Varieties of suffering: Living with the risk of ovarian cancer

Fluctuating salience in those living with genetic risk of motor neuron disease: A qualitative interview study

BACKGROUND

Motor neuron disease (MND) (also known as amyotrophic lateral sclerosis) is a life-limiting neurodegenerative condition. In up to 20% of people with MND, a pathogenic variant associated with autosomal dominant inheritance can be identified. Children of people carrying a pathogenic variant have a 50% chance of inheriting this and a higher, although harder to predict, chance of developing the disease compared to the general adult population. This paper explores the experience of living with the genetic risk of MND.

METHODS

We undertook a UK-based interview study with 35 individuals, including: 7 people living with genetically-mediated forms of MND; 24 asymptomatic relatives, the majority of whom had an increased risk of developing the disease; and 4 unrelated partners.

RESULTS

We explore how individuals make sense of genetic risk, unpacking the interplay between genetic knowledge, personal perception, experiences of the disease in the family, age and life stage and the implications that living with risk has for different aspects of their lives. We balance an emphasis on the emotional and psychological impact described by participants, with a recognition that the salience of risk fluctuates over time. Furthermore, we highlight the diverse strategies and approaches people employ to live well in the face of uncertainty and the complex ways they engage with the possibility of developing symptoms in the future. Finally, we outline the need for open-ended, tailored support and information provision.

CONCLUSIONS

Drawing on wider literature on genetic risk, we foreground how knowledge of MND risk can disrupt individuals' taken-for-granted assumptions on life and perceptions of the future, but also its contextuality, whereby its relevance becomes more prominent at critical junctures. This research has been used in the development of a public-facing resource on the healthtalk.org website.

PATIENT OR PUBLIC CONTRIBUTION

People with experience of living with genetic risk were involved throughout the design and conduct of the study and advised on aspects including the topic guide, sampling and recruitment and the developing analysis. Two patient and public involvement contributors joined a formal advisory panel.

Risky (information) business: an informational risk research agenda

Purpose

The purpose of this conceptual paper is to suggest that the growing sociocultural theorisation of risk calls for a more robust research focus on the role that information and in particular, information literacy, plays in mediating hazards and danger.

Design/methodology/approach

Starting by tracing how information has been conceptualised in relation to risk through technoscientific, cognitive and sociocultural lenses, the paper then focuses on emerging sociocultural understandings of risk to present a research agenda for a renewed sociocultural exploration of how risk is shaped through the enactment of information literacy.

Findings

The paper identifies and examines how information literacy shapes four key aspects of risk, including risk perception, risk management, risk-taking and “at-risk” populations. These four aspects are further connected through broader themes of learning, identity, work and power, which form the basis of the sociocultural risk research agenda.

Originality/value

This paper is the first study bringing together the many understandings related to how risk is informed and establishes risk as a key area of interest within information literacy research.

Using the Health Belief Model to explore why women decide for or against the removal of their ovaries to reduce their risk of developing cancer

BACKGROUND

Women at an increased risk of ovarian cancer often have to decide for or against the surgical removal of their healthy ovaries to reduce their cancer risk. This decision can be extremely difficult. Despite this, there is a lack of guidance on how to best support women in making this decision. Research that is guided by theoretical frameworks is needed to help inform clinical practice. We explored the decision-making process of women who are at an increased risk of developing ovarian cancer and had to decide for or against the removal of their ovaries.

METHODS

A qualitative study of 18 semi-structured interviews with women who have attended a cancer treatment centre or cancer counselling and information service in New South Wales, Australia. Data collection and analysis were informed by the Health Belief Model (HBM). Data was analysed using qualitative content analysis.

RESULTS

The paper describes women's decision making with the help of the four constructs of the HBM: perceived susceptibility, perceived severity, perceived benefits, and perceived barriers. The more anxious and susceptible women felt about getting ovarian cancer, the more likely they were to have an oophorectomy. Women's anxiety was often fuelled by witnessing family members suffer or die from cancer. Women considered a number of barriers and potential benefits to having the surgery but based their decision on "gut feeling" and experiential factors, rather than statistical risk assessment. Age, menopausal status and family commitments seemed to influence but not determine women's decisions on oophorectomy. Women reported a lack of decision support and appreciated if their doctor explained their treatment choice, provided personalised information, involved their general practitioner in the decision-making process and offered a second consultation to follow-up on any questions women might have.

CONCLUSIONS

These findings suggest that deciding on whether to have an oophorectomy is a highly personal decision which can be described with the help of the HBM. The results also highlight the need for tailored decision support which could help improve doctor-patient-communication and patient-centred care related to risk reducing surgery in women at an increased risk of ovarian cancer.

