the cancer care sector; however, conceptual clarity is needed to guide the development of robust equity goals, and the development of sustainable, measurable actions that redress inequities across the cancer control continuum. If we are to advance health and healthcare equity in the cancer care sector, a coordinated and integrated approach will be required to enact transformative and meaningful change.

"My Cancer Is Worth Only Fifteen Weeks"? A Critical Analysis of the Lived Experiences of Financial Toxicity and Cancer in Canada

BACKGROUND

Cancer patients experience financial hardship due to rising expenses related to cancer treatment and declining income levels associated with reduced employability. Employment Insurance Sick Benefits (EI-SB) is a social income support program which provides temporary income replacement to Canadians when they fall ill. Although EI-SB is designed to maintain continuity of income during an illness, little is known about the perspectives of cancer patients who receive EI-SB. This knowledge can inform the development of public policies which are responsive to the needs and priorities of cancer patients.

METHODS

We conducted a theory-informed thematic analysis of data collected from twenty semi-structured interviews with participants who were receiving care in a cancer centre in Cape Breton, Nova Scotia and had received EI-SB. A coding framework was developed using Taplin and colleagues' intermediate outcomes of patient care across the cancer care continuum. Interpretation of findings was guided by the synergies of oppression theoretical lens.

RESULTS

Three overarching themes describe the experiences of cancer patients receiving social income support: Economic exclusion, in which the structure of the labour market and social welfare system determine access to workplace benefits and continuity of reasonable income; financial toxicity, a vicious cycle of financial burden and increasing financial distress; and constrained choices, where cancer influences employability and lowered income influences the need to be employed.

CONCLUSION

Cancer patients need income support programs that are tailored to match their healthcare priorities. In addition, policies which strengthen working conditions and facilitate a reintegration to work when possible will be important in addressing the structural drivers of income insecurity experienced by cancer patients.

An Examination of the Ethical and Legal Limits in Implementing "Traceback Testing" for Deceased Patients

This paper examines the legal and ethical aspects of traceback testing, a process in which patients who have been previously diagnosed with ovarian cancer are identified and offered genetic testing so that their family members can be informed of their genetic risk and can also choose to undergo testing. Specifically, this analysis examines the ethical and legal limits in implementing traceback testing in cases when the patient is deceased and can no longer consent to genetic testing.

Advancing health equity in cancer care: The lived experiences of poverty and access to lung cancer screening

Background

Individuals living with low income are more likely to smoke, have a higher risk of lung cancer, and are less likely to participate in preventative healthcare (i.e., low-dose computed tomography (LDCT) for lung cancer screening), leading to equity concerns. To inform the delivery of an organized pilot lung cancer screening program in Ontario, we sought to contextualize the lived experiences of poverty and the choice to participate in lung cancer screening.

Methods

At three Toronto academic primary-care clinics, high-risk screen-eligible patients who chose or declined LDCT screening were consented; sociodemographic data was collected. Qualitative interviews were conducted. Theoretical thematic analysis was used to organize, describe and interpret the data using the morphogenetic approach as a guiding theoretical lens.

Results

Eight participants chose to undergo screening; ten did not. From interviews, we identified three themes: Pathways of disadvantage (social trajectories of events that influence lung-cancer risk and health-seeking behaviour), lung-cancer risk and early detection (upstream factors that shape smoking behaviour and lung-cancer screening choices), and safe spaces of care (care that is free of bias, conflict, criticism, or potentially threatening actions, ideas or conversations). We illuminate how ‘choice’ is contextual to the availability of material resources such as income and housing, and how ‘choice’ is influenced by having access to spaces of care that are free of judgement and personal bias.

Conclusion

Underserved populations will require multiprong interventions that work at the individual, system and structural level to reduce inequities in lung-cancer risk and access to healthcare services such as cancer screening.

