The future in clinical genetics: affective forecasting biases in patient and clinician decision making

Willingness to trade-off years of life for an HIV cure - an experimental exploration of affective forecasting

BACKGROUND

In the US, 1.2 million people live with HIV (PWH). Despite having near-normal life expectancies due to antiretroviral therapy (ART), many PWH seek an HIV cure, even if it means risking their lives. This willingness to take risks for a cure raises questions about "affective forecasting biases," where people tend to overestimate the positive impact of future events on their well-being. We conducted a study to test two interventions to mitigate affective forecasting in the decisions of PWH about taking HIV cure medication.

METHODS

We recruited PWH to complete a 30-minute survey about their current quality of life (QoL) and the QoL they anticipate after being cured of HIV, and assigned them to either no additional intervention, to one of two interventions intended to reduce affective forecasting bias, or to both interventions: (1) a defocusing intervention designed to broaden the number of life domains people consider when imagining life changes associated with new circumstances (e.g. HIV cure); and (2) an adaptation intervention to help them gauge fading of strong emotions over time. The study design included a 2 × 2 design: defocusing (yes/no) x adaptation (yes/no) intervention. We assessed PWH's willingness to take hypothetical HIV sterilizing cure medication using the Time Trade-Off (TTO) and their quality of life predictions with WHOQOL-HIV.

RESULTS

296 PWH participated. Counter to what we had hypothesized, neither intervention significantly reduced PWH's willingness to trade time for a cure. Instead, the defocusing intervention increased their willingness to trade time (IRR 1.77, p = 0.03). Exploratory analysis revealed that PWH with lower current quality of life who received the defocusing intervention were more willing to trade time for a cure.

CONCLUSION

These negative findings suggest that either these biases are difficult to overcome in the settings of HIV curative medication or other factors beyond affective forecasting biases influence willingness to participate in HIV curative studies, such as respondents' current quality of life.

Predictive genetic testing for Huntington's disease: Exploring participant experiences of uncertainty and ambivalence between clinic appointments

Ambivalence and uncertainty are key themes throughout the psychology of healthcare literature. This is especially so for individuals at risk of Huntington's disease (HD) deliberating the decision to undergo genetic testing because there is currently no treatment that modifies disease progression. A better understanding of the experience of making a decision about genetic prediction will help practitioners support and guide individuals through this process. Our aim was to capture participants' experiences of uncertainty and ambivalence in between their genetic counseling appointments. We explored these issues through the experiences of nine participants who were referred for predictive HD testing at four regional genetics services in England and Wales. Data consisted of recordings of clinic consultations, diaries, and an in-depth interview conducted at the end of the testing process. Data were analyzed thematically. Four themes were identified representing four possible futures, each future dependent on the decision to undergo testing and the result of that test. Our results showed that participants, as well as attending more to a future that represents their current situation of not having undergone predictive testing, also attended more to a distant future where a positive predictive result is received and symptoms have started. Participants attended less to the two futures that were more immediate once testing was undertaken (a future where a positive result is received and symptoms have not started and a future where a negative result is received). The use of diaries gave us a unique insight into these participants' experiences of ambivalence and uncertainty, psychological distress, and the emotional burden experienced. These findings help inform discussions within the clinic appointment as well as encourage researchers to consider diary use as a method of exploring what happens for individuals outside of clinical encounters.

'A good decision is the one that feels right for me': Codesign with patients to inform theoretical underpinning of a decision aid website

INTRODUCTION

Patient decision aids (PtDA) complement shared decision-making with healthcare professionals and improve decision quality. However, PtDA often lack theoretical underpinning. We are codesigning a PtDA to help people with increased genetic cancer risks manage choices. The aim of an innovative workshop described here was to engage with the people who will use the PtDA regarding the theoretical underpinning and logic model outlining our hypothesis of how the PtDA would lead to more informed decision-making.

