Cancer risk management decision making for BRCA+ women

Decisional conflict and knowledge in women with BRCA1/2 pathogenic variants: An exploratory age group analysis of a randomised controlled decision aid trial

Female BRCA1/2 pathogenic variant (PV) carriers face substantial risks for breast and ovarian cancer. Evidence-based decision aids (DAs) can facilitate these women in their decision-making process on an individually suitable preventive strategy. However, there is a gap in previous literature exploring whether DA effectiveness varies according to women's age. This is an exploratory subanalysis with a descriptive approach from a randomised controlled study assessing the effectiveness of a German decision aid (DA) for women with BRCA1/2 PVs compared to no DA use. From the original sample, women aged 18-40 years and >40 years and the intervention and control groups (IG, CG) within each of the age groups were compared regarding decisional conflict (using the Decisional Conflict Scale DCS) and knowledge at baseline and after DA use three and six months post study inclusion. The subanalysis involved 236 women aged 18-40 and 181 women aged >40 years. At baseline, both age groups differed significantly in all socio-demographic variables, except BRCA1/2 PV distributions. The younger age group displayed higher scores in the DCS subscale informed (p = .002) and higher knowledge (p = .010). Among the 18-40-year-olds, DA use (versus no DA) led to improvements in the DCS subscale informed at three (p = .025) and six months (p = .000). In the >40-year-olds, DA use (versus no DA) led to improvements in the DCS subscales informed (p = .028), values clarity (p = .028) and support (p = .030) and increased knowledge at three months (p = .048). These results indicate that both age groups benefited from DA use, but the older ones did so to a greater extent. This suggests that it might be useful to tailor DAs more closely to age- or life stage-related needs to enable more personalised care and support for women with BRCA1/2 PVs.

Decision-making process for risk-reducing salpingo-oophorectomy among Korean women with hereditary breast cancer: A grounded theory study

PURPOSE

To explore the decision-making process regarding Risk-Reducing Salpingo-Oophorectomy (RRSO) among women with hereditary breast cancer in Korea, with a focus on complex interpersonal interactions and sociocultural influences.

METHOD

This qualitative, grounded theory study conducted semi-structured and in-depth interviews with 17 women with hereditary breast cancer between March and December 2021. Theoretical sampling and constant comparison were utilized for data analysis.

RESULTS

The core concept identified was 'Navigating optimal trajectories for preserving myself,' encompassing four stages: (1) conflicting between cancer-free health and maintaining integrated self; (2) recognizing the decision-maker: myself vs. physician; (3) seeking meaningful information; and (4) evaluating decision results and prioritizing values. Women's conflict was influenced by the time given to decide, the timing of BRCA results, complexity of surgical choices, diverse perspectives, and the quality of information. This process often reiterated until RRSO was undertaken.

CONCLUSION

Women with hereditary breast cancer grapple with conflicting decisions to preserve their integrated selves. The decision-making process is complex and subjective, influenced by physician-dominated decision-making culture, subjective meaningful information, individual values, and decisional circumstances. Supporting women in prioritizing their values and providing comprehensive information on the physical, emotional, relational, and social impacts of each option are crucial. Oncology nurses can play a vital role in bridging the gap between physician-dominated decision-making and patient autonomy by facilitating communication and supporting patient-centered care.

Decision-making for bilateral risk-reducing mastectomy for an increased lifetime breast cancer risk: A qualitative metasynthesis

OBJECTIVE

Previvor is a term applied to a person with an identified, elevated lifetime cancer risk but without an actual cancer diagnosis. Previvorship entails the selection of risk management strategies. For women with a genetic mutation that increases their predisposition for a breast cancer diagnosis, bilateral risk-reducing mastectomy (BRRM) is the most effective prevention strategy. However, BRRM can change a woman's breast appearance and function. The purpose of this qualitative metasynthesis (QMS) was to better understand the decision-making process for BRRM among previvors.

METHODS

A theory-generating QMS approach was used to analyze and synthesize qualitative findings. Research reports were considered for inclusion if: (1) women over 18 years of age possessed a genetic mutation increasing lifetime breast cancer risk or a strong family history of breast cancer; (2) the sample was considering, or had completed, BRRM; (3) the results reported qualitative findings. Exclusion criteria were male gender, personal history of breast cancer, and research reports which did not separate findings based on cancer diagnosis and/or risk-reduction surgery.