The need for polygenic score reporting standards in evidence-based practice: lipid genetics use case

PURPOSE OF REVIEW

Polygenic scores (PGS) are used to quantify the genetic predisposition for heritable traits, with hypothesized utility for personalized risk assessments. Lipid PGS are primed for clinical translation, but evidence-based practice changes will require rigorous PGS standards to ensure reproducibility and generalizability. Here we review applicable reporting and technical standards for dyslipidemia PGS translation along phases of the ACCE (Analytical validity, Clinical validity, Clinical utility, Ethical considerations) framework for evaluating genetic tests.

RECENT FINDINGS

New guidance suggests existing standards for study designs incorporating the ACCE framework are applicable to PGS and should be adopted. One recent example is the Clinical Genomics Resource (ClinGen) and Polygenic Score Catalog's PRS reporting standards, which define minimal requirements for describing rationale for score development, study population definitions and data parameters, risk model development and application, risk model evaluation, and translational considerations, such as generalizability beyond the target population studied.

SUMMARY

Lipid PGS are likely to be integrated into clinical practice in the future. Clinicians will need to be prepared to determine if and when lipid PGS is useful and valid. This decision-making will depend on the quality of evidence for the clinical use of PGS. Establishing reporting standards for PGS will help facilitate data sharing and transparency for critical evaluation, ultimately benefiting the efficiency of evidence-based practice.

Examining the uptake of predictive BRCA testing in the UK; findings and implications

Predictive BRCA testing is offered to asymptomatic individuals to predict future risk where a variant has been identified in a relative. It is uncertain whether all eligible relatives access testing, and whether this is related to health care inequalities. Our aim was to analyse trends and inequalities in uptake of testing, and identify predictors of testing and time-to-receipt of testing. A database from April 2010 to March 2017 was collated. Multivariate analysis explored individual associations with testing. Predictor variables included gender, BRCA test type, cancer history, Index of Multiple Deprivation (IMD) and education status. To evaluate factors associated with time-to-testing, a Cox proportional-hazards (CP) model was used. Of 779 tests undertaken, 336 (43.1%) were identified with a BRCA variant. A total of 537 (68.9%) were female and in 83.4% (387/464) of probands, predictive testing was received by relatives. Analysis identified inequalities since decreased testing was found when the proband was unaffected by cancer (OR 0.14, 95% CI 0.06-0.33). Median time-to-testing was 390 days (range, 0-7090 days) and the CP model also identified inequalities in the hazard ratio (HR) for testing for people aged >40 was higher than for aged <40 (HR 1.41, 95% CI 1.20-1.67) and BRCA2 testing was higher than for BRCA1 testing (HR 1.39, 95% CI 1.18-1.64). Reduced testing was found when probands were unaffected by cancer and time-to-testing was found to vary by age and BRCA1/2 test. Given limited study sample size, further research is recommended to examine inequalities in predictive BRCA testing.

Genetic Testing Consumers in Italy: A Preliminary Investigation of the Socio-Demographic Profile, Health-Related Habits, and Decision Purposes

Aim of the study: Genetic testing is becoming increasingly common in clinical practice and health management; nonetheless, little is known about how the population approaches genetic services through private companies. Our study aims to describe socio-demographic aspects, health-related habits, and overall beliefs and knowledge about genetic risk and testing in a population of Italian citizens who decided to undergo a genetic examination through a private genetic company.

Study design: A sample of 152 clients from an Italian private genetic company completed an ad-hoc survey from September 2016 to February 2018, addressing socio-demographic data, health habits, psycho-physic condition, perceived utility of genetic results, decision purposes about data sharing, and behavioral changes after results.

Results: Participants (mean age 42.4) were predominantly female (82.2%) and were overall well-educated. Their main source of information were physicians (77%), and 41.1% entrusted the management of results to the same. Thirty-eight percentage underwent genetic analysis for cancer predisposition, 31.3% for fertility problems, 24% for dietary or intolerance issues in the period of enrolment. More than half of them (62.7%) reported a family history of the disease, and overall 69% had a current or past experience with a disease. Clients perceived the genetic screening as useful to adopt behaviors that may prevent disease onset (37.7%), to know their “real health status” (27.4%), and to adopt health-related behaviors (23.3%). 62.8% claimed they were motivated to change behaviors after results (healthier diet, practice exercise, medical checks), and they wanted to share results with their physician and family members.

