Predictors of patient uptake of colorectal cancer gene environment risk assessment

Behavioral and Psychological Outcomes Associated with Skin Cancer Genetic Testing in Albuquerque Primary Care

Simple Summary

Genetic information is publicly available but research examining the best use of such information has not engaged diverse members of the public. We examined public reactions to melanoma genetic testing (using the melanocortin-1 receptor [MC1R] gene) in a study randomizing (like the flip of a coin) 600 diverse primary care patients to a MC1R test offer or usual care. We found that testing did not improve sun protection and skin cancer screening, nor did it lead worry to increase. However, groups less aware of their skin cancer risk, including those who thought their risk was “unlikely” at the start of the study, showed significant improvements in sun protection at three months. In conclusion, testing might be very helpful for certain people who have the most to learn about their risk, who may become motivated to protect themselves from the damaging effects of the sun as a result of skin cancer genetic testing.

Abstract

Public availability of genetic information is increasing; thus, efforts to improve diversity in basic and translational research in genomics is a top priority. Given the increasing U.S. incidence and mortality of melanoma, and the prevalence of common melanocortin-1 receptor (MC1R) gene melanoma risk variants in the general population, we examined genomic testing of MC1R for skin cancer risk in a randomized controlled trial in Albuquerque, New Mexico primary care. Participants were 48% Hispanic and were randomized 5:1 to a MC1R test invitation or usual care. We assessed 3 month sun protection, skin cancer screening, and skin cancer worry outcomes associated with testing, and key effect moderators (e.g., cancer risk perceptions, and skin cancer risk factors). Our findings indicate that the primary outcomes were unchanged by the MC1R test offer, test acceptance, and level of risk feedback. Moderator analyses showed that those with lower risk perception, and those with skin that readily tans, significantly increased their sun protection in response to higher than average risk feedback. Risk feedback did not prompt cancer worry, and average risk feedback did not erode existing sun protection. This study paves the way for the development of tailored strategies to address low skin cancer risk awareness in this understudied context of public health genomics.

Can Cost-effectiveness Analysis Inform Genotype-Guided Aspirin Use for Primary Colorectal Cancer Prevention?

BACKGROUND

Inherited genetic variants can modify the cancer-chemopreventive effect of aspirin. We evaluated the clinical and economic value of genotype-guided aspirin use for colorectal cancer chemoprevention in average-risk individuals.

METHODS

A decision analytical model compared genotype-guided aspirin use versus no genetic testing, no aspirin. The model simulated 100,000 adults ≥50 years of age with average colorectal cancer and cardiovascular disease risk. Low-dose aspirin daily starting at age 50 years was recommended only for those with a genetic test result indicating a greater reduction in colorectal cancer risk with aspirin use. The primary outcomes were quality-adjusted life-years (QALY), costs, and incremental cost-effectiveness ratio (ICER).

RESULTS

The mean cost of using genotype-guided aspirin was $187,109 with 19.922 mean QALYs compared with $186,464 with 19.912 QALYs for no genetic testing, no aspirin. Genotype-guided aspirin yielded an ICER of $66,243 per QALY gained, and was cost-effective in 58% of simulations at the $100,000 willingness-to-pay threshold. Genotype-guided aspirin was associated with 1,461 fewer polyps developed, 510 fewer colorectal cancer cases, and 181 fewer colorectal cancer-related deaths. This strategy prevented 1,078 myocardial infarctions with 1,430 gastrointestinal bleeding events, and 323 intracranial hemorrhage cases compared with no genetic testing, no aspirin.

CONCLUSIONS

Genotype-guided aspirin use for colorectal cancer chemoprevention may offer a cost-effective approach for the future management of average-risk individuals.

IMPACT

A genotype-guided aspirin strategy may prevent colorectal cancer, colorectal cancer-related deaths, and myocardial infarctions, while minimizing bleeding adverse events. This model establishes a framework for genetically-guided aspirin use for targeted chemoprevention of colorectal cancer with application toward commercial testing in this population.

