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Aggarwal P, Bhat D. Genetic counseling in sickle cell disease: Insights from the Indian tribal population. J Community Genet 2023; 14:345-353. [PMID: 37540483 PMCID: PMC10444709 DOI: 10.1007/s12687-023-00661-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 07/25/2023] [Indexed: 08/05/2023] Open
Abstract
Sickle cell disease (SCD) is an inherited disorder of hemoglobin. With an overall prevalence of 4.3%, India is the second-largest hub of SCD after Africa. Genetic counseling (GC) is the most cost-effective intervention to reduce the burden of a genetic disease including SCD. Even though GC's role in reducing SCD birth prevalence is well established, it is still not incorporated into Indian national policy and is unavailable to most Indians approaching their marriageable age and childbirth. GC perception and efficacy have also not been explored yet among young adults, especially in Indian tribal communities. Counseling in these communities requires careful consideration of their socioeconomic, cultural, and ethical values. Community engagement with local tribes and healthcare infrastructure in a multitier approach is essential for an effective GC. This review aims to provide healthcare providers and genetic counselors with the essentials of GC in the prevention and management of SCD among tribal communities based on the author's counseling experience in South India.
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Affiliation(s)
- Pooja Aggarwal
- Department of Anatomy, JSS Medical College, JSS Academy of Higher Education & Research, Mysore, Karnataka, India
| | - Deepa Bhat
- Department of Anatomy, JSS Medical College, JSS Academy of Higher Education & Research, Mysore, Karnataka, India.
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Jull J, Köpke S, Smith M, Carley M, Finderup J, Rahn AC, Boland L, Dunn S, Dwyer AA, Kasper J, Kienlin SM, Légaré F, Lewis KB, Lyddiatt A, Rutherford C, Zhao J, Rader T, Graham ID, Stacey D. Decision coaching for people making healthcare decisions. Cochrane Database Syst Rev 2021; 11:CD013385. [PMID: 34749427 PMCID: PMC8575556 DOI: 10.1002/14651858.cd013385.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Decision coaching is non-directive support delivered by a healthcare provider to help patients prepare to actively participate in making a health decision. 'Healthcare providers' are considered to be all people who are engaged in actions whose primary intent is to protect and improve health (e.g. nurses, doctors, pharmacists, social workers, health support workers such as peer health workers). Little is known about the effectiveness of decision coaching. OBJECTIVES To determine the effects of decision coaching (I) for people facing healthcare decisions for themselves or a family member (P) compared to (C) usual care or evidence-based intervention only, on outcomes (O) related to preparation for decision making, decisional needs and potential adverse effects. SEARCH METHODS We searched the Cochrane Library (Wiley), Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), CINAHL (Ebsco), Nursing and Allied Health Source (ProQuest), and Web of Science from database inception to June 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs) where the intervention was provided to adults or children preparing to make a treatment or screening healthcare decision for themselves or a family member. Decision coaching was defined as: a) delivered individually by a healthcare provider who is trained or using a protocol; and b) providing non-directive support and preparing an adult or child to participate in a healthcare decision. Comparisons included usual care or an alternate intervention. There were no language restrictions. DATA COLLECTION AND ANALYSIS Two authors independently screened citations, assessed risk of bias, and extracted data on characteristics of the intervention(s) and outcomes. Any disagreements were resolved by discussion to reach consensus. We used the standardised mean difference (SMD) with 95% confidence intervals (CI) as the measures of treatment effect and, where possible, synthesised results using a random-effects model. If more than one study measured the same outcome using different tools, we used a random-effects model to calculate the standardised mean difference (SMD) and 95% CI. We presented outcomes in summary of findings tables and applied GRADE methods to rate the certainty of the evidence. MAIN RESULTS Out of 12,984 citations screened, we included 28 studies of decision coaching interventions alone or in combination with evidence-based information, involving 5509 adult participants (aged 18 to 85 years; 64% female, 52% white, 33% African-American/Black; 68% post-secondary education). The studies evaluated decision coaching used for a range of healthcare decisions (e.g. treatment decisions for cancer, menopause, mental illness, advancing kidney disease; screening decisions for cancer, genetic testing). Four of the 28 studies included three comparator arms. For decision coaching compared with usual care (n = 4 studies), we are uncertain if decision coaching compared with usual care improves any outcomes (i.e. preparation for decision making, decision self-confidence, knowledge, decision regret, anxiety) as the certainty of the evidence was very low. For decision coaching compared with evidence-based information only (n = 4 studies), there is low certainty-evidence that participants exposed to decision coaching