What you don't know can hurt you: adverse psychologic effects in members of BRCA1-linked and BRCA2-linked families who decline genetic testing

Three diverse motives for information sharing

Knowledge is distributed over many individuals. Thus, humans are tasked with informing one another for the betterment of all. But as information can alter people's action, affect and cognition in both positive and negative ways, deciding whether to share information can be a particularly difficult problem. Here, we examine how people integrate potentially conflicting consequences of knowledge, to decide whether to inform others. We show that participants (Exp1: N = 114, Pre-registered replication: N = 102) use their own information-seeking preferences to solve complex information-sharing decisions. In particular, when deciding whether to inform others, participants consider the usefulness of information in directing action, its valence and the receiver's uncertainty level, and integrate these assessments into a calculation of the value of information that explains information sharing decisions. A cluster analysis revealed that participants were clustered into groups based on the different weights they assign to these three factors. Within individuals, the relative influence of each of these factors was stable across information-seeking and information-sharing decisions. These results suggest that people put themselves in a receiver position to determine whether to inform others and can help predict when people will share information.

"How" web searches change under stress

To adjust to stressful environments, people seek information. Here, we show that in response to stressful public and private events the high-level features of information people seek online alter, reflecting their motives for seeking knowledge. We first show that when people want information to guide action they selectively ask "How" questions. Next, we reveal that "How" searches submitted to Google increased dramatically during the pandemic (controlling for search volume). Strikingly, the proportion of these searches predicted weekly self-reported stress of ~ 17K individuals. To rule out third factors we manipulate stress and find that "How" searches increase in response to stressful, personal, events. The findings suggest that under stress people ask questions to guide action, and mental state is reflected in features that tap into why people seek information rather than the topics they search for. Tracking such features may provide clues regrading population stress levels.

Multifaceted information-seeking motives in children

From an early age, children need to gather information to learn about their environment. Deciding which knowledge to pursue can be difficult because information can serve several, sometimes competing, purposes. Here, we examine the developmental trajectories of such diverse information-seeking motives. Over five experiments involving 521 children (aged 4-12), we find that school-age children integrate three key factors into their information-seeking choices: whether information reduces uncertainty, is useful in directing action, and is likely to be positive. Choices that likely reveal positive information and are useful for action emerge as early as age 4, followed by choices that reduce uncertainty (at ~age 5). Our results suggest that motives related to usefulness and uncertainty reduction become stronger with age, while the tendency to seek positive news does not show a statistically significant change throughout development. This study reveals how the relative importance of diverging, sometimes conflicting, information-seeking motives emerges throughout development.

Long-Term Adaptation Among Adolescent and Young Adult Children to Familial Cancer Risk

BACKGROUND

It is important to examine adolescent and young adult (AYA) children's long-term psychosocial and behavioral adaptation to disclosure of maternal BRCA-positive carrier status (BRCA+) to inform approaches for familial cancer risk communication, education, and counseling.

METHODS

Mothers underwent BRCA genetic testing 1 to 5 years earlier. Group differences in AYAs' self-reported outcomes were analyzed by maternal health and carrier status, and child age and sex.

RESULTS

A total of N = 272 AYAs were enrolled: 76.1% of their mothers were breast or ovarian cancer survivors and 17.3% were BRCA+. AYAs' cancer risk behavior (tobacco and alcohol use, physical activity) and psychologic distress levels did not vary by maternal status. In bivariate analyses, AYAs of cancer-surviving mothers believed themselves to be at greater risk for, and were more knowledgeable about, cancer than AYAs of mothers without cancer. AYAs of BRCA+ mothers were more concerned about cancer, held stronger beliefs about genetic risk, and placed a higher value on learning about genetics. In adjusted models, maternal cancer history (not BRCA+) remained associated with AYAs' greater perceptions of cancer risk (P = .002), and knowledge about cancer (P = .03) and its causes (P = .002).

CONCLUSIONS

Disclosing maternal BRCA+ status did not influence children's lifestyle behavior or adversely affect quality of life long term. AYAs of BRCA+ mothers were more aware of and interested in genetic risk information. Such families may benefit from support to promote open communication about genetic testing choices.