Discussion/Conclusion: The overview of consumers' profiles in Italy and other European countries can contribute to tailoring and regulating genetic services in a way that could be efficient in terms of healthy choices, behaviors, and health resource expenditures for the general public.

Predictors of genetic beliefs toward cancer risk perceptions among adults in the United States: Implications for prevention or early detection

The objective of this study is to assess predictors of genetic beliefs toward cancer risk perceptions among adults, aged 18 years and over, in the United States (US). Data were obtained from the National Cancer Institute's (NCI) Health Information National Trends Survey 2014 (HINTS) 4 Cycle 4. Bivariate and multivariable logistic regression analyses were conducted to assess factors associated with an individual's beliefs about genetic and cancer risk perceptions. The results showed that African Americans, Non-White Hispanics, Non-Hispanic Asians, individuals with a high school education or less, and annual household incomes less than $20,000 and do not believe that health behaviors play some role in determining whether a person will develop cancer was significantly less likely to report that genetics plays at least some role in whether a person will develop cancer. Findings of this study provide an opportunity for genetic counselors to address beliefs about genetics and cancer risk perceptions among minority populations and promote health equity.

Regarding the Yin and Yang of Precision Cancer- Screening and Treatment: Are We Creating a Neglected Majority?

In this commentary, we submit that the current emphasis of precision cancer screening and treatment (PCST) has been to provide and interpret the implications of "positive" screening results for those deemed to be at greatest risk for cancer or most likely to benefit from targeted treatments. This is an important, but proportionately small target group, regardless of the cancer context. Overlooked by this focus is the larger majority of those screened who receive "negative" results. We contend that for optimal dissemination of PCST, the complement of positive and negative results be viewed as an inseparable yin-yang duality with the needs of those who receive negative screening results viewed as important as those deemed to be at highest risk or derive targeted treatment benefit. We describe three areas where communication of negative PCST results warrant particular attention and research consideration: population-based family history screening, germline testing for hereditary cancer syndromes, and tumor testing for targeted cancer treatment decision-making. Without thoughtful consideration of the potential for negative results to have psychological and behavioral influences, there is a potential to create a "neglected majority". This majority may be inclined to misinterpret results, disseminate inaccurate information to family, dismiss the credibility of results, or become disillusioned with existing medical treatments.

Health Equity in National Cancer Control Plans: An Analysis of the Ontario Cancer Plan

BACKGROUND

National cancer control plans (NCCPs) are important documents that guide strategic priorities in cancer care and plan for the appropriate allocation of resources based on the social, geographic and economic needs of a population. Despite the emphasis on health equity by the World Health Organization (WHO), few NCCPs have a focus on health equity. The Ontario Cancer Plan (OCP) IV, (2015 to 2019) is an example of an NCCP with clearly defined health equity goals and objectives.

METHODS

This paper presents a directed-content analysis of the OCP IV health equity goals and objectives, in light of the synergies of oppression analytical framework.

RESULTS

The OCP IV confines equity to an issue of access-to-care. As a result, it calls for training, funding, and social support services to increase accessibility for high-risk population groups. However, equity has a broader definition. And as such, it also implies that systematic differences in health outcomes between social groups should be minimal. This is particularly significant given that socially disadvantaged cancer patients in Ontario have distinctly poorer cancer-related health outcomes.

CONCLUSION

Health systems are seeking ways to reduce the health equity gap. However, to reduce health inequities which are socially-based will require a recognition of the living and working conditions of patients which influence risk, mortality and survival. NCCPs represent a way to politically advocate for the determinants of health which profoundly influence cancer risk, outcomes and mortality.