may have little or no change in knowledge (SMD -0.23, 95% CI: -0.50 to 0.04; 3 studies, 406 participants). There is low certainty-evidence that participants exposed to decision coaching may have little or no change in anxiety, compared with evidence-based information. We are uncertain if decision coaching compared with evidence-based information improves other outcomes (i.e. decision self-confidence, feeling uninformed) as the certainty of the evidence was very low. For decision coaching plus evidence-based information compared with usual care (n = 17 studies), there is low certainty-evidence that participants may have improved knowledge (SMD 9.3, 95% CI: 6.6 to 12.1; 5 studies, 1073 participants). We are uncertain if decision coaching plus evidence-based information compared with usual care improves other outcomes (i.e. preparation for decision making, decision self-confidence, feeling uninformed, unclear values, feeling unsupported, decision regret, anxiety) as the certainty of the evidence was very low. For decision coaching plus evidence-based information compared with evidence-based information only (n = 7 studies), we are uncertain if decision coaching plus evidence-based information compared with evidence-based information only improves any outcomes (i.e. feeling uninformed, unclear values, feeling unsupported, knowledge, anxiety) as the certainty of the evidence was very low. AUTHORS' CONCLUSIONS Decision coaching may improve participants' knowledge when used with evidence-based information. Our findings do not indicate any significant adverse effects (e.g. decision regret, anxiety) with the use of decision coaching. It is not possible to establish strong conclusions for other outcomes. It is unclear if decision coaching always needs to be paired with evidence-informed information. Further research is needed to establish the effectiveness of decision coaching for a broader range of outcomes.
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Affiliation(s)
- Janet Jull
- School of Rehabilitation Therapy, Faculty of Health Sciences, Queen's University, Kingston, Canada
| | - Sascha Köpke
- Institute of Nursing Science, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | | | - Meg Carley
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Jeanette Finderup
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Research Centre for Patient Involvement, Aarhus University & the Central Denmark Region, Aarhus, Denmark
| | - Anne C Rahn
- Institute of Social Medicine and Epidemiology, Nursing Research Unit, University of Lubeck, Lubeck, Germany
| | - Laura Boland
- Integrated Knowledge Translation Research Network, The Ottawa Hospital Research Institute, Ottawa, Canada
- Western University, London, Canada
| | - Sandra Dunn
- BORN Ontario, CHEO Research Institute, School of Nursing, University of Ottawa, Ottawa, Canada
| | - Andrew A Dwyer
- William F. Connell School of Nursing, Boston University, Chestnut Hill, Massachusetts, USA
- Munn Center for Nursing Research, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jürgen Kasper
- Department of Nursing and Health Promotion, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Simone Maria Kienlin
- Faculty of Health Sciences, Department of Health and Caring Sciences, University of Tromsø, Tromsø, Norway
- The South-Eastern Norway Regional Health Authority, Department of Medicine and Healthcare, Hamar, Norway
| | - France Légaré
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec City, Canada
| | - Krystina B Lewis
- School of Nursing, University of Ottawa, Ottawa, Canada
- University of Ottawa Heart Institute, University of Ottawa, Ottawa, Canada
| | | | - Claudia Rutherford
- School of Psychology, Quality of Life Office, University of Sydney, Camperdown, Australia
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
| | - Junqiang Zhao
- School of Nursing, University of Ottawa, Ottawa, Canada
| | - Tamara Rader
- Canadian Agency for Drugs and Technologies in Health (CADTH), Ottawa, Canada
| | - Ian D Graham
- Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology, Public Health and Preventative Medicine, University of Ottawa, Ottawa, Canada
| | - Dawn Stacey
- School of Nursing, University of Ottawa, Ottawa, Canada
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Rana K, Gupta A, Sood A, Gupta M. Factors leading to neonatal mortality due to neonatal purpura fulminans through the lens of a child death review. BMJ Case Rep 2021; 14:e237281. [PMID: 34167969 PMCID: PMC8230994 DOI: 10.1136/bcr-2020-237281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2021] [Indexed: 11/04/2022] Open
Abstract
A case of neonatal death due to neonatal purpura fulminans (NPF) was brought to community physicians' notice by the auxiliary nurse midwife in her catchment area as part of the routine demographic health surveillance. The community physician then conducted the child death review in the community. The neonate was born out of consanguineous marriage (mother married to her first-degree maternal cousin) with spontaneous conception. This neonate was fourth in the birth order. The second-order and third-order births had also suffered from NPF and died. The baby was delivered in a tertiary care setting, and the paediatric surgeon planned debridement of the affected part on the third day of the birth, as per the mother. However, due to inadequate counselling regarding the procedure, mother left the hospital without seeking care against medical advice, and the child died at home.