RESULTS

A theory and corresponding model emerged, comprised of seven themes addressing the decision-making process for or against BRRM. While some factors to decision-making were decisive for surgery, others were more indefinite and contributed to women changing, processing, or suspending their decision-making for a period of time.

CONCLUSIONS

Regardless of the decision previvors make about BRRM, physical and psychosocial well-being should be considered and promoted through shared decision-making in the clinical setting.

Previvorship Posting: Why Breast Cancer Previvors Share Their Stories on Social Media

Research on previvors, individuals with a genetic predisposition to develop hereditary breast and ovarian cancer but who have not yet been diagnosed with breast or other cancers, examines online information gathering and community support to alleviate uncertainty. However, research exploring online content published by previvors themselves is limited. We examined content published to Instagram and TikTok to explore how breast cancer previvors discussed their lived experience which included, but was not limited to, genetic testing, diagnosis with a BRCA1/2 pathogenic (i.e. risk-increasing) variant, the decision to undergo preventative measures like surgery and/or reconstruction, and how they cope after diagnosis and surgical procedures. In the findings, we explicate how many previvors feel a responsibility to share their authentic experience on social media in order to help others and mitigate their own feelings of uncertainty. This study offers a snapshot of how women are sharing breast cancer previvorship and building social connections with each other online.

"You Always Have It in the Back of Your Mind"-Feelings, Coping, and Support Needs of Women with Pathogenic Variants in Moderate-Risk Genes for Hereditary Breast Cancer Attending Genetic Counseling in Germany: A Qualitative Interview Study

Hereditary breast cancer accounts for approximately 30% of newly diagnosed breast cancer (BC) cases. Pathogenic variants in moderate-risk BC genes (MBCG) differ from those in high-risk genes in terms of associated cancer risks, affected organs, and available preventive options. Little is known about how MBCG pathogenic variant carriers who have attended post-test genetic counseling perceive their situation, how they cope with their situation, and which support needs they might have. Problem-centered, guided, individual interviews were conducted with twelve women carrying pathogenic variants in MBCG. The interview analysis was based on Mayring's qualitative content analysis. The women were between 29 and 59 years old and carried pathogenic variants in the risk genes CHEK2 (n = 8), ATM (n = 1), or PALB2 (n = 3). Women reported a wide range of feelings, both positive (relief, calmness) and negative (overwhelm, fear, grief, guilt). All women applied strategies of emotion-focused coping to deal with this lifelong situation. Appraisal and evaluation of the affected mother's coping might influence the patient's own behavior and coping style. These results could be used during and after post-test genetic counseling to provide more needs-oriented counseling, and to help women in adjusting to and coping with being a pathogenic variant carrier.

Development and Testing of a Decision Aid for Unaffected Women with a BRCA1 or BRCA2 Mutation

For women who are unaffected carriers of a pathogenic BRCA mutation, cancer risk management requires ongoing education, counseling, and support from an interdisciplinary team of medical specialists, genetic counselors, and nurses specializing in genomics. The purpose of this study was to develop and pilot test an educational, patient-focused decision aid to facilitate shared decision making. A steering committee developed the prototype aid after an extensive review of the literature. The aid was designed at the ninth-grade reading level, to be consistent with internationally accepted clinical guidelines and inclusive of all risk management options and psychosocial issues important to cancer risk management decision making. The aid was tested with 23 participants: eight experts and 15 end users. Eleven survey items were asked related to organization, clarity, usefulness, comprehensiveness, ease of understanding, and relevance to the cancer risk management decision-making process. Mean scores were 3 or higher on Likert scales of 1-4 (high) for each of the 11 items. Two open-ended questions elicited general comments and suggestions for additions, deletions, or revisions to the decision aid. The steering committee made final revisions to the aid based on participant feedback and committee consensus.

Genetic counseling and previvorship in patients with urologic malignancies

PURPOSE OF REVIEW

With the increasing use of precision medicine in oncology, genetic counseling and germline genetic testing are becoming increasingly important in urologic malignancies. In this review, we summarize the most relevant recent literature regarding genetic counseling in prostate and kidney cancers.

RECENT FINDINGS

Genetic counseling and testing is considered as an important component of workup for many patients with urologic malignancies but is likely underutilized. Genetic counseling in prostate cancer is a timely topic, especially as the demand for genetic counselors in oncology continues to increase with expanding guidelines for consideration of genetic testing. Genetic testing has historically been limited to only those with the most suspicious histories, but emerging data from larger studies indicates that the clinical presentation of inherited cancer syndromes are broader than previously appreciated. New models need to be developed for pretest counseling to meet increased demand.