Interactions between ventrolateral prefrontal and anterior cingulate cortex during learning and behavioural change

Hypotheses and beliefs guide credit assignment - the process of determining which previous events or actions caused an outcome. Adaptive hypothesis formation and testing are crucial in uncertain and changing environments in which associations and meanings are volatile. Despite primates' abilities to form and test hypotheses, establishing what is causally responsible for the occurrence of particular outcomes remains a fundamental challenge for credit assignment and learning. Hypotheses about what surprises are due to stochasticity inherent in an environment as opposed to real, systematic changes are necessary for identifying the environment's predictive features, but are often hard to test. We review evidence that two highly interconnected frontal cortical regions, anterior cingulate cortex and ventrolateral prefrontal area 47/12o, provide a biological substrate for linking two crucial components of hypothesis-formation and testing: the control of information seeking and credit assignment. Neuroimaging, targeted disruptions, and neurophysiological studies link an anterior cingulate - 47/12o circuit to generation of exploratory behaviour, non-instrumental information seeking, and interpretation of subsequent feedback in the service of credit assignment. Our observations support the idea that information seeking and credit assignment are linked at the level of neural circuits and explain why this circuit is important for ensuring behaviour is flexible and adaptive.

Individual differences in information-seeking

Vast amounts of personalized information are now available to individuals. A vital research challenge is to establish how people decide what information they wish to obtain. Here, over five studies examining information-seeking in different domains we show that information-seeking is associated with three diverse motives. Specifically, we find that participants assess whether information is useful in directing action, how it will make them feel, and whether it relates to concepts they think of often. We demonstrate that participants integrate these assessments into a calculation of the value of information that explains information seeking or its avoidance. Different individuals assign different weights to these three factors when seeking information. Using a longitudinal approach, we find that the relative weights assigned to these information-seeking motives within an individual show stability over time, and are related to mental health as assessed using a battery of psychopathology questionnaires.

Patient-Reported Outcomes following Genetic Testing for Familial Hypercholesterolemia, Breast and Ovarian Cancer Syndrome, and Lynch Syndrome: A Systematic Review

Background: Patient-reported outcomes (PROs) and PRO measures (PROMs) are real-world evidence that can help capture patient experiences and perspectives regarding a clinical intervention such as genetic testing. Objective: To identify and capture methods and qualitative PRO themes among studies reporting PROs following genetic testing for FH, breast and ovarian cancer syndrome, and Lynch syndrome. Methods: A systematic review was conducted via PubMed/MEDLINE, EMBASE, and Yale University’s TRIP Medical Databases on articles published by April 2021. Results: We identified 24 studies published between 1996 and 2021 representing 4279 participants that reported PROs following genetic testing for FH, breast and ovarian cancer syndrome, and Lynch syndrome. Studies collected and reported PROs from validated PROM instruments (n = 12; 50%), validated surveys (n = 7; 26%), and interviews (n = 10; 42%). PRO themes ranged across all collection methods (e.g., psychological, knowledge, coping and satisfaction, concern about stigma/discrimination, etc.). Conclusions: Important gaps identified include (1) most studies (n = 18; 75%) reported PROs following genetic testing for breast and ovarian cancer, and (2) populations reporting PROs overall were largely of White/Caucasian/Northern European/Anglo-Saxon descent. We offer recommendations and describe real-world implications for the field moving forward.

A prefrontal network integrates preferences for advance information about uncertain rewards and punishments

Humans and animals can be strongly motivated to seek information to resolve uncertainty about rewards and punishments. In particular, despite its clinical and societal relevance, very little is known about information seeking about punishments. We show that attitudes toward information about punishments and rewards are distinct and separable at both behavioral and neuronal levels. We demonstrate the existence of prefrontal neuronal populations that anticipate opportunities to gain information in a relatively valence-specific manner, separately anticipating information about either punishments or rewards. These neurons are located in anatomically interconnected subregions of anterior cingulate cortex (ACC) and ventrolateral prefrontal cortex (vlPFC) in area 12o/47. Unlike ACC, vlPFC also contains a population of neurons that integrate attitudes toward both reward and punishment information, to encode the overall preference for information in a bivalent manner. This cortical network is well suited to mediate information seeking by integrating the desire to resolve uncertainty about multiple, distinct motivational outcomes.