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Affiliation(s)
- Kirtan Rana
- Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Atul Gupta
- Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aditya Sood
- Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Madhu Gupta
- Department of Community Medicine and School of Public Health, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Page RL, Murphey C, Aras Y, Chen LS, Loftin R. Pregnant Hispanic women's views and knowledge of prenatal genetic testing. J Genet Couns 2021; 30:838-848. [PMID: 33496987 PMCID: PMC8248231 DOI: 10.1002/jgc4.1383] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 12/11/2022]
Abstract
Pregnant Hispanic women are underserved with their needs for genetic counseling, despite birth defects remaining the leading cause of infant death in the United States. We present the qualitative findings of a study to understand knowledge and perceptions of prenatal testing in a sample of hard‐to‐reach underrepresented Hispanic pregnant women in South Texas. The sample for this study was 10 Hispanic pregnant women who were recruited from a high‐risk prenatal clinic in South Texas in 2019. The semi‐structured interview questions were created based on the researchers' clinical experiences with this population and were designed to examine knowledge and perceptions of participants toward prenatal testing. Analysis of the qualitative data yielded several themes related to prenatal testing: (a) knowledge, (b) confusion, (c) partner's and support persons' opinions, (d) information sharing from providers, (e) psychological benefits, (f) preparation for baby, (g) obstacles, (h) religious influence, and (i) educational tools to assist with understanding. Women's understanding and knowledge of prenatal testing was limited, specifically regarding its purpose, how it works, the benefits, and why it was recommended by their provider. Lack of clarity about why they should take the test and its risks for them and their babies was perceived as something that could impede their acceptance of prenatal testing. All participants agreed that healthcare providers should share more information about prenatal testing in a way that uses ‘everyday language' so that they can understand it better. All respondents mentioned that prenatal testing provides information about their baby's health conditions, alleviates their stress and concerns, and psychologically prepares them and their family for what is to come. Identifying ways to increase culturally appropriate education delivered by genetic counselors such as through the adoption of telemedicine and mobile technology can help fill the gap for this underserved population.
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Affiliation(s)
- Robin L Page
- Texas A&M University College of Nursing, College Station, TX, USA
| | - Christina Murphey
- College of Nursing & Health Sciences, Texas A&M University-Corpus Christi, Corpus Christi, TX, USA
| | - Yahyahan Aras
- Department of Counseling and Educational Psychology, Texas A&M University-Corpus Christi, Corpus Christi, TX, USA
| | - Lei-Shih Chen
- Texas A&M University College of Education and Human Development, College Station, TX, USA
| | - Ryan Loftin
- Driscoll Health System, Maternal-Fetal Medicine, Corpus Christi, TX, USA
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Appiah S, Korsah KA, AmpongAdjei C, Appiah OE. Genetic counselling in sickle cell disease: views of single young adults in Ghana. J Community Genet 2020; 11:485-493. [PMID: 32613518 PMCID: PMC7475149 DOI: 10.1007/s12687-020-00474-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 06/21/2020] [Indexed: 11/28/2022] Open
Abstract
Sickle cell disease is a chronic inherited blood disorder affecting many people globally as well as in Sub-Saharan Africa. In Ghana, the disease has a prevalence of 2% with carrier rate of 20-25% among the populace. Genetic counselling is a cost-effective strategy in reducing the burden of this disorder. However, little is known about the relevance of this intervention particularly among young adults in their reproductive age. The purpose of this is to explore the views of single young adults about genetic counselling in the Accra metropolis, Ghana. An exploratory descriptive qualitative designed was used. Thirty-two (32) young adults between the ages of 18 and 28 years were purposively selected from a private university in Ghana. Four focus group discussions and twelve in-depth interviews were conducted. Data was analysed using content analysis technique. The results of the study revealed that young adults had knowledge about SCD and due to that showed positive perceptions towards genetic counselling in SCD. However, they were unaware of genetic counselling facilities in the country. They expressed willingness to accept genetic counselling related to SCD whether for a fee or for free. It was concluded that establishment of a number of genetic counselling centres is very crucial in the metropolis.
