Advanced cancer patients’ attitudes towards, and experiences with, screening for somatic mutations in tumours: a qualitative study

Psychological impact of comprehensive tumor genomic profiling results for advanced cancer patients

OBJECTIVE

Comprehensive tumor genomic profiling (CTGP) is increasingly used to personalize treatments, providing hope, but potentially disappointment, for patients. We explored psychological outcomes in patients with advanced, incurable cancer, after receiving CTGP results.

METHODS

Participants with advanced, incurable cancer (n = 560, mean age 56, 43% university educated) in this longitudinal substudy of the Molecular Screening and Therapeutics Program (MoST), completed questionnaires before and after receiving CGP results. MoST participants, recruited from Australian oncology clinics, undergo CTGP, and if there are actionable findings, are offered treatment in a related therapeutic trial if available.

RESULTS

Patients who received actionable results, (n = 356, 64%) had lower gene-related distress (MICRA) (p < 0.001) and Impact of Events scores (p = 0.039) than patients with non-actionable results. Those with actionable results offered ensured access to tailored treatment (n = 151) reported lower anxiety (p = 0.002) and depressive symptoms (p = 0.01) and greater hope (p = 0.002) than those not offered. Positive attitudes towards uncertainty and higher self-efficacy for coping with results were associated with lower psychological distress and uncertainty, and higher hope and satisfaction with the decision to have CTGP (ps=0.001-0.047). Those with higher knowledge reported greater anxiety (p = 0.034).

CONCLUSION

Receiving a non-actionable CTGP result, or an actionable result without ensured access to treatment, may cause increased distress in advanced cancer patients. Coping style was also associated with distress.

PRACTICE IMPLICATIONS

Pre-testing assessment and counseling addressing attitudes toward uncertainty and self-efficacy, and post-CTGP result support for patients receiving a non-actionable result or who receive an actionable results without ensured access to treatment, may benefit patients.

Information Overload in Patient Education: A Wilsonian Concept Analysis

The authors of this concept analysis seek to clarify the concept of information overload within the context of patient education in healthcare. A modified six-step Wilsonian concept analysis method with a review of qualified manuscripts from PubMed, PsycInfo, CINAHL, and MEDLINE from 2000 to 2018 was conducted. Information overload occurs when an individual acknowledges that information received is beyond his or her information-absorbing threshold. The causes include quantity and quality of the information and information delivery structures. Information overload is associated with higher levels of stress and poor self-care performance. It is significant for healthcare providers to recognize patients' feelings of information overload.

Physicians' perceptions of the factors influencing disclosure of secondary findings in tumour genomic profiling in Japan: a qualitative study

Tumour genomic profiling (TGP), conducted in search of therapeutics, sometimes reveals potentially pathogenic germline variants as secondary findings (SFs). Physicians involved in TGP are often specialised in oncology and not in clinical genetics. To better utilise SFs, we explored issues physicians have during disclosure and the potential for collaborations with clinical genetics professionals. Semi-structured interviews were conducted with 14 physicians who had experience in handling outpatient TGP at designated core hospitals for cancer genomic medicine in Japan. The data were analysed thematically. The difficulties physicians experienced during informed consent (IC) included educating patients about SFs, providing detailed information on SFs, and explaining the impact of SFs on patients' family members. When SFs were detected, physicians had reservations regarding the relevance of the disclosure criteria. Confirmatory germline tests were performed using peripheral blood when tumour-only tests detected suspected SFs. Some physicians had reservations about the necessity of confirmatory tests when they did not affect the patients' treatment options. To encourage patients to receive confirmatory tests, improvements are necessary in the healthcare system, such as insurance reimbursements, education for physicians so that they can provide a better explanation to their patients, and genetic literacy of physicians and patients. The physicians offered insights into the challenges they experienced related to IC, disclosure of SFs, and expectations for active collaborations with clinical genetics professionals. Wider healthcare insurance coverage and better genetic literacy of the population may lead to more patients taking confirmatory tests when SFs are suspected.