Fear of cancer recurrence in patients undergoing germline genome sequencing

PURPOSE

Fear of cancer recurrence/occurrence (FCR/O) is prevalent and associated with poorer psychological outcomes but can also motivate individuals to pursue genomic information about cancer risk. Guided by Protection Motivation Theory, this study investigated FCR/O prevalence and associated factors among probands previously diagnosed with a cancer of likely heritable origin, and their relatives, who had agreed to have germline genome sequencing.

METHODS

Three hundred and forty-eight probands and 167 relatives completed the Concerns about Recurrence Questionnaire (adapted for occurrence for some relatives) within 1 month of agreeing to undertake genome sequencing. Linear regressions investigated demographic, disease, attitude and behavioral associations with FCR/O.

RESULTS

Probands demonstrated greater FCR compared to relatives. In probands, greater FCR was associated with being female, non-English speaking at home, less time since diagnosis, greater intention to change behavior if gene variant found, lower perceived ability to cope with results, higher perceived susceptibility to having a recurrence, and more negative attitudes towards uncertainty. For relatives with cancer, greater FCR was associated with being male, greater intention to change behavior if a gene variant found, and higher perceived susceptibility to recurrence. In relatives without cancer, greater FCO was associated with not having had genetic testing prior to this study, lower perceived ability to cope with results, and higher perceived susceptibility to developing cancer.

CONCLUSION

Current findings on FCR/O prevalence and associated demographic and attitudinal variables in those who pursue genomic risk information might be used to target interventions that can prevent adverse psychological outcomes in vulnerable patients.

Cancer Genetic Counseling-Current Practice and Future Challenges

Cancer genetic counseling practice is rapidly evolving, with services being provided in increasingly novel ways. Pretest counseling for cancer patients may be abbreviated from traditional models to cover the elements of informed consent in the broadest of strokes. Genetic testing may be ordered by a cancer genetics professional, oncology provider, or primary care provider. Increasingly, direct-to-consumer testing options are available and utilized by consumers anxious to take control of their genetic health. Finally, genetic information is being used to inform oncology care, from surgical decision-making to selection of chemotherapeutic agent. This review provides an overview of the current and evolving practice of cancer genetic counseling as well as opportunities and challenges for a wide variety of indications in both the adult and pediatric setting.

Risk-reducing mastectomy rates in the US: a closer examination of the Angelina Jolie effect

PURPOSE

In 2013, Angelina Jolie disclosed in the New York Times (NYT) that she had undergone risk-reducing bilateral mastectomy (RRBM) after learning that she was a BRCA1 mutation carrier. We examined the rates of BRCA testing and RRBM from 1997 to 2016, and quantified trends before and after the Jolie op-ed.

METHODS

This observational study of insurance claims data representative of the commercially-insured US population (Truven MarketScan® database) measured BRCA testing and RRBM rates among females ≥ 18 years. Censoring events were breast cancer or ovarian cancer diagnosis, last follow-up date (September 2016), or death. Interrupted time series analyses were used to quantify trends before and after the op-ed.

RESULTS

Angelina Jolie's NYT op-ed led to a statistically significant increase in the uptake of genetic testing and in RRBM among women without previous diagnosis of breast or ovarian cancer in the US population, and in women who did not undergo testing for BRCA (P < 0.0001 for both). The rate (slope) of RRBM among women who were previously tested for BRCA (P = 0.70) was unchanged. After excluding women with in-situ tumors, the editorial's effect became less pronounced, suggesting that high-risk women with in-situ breast cancers were most influenced by Jolie's announcement.