A survey of aortic disease biorepository participants' preferences for return of research genetic results

There is ongoing debate on whether and what research genetic results to return to study participants. To date, no study in this area has focused on aortopathy populations despite known genes that are clinically actionable. Participants (n = 225, 79% male, mean age = 61 years) with an aortopathy were surveyed to assess preferences for receiving research genetic results. Participants were 'very' or 'extremely likely' to want results for pathogenic variants in aortopathy genes with implications for family members (81%) or that would change medical management (76%). Similarly, participants were 'very' or 'extremely likely' to want actionable secondary findings related to cancer (75%) or other cardiac diseases (70%). Significantly lower interest was observed for non-actionable findings-pathogenic variants in aortopathy genes that would not change medical management (51%) and variants of uncertain significance (38%) (p < .0001). Higher health and genomic literacy were positively associated with interest in actionable findings. Most participants (>63%) were accepting of any means of return; however, a substantial minority (18%-38%) deemed certain technological means unacceptable (e.g., patient portal). Over 90% of participants reported that a range of health professionals, including cardiovascular specialists, genetics specialists, and primary care providers, were acceptable to return results. Participants with aortopathies are highly interested in research genetic results perceived to be medically actionable for themselves or family members. Participants are accepting of a variety of means for returning results. Findings suggest that research participants should be asked what results are preferred at time of informed consent and that genetic counseling may clarify implications of results that are not personally medically actionable.

State of recent literature on communication about cancer genetic testing among Latinx populations

Cancer-related genetic testing (hereafter CGT) has transformed cancer prevention, treatment, and care. Researchers debate whether diffusion and use of genetic testing will reduce or widen cancer health disparities through effects on improving or worsening cancer-related mortality, morbidity, and outcomes that disproportionately affect racial and ethnic minority populations. Cancer disparities by race and ethnicity have been associated with social determinants of health and healthcare access and experience. However, little research has explored how communication about CGT may contribute to these disparities. As such, the goal of this study was to characterize the literature published between 2010 and 2017 on communication about CGT among Latinx populations through a secondary analysis of papers identified in a larger scoping review. We found thirteen (2.5%) of 513 papers in the parent scoping review had over 50% Latinx representation; only nine of these (69%) had fully Latinx comprised study cohorts. The majority of the 13 identified studies (n = 9) were conducted to assess knowledge and attitudes regarding CGT. Most studies included services or materials in both Spanish and English. Few studies assessed language preference or acculturation or compared outcomes across sub-ethnicities. We identified opportunities for researchers to explore differences in outcomes by language preference and acculturation, and between sub-ethnicities in future studies. Leveraging a greater understanding of the heterogeneity within the Latinx population will allow genetics researchers and providers to improve utilization of CGT and therein health outcomes to advance health equity.

Psychosocial and Cultural Determinants of Interest and Uptake of Skin Cancer Genetic Testing in Diverse Primary Care

BACKGROUND

Translational research in genomics has limited reach and requires efforts to broaden access and utility in diverse populations. Skin cancer is common and rates are rising, including among Hispanics. Germline variants in the melanocortin-1 receptor (MC1R) gene are common in the population and confer moderate risk for melanoma and basal cell cancers across skin types. Feedback about MC1R risk status may promote skin cancer risk awareness and risk reduction.

AIMS

We examined the level of interest in pursuing MC1R testing, and patterns of interest across skin cancer perceived threat and control attitudes, cultural beliefs (family influence on health, health system distrust, cancer fatalism, skin cancer misconceptions), and health literacy.

METHODS

We used a study website to inform primary care patients in Albuquerque, NM about the benefits and drawbacks of MC1R testing. Website logon, request of a saliva test kit, and return of the test kit (yes vs. no) were primary assessments of study interest and uptake.