METHODS

Short presentations about psychological and behavioural theories by an expert were interspersed with facilitated, small-group discussions led by patients. Patients were asked what is important to them when they make health decisions, what theoretical constructs are most meaningful and how this should be applied to codesign of a PtDA. An artist created a visual summary. Notes from patient discussions and the artwork were analysed using reflexive thematic analysis.

RESULTS

The overarching theme was: It's personal. Contextual factors important for decision-making were varied and changed over time. There was no one 'best fit' theory to target support needs in a PtDA, suggesting an inductive, flexible framework approach to programme theory would be most effective. The PtDA logic model was revised based on patient feedback.

CONCLUSION

Meaningful codesign of PtDA including discussions about the theoretical mechanisms through which they support decision-making has the potential to lead to improved patient care through understanding the intricately personal nature of health decisions, and tailoring content and format for holistic care.

PATIENT CONTRIBUTION

Patients with lived experience were involved in codesign and coproduction of this workshop and analysis as partners and coauthors. Patient discussions were the primary data source. Facilitators provided a semi-structured guide, but they did not influence the patient discussions or provide clinical advice. The premise of this workshop was to prioritise the importance of patient lived experience: to listen, learn, then reflect together to understand and propose ideas to improve patient care through codesign of a PtDA.

Emotions and Narrative Reappraisal Strategies of Users of Breast Cancer Screening: Reconstructing the Past, Passing Through the Present, and Predicting Emotions

Emotional forecasting, meaning how a person anticipates feeling as a consequence of their choices, drives healthcare decision-making. Research, however, suggests that people often do not fully anticipate or otherwise grasp the future emotional impacts of their decisions. Emotional reappraisal strategies, such as putting emotions into words and sharing emotions with others, may mitigate potential undesirable effects of emotions on decision-making. The use of such strategies is important for consequential decisions, such as obtaining timely mammography screening for breast cancer, whereby earlier diagnosis may impact the success of treatment. In this study, we explored the use of emotional reappraisal strategies for decision-making regarding breast cancer screening attendance among women aged 50-69 years. Data were collected through semi-structured interviews following mammography with a reflexive thematic methodological approach employed for analysis. Results shed light on how participants' emotional response narratives were reconstructed before the mammography, felt during the mammography, and forecasted while awaiting the results. Future research should consider how individuals experience and manage their emotions as they access breast screening services.

Attitudes towards genetic testing: The role of genetic literacy, motivated cognition, and socio-demographic characteristics

Understanding reasons for why people choose to have or not to have a genetic test is essential given the ever-increasing use of genetic technologies in everyday life. The present study explored the multiple drivers of people's attitudes towards genetic testing. Using the International Genetic Literacy and Attitudes Survey (iGLAS), we collected data on: (1) willingness to undergo testing; (2) genetic literacy; (3) motivated cognition; and (4) demographic and cultural characteristics. The 37 variables were explored in the largest to-date sample of 4311 participants from diverse demographic and cultural backgrounds. The results showed that 82% of participants were willing to undergo genetic testing for improved treatment; and over 73%-for research. The 35 predictor variables together explained only a small proportion of variance: 7%-in the willingness to test for Treatment; and 6%-for Research. The strongest predictors of willingness to undergo genetic testing were genetic knowledge and deterministic beliefs. Concerns about data misuse and about finding out unwanted health-related information were weakly negatively associated with willingness to undergo genetic testing. We also found some differences in factors linked to attitudes towards genetic testing across the countries included in this study. Our study demonstrates that decision-making regarding genetic testing is influenced by a large number of potentially interacting factors. Further research into these factors may help consumers to make decisions regarding genetic testing that are right for their specific circumstances.