Psychological predictors of advanced cancer patients' preferences for return of results from comprehensive tumor genomic profiling

This study assessed the psychological predictors of preferences for return of comprehensive tumor genomic profiling (CTGP) results in patients with advanced cancers, enrolled in the Molecular Screening and Therapeutics Program. Patients completed a questionnaire prior to undergoing CTGP. Of the 1434 who completed a questionnaire, 96% would like to receive results that can guide treatment for their cancer, and preference for receiving this type of result was associated with lower tolerance of uncertainty. Sixty-four percent would like to receive results that cannot guide treatment, and lower tolerance of uncertainty, self-efficacy, and perceived importance were associated with this preference. Fifty-nine percent would like to receive variants of unknown significance, which was associated with lower tolerance of uncertainty, higher self-efficacy, and perceived importance. Eighty-six percent wanted to receive germline results that could inform family risk. This was associated with higher self-efficacy, perceived importance, and perceived susceptibility. Although most patients wanted to receive all types of results, given the differing patient preferences regarding the return of results depending on the utility of the different types of results, it appears critical to safeguard patient understanding of result utility to achieve informed patient choices. This should be accompanied by appropriate consent processes.

Challenges adopting next-generation sequencing in community oncology practice

PURPOSE OF REVIEW

We are in an exhilarating time in which innovations exist to help reduce the impact of cancer for individuals, practitioners and society. Innovative tools in cancer genomics can optimize decision-making concerning appropriate drugs (alone or in combination) to cure or prolong life. The genomic characterization of tumours can also give direction to the development of novel drugs. Next-generation tumour sequencing is increasingly becoming an essential part of clinical decision-making, and, as such, will require appropriate coordination for effective adoption and delivery.

RECENT FINDINGS

There are several challenges that will need to be addressed if we are to facilitate cancer genomics as part of routine community oncology practice. Recent research into this novel testing paradigm has demonstrated the barriers are at the individual level, while others are at the institution and societal levels.

SUMMARY

This article, based on the authors' experience in community oncology practice and summary of literature, describes these challenges so strategies can be developed to address these challenges to improve patient outcomes.

Involving patients and their families in deciding to use next generation sequencing: Results from a nationally representative survey of U.S. oncologists

OBJECTIVE

Next generation sequencing (NGS) may aid in tumor classification and treatment. Barriers to shared decision-making may influence use of NGS. We examined, from oncologists' perspectives, whether barriers to involving patients/families in decision-making were associated with NGS use.

METHODS

Using data from the first national survey of medical oncologists' perspectives on precision medicine (N = 1281), we approached our analyses in two phases. Bivariate analyses initially evaluated associations between barriers to involving patients/families in deciding to use NGS and provider- and organizational-level characteristics. Modified Poisson regressions then examined associations between patient/family barriers and NGS use.

RESULTS

Approximately 59 % of oncologists reported at least one barrier to involving patients/families in decision-making regarding NGS use. Those reporting patient/family barriers tended to have fewer genomic resources at their practices, to be in rural or suburban areas, and to have a higher proportion of Medicaid patients. However, these barriers were not associated with NGS use.

CONCLUSIONS

Oncologists encounter barriers to involving patients/families in NGS testing decisions. Organizational barriers may also potentially play a role in testing decisions.

PRACTICE IMPLICATIONS

To foster patient-centered care, strategies to support patient involvement in genomic testing decisions are needed, particularly among practices in low-resource settings.

Information, communication, and cancer patients' trust in the physician: what challenges do we have to face in an era of precision cancer medicine?

Purpose

Despite promising achievements in precision cancer medicine (PCM), participating patients are still faced with manifold uncertainties, especially regarding a potential treatment benefit of molecular diagnostics (MD). Hence, MD poses considerable challenges for patient information and communication. To meet these challenges, healthcare professionals need to gain deeper insight into patients’ subjective experiences. Therefore, this qualitative study examined information aspects of MD programs in cancer patients.

Methods

In two German Comprehensive Cancer Centers, 30 cancer patients undergoing MD participated in semi-structured interviews on information transfer and information needs regarding MD. Additionally, patients provided sociodemographic and medical data and indicated their subjective level of information (visual analogue scale, VAS, 0–10).

Results

On average patients had high levels of information (mean = 7, median = 8); nevertheless 20% (n = 6) showed an information level below 5 points. Qualitative analysis revealed that patients show limited understanding of the complex background of MD and have uncertainties regarding their personal benefit. Further, patients described unmet information needs. Existential threat in awaiting the results was experienced as burdensome. To withstand the strains of their situation, patients emphasized the importance of trusting their physician.