SUMMARY

Genetic counseling and testing will become increasingly important for patients with urologic malignancies. There is limited literature on this topic, especially related to kidney cancers. Further studies are needed to determine the best way to incorporate genetic counseling and testing into the care of these patients.

Are young women ready for BRCA testing? Comparing attitudes and comprehension of two age groups of healthy Italian women

BACKGROUND

Mutations in the BRCA 1/2 genes increase the risk of developing breast and/or ovarian cancer compared with the general population. However, the risk is low at age 30, and for women younger than 25, no preventive or screening options are available. Scientists wonder whether genetic predictive BRCA testing is appropriate at a very young age. Furthermore, although young women have positive attitudes toward testing, their understanding of genetic information seems scarce.

OBJECTIVE

To assess how young (18-24) versus adult (30-45) women at general population- level risk understand information about BRCA testing.

METHODS

302 women read an informative pamphlet and answered an ad-hoc questionnaire assessing usefulness of the information for decision making, intention to undergo predictive testing, and comprehension (perceived, general, and risk comprehension; open-ended questions).

RESULTS

Younger women had a lower comprehension of important BRCA information; it was more difficult for young women to identify the risk figures of cancer, and they showed errors when answering open-ended questions.

LIMITATIONS

Results are limited by the study's hypothetical nature.

CONCLUSIONS

Young women seem to have particular difficulty understanding BRCA information.

PRACTICE IMPLICATIONS

Counsellors should be aware of the difficulties young women have in understanding information about BRCA predictive testing.

Black and Minority Ethnic women's decision-making for risk reduction strategies after BRCA testing: Use of context and knowledge

Within the field of breast cancer care, women concerned about their family history are offered genetic testing and subsequent treatment options based on several factors which include but are not limited to personal and family cancer disease histories and clinical guidelines. Discussions around decision-making in genetics in Black and Minority Ethnic (BME) groups are rarely documented in literature, and information regarding interactions with genetics services is usually discussed and linked to lack of scientific knowledge. As such, counselling sessions based only on scientific and medical information miss out the many reasons participants consider in making health decisions, information which can be used to encourage BME women to engage in cancer genetics services. 10 BME women with a mixed personal and family history of breast and ovarian cancer backgrounds, were interviewed in a study exploring issues of knowledge about familial breast cancer syndromes, to understand how they created and used familial knowledge for health decisions, with a particular focus on attitudes towards risk reducing strategies. Study results show that our participants are not unique in the ways they make decisions towards the use of cancer genetics and risk reduction strategies and as such, there are no specific ethnically defined pathways for decision-making. Our participants demonstrated mixed biomedical, social and individual cultural reasons for their decision-making towards risk reduction surgeries and treatment options which are similar to women from different ethnicities and are individual rather than group-specific. Narratives about suspicion of scientific utility of genetic knowledge, the perceived predictive value of mutations for future cancers or the origin of mutations and family disease patterns feature heavily in how participants evaluated genetic information and treatment decisions. The diversity of results shows that our participants are interested in engaging with genetic information but use multiple sources for evaluating the extent of involvement in genetic services and the place of genetic information and treatment options for themselves and their families. Genetic information is considered within various bio-social scenarios before decision-making for risk reduction is undertaken. BME women are shown to undertake evaluative processes which clinicians are encouraged to explore for better patient support. Continuing to focus on links between superficial and un-representative meanings of ethnicity, ethnic identity and attitudes and behaviours by only searching for differences between ethnic groups, are unhelpful in further understanding how women from those diverse backgrounds make decisions towards risk reduction interventions. Future research must find ways of investigating and understanding populations in ways that are not focussed solely on ethnic differences but on how meaning is created out of social circumstances and experiences.

Involvement and Influence of Healthcare Providers, Family Members, and Other Mutation Carriers in the Cancer Risk Management Decision-Making Process of BRCA1 and BRCA2 Mutation Carriers

Deciding between increased cancer screening or prophylactic surgery and the timing of such procedures can be a difficult and complex process for women with BRCA mutations. There are gaps in our understanding of involvement of others in the decision-making process for women with BRCA mutations. This study evaluated the management decision-making process of women with BRCA mutations, focusing on the involvement of others. Grounded theory was used to analyze and code risk management decision-making information from interviews with 20 BRCA mutation carriers. Unaffected at-risk participants with a BRCA mutation, those under age 40, and those with no children described having a difficult time making risk management decisions. Physicians were an integral part of the decision-making process by providing decisional support and management recommendations. Family members and other mutation carriers filled similar yet distinct roles by providing experiential information as well as decisional and emotional support for carriers. Participants described genetic counselors as short-term providers of risk information and management recommendations. The study findings suggest that unaffected at-risk women, women under 40, and those who do not have children may benefit from additional support and information during the decision-making process. Genetic counselors are well trained to help women through this process and connect them with resources, and may be under-utilized in long-term follow-up for women with a BRCA mutation.