Motivations to learn genomic information are not exceptional: Lessons from behavioral science

Whether to undergo genome sequencing in a clinical or research context is generally a voluntary choice. Individuals are often motivated to learn genomic information even when clinical utility-the possibility that the test could inform medical recommendations or health outcomes-is low or absent. Motivations to seek one's genomic information can be cognitive, affective, social, or mixed (e.g., cognitive and affective) in nature. These motivations are based on the perceived value of the information, specifically, its clinical utility and personal utility. We suggest that motivations to learn genomic information are no different from motivations to learn other types of personal information, including one's health status and disease risk. Here, we review behavioral science relevant to motivations that may drive engagement with genome sequencing, both in the presence of varying degrees of clinical utility and in the absence of clinical utility. Specifically, we elucidate 10 motivations that are expected to underlie decisions to undergo genome sequencing. Recognizing these motivations to learn genomic information will guide future research and ultimately help clinicians to facilitate informed decision making among individuals as genome sequencing becomes increasingly available.

Anticipated suicidal and death ideation in response to an imagined dementia diagnosis: A qualitative study

Alzheimer's disease and related dementias are prevalent, highly impactful, and feared diagnoses. A mixed methods study using semi-structured interviews was conducted to clarify causes of dementia-related anxiety. Fifty community-dwelling adults aged 58 to 89 (M = 70.92, SD = 6.08) were recruited from a university participant registry and Memory Clinic; none had dementia diagnoses. Analyses revealed that 42% (n = 21) of participants anticipated suicidal or death ideation if diagnosed with dementia. Among participants endorsing anticipated suicidal or death ideation, responses ranged from active, specific plans, including interest in physician-assisted suicide, to more passive wishes to hasten death rather than continue to live with dementia. Within reports of both anticipated suicidal and death ideation, three subthemes emerged. Participants reported concerns about becoming a burden to others, the devaluation of life/loss of self with dementia, and the desire for (and anticipated thwarting of) personal control as factors contributing to their anticipated responses to a dementia diagnosis. Statements of anticipated suicidal and death ideation were contingent on a dementia diagnosis and may reflect errors in affective forecasting. Nevertheless, given the prevalence of dementias and older adults' elevated rates of suicide, the intersection of these two public health issues warrants greater attention.

Be optimistic or be cautious? Affective forecasting bias in allocation decisions and its effect

Introduction

People's forecasts of their future emotions play an essential role in their behavior and experience of well-being. However, their emotional reactions may fall short of what they expect, which has implications for subsequent decision making. The current paper investigated the accuracy of affective forecasting about resource allocations and how this (in)accuracy predicts future allocation decisions.

Methods

Two experimental studies were conducted. Study 1 (N = 84) examined the extent to which people can accurately predict how allocation decisions will feel using an ultimatum game on the part of the allocator. Study 2 tested whether the affective forecasting bias affects future allocation decisions, with 192 participants playing a two-round ultimatum game on the part of allocators.

Results

Study 1 found an affective forecasting bias, and people anticipated more powerful emotional reactions to both positive and negative allocation events than they actually experienced when the events occurred. Study 2 found that increased affective forecasting bias resulted in less generous decisions in positive event conditions and more generous decisions in negative event conditions.

Discussion

These results extend previous findings concerning affective forecasting bias and the feelings-as-information model in resource allocation interactions and show that the difference between anticipated and experienced emotion is also informative in allocation decisions. The results suggest that being more cautious when forecasting positive outcomes and more optimistic when forecasting negative outcomes can be beneficial to one's well-being.

Surprisingness and Occupational Engagement Influence Affective Forecasting in Career-Relevant Contexts

People tend to misestimate their future emotions. This phenomenon is thought to be associated with information accessibility. However, few studies have demonstrated the impact of context-specific information accessibility on affective forecasting. This research investigated the effects of information accessibility on affective forecasting in career context (i.e., occupational engagement was seen as information accessibility), during which surprise or not surprise context was played simultaneously. We found that affective forecasting appeared stably across emotional response types. Specifically, there was an underestimation in interest appraisals and an overestimation in satisfaction. These biases were influenced by occupational engagement, which only worked in career interest appraisals. High occupational engagement made people estimate their future emotions more accurately and overcome their forecasting bias. Surprisingness was then manipulated further to explain whether it could impact the effect of occupational engagement on affective forecasting. The emotional responses in both prediction and experience were affected by surprisingness, thus causing no affective forecasting biases. These results suggest the role of occupational engagement in affective forecasting and provide evidence supporting the information accessibility model about the mechanism in affective forecasting.