RESULTS

Of 499 participants provided with a test offer, 33% requested and returned the test. Lower family influence on participants' health was an important factor both overall and within ethnicity subgroups, and may indicate that primary care patients interested in skin cancer genetic testing see themselves as proactive health seekers, independent from family encouragement. Lower self-efficacy for skin cancer prevention was also an important characteristic of those who tested.

CONCLUSION

As evidence for common genetic markers for skin cancer accumulates, these findings suggest characteristics of those most likely to pursue genetic testing for skin cancer risk.

Racial and ethnic differences in knowledge and attitudes about genetic testing in the US: Systematic review

Precision medicine has grown over the past 20 years with the availability of genetic tests and has changed the one-size-fits-all paradigm in medicine. Precision medicine innovations, such as newly available genetic tests, could potentially widen racial and ethnic disparities if access to them is unequal and if interest to use them differs across groups. The objective of this systematic review was to synthesize existing evidence on racial and ethnic differences in knowledge of and attitudes toward genetic testing among adult patients and the general public in the US, focusing on research about the use of genetic testing in general, not disease-specific tests. Twelve articles published in 1997-2017 met inclusion and exclusion criteria, with 10 including knowledge variables and seven including attitude variables. Studies found consistent patterns of lower awareness of genetic testing in general among non-Whites compared to Whites, lower factual knowledge scores among Blacks and Hispanics/Latinos, and mixed findings of differences in awareness of direct-to-consumer (DTC) genetic testing or the term precision medicine. Blacks, Hispanics/Latinos, and non-Whites generally had more concerns about genetic testing than Whites. The findings suggest that patients and the general public need access to culturally appropriate educational material about the use of genetic testing in precision medicine.

Implementing an Internet-Delivered Skin Cancer Genetic Testing Intervention to Improve Sun Protection Behavior in a Diverse Population: Protocol for a Randomized Controlled Trial

Background

Limited translational genomic research currently exists to guide the availability, comprehension, and appropriate use of personalized genomics in diverse general population subgroups. Melanoma skin cancers are preventable, curable, common in the general population, and disproportionately increasing in Hispanics.

Objective

Variants in the melanocortin-1 receptor (MC1R) gene are present in approximately 50% of the population, are major factors in determining sun sensitivity, and confer a 2-to-3-fold increase in melanoma risk in the general population, even in populations with darker skin. Therefore, feedback regarding MC1R risk status may raise risk awareness and protective behavior in the general population.

Methods

We are conducting a randomized controlled trial examining Internet presentation of the risks and benefits of personalized genomic testing for MC1R gene variants that are associated with increased melanoma risk. We will enroll a total of 885 participants (462 participants are currently enrolled), who will be randomized 6:1 to personalized genomic testing for melanoma risk versus waiting list control. Control participants will be offered testing after outcome assessments. Participants will be balanced across self-reported Hispanic versus non-Hispanic ethnicity (n=750 in personalized genomic testing for melanoma risk arm; n=135 in control arm), and will be recruited from a general population cohort in Albuquerque, New Mexico, which is subject to year-round sun exposure. Baseline surveys will be completed in-person with study staff and follow-up measures will be completed via telephone.

Results

Aim 1 of the trial will examine the personal utility of personalized genomic testing for melanoma risk in terms of short-term (3-month) sun protection and skin screening behaviors, family and physician communication, and melanoma threat and control beliefs (ie, putative mediators of behavior change). We will also examine potential unintended consequences of testing among those who receive average-risk personalized genomic testing for melanoma risk findings, and examine predictors of sun protection at 3 months as the outcome. These findings will be used to develop messages for groups that receive average-risk feedback. Aim 2 will compare rates of test consideration in Hispanics versus non-Hispanics, including consideration of testing pros and cons and registration of a decision to either accept or decline testing. Aim 3 will examine personalized genomic testing for melanoma risk feedback comprehension, recall, satisfaction, and cancer-related distress in those who undergo testing, and whether these outcomes differ by ethnicity (Hispanic vs non-Hispanic), or sociocultural or demographic factors. Final outcome data collection is anticipated to be complete by October 2017, at which point data analysis will commence.