Conclusion

The challenges in PCM consist in providing unambiguous information, especially concerning treatment benefit, and providing guidance and support. Therefore, psycho-oncology needs to develop guidelines for adequate patient communication in order to help healthcare providers and cancer patients to handle these challenges in the developing field of PCM.

Electronic supplementary material

The online version of this article (10.1007/s00520-020-05692-7) contains supplementary material, which is available to authorized users.

Advanced Cancer Patient Knowledge of and Attitudes towards Tumor Molecular Profiling

Limited research has indicated that despite their overwhelming interest in tumor molecular profiling (MP),1 cancer patients have poor knowledge about MP. The current study aimed to investigate demographic and psychological predictors of knowledge and perceived importance of MP in an advanced cancer patient cohort. Eligible participants had advanced solid cancers of any histological type with sufficient accessible tissue for MP and were enrolled in the Molecular Screening and Therapeutics (MoST) Program. A questionnaire was completed by 1074 participants (91% response rate) after consent, prior to undergoing MP. Overall, participants had poor to moderate knowledge of MP, yet perceived MP to have high importance. Higher education, speaking English at home, and greater satisfaction with the decision to undergo MP were associated with higher knowledge scores. More negative attitudes towards uncertainty, greater self-efficacy to cope with results, and lower perceived likelihood of cancer progression were associated with greater perceived importance of MP. Less educated participants and those who do not speak English at home will need clear explanations, visual aids and ample opportunity to ask questions about MP at the time of their decision-making. Clinicians also need to consider psychological factors relevant to patients' decision to pursue MP. Given the increased awareness of and demand for cancer genomic information and the rapidly changing nature of the actionability of MP, these findings will help inform an important ongoing debate on how to facilitate ethical and informed consent and manage patient expectations about personalized treatments.

Metastatic breast cancer patient perceptions of somatic tumor genomic testing

BACKGROUND

To assess metastatic breast cancer (MBC) patient psychological factors, perceptions, and comprehension of tumor genomic testing.

METHODS

In a prospective, single institution, single-arm trial, patients with MBC underwent next-generation sequencing at study entry with sequencing results released at progression. Patients who completed surveys before undergoing sequencing were included in the present secondary analysis (n = 58). We administered four validated psychosocial measures: Center for Epidemiologic Studies Depression Scale, Beck Anxiety Inventory, Trust in Physician Scale, and Communication and Attitudinal Self-Efficacy scale for Cancer. Genetic comprehension was assessed using 7-question objective and 6-question subjective measures. Longitudinal data were assessed (n = 40) using paired Wilcoxon signed rank and McNemar's test of agreement.

RESULTS

There were no significant differences between the beginning and end of study in depression, anxiety, physician trust, or self-efficacy (median time on study: 7.6 months). Depression and anxiety were positively associated with each other and both negatively associated with self-efficacy. Self-efficacy decreased from pre- to post-genomic testing (p = 0.05). Objective genetics comprehension did not significantly change from pre- to post-genomic testing, but patients expressed increased confidence in their ability to teach others about genetics (p = 0.04). Objective comprehension was significantly lower in non-white patients (p = 0.02) and patients with lower income (p = 0.04).

CONCLUSIONS

This is the only study, to our knowledge, to longitudinally evaluate multiple psychological metrics in MBC as patients undergo tumor genomic testing. Overall, psychological dimensions remained stable over the duration of tumor genomic testing. Among patients with MBC, depression and anxiety metrics were negatively correlated with patient self-efficacy. Patients undergoing somatic genomic testing had limited genomic knowledge, which varied by demographic groups and may warrant additional educational intervention.

CLINICAL TRIAL INFORMATION

NCT01987726, registered November 13, 2013.

Health information overload among health consumers: A scoping review

OBJECTIVE

To examine and identify the scope of research addressing health information overload in consumers.

METHODS

In accordance with a published protocol, six electronic databases (PubMed, CINAHL, ERIC, PsycINFO, Embase, and Scopus), reference lists of included articles, and grey literature (Google Advanced Search and WorldCat) were searched. Articles in English were included, without any limit on the date of publication.