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Affiliation(s)
- Stella Appiah
- Department of Nursing, Valley View University, Box AF 595, Adentan, Accra, Ghana
| | - Kwadwo Ameyaw Korsah
- Department of Adult Health, School of Nursing, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Charles AmpongAdjei
- Department of Community Health Nursing, School of Nursing, College of Health Sciences, University of Ghana, Accra, Ghana
| | - Osei Evans Appiah
- Ghana Health Service, Ga-West Municipal Hospital, Amasaman, Accra, Ghana
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Lunsford NB, Sapsis KF, Smither B, Reynolds J, Wilburn B, Fairley T. Young Women's Perceptions Regarding Communication with Healthcare Providers About Breast Cancer, Risk, and Prevention. J Womens Health (Larchmt) 2017; 27:162-170. [PMID: 28472603 DOI: 10.1089/jwh.2016.6140] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Women younger than 45 years old have lower rates of breast cancer, but higher risk of recurrence and mortality after a cancer diagnosis. African American women are at risk for early onset and increased mortality; Ashkenazi Jewish women are at risk for genetic mutations leading to breast and ovarian cancer. Although younger women are encouraged to talk to doctors about their family history, little is known about these discussions. MATERIALS AND METHODS In 2015, 167 women aged 18-44 years participated in 20 focus groups segmented by geographic location, age, race/ethnicity, and family history of breast and ovarian cancer. Transcript data were analyzed using NVivo 10 software. RESULTS Although the majority of women talked to their doctor about breast and ovarian cancer, these conversations were brief and unsatisfying due to a lack of detail. Topics included family history, breast cancer screening, and breast self-examination. Some women with and without family history reported that healthcare providers offered screening and early detection advice based on their inquiries. However, few women took action or changed lifestyle behaviors with the intent to reduce risk as a result of the conversations. CONCLUSIONS Conversations with young women revealed missed opportunities to: enhance patient-provider communication and increase knowledge about breast cancer screening and surveillance for higher risk patients. Physicians, allied health professionals, and the public health community can better assist women in getting accurate and timely information about breast and ovarian cancer, understanding their family history to determine risk, and increasing healthy behaviors.
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Affiliation(s)
- Natasha Buchanan Lunsford
- 1 Division of Cancer Prevention and Control, Centers for Disease Control and Prevention , Atlanta, Georgia
| | - Karena F Sapsis
- 2 Office on Smoking and Health, Centers for Disease Control and Prevention , Atlanta, Georgia
| | - Betsy Smither
- 3 Oak Ridge Associated Universities , Oak Ridge, Tennessee
| | | | - Ben Wilburn
- 3 Oak Ridge Associated Universities , Oak Ridge, Tennessee
| | - Temeika Fairley
- 1 Division of Cancer Prevention and Control, Centers for Disease Control and Prevention , Atlanta, Georgia
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Tang J, Tang CY, Wang F, Guo Y, Tang HN, Zhou CL, Tan SW, Liu SP, Zhou ZG, Zhou HD. Genetic diagnosis and treatment of a Chinese ketosis-prone MODY 3 family with depression. Diabetol Metab Syndr 2017; 9:5. [PMID: 28105082 PMCID: PMC5240193 DOI: 10.1186/s13098-016-0198-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 12/04/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To analyze the gene mutation and mental disorder of a Chinese ketosis-prone diabetes (KPD) family, and to make a precise diagnosis and give a treatment for them. METHODS We studied a Chinese family with a clinical diagnosis of maturity-onset diabetes of the young (MODY). The clinical data and the blood samples were collected. The promotor and coding regions inclusive intron exon boundaries of the HNF1A, HNF4A were detected by polymerase chain reaction (PCR) and direct sequencing. The missense mutation was also analyzed by bioinformatics. Genetic counseling was performed twice a month to relieve the mental disorder of the persons. RESULTS The missense mutation c.779 C>T (p.T260M) in exon4 of HNF1A gene was detected, and the symptom heterogenicity among persons in this family were found. All the members were retreated with Gliclazide and stopped to use other medicine, the blood glucose of them were well controlled. We also performed an active genetic counseling to them and the mental disorder of the proband's sister was relieved. CONCLUSIONS A missense mutation of HNF1A gene was first found in Chinese ketosis-prone MODY family with manifestations heterogenicity among the persons. Sulphonylureas medicine and genetic counseling are efficiency ways to treat MODY 3 and its' mental disorder respectively.