CONCLUSION

The Angelina Effect-a term coined by Time magazine to describe the rise in internet searches related to breast cancer genetics and counseling-represents a long-lasting impact of celebrity on public health awareness as significant increases in genetic testing and mastectomy rates were observed and sustained in subsequent years.

Valuation of knowledge and ignorance in mesolimbic reward circuitry

Humans desire to know what the future holds. Yet, at times they decide to remain ignorant (e.g., reject medical screenings). These decisions have important societal implications in domains ranging from health to finance. We show how the opportunity to gain information is valued and explain why knowledge is not always preferred. Specifically, the mesolimbic reward circuitry selectively treats the opportunity to gain knowledge about favorable, but not unfavorable, outcomes as a reward to be approached. This coding predicts biased information seeking: Participants choose knowledge about future desirable outcomes more than about undesirable ones, vice versa for ignorance, and are willing to pay for both. This work demonstrates a role for valence in how the human brain values knowledge.

The pursuit of knowledge is a basic feature of human nature. However, in domains ranging from health to finance people sometimes choose to remain ignorant. Here, we show that valence is central to the process by which the human brain evaluates the opportunity to gain information, explaining why knowledge may not always be preferred. We reveal that the mesolimbic reward circuitry selectively treats the opportunity to gain knowledge about future favorable outcomes, but not unfavorable outcomes, as if it has positive utility. This neural coding predicts participants’ tendency to choose knowledge about future desirable outcomes more often than undesirable ones, and to choose ignorance about future undesirable outcomes more often than desirable ones. Strikingly, participants are willing to pay both for knowledge and ignorance as a function of the expected valence of knowledge. The orbitofrontal cortex (OFC), however, responds to the opportunity to receive knowledge over ignorance regardless of the valence of the information. Connectivity between the OFC and mesolimbic circuitry could contribute to a general preference for knowledge that is also modulated by valence. Our findings characterize the importance of valence in information seeking and its underlying neural computation. This mechanism could lead to suboptimal behavior, such as when people reject medical screenings or monitor investments more during bull than bear markets.

Evolution of cancer risk assessment and counseling related to psychological, financial and legal implications

Cancer risk assessment, genetic counseling and genetic testing have experienced advances and changes over the past two decades due to improved technology, legal movements to protect those at an increased risk for cancer due to genetics, as well as advances in detection, prevention and treatment. This brief article will provide a summary of these advances over three eras of cancer genetics: pre-discovery of the more common high impact genes, namely BRCA1/BRCA2 and the mismatch repair genes associated with Lynch syndrome; the time during which the genes were being discovered; and current day.

Psychosocial outcomes and counselee satisfaction following genetic counseling for hereditary breast and ovarian cancer: A patient-reported outcome study

OBJECTIVE

We investigated the psychosocial consequences of genetic counseling and testing (GCT) for hereditary breast and ovarian cancer (HBOC) at follow-up in a "real-life" sample of counselees at an Austrian tertiary care center.

METHODS

The study cohort included counselees who had undergone genetic counseling for HBOC and completed a follow-up self-report questionnaire battery on psychosocial outcomes (quality of life, psychological distress, satisfaction with counseling and decisions). For comparison of distress, we recruited a reference sample of breast cancer survivors (BCS; n=665) who had not requested GCT in the same setting.

RESULTS

Overall, counselees did not exhibit increased levels of anxiety and depression when compared to BCS. No specific follow-up deleterious psychosocial consequences were detected among the former group. Of the 137 counselees, 22.6% and 9.8% experienced clinically relevant levels of anxiety and depression, respectively, at an average follow-up time of 1.8years. However, both anxiety and depression significantly decreased with time and were alike between counselees with and without cancer diagnosis. Follow-up cancer worry seems to be significantly higher among counselees who had not undergone genetic testing or were undecided about it than among counselees who had been tested.

CONCLUSION

Our results strongly support GCT as part of routine care for patients with HBOC. The risk factors of increased distress in specific subgroups of counselees, such as recent cancer diagnosis or uncertainty about testing, warrant further exploration and specific attention in clinical routines. Particularly, the psychological needs of undecided counselees warrant ongoing attention and potential follow-ups.