Increasing confidence and changing behaviors in primary care providers engaged in genetic counselling

BACKGROUND

Screening and counseling for genetic conditions is an increasingly important part of primary care practice, particularly given the paucity of genetic counselors in the United States. However, primary care physicians (PCPs) often have an inadequate understanding of evidence-based screening; communication approaches that encourage shared decision-making; ethical, legal, and social implication (ELSI) issues related to screening for genetic mutations; and the basics of clinical genetics. This study explored whether an interactive, web-based genetics curriculum directed at PCPs in non-academic primary care settings was superior at changing practice knowledge, attitudes, and behaviors when compared to a traditional educational approach, particularly when discussing common genetic conditions.

METHODS

One hundred twenty one PCPs in California and Pennsylvania physician practices were randomized to either an Intervention Group (IG) or Control Group (CG). IG physicians completed a 6 h interactive web-based curriculum covering communication skills, basics of genetic testing, risk assessment, ELSI issues and practice behaviors. CG physicians were provided with a traditional approach to Continuing Medical Education (CME) (clinical review articles) offering equivalent information.

RESULTS

PCPs in the Intervention Group showed greater increases in knowledge compared to the Control Group. Intervention PCPs were also more satisfied with the educational materials, and more confident in their genetics knowledge and skills compared to those receiving traditional CME materials. Intervention PCPs felt that the web-based curriculum covered medical management, genetics, and ELSI issues significantly better than did the Control Group, and in comparison with traditional curricula. The Intervention Group felt the online tools offered several advantages, and engaged in better shared decision making with standardized patients, however, there was no difference in behavior change between groups with regard to increases in ELSI discussions between PCPs and patients.

CONCLUSION

While our intervention was deemed more enjoyable, demonstrated significant factual learning and retention, and increased shared decision making practices, there were few differences in behavior changes around ELSI discussions. Unfortunately, barriers to implementing behavior change in clinical genetics is not unique to our intervention. Perhaps the missing element is that busy physicians need systems-level support to engage in meaningful discussions around genetics issues. The next step in promoting active engagement between doctors and patients may be to put into place the tools needed for PCPs to easily access the materials they need at the point-of-care to engage in joint discussions around clinical genetics.

[Entitlement to prophylactic treatment in cases of genetic predisposition for breast cancer : Interdisciplinary perspectives]

Genetic tests can detect the predisposition to various diseases. The demand for gene diagnostics and corresponding prophylactic measures is increasing steadily. In the German healthcare system, however, legal uncertainties exist as to whether a mere risk of disease is reason enough to bear the costs for prophylactic measures. When medically effective prophylactic measures are available in certain cancer diseases, such as in hereditary breast cancer, the current practice of deciding in individual cases appears to be insufficient.The fact that persons with a high or very increased risk of breast cancer are precluded from a standard care procedure raises questions concerning ethical justification as well as medical plausibility. Moreover, it is remarkable that the statutory healthcare system treats persons at risk differently. In some cases there is a regulated way of reimbursement for preventive measures for persons at risk (factor V Leiden mutation) and in other cases there are only case-by-case decisions. Finally, in light of social regulations for persons at high and very increased risk this article considers the need of optimization regarding the risk communication in the decision-making process and the crucial question of budgetary impact for the German healthcare system.From a medical, ethical and legal perspective, a social regulation for persons at high and very increased risk of disease is inevitable and the consequences should be discussed in advance.

The management of sexuality, intimacy, and menopause symptoms (SIMS) after prophylactic bilateral salpingo-oophorectomy: How to maintain sexual health in "previvors"

"Previvors", or "pre-survivors", are individuals who do not have cancer but have a genetic predisposition to cancer. One such example is women with BRCA mutations. As a result of their predisposition to cancer, many will undergo a bilateral salpingo-oophorectomy when they are premenopausal. For premenopausal women, the removal of ovaries results in the depletion of estrogen, immediate menopause, and, in many cases, resultant Sexuality, Intimacy, and Menopausal Symptoms (SIMS). Furthermore, they may undergo changes in body image. SIMS are underreported by patients and underdiagnosed by practitioners. At the time of diagnosis or at preoperative visits, women should be informed of the potential physiologic, hormonal, and psychosocial effects of their risk-reducing surgery. There are many modalities for management of these symptoms. Successful treatment requires the provider's awareness of the problem, ability to identify it, and willingness to treat it.