Causal theoretical frameworks that explain veteran mental health help-seeking behavior: a scoping review protocol

OBJECTIVE

This scoping review will determine what causal theoretical frameworks have been used to examine veteran mental health help-seeking behavior. The review will also examine the causal factors proposed by these theoretical frameworks, and whether they account for the complex cultural, social, and affective experiences of veterans, which may drive both uptake or avoidance of mental health help-seeking.

INTRODUCTION

Some military veterans delay mental health help-seeking, preventing early intervention, creating poor long-term quality of life and functional outcomes, and increasing the likelihood of reaching crisis point before seeking help. There is a distinct lack of research utilizing causal motivational frameworks to explain veteran mental health help-seeking behavior (both engagement and avoidance). To date, no review has been conducted on motivational frameworks used to explain veteran help-seeking behavior. This scoping review will be the first to identify the motivational models that have been used to explain veteran mental health help-seeking, as well as table the proposed causal factors, and determine whether the models account for the cultural, social, and affective experiences of veterans.

INCLUSION CRITERIA

This scoping review will only consider studies on veteran cohorts. Studies in English that utilize or create an explanatory theory, model, or framework for veteran mental health help-seeking behavior will be included. Literature that focuses solely on intentions rather than behavior will be excluded.

METHODS

Published and unpublished studies and gray literature will be included. Titles and abstracts will be screened, followed by full-text screening. Factors, theories, models, and frameworks used to explain veteran help-seeking behavior will be extracted, charted, and narratively summarized. The JBI methodology for scoping reviews will be used.

The role of future-oriented affect in engagement with genomic testing results

Future-oriented emotions such as anticipatory affect (i.e., current affect experienced regarding a potential future outcome) and anticipated affect (i.e., expectations about potential future affect), are uniquely associated with health decision-making (e.g., electing to receive results of genomic testing). This study investigated the degree to which negative anticipated and anticipatory emotions predict health decision making over time, and whether such emotions predict social, emotional, and behavioral responses to anticipated information (e.g., genomic testing results). 461 participants (M age = 63.9, SD = 5.61, 46% female) in a genomic sequencing cohort who elected to receive genomic sequencing (carrier) results were included in the current study. Anticipated and anticipatory affect about sequencing results were assessed at baseline. Psychological and behavioral responses to sequencing results, including participants' reported anxiety, decisional conflict, and distress about sequencing results, whether they shared results with family members, and their intentions to continue learning results in the future, were collected immediately, one month, and/or six months after receiving results. More negative anticipated and anticipatory affect at baseline was significantly and independently associated with lower intentions to continue learning results in the future, as well as higher levels of anxiety and uncertainty at multiple time points after receiving results. Anticipated negative affect was also associated with greater decisional conflict, and anticipatory negative affect was also associated with greater distress after receiving results. Future-oriented emotions may play an important role in decisions that unfold over time, with implications for genomic testing, behavioral medicine, and health decision-making broadly.

Opportunities for theory-informed decision science in cancer control

Cancer prevention and control involves navigation of complex clinical decisions, often laden with uncertainty and/or intricate interpersonal dynamics, which have implications for both physical health and quality of life. Cancer decision-making research in recent decades has primarily focused on working to improve the quality of decisions by providing patients with detailed information about their choices and through an increased emphasis in medicine on the importance of shared decision making. This emphasis is reflective of a model of decision making that emphasizes knowledge, options, and deliberative synthesis of information as primary to decision making; yet, decades of research in psychology, decision science, and behavioral economics have taught us that our decisions are not influenced only by our objective knowledge of facts, but by our emotions, by the influence of others, and by biased cognitive processes. We present a conceptual framework for a future of research in decision science and cancer that is informed by decision science theories. Our framework incorporates greater recognition of the interpersonal dynamics of shared decision making, including the biases (including cognitive heuristics and race-based bias) that may affect multiple actors in the decision-making process, and emphasizes study of the interaction between deliberative and affective psychological processes as they relate to decision making. This work should be conducted with an eye toward informing efforts to improve decision making across the cancer care continuum, through interventions that are also informed by theory.