Incorporating a Psychological Counselor in a Cancer Risk Assessment Program: Necessity, Acceptability, and Potential Roles

Evidence suggests that cancer risk assessment may be associated with increased psychological distress. This exploratory study assessed the necessity and acceptability of incorporating psychological counseling into routine clinic procedures at a cancer risk program. Following a visit to a university-based cancer risk clinic, patients (N = 102) completed an anonymous self-report instrument. Participants reported experiencing current stress and anxiety (41%), depression (29%), and suicidal ideation (2%). Patients with a history of cancer were more likely to be experiencing current emotional difficulties. Sixty-nine percent of the participants found the visit with the psychological counselor to be helpful, while 41% of the participants reported interest in follow-up psychological services. Interest in receiving future psychological services was positively correlated with levels of anxiety, depression, and cancer worry. This pilot study demonstrates the acceptability and potential role for psychological counselors in increasing adjustment in high-risk patients undergoing genetic counseling for inherited cancers.

Milestones of Lynch syndrome: 1895-2015

Lynch syndrome, which is now recognized as the most common hereditary colorectal cancer condition, is characterized by the predisposition to a spectrum of cancers, primarily colorectal cancer and endometrial cancer. We chronicle over a century of discoveries that revolutionized the diagnosis and clinical management of Lynch syndrome, beginning in 1895 with Warthin's observations of familial cancer clusters, through the clinical era led by Lynch and the genetic era heralded by the discovery of causative mutations in mismatch repair (MMR) genes, to ongoing challenges.

Psychiatric implications of cancer genetic testing

As genetic testing for hereditary cancer syndromes has transitioned from research to clinical settings, research regarding its accompanying psychosocial effects has grown. Men and women being tested for hereditary cancer syndromes may experience some psychological distress while going through the process of testing or after carrier status is identified. Psychological distress appears to decrease over the course of the first year and it is typically not clinically significant. Longer term studies show mixed results with some mutation carriers continuing to experience elevated distress. Baseline distress is the greatest risk factor for both immediate (weeks-12 months) and long-term psychological distress (18 mo-8 years post genetic testing). In addition to baseline psychological distress, other risk factors can be identified to help identify individuals who may need psychosocial interventions during the genetic testing process. The challenges of providing clinical care to the growing population of individuals identified to be at increased risk for heritable cancers present opportunities for research and new models of care.

What Factors Impact upon a Woman's Decision to Undertake Genetic Cancer Testing?

INTRODUCTION

The advent of human genome project has lead to genetic tests that identify high-risk states for certain cancers. Many are privately marketed on the Internet. Despite the availability of tests, limited data has evaluated factors that lead to test uptake. The aim of the present study was to explore the attitudes of a cohort of new mothers toward uptake of a genetic cancer test with a 50% predictive value of cancer.

METHODS

A cross-sectional survey was undertaken. The project targeted women who had recently given birth at an Australian tertiary referral hospital. Women were asked about a theoretical blood test that detected an increased risk for the development of cancer. Attitudes and knowledge questionnaires were completed.

RESULTS

Of 232 consecutive women approached, 32 declined, giving a response rate of 86.2%. Only 63 (31.5%) women stated they would have the test. Absence of religious belief, higher level of education, better knowledge of terms used in genetics, an absence of concern over emotional, employment, and insurance discrimination, and previous acceptance of Down syndrome screening in pregnancy were each associated with significantly higher rate of test uptake in univariate analysis (all p < 0.03). In multivariate analysis, a lack of concern over discrimination and a history of having accepted Down syndrome screening in the previous pregnancy remained significantly associated with test uptake (all p < 0.0001).

CONCLUSION

Concern over discrimination and having made a prior decision to have genetic testing were the principal factors associated with decision-making.