Identity, community and care in online accounts of hereditary colorectal cancer syndrome

Sociological literature has explored how shifts in the point at which individuals may be designated as diseased impact upon experiences of ill health. Research has shown that experiences of being genetically "at risk" are shaped by and shape familial relations, coping strategies, and new forms of biosociality. Less is known about how living with genetic risk is negotiated in the everyday and over time, and the wider forms of identity, communities and care this involves. This article explores these arrangements drawing on online bloggers' accounts of Familial Adenomatous Polyposis (FAP). We show how accounts of genetic risk co-exist with more palpable experiences of FAP in everyday life, notably the consequences of prophylactic surgeries. We consider how the act of blogging represents but also constitutes everyday experiences of hereditary cancer syndrome as simultaneously ordinary and exceptional, and reflect on the implications of our analysis for understanding experiences of genetic cancer risk.

Expert Knowledge Influences Decision-Making for Couples Receiving Positive Prenatal Chromosomal Microarray Testing Results

To assess how participants receiving abnormal prenatal genetic testing results seek information and understand the implications of results, 27 US female patients and 12 of their male partners receiving positive prenatal microarray testing results completed semi-structured phone interviews. These interviews documented participant experiences with chromosomal microarray testing, understanding of and emotional response to receiving results, factors affecting decision-making about testing and pregnancy termination, and psychosocial needs throughout the testing process. Interview data were analyzed using a modified grounded theory approach. In the absence of certainty about the implications of results, understanding of results is shaped by biomedical expert knowledge (BEK) and cultural expert knowledge (CEK). When there is a dearth of BEK, as in the case of receiving results of uncertain significance, participants rely on CEK, including religious/spiritual beliefs, "gut instinct," embodied knowledge, and social network informants. CEK is a powerful platform to guide understanding of prenatal genetic testing results. The utility of culturally situated expert knowledge during testing uncertainty emphasizes that decision-making occurs within discourses beyond the biomedical domain. These forms of "knowing" may be integrated into clinical consideration of efficacious patient assessment and counseling.

An investigation of the factors effecting high-risk individuals' decision-making about prophylactic total gastrectomy and surveillance for hereditary diffuse gastric cancer (HDGC)

Hereditary diffuse gastric cancer has an early onset and poor prognosis, therefore, individuals who carry a pathogenic (CDH1) mutation in the E-cadherin gene (CDH1) are offered endoscopic surveillance and advised to undergo prophylactic total gastrectomy (PTG) in their early to mid-twenties. Patients not ready or fit to undergo gastrectomy, or in whom the genetic testing result is unknown or ambiguous, are offered surveillance. Little is known about the factors that influence decisions to undergo or decline PTG, making it difficult to provide optimal support for those facing these decisions. Qualitative interviews were carried out with 35 high-risk individuals from the Familial Gastric Cancer Study in the UK. Twenty-seven had previously undergone PTG and eight had been identified as carrying a pathogenic CDH1 mutation but had declined surgery at the time of interview. The interviews explored the experience of decision-making and factors influencing risk-management decisions. The data suggest that decisions to proceed with PTG are influenced by a number of potentially competing factors: objective risk confirmation by genetic testing and/or receiving a positive biopsy; perceived familial cancer burden and associated risk perceptions; perceptions of post-surgical life; an increasing inability to tolerate endoscopic procedures; a concern that surveillance could miss a cancer developing and individual's life stage. These findings have implications for advising this patient group.

Risk of Sexual Violence: Perspectives and Experiences of Women in a Hospital in the Democratic Republic of Congo

Sexual violence in conflict situations is gaining worldwide recognition as a human rights issue. There is growing awareness and concern about the risks associated with sexual violence against women. This study was conducted in order to explore the perceptions and experiences of the risk of sexual violence in the Democratic Republic of Congo. The study draws on qualitative, in-depth interviews with women at a hospital in Bukavu. The findings show that women suffered humiliation, torture and beatings during their rape. Most women were raped by a number of men and others were forced to have sex with close family members. The rapist often used extreme brutality against the women which had major long-term consequences for women including unwanted pregnancies and/or HIV/AIDS. Many of the women experienced great uncertainty about their future and that of their children.

Knowledge is power? The role of experiential knowledge in genetically 'risky' reproductive decisions

Knowledge of the condition being tested for is increasingly acknowledged as an important factor in prenatal testing and screening decisions. An analysis of the way in which family members living with an inheritable condition use and value this knowledge has much to add to debates about whether and how this type of knowledge could be made available to prospective parents facing screening decisions. This article reports on in-depth interviews (conducted between 2007 and 2009) with 61 people with a genetic condition, spinal muscular atrophy (SMA) in their family. Many participants reported that their intimate familial knowledge of SMA offered them valuable insights with which they could imagine future lives. Other participants, however, found themselves trapped between their experiential knowledge of SMA and their (often) competing responsibility to maintain the wellbeing of their family. Still, others established a hierarchy of knowledge to rank the authenticity of different family member's accounts of SMA in order to discredit or justify their decisions. This article highlights the way in which experiential knowledge of the condition being tested for cannot be unproblematically assumed to be a useful resource in the context of prenatal testing decisions and may actually constrain reproductive decisions.