Conclusions

This study has important implications for personalized genomics in the context of melanoma risk, and may be broadly applicable as a model for delivery of personalized genomic feedback for other health conditions.

Discussing race-related limitations of genomic testing for colon cancer risk: implications for education and counseling

This study examines communication about limitations of genomic results interpretation for colon cancer risk during education and counseling of minority participants. As part of a larger study conducted from 2010 to 2012, participants recruited from a large primary care clinic were offered testing for a research panel of 3 genomic markers (single nucleotide polymorphisms or SNPs) for colorectal cancer risk. Genetic counselors conducted pre- and post-test sessions which included discussion of limitations of result interpretation due to the lack of racial/ethnic diversity in research populations from which risk data are derived. Sessions were audio-recorded, transcribed and thematically analyzed. Many participants did not respond directly to this limitation. Among the participants that responded directly to this race-related limitation, many responses were negative. However, a few participants connected the limited minority information about SNPs with the importance of their current research participation. Genetic counselor discussions of this limitation were biomedically focused with limited explanations for the lacking data. The communication process themes identified included: low immediacy (infrequent use of language directly involving a participant), verbal dominance (greater speaking ratio of the counselor to the patient) and wide variation in the degree of interactivity (or the amount of turn-taking during the discussion). Placed within the larger literature on patient-provider communication, these present results provide insight into the dynamics surrounding race-related educational content for genomic testing and other emerging technologies. Clinicians may be better able to engage patients in the use of new genomic technology by increasing their awareness of specific communication processes and patterns during education or counseling sessions.

The promise of using personalized genomic information to promote behavior change: is the debate over, or just beginning?

Over recent years, significant debate has centered on whether and how communication of personalized genomic risk information can positively influence health behavior change. Several thoughtful commentaries have cautioned that efforts to incorporate genomic risk feedback to motivate health behavior change have had little success. As a field, we should consider the reasons for this limited success and be strategic in the next steps for this line of research. In this article, we consider several reasons that prior research that integrates personalized genomic information has had relative degrees of success in changing or maintaining health behaviors. We suggest ways forward and outline the possibilities presented by emerging technologies and novel approaches in translational genomic research.

Bumps along the translational pathway: anticipating uptake of tailored smoking cessation treatment

AIM

To assess potential barriers to clinical integration of tailored smoking cessation treatment among African American and white smokers in the USA.

METHODS

A total of 392 smokers (203 white and 189 African American) identified within a national random digit dial survey (response rate: 40.1%; 81.2% among households with whom we were able to make contact) of 1200 African Americans and 1200 white Americans. Respondents answered several closed-ended survey items addressing beliefs regarding what influences a smoker's ability to quit, past pharmacotherapy use, and their willingness to undergo genetic assessment in order to be matched to optimal treatment, among other items.

RESULTS

In this first nationally representative survey of US smokers, 77% of respondents expressed willingness to undergo genetic testing in order to be matched to optimal pharmacotherapy, yet only 18% had ever used pharmacotherapy in a previous quit attempt. Smokers who rated 'medications and counseling' as very important in quitting were significantly more likely to endorse genetic testing (odds ratio [OR]: 8.94; 95% CI: 1.86-43.06), while those rating 'having God's help' as very important were significantly less likely to express willingness to undergo testing (OR: 0.11; 95% CI: 0.02-0.71). African American smokers were more likely than white smokers to express willingness to undergo genetic testing (OR: 3.80; 95% CI: 1.09-13.22), despite lower rates of previous pharmacotherapy use.

CONCLUSION

While smokers reported high rates of willingness to undergo genetic testing to be matched to optimal treatment, these results suggest that smokers' willingness to use medications indicated by genetic test results may prove a significant barrier to realizing the promise of tailored smoking cessation treatment. The role of spirituality in smokers' willingness to use medication is an area for further study.