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Affiliation(s)
- Jun Tang
- Department of Metabolism and Endocrinology, National Clinical Research Center for Metabolic Disease, The Second Xiang-Ya Hospital of Central South University, 139 Middle Ren-Min Road, Changsha, China
| | - Chen-Yi Tang
- Department of Metabolism and Endocrinology, National Clinical Research Center for Metabolic Disease, The Second Xiang-Ya Hospital of Central South University, 139 Middle Ren-Min Road, Changsha, China
| | - Fang Wang
- Department of Metabolism and Endocrinology, National Clinical Research Center for Metabolic Disease, The Second Xiang-Ya Hospital of Central South University, 139 Middle Ren-Min Road, Changsha, China
| | - Yue Guo
- Department of Metabolism and Endocrinology, National Clinical Research Center for Metabolic Disease, The Second Xiang-Ya Hospital of Central South University, 139 Middle Ren-Min Road, Changsha, China
| | - Hao-Neng Tang
- Department of Metabolism and Endocrinology, National Clinical Research Center for Metabolic Disease, The Second Xiang-Ya Hospital of Central South University, 139 Middle Ren-Min Road, Changsha, China
| | - Ci-La Zhou
- Department of Metabolism and Endocrinology, National Clinical Research Center for Metabolic Disease, The Second Xiang-Ya Hospital of Central South University, 139 Middle Ren-Min Road, Changsha, China
| | - Shu-Wen Tan
- Department of Metabolism and Endocrinology, National Clinical Research Center for Metabolic Disease, The Second Xiang-Ya Hospital of Central South University, 139 Middle Ren-Min Road, Changsha, China
| | - Shi-Ping Liu
- Department of Metabolism and Endocrinology, National Clinical Research Center for Metabolic Disease, The Second Xiang-Ya Hospital of Central South University, 139 Middle Ren-Min Road, Changsha, China
| | - Zhi-Guang Zhou
- Department of Metabolism and Endocrinology, National Clinical Research Center for Metabolic Disease, The Second Xiang-Ya Hospital of Central South University, 139 Middle Ren-Min Road, Changsha, China
| | - Hou-De Zhou
- Department of Metabolism and Endocrinology, National Clinical Research Center for Metabolic Disease, The Second Xiang-Ya Hospital of Central South University, 139 Middle Ren-Min Road, Changsha, China
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Esplen MJ, Wong J, Aronson M, Butler K, Rothenmund H, Semotiuk K, Madlensky L, Way C, Dicks E, Green J, Gallinger S. Long-term psychosocial and behavioral adjustment in individuals receiving genetic test results in Lynch syndrome. Clin Genet 2015; 87:525-32. [PMID: 25297893 PMCID: PMC4391982 DOI: 10.1111/cge.12509] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 09/19/2014] [Accepted: 09/23/2014] [Indexed: 11/29/2022]
Abstract
A cross-sectional study of 155 participants who underwent genetic testing for Lynch syndrome (LS) examined long-term psychosocial and behavioral outcomes. Participants completed standardized measures of perceived risk, psychosocial functioning, knowledge, and a questionnaire of screening activities. Participants were on average 47.3 years and had undergone testing a mean of 5.5 years prior. Eighty four (54%) tested positive for a LS mutation and 71 (46%) negative. For unaffected carriers, perceived lifetime risk of colorectal cancer was 68%, and surprisingly, 40% among those testing negative. Most individuals demonstrated normative levels of psychosocial functioning. However, 25% of those testing negative had moderate depressive symptoms, as measured by the Center for Epidemiologic Studies for Depression Scale, and 31% elevated state anxiety on the State-Trait Anxiety Inventory. Being female and a stronger escape - avoidant coping style were predictive of depressive symptoms. For state anxiety, similar patterns were observed. Quality of life and social support were significantly associated with lower anxiety. Carriers maintained higher knowledge compared to those testing negative, and were more engaged in screening. In summary, most individuals adapt to genetic test results over the long term and continue to engage in screening. A subgroup, including some non-carriers, may require added psychosocial support.
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Affiliation(s)
- M J Esplen
- University Health Network, Toronto, Canada; Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Canada; de Souza Institute, Toronto, Canada
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