The problem of suffering as a driving force of rationalization and social change

This article documents and analyses a reconstructed Weberian conception of the problem of suffering. In this setting a focus is brought to how the problem of suffering is constituted in the dynamic interplay between, on the one hand, the compulsion to impose rational sense and order on the world, and on the other, the necessity to find a means to satiate charismatic needs. The discussion highlights Weber's account of the tendency for problems of suffering to increase in volume and scale along with the intensification and spread of modern processes of rationalization. It offers a case for the development of further sociological inquiries into the role played by experiences of the problem of suffering within the dynamics of social and cultural change.

BRCA patients in Cuba, Greece and Germany: Comparative perspectives on public health, the state and the partial reproduction of 'neoliberal' subjects

The relationship among genetic technologies, biosocial identity and patient subjectivity has been the focus of an increasing range of social science literature. Examining mainly European and North American contexts this work has demonstrated the variable configurations of genetic knowledge-practices and the diverse implications for at-risk individuals and populations. This article brings together ethnographic research on genomic medicine, public health and breast cancer in Cuba, Greece and Germany. Although each case study addresses different publics/patients, institutional settings and risk-related practices, they all critically examine 'neoliberal' subjectivity and BRCA patienthood, at the intersection of political rationalities, medical discourses, social conditions and moral codes. In the Cuban case, cultural articulations of inherited and other embodied risks relating to breast cancer are analysed in relation to state provision of 'community genetics', and the shifting dynamics of public health in response to global social processes. The Greek case explores how culturally embedded values, notions of inherited risk and care inform or are re-articulated through institutional practices and ambivalent subject positions, at the meeting point between individualised medicine, religious philanthropy and the particularities of public health. In the German context, diverging patient subjectivities are examined against the background of prevailing social discourses and institutionalised risk management practices that promote proactive individuality. Drawing on deconstructive and feminist analyses, these case studies reveal how normative 'neoliberal' patient subjects are only 'partially reproduced' in situated contexts, neither stable nor homogeneous, as different actors and publics variously articulate, embrace or engage with transnational as well as culturally embedded discourses and health practices.

Beliefs and beyond: what can we learn from qualitative studies of lay people's understandings of cancer risk?

BACKGROUND

Clinicians and public health professionals are centrally concerned with mediating risk. However, people often resist the risk-related information that is communicated to them by experts, or have their own models of risk that conflict with expert views. Quantitative studies have clearly demonstrated the importance of health beliefs and various cognitive and emotional processes in shaping risk perception. More recently, a growing body of qualitative research has emerged, exploring lay conceptualizations, experiences and constructions of cancer risk. To date, this literature has not been synthesized.

OBJECTIVE

We report the findings of a synthesis of qualitative literature regarding the ways in which lay people construct and experience cancer risk.

DESIGN

We identified 87 articles and used the method of 'thematic synthesis' to identify and interpret key concepts from existing studies.

RESULTS

Eight analytic categories were developed: (i) perceptions of risk factors; (ii) process of risk perception; (iii) seeking control and taking responsibility (motivational factors); (iv) experiencing cancer directly; (v) constructing risk temporally; (vi) embodying risk; (vii) identifying with risk; and (viii) constructing risk in a social context.

CONCLUSIONS

Qualitative enquiry can provide us with a rich and nuanced picture of the ways in which people understand, experience and construct risk and how being 'at risk' is managed, and can assist us in our communication with both individual patients and populations.

Embodiment and breast cancer among African American women

African American women have historically been screened for breast cancer less than other women, contributing to higher mortality rates. Previous research has focused on social and cultural factors, such as discrimination and religiosity, as shaping African American women's screening practices. This article extends this research by (a) examining the decisions and justifications of African American women with regard to screening practices, and (b) using a theoretical focus on embodiment to better understand women in relation to their own bodies. Ethnographic research consisted of 5 months of participant observation at an Indiana (USA) breast cancer care center, and 15 in-depth, semi-structured interviews along the continuum of screening practices. The results showed that embodied understandings of the body, personal (rather than biomedical) considerations of screening and treatment, and the quality of doctor/patient interactions all play a significant role in women's decisions about whether to screen for breast cancer or not. Based on these results and a review of the literature, six ways to include embodiment in public health initiatives are outlined.

Information processing in the context of genetic risk: implications for genetic-risk communication

Communicating genetic-risk information is fraught with difficulties, and there are no universally accepted guidelines for clinical practice. In this paper, we suggest that information-processing models may offer some guidance for the communication of genetic risk. The paper reviews selected literature from health and social psychology, including defensive reactions to threatening health information, the Extended Parallel Process Model (EPPM) and Self Affirmation Theory. Ultimately, it presents the Heuristic-Systematic Model (HSM) of information processing as a useful perspective from which to view genetic-risk communication. Through our review of this literature, we identify some of the variables found to influence the systematic or heuristic processing of risk information and note their relevance to genetic counseling contexts. We suggest that systematic information processing is conducive to informed decision-making, as well as improved understanding of risk information. Clinical practice implications derived from our review of these literatures are noted.