RESULTS

Of the 69 records included for final analysis, 22 studies specifically examined health information overload, whereas the remainder peripherally discussed the concept alongside other concepts. The 22 studies focused on one or more of the following: 1) ways to measure health information overload (multi-item/single-item scales); 2) predictors of health information overload - these included low education level, health literacy, and socioeconomic status; and 3) interventions to address information overload, such as videotaped consultations or written materials. Cancer information overload was a popular topic amongst studies that focused on information overload.

CONCLUSION

Based on the identified studies, there is a clear need for future studies that investigate health information overload in consumers with chronic medical conditions other than cancer.

PRACTICE IMPLICATIONS

This review is the initial step in facilitating future efforts to create health information that do not overload consumers.

Patient perspectives on molecular tumor profiling: "Why wouldn't you?"

Aim

This study explored the attitudes of patients with advanced cancer towards MTP and return of results, prior to undergoing genomic testing within a research program.

Methods

Participants were recruited as part of the longitudinal PiGeOn (Psychosocial Issues in Genomics in Oncology) study involving patients with advanced/metastatic solid cancer who had exhausted therapeutic options and who were offered MTP in order to identify cognate therapies. Twenty patients, selected by purposive sampling, were interviewed around the time they gave consent to MTP. Interviews were audio recorded, transcribed and analysed using thematic analysis. Themes identified in the transcripts were cross-validated via qualitative responses to the PiGeOn study survey (n = 569; 63%).

Results

All interviewed participants gave consent to MTP without reservation. Three themes were identified and further supported via the survey responses: (1) Obvious agreement to participate, primarily because of desire for new treatments and altruism. (2) The black box – while participant knowledge of genomics was generally poor, faith in their oncologists and the scientific process encouraged them to proceed with testing; and (3) Survival is the priority – receiving treatment to prolong life was the priority for all participants, and other issues such as identification of a germline variant were generally seen as ancillary.

Conclusion

Having advanced cancer seemed to abrogate any potential concerns about MTP. Participants valued the research for varied reasons, but this was secondary to their priority to survive. While no negative attitudes toward MTP emerged, limitations in understanding of genomics were evident.

Electronic supplementary material

The online version of this article (10.1186/s12885-019-5920-x) contains supplementary material, which is available to authorized users.

Attitudes toward genomic tumor profiling tests in Japan: patients, family members, and the public

Genomic tumor profiling tests (GTPTs) to find molecular targeted drugs for patients with advanced cancer are being introduced into clinical settings, which may result in secondary germline findings. Although small-scale qualitative studies have revealed patients’ attitudes toward GTPTs and preferences on receiving germline findings, no large-scale quantitative research exists that includes family members. We conducted anonymous surveys with 757 cancer patients (CPs), 763 family members (FMs), and 3697 general adults (GAs) in Japan. Awareness of GTPTs was low in all groups, however, both CPs and FMs showed a higher degree of recognition in the benefits of GTPTs. FMs wanted information on germline findings to be shared more than the CPs. Since advanced CPs may have psychological burdens that make it difficult to express their opinions on their therapeutic options and sharing germline findings, GTPTs should be offered with advanced care planning for patients.

The Patient in Precision Medicine: A Systematic Review Examining Evaluations of Patient-Facing Materials

Precision medicine (PM) has the potential to tailor healthcare to the individual patient by using their genetic information to guide treatment choices. However, this process is complex and difficult to understand for patients and providers alike. With a recent push in the healthcare community to understand the patient experience and engage patients in their care, it is important to give patients the opportunity to learn about PM. We performed a systematic review to identify previous work assessing the quality of patient-facing PM materials from 2008 to July 2018. Ten studies were identified, which used varying methods and measures. A qualitative assessment was conducted to compare key elements of the studies, including study design, characteristics of the participant population, what measurements were used to assess the PM materials, understandability, preference, psychological reactions, and the type of PM materials being assessed. The studies identified provide important groundwork by highlighting consistent aspects of design that aid in comprehension. Eight of the ten studies focused on the content and organization of genomic test results, while the remaining two assessed educational tools. Two main design elements that appeared across the studies were appropriately designed visual aids and simplified language. The studies identified were limited by the participant populations that were used, which were primarily white and well educated. Only one study attempted to oversample patient populations typically underrepresented in this type of research. Through our systematic review, it is evident that the breadth of knowledge in this field is limited in scope and that more work must be done to ensure that patients can engage in their care when faced with PM.