Investigating perceived heritability of mental health disorders and attitudes toward genetic testing in the United States, United Kingdom, and Australia

Our beliefs about the heritability of psychiatric traits may influence how we respond to the use of genetic information in this area. In the present study, we aim to inform future education campaigns as well as genetic counseling interventions by exploring common fears and misunderstandings associated with learning about genetic predispositions for mental health disorders. We surveyed 3,646 genetic research participants from Australia, and 960 members of the public from the United Kingdom, and the United States, and evaluated attitudes toward psychiatric genetic testing. Participants were asked hypothetical questions about their interest in psychiatric genetic testing, perceived usefulness of psychiatric genetic testing, and beliefs about malleability of behavior, among others. We also asked them to estimate the heritability of alcohol dependence, schizophrenia, and major depression. We found a high interest in psychiatric genetic testing. In most cases, more than a third of the participants showed serious concerns related to learning about personal genetic predisposition, such as not wanting to have children if they knew they had a high genetic predisposition, or not wanting to choose a partner with a high genetic predisposition for a mental health problem. Finally, we found a significant association between most participants' attitudes and their lay estimates of heritability, which highlights the complexity of educating the public about genetics.

Stigmatization of Not-Knowing as a Public Health Tool

Predictive interventions and practices are becoming a defining feature of medicine. The author points out that according to the inner logic and external supporters (i.e., state, industry, and media) of modern medicine, participating in healthcare increasingly means participating in knowing, sharing, and using of predictive information. At the same time, the author addresses the issue that predictive information may also have problematic side effects like overdiagnosis, health-related anxiety, and worry as well as impacts on personal life plans. The question is raised: Should we resort to stigmatization if doing so would increase participation in predictive interventions, and thereby save healthcare costs and reduce morbidity and premature death? The paper concludes that even if such a strategy cannot be ruled out in some forms and contexts, we ought to be very cautious about the dangers of shame and stigmatization.

Perceived importance of affective forecasting in cancer treatment decision making

PURPOSE

To examine whether adults with cancer view affective forecasting as important for treatment decisions, and to examine these perceptions among key subgroups.

DESIGN

Adults with cancer (N = 376) completed a cross-sectional survey that included demographic and clinical characteristics, the IPIP five-factor personality measure, and a rating of the perceived importance of affective forecasting for cancer treatment decisions. Descriptive statistics characterized the importance of affective forecasting. Multivariate analyses examined whether health and personality variables were associated with affective forecasting importance.

FINDINGS

Most participants (89.6%) identified affective forecasting as important for treatment decisions. Affective forecasting was more likely to be rated as important among patients with prostate cancer (p < .001), patients lower in neuroticism (p = .02), and patients higher in agreeableness (p = .004). Conclusions/Implications: Patients believe it is important to understand how treatments will impact their emotional well-being. Oncology clinicians should discuss with patients these consequences during healthcare decision-making.

Moving beyond categorization to understand affective influences on real world health decisions

This paper provides an overview of affect and health decision-making research, with a focus on identifying gaps, opportunities, and challenges to guide future research. We begin by defining common categorical distinctions of affective processes that influence health decisions: integral (i.e., related to the decision) and incidental (i.e., normatively unrelated to the decision) influences, and current (experienced in the moment) and anticipated ("cognitive representations" of future affect) affect. We then summarize key discoveries within the most common categories of affective influences on health decision making: current integral affect, current incidental affect, and anticipated integral affect. Finally, we highlight research gaps, challenges, and opportunities for future directions for research aimed at translating affective and decision science theory to improve our understanding of, and ability to intervene upon, health decision making.