Captious certainties: makings, meanings and misreadings of consumer-oriented genetic testing

Members of the scientific and medical communities concerned with genetic testing might wonder, why cultural and ethical analyses of genetic testing are increasing again, especially since legal frameworks have, by now, come to provide more solid grounds for the routine application of genetic testing on both levels of application, diagnostics, and prediction. This contribution aims to shed light on the changing concept of genetic testing as it is raised by novel cultural practices and perceptions mainly triggered by direct-to-consumer predictive testing, including the phenomenon of a new genetic exceptionalism "from below". We are seeking to determine what is at stake in this practice and what consequences arise from it for the medical and scientific community. What exactly happens as we move from diagnostic to prognostic medicine? Above all, this article pivots on the notion of captious certainties, a concept, which we will elaborate on as our argument progresses.

Hereditary breast/ovarian cancer syndrome: a primer for obstetricians/gynecologists

An understanding of the diagnosis and clinical management of hereditary breast and ovarian cancer syndrome (HBOC) is essential for obstetricians/gynecologists. This article provides practical information regarding collecting a family history, cancer risk assessment and genetic testing, BRCA-associated cancer prognosis and treatment, screening recommendations, and prevention strategies. Through appropriate cancer risk assessment, women with BRCA1/2 mutations can be identified, and screening and prevention strategies can be used before a diagnosis of cancer occurs. Women's health providers with a strong working knowledge of HBOC are able to improve the quality of care for women and families impacted by BRCA1/2 mutations.

Can pharmacoeconomics and outcomes research contribute to the empowerment of women affected by breast cancer?

Breakthroughs in genetic testing have informed patients and physicians in the treatment of breast cancer; however, they have also added to the complexity of decision-making. Genetic testing for breast cancer susceptibility not only changes treatment and screening options, but also challenges the way in which interventions are evaluated. While comparative effectiveness and cost-effective analysis methods are now standard for evaluation at the societal level, technologies such as genetic testing require us to consider the role of patient preference, especially as we move towards more personalized approaches to medicine. In this review, we discuss the changing role of pharmacoeconomics and outcomes research by highlighting how the discipline could use patient preference methods, such as conjoint analysis, to promote shared decision-making and to empower breast cancer patients. By adopting these methods we could move our focus from what is best for payers or society to one that applies scientific methods to identify what is best for patients.

Improving mutation notification when new genetic information is identified in research: a trial of two strategies in familial breast cancer

PURPOSE

The Kathleen Cuningham Foundation Consortium for Research into Familial Aspects of Breast Cancer (kConFab) is a large-scale research study that notifies participants when new, personally relevant, information is discovered. In 2009, the (kConFab) instituted an intensive notification process to ensure at-risk individuals were effectively notified. This study (i) evaluated the impact of intensive notification on genetic testing uptake; (ii) identified those most likely to undergo testing postnotification; and (iii) identified those most likely to acknowledge that they had been notified.

METHODS

Clinical/demographic data were retrieved from the (kConFab) database. Logistic regression analyses were conducted to identify potential predictors of testing uptake and notification acknowledgment using IBM SPSS.

RESULTS

A total of 155 of 1,812 individuals underwent testing after standard notification (8.6%). In comparison, 23/291 individuals (7.9%) notified using the "intensive" approach underwent testing (χ(2) = 0.14; P = 0.71). After controlling for notification process, females and participants with a previous cancer were most likely to have undergone testing (P < 0.006). Older individuals (50+ years) were most likely to acknowledge they had been notified (P = 0.038).

CONCLUSION

Increasing the intensity of participant follow-up did not increase genetic testing uptake. The challenge to effectively notify participants, and increase the proportion whose risk is managed clinically, remains, particularly for males and individuals unaffected by cancer.Genet Med 2013:15(3):187-194.

A Pilot study of the Sharing Risk Information Tool (ShaRIT) for Families with Hereditary Breast and Ovarian Cancer Syndrome

Background

Individuals who carry deleterious BRCA mutations face significantly elevated risks of breast, ovarian, and other cancers. These individuals are also responsible for informing relatives of their increased risk for carrying the family BRCA mutation. Few interventions have been developed to facilitate this family communication process.

Methods

We developed the Sharing Risk Information Tool (ShaRIT), a personalized educational intervention, to support