Decision making for breast cancer prevention among women at elevated risk

Several medical management approaches have been shown to be effective in preventing breast cancer and detecting it early among women at elevated risk: 1) prophylactic mastectomy; 2) prophylactic oophorectomy; 3) chemoprevention; and 4) enhanced screening routines. To varying extents, however, these approaches are substantially underused relative to clinical practice recommendations. This article reviews the existing research on the uptake of these prevention approaches, the characteristics of women who are likely to use various methods, and the decision-making processes that underlie the differing choices of women. It also highlights important areas for future research, detailing the types of studies that are particularly needed in four key areas: documenting women's perspectives on their own perceptions of risk and prevention decisions; explicit comparisons of available prevention pathways and their likely health effects; the psychological, interpersonal, and social processes of prevention decision making; and the dynamics of subgroup variation. Ultimately, this research could support the development of interventions that more fully empower women to make informed and values-consistent decisions, and to move towards favorable health outcomes.

Adherence to Recommended Risk Management among Unaffected Women with a BRCA Mutation

Identifying unaffected women with a BRCA mutation can have a significant individual and population health impact on morbidity and mortality if these women adhere to guidelines for managing cancer risk. But, little is known about whether such women are adherent to current guidelines. We conducted telephone surveys of 97 unaffected BRCA mutation carriers who had genetic counseling at least one year prior to the survey to assess adherence to current guidelines, factors associated with adherence, and common reasons for performing and not performing recommended risk management. More than half of participants reported being adherent with current risk management recommendations for breast cancer (69 %, n = 67), ovarian cancer (82 %, n = 74) and both cancers (66 %, n = 64). Older age (OR = 10.53, p = 0.001), white race (OR = 8.93, p = 0.019), higher breast cancer genetics knowledge (OR = 1.67, p = 0.030), higher cancer-specific distress (OR = 1.07, p = 0.002) and higher physical functioning (OR = 1.09, p = 0.009) were significantly associated with adherence to recommended risk management for both cancers. Responses to open-ended questions about reasons for performing and not performing risk management behaviors indicated that participants recognized the clinical utility of these behaviors. Younger individuals and those with lower physical functioning may require targeted interventions to improve adherence, perhaps in the setting of long-term follow-up at a multi-disciplinary hereditary cancer clinic.

Impact of a randomized controlled educational trial to improve physician practice behaviors around screening for inherited breast cancer

BACKGROUND

Many primary care physicians (PCPs) are ill-equipped to provide screening and counseling for inherited breast cancer.

OBJECTIVE

To evaluate the outcomes of an interactive web-based genetics curriculum versus text curriculum for primary care physicians.

DESIGN

Randomized two-group design.

PARTICIPANTS

121 California and Pennsylvania community physicians.

INTERVENTION

Web-based interactive genetics curriculum, evaluated against a control group of physicians who studied genetics review articles. After education, physicians interacted with an announced standardized patient (SP) at risk for inherited breast cancer.

MAIN MEASURES

Transcripts of visit discussions were coded for presence or absence of 69 topics relevant to inherited breast cancer.

KEY RESULTS

Across all physicians, history-taking, discussions of test result implications, and exploration of ethical and legal issues were incomplete. Approximately half of physicians offered a genetic counseling referral (54.6%), and fewer (43.8%) recommended testing. Intervention physicians were more likely than controls to explore genetic counseling benefits (78.3% versus 60.7%, P = 0.048), encourage genetic counseling before testing (38.3% versus 21.3%, P = 0.048), ask about a family history of prostate cancer (25.0% versus 6.6%, P = 0.006), and report that a positive result indicated an increased risk of prostate cancer for male relatives (20.0% versus 1.6%, P = 0.001). Intervention-group physicians were less likely than controls to ask about Ashkenazi heritage (13.3% versus 34.4%, P = 0.01) or to reply that they would get tested when asked, "What would you do?" (33.3% versus 54.1%, P = 0.03).

CONCLUSIONS

Physicians infrequently performed key counseling behaviors, and this was true regardless of whether they had completed the web-based interactive training or read clinical reviews.