Incidental Findings in Low-Resource Settings

Much new global genetic research employs whole genome sequencing, which provides researchers with large amounts of data. The quantity of data has led to the generation and discovery of more incidental or secondary findings and to vigorous theoretical discussions about the ethical obligations that follow from these incidental findings. After a decade of debate in the genetic research community, there is a growing consensus that researchers should, at the very least, offer to return incidental findings that provide high-impact, medically relevant information, when it is not unduly burdensome to the research enterprise to do so. Much as genetic research has been limited to U.S. and European settings, the incidental findings debate has primarily focused on research conducted in high-income countries. In a 2015 paper, Alberto Ortiz-Osorno, Linda Ehler, and Judith Brooks note salient differences between the circumstances of research participants in low- and high-resource settings that alter the analysis of when and why incidental findings should be offered to research participants. In this article, we expand on their analysis and present a framework for thinking about how investigators' obligations to return genomic data might change in low-resource settings, particularly in settings where participants do not have access to the medical care needed to treat, assess, or monitor incidental findings that are actionable in settings with plentiful resources.

On What We Have Learned and Still Need to Learn about the Psychosocial Impacts of Genetic Testing

Since the start of the program to investigate the ethical, legal, and social implications (ELSI) of the Human Genome Project in 1990, many ELSI scholars have maintained that genetic testing should be used with caution because of the potential for negative psychosocial effects associated with receiving genetic information. More recently, though, some ELSI scholars have produced evidence suggesting that the original ELSI concerns were unfounded, exaggerated, or, at a minimum, misdirected. At least in the contexts that have been most studied, large negative impacts have not been found in the vast majority of people studied. What might explain the discrepancy between the original hypothesized outcomes and the growing impression that large negative effects appear to be few and far between? And if the original predictions of large negative psychosocial effects were simply wrong, is it time for ELSI researchers to move on? Should genetic testing be routinized, and would it be appropriate to relax or abandon the practice of engaging patients in a process of detailed informed consent before they receive genetic information? To confront those questions, we convened a conference entitled "Looking for the Psychosocial Impacts of Genomic Information" to review what is known about the negative impacts of genetic information on a variety of populations and in multiple medical and social contexts, to explore the implications of the findings, and to consider whether future research might benefit from different methods than have been used to date.

Reconceptualizing harms and benefits in the genomic age

As new, high-powered sequencing technologies are increasingly incorporated into genomics research, we believe that there has been a break point in how risks and benefits associated with genetic information are being characterized and understood. Genomic sequencing provides the potential benefit of a wealth of information, but also has the potential to alter how we conceptualize risks of sequencing. Until now, our conceptions of risks and benefits have been generally static, arising out of the early ethical, legal and social implications studies conducted in the context of targeted genetics. This paper investigates how the increasing availability of genetic information is changing views about risks and benefits, particularly examining our evolving understanding of psychosocial harms and our expanding conception of benefit. We argue that the lack of robust empirical evidence of psychosocial harms and the expanding view that benefits of genomic research include indirect familial benefit necessitate continued ethical, legal and social implications research.

Interventions to Engage Affective Forecasting in Health-Related Decision Making: A Meta-Analysis

Background

People often use affective forecasts, or predictions about how a decision will make them feel, to guide medical and health decision making. However, these forecasts are susceptible to biases and inaccuracies that can have consequential effects on decision making and health.

Purpose

A meta-analysis was performed to determine the effectiveness of intervening to address affective forecasting as a means of helping patients make better health-related choices.

Methods

We included between-subjects experimental and intervention studies that targeted variables related to affective forecasting (e.g., anticipated regret, anticipated affect) as a means of changing health behaviors or decisions. We determined the overall effect of these interventions on targeted affective constructs and behavioral outcomes, and whether conceptual and methodological factors moderated these effects.

