“Your risk is low, because …”: argument-driven online genetic counselling

A systematic review of communication interventions to help healthcare professionals discuss genetic testing for breast cancer

Purpose

This systematic review examined educational training interventions for healthcare professionals (HCPs) discussing genetic testing and risk for hereditary breast cancer. There was a particular focus on the presence, and content, of communication elements within these packages.

Methods

Searches were run via CINAHL, EMBASE, PUBMED, and PsychInfo in February 2019 to identify training interventions available to HCPs with reference to communication skills. Studies were assessed for quality, with relevant intervention and outcome data extracted and synthesized. This review followed the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) statement and was registered on the PROSPERO database (CRD42019124010).

Results

Of 3,988 items, seven papers, two of which were linked, were eligible for inclusion. There was a mix of randomized and single arm studies with web-based and face-to-face interventions. Content included an overview of genetics, hereditary and familial background, and recommended practice techniques. Outcomes focused on communication, self-efficacy, knowledge, and satisfaction. Interventions were designed for genetic counselors, physicians, primary care physicians (PCPs), medical students, and nurses. None of the papers featured oncologists or surgeons.

Conclusions

This review revealed an overall lack of publications which evaluated interventions to assist HCPs discussing hereditary breast cancer risk and testing. Studies failed to operationalize which ‘communication skills’ they included, nor did they consistently report randomization, outcome measures, or analysis.

Discussing the need for, and management of, genetic testing for inherited cancer risk with individuals and their families can be challenging. As genetic testing in breast cancer becomes more common, the provision of specific communication-based training programs, with reference to genetic testing, risk assessments, and counseling skills is warranted.

Electronic supplementary material

The online version of this article (10.1007/s10549-020-05741-z) contains supplementary material, which is available to authorized users.

Internet Versus Virtual Reality Settings for Genomics Information Provision

Current models of genomic information provision will be unable to handle large-scale clinical integration of genomic information, as may occur in primary care settings. Therefore, adoption of digital tools for genetic and genomic information provision is anticipated, primarily using Internet-based, distributed approaches. The emerging consumer communication platform of virtual reality (VR) is another potential intermediate approach between face-to-face and distributed Internet platforms to engage in genomics education and information provision. This exploratory study assessed whether provision of genomics information about body weight in a simulated, VR-based consultation (relative to a distributed, Internet platform) would be associated with differences in health behavior-related attitudes and beliefs, and interpersonal reactions to the avatar-physician. We also assessed whether outcomes differed depending upon whether genomic versus lifestyle-oriented information was conveyed. There were significant differences between communication platforms for all health behavior-oriented outcomes. Following communication in the VR setting, participants reported greater self-efficacy, dietary behavioral intentions, and exercise behavioral intentions than in the Internet-based setting. There were no differences in trust of the physician by setting, and no interaction between setting effects and the content of the information. This study was a first attempt to examine the potential capabilities of a VR-based communication setting for conveying genomic content in the context of weight management. There may be benefits to use of VR settings for communication about genomics, as well as more traditional health information, when it comes to influencing the attitudes and beliefs that underlie healthy lifestyle behaviors.

Rational versus unreasonable persuasion in doctor-patient communication: a normative account

OBJECTIVE

Persuasion plays a critical role in doctor-patient communication. The relevant literature tends to equate persuasion to manipulation as a suboptimal form of interaction. The objective of this paper is to distinguish among different types of persuasion processes and to highlight when their use can be beneficial or risky from the perspective of the patient's autonomy.

METHODS

This paper presents a conceptual analysis of persuasion based on the analytical and normative frameworks of argumentation theory.

RESULTS

Persuasion is a generic term that refers to at least four main forms of persuasion: rational persuasion, unintentional unreasonable persuasion, intentional (without deception) unreasonable persuasion and intentional (with deception) unreasonable persuasion (i.e., manipulation).

CONCLUSION

Rational persuasion can be a process of value for the medical encounter. The other forms of persuasion can negatively impact patients' decision making. They are suboptimal for different reasons that are partly due to the quality of communication, and partly due to ethics of the medical conduct.

PRACTICE IMPLICATIONS

This paper offers a basis for developing training opportunities that foster deeper understanding of different forms and uses of persuasion. Also, it can inspire the development of educational material for patients targeted to the enhancement of their critical health literacy.

Communicating risk of hereditary breast and ovarian cancer with an interactive decision support tool

OBJECTIVE

Women with hereditary breast and ovarian cancer syndrome (HBOC) face a higher risk of earlier, more aggressive cancer. Because of HBOC's rarity, screening is recommended only for women with strong cancer family histories. However, most patients do not have accurate history available and struggle to understand genetic concepts.

METHODS

Cancer in the Family, an online clinical decision support tool, calculated women's HBOC risk and promoted shared patient-provider decisions about screening. A pilot evaluation (n=9 providers, n=48 patients) assessed the tool's impact on knowledge, attitudes, and screening decisions. Patients used the tool before wellness exams and completed three surveys. Providers accessed the tool during exams, completed exam checklists, and completed four surveys.

RESULTS

Patients entered complete family histories (67%), calculated personal risk (96%), and shared risk printouts with providers (65%). HBOC knowledge increased dramatically for patients and providers, and many patients (75%) perceived tool results as valid. The tool prompted patient-provider discussions about HBOC risk and cancer family history (88%).

CONCLUSIONS

The tool was effective in increasing knowledge, collecting family history, and sparking patient-provider discussions about HBOC screening.

PRACTICE IMPLICATIONS

Interactive tools can effectively communicate personalized risk and promote shared decisions, but they are not a substitute for patient-provider discussions.