Results

A total of 133 independent effect sizes were identified from 37 publications (N = 72,020). Overall, affective forecasting interventions changed anticipated regret, d = 0.24, 95% confidence interval (CI) (0.15, 0.32), p < .001, behavior, d = 0.29, 95% CI (0.13, 0.45), p < .001, and behavioral intentions, d = 0.19, 95% CI (0.11, 0.28), p < .001, all measured immediately postintervention. Interventions did not change anticipated positive and negative affect, and effects on intentions and regret did not extend to follow-up time points, ps > .05. Generally, effects were not moderated by conceptual model, intervention intensity, or behavioral context.

Conclusions

Affective forecasting interventions had a small consistent effect on behavioral outcomes regardless of intervention intensity and conceptual framework, suggesting such constructs are promising intervention targets across several health domains.

Risk Perception and Psychological Distress in Genetic Counselling for Hereditary Breast and/or Ovarian Cancer

Oncological Genetic Counselling (CGO) allows the identification of a genetic component that increases the risk of developing a cancer. Individuals' psychological reactions are influenced by both the content of the received information and the subjective perception of their own risk of becoming ill or being a carrier of a genetic mutation. This study included 120 participants who underwent genetic counselling for breast and/or ovarian cancer. The aim of the study was to examine the relation between their cancer risk perception and the genetic risk during CGO before receiving genetic test results, considering the influence of some psychological variables, in particular distress, anxiety and depression. Participants completed the following tools during a psychological interview: a socio-demographic form, Cancer Risk Perception (CRP) and Genetic Risk Perception (GRP), Hospital Anxiety and Depression Scale (HADS) and Distress Thermometer (DT). The data seem to confirm our hypothesis. Positive and significant correlations were found between the observed variables. Moreover, genetic risk perception determined an increase in depressive symptomatology and cancer risk perception led to an increase in anxious symptomatology, specifically in participants during cancer treatment. The present results suggest the importance of assessing genetic and cancer risk perception in individuals who undergo CGO, to identify those who are at risk of a decrease in psychological well-being and of developing greater psychological distress.

Genetic Testing Awareness and Attitudes among Latinos: Exploring Shared Perceptions and Gender-Based Differences

BACKGROUND

Latinos, whose views are infrequently examined in genomic research, may be at risk of missing out on the benefits of genomic medicine.

AIMS

To explore this possibility, we conducted a qualitative study of awareness and attitudes about genetic testing among Latinos with lower acculturation in New York City.

METHODS

We conducted four focus groups (7 English-speaking men, 5 Spanish-speaking men, 13 English-speaking women and 13 Spanish-speaking women) to explore factors that influence the adoption of new innovations through the discussion of genetic testing in general, and a hypothetical vignette describing a genetic test for skin cancer risk, in particular.

RESULTS

Through inductive thematic text analysis of focus group transcripts, our multidisciplinary team identified themes within knowledge and attitudes, communication and sources of information, anticipated responses, factors that may increase adoption, and barriers to adoption of genetic testing. Specifically, a majority of participants expressed some degree of uncertainty regarding the purpose of genetic tests and information these tests provide, rarely discussed genetic testing with others in their social networks, and expressed concerns about the misuse of and possible adverse emotional responses to genetic information. However, participants also expressed high levels of interest in receiving a skin cancer genetic test in response to the vignette and believed that receiving actionable health information was a primary reason to consider testing. Gender-based differences in perceived barriers to testing emerged.

CONCLUSIONS

The results highlight beliefs and barriers that future interventions could target to help ensure that Latinos have adequate understanding of and access to genomic medicine advances.

Ethical signposts for clinical geneticists in secondary variant and incidental finding disclosure discussions

While ethical and empirical interest in so-called secondary variants and incidental findings in clinical genetics contexts is growing, critical reflection on the ethical foundations of the various recommendations proposed is thus far largely lacking. We examine and critique the ethical justifications of the three most prominent disclosure positions: briefly, the clinical geneticist decides, a joint decision, and the patient decides. Subsequently, instead of immediately developing a new disclosure option, we explore relevant foundational ethical values and norms, drawing on the normative and empirical ethical literature. Four ethical signposts are thereby developed to help guide disclosure discussions. These are: respectful sharing of the clinician's expertise; transparent communication; epistemic modesty; and respect for the embedded nature of the patient. We conclude by considering the most common current disclosure positions in the light of the four ethical signposts.

Ethics of genetic and biomarker test disclosures in neurodegenerative disease prevention trials

OBJECTIVE

Prevention trials for neurodegenerative diseases use genetic or other risk marker tests to select participants but there is concern that this could involve coercive disclosure of unwanted information. This has led some trials to use blinded enrollment (participants are tested but not told of their risk marker status). We examined the ethics of blinded vs transparent enrollment using well-established criteria for assessing the ethics of clinical research.

METHODS

Normative analysis applying 4 key ethical criteria-favorable risk-benefit ratio, informed consent, fair subject selection, and scientific validity-to blinded vs transparent enrollment, using current evidence and state of Alzheimer disease (AD) and other prevention trials.

RESULTS

Current evidence on the psychosocial impact of risk marker disclosure and considerations of scientific benefit do not support an obligation to use blinded enrollment in prevention trials. Nor does transparent enrollment coerce or involve undue influence of potential participants. Transparent enrollment does not unfairly exploit vulnerable participants or limit generalizability of scientific findings of prevention trials. However, if the preferences of a community of potential participants would affect the rigor or feasibility of a prevention trial using transparent enrollment, then investigators are required by considerations of scientific validity to use blinded enrollment.

CONCLUSIONS

Considerations of risks and benefits, informed consent, and fair subject selection do not require the use of blinded enrollment for AD prevention trials. Blinded enrollment in AD prevention trials may sometimes be necessary because of the need for scientific validity, not because it prevents coercion or undue influence.

The role of current affect, anticipated affect and spontaneous self-affirmation in decisions to receive self-threatening genetic risk information

One reason for not seeking personally threatening information may be negative current and anticipated affective responses. We examined whether current (e.g., worry) and anticipated negative affect predicted intentions to seek sequencing results in the context of an actual genomic sequencing trial (ClinSeq®; n = 545) and whether spontaneous self-affirmation mitigated any (negative) association between affect and intentions. Anticipated affective response negatively predicted intentions to obtain and share results pertaining to both medically actionable and non-actionable disease, whereas current affect was only a marginal predictor. The negative association between anticipated affect and intentions to obtain results pertaining to non-actionable disease was weaker in individuals who were higher in spontaneous self-affirmation. These results have implications for the understanding of current and anticipated affect, self-affirmation and consequential decision-making and contribute to a growing body of evidence on the role of affect in medical decisions.

Women's concerns about the emotional impact of awareness of heritable breast cancer risk and its implications for their children

Women tested for mutations in BRCA1/2 genes who have minor-aged children confront difficult decisions about if, when, and how to share information about hereditary cancer risk with their children. These choices are often seemingly influenced by how mothers anticipate the emotional burdens they and their children will experience in response to test results. Here, we investigate the association between maternal cognitions, pretest psychological well-being, and coping style with mothers' anticipated emotional reactions to learning that they are BRCA1/2 mutation carriers (N = 205). In a linear regression model adjusted for maternal demographics, stronger tendencies to ruminate about information (B = .14, p = .03), greater psychological strain (B = .14, p < .001), and poorer appraisals of one's ability to cope with genetic test results conveying increased breast cancer risk information (B = -.25, p < .001) were significantly associated with anticipating more negative affect surrounding BRCA1/2 mutation identification in mothers. Our data contribute to the growing awareness of special concerns that mothers have about knowing their BRCA1/2 mutation status and highlight the need for more tailored patient education and counseling resources to improve outcomes among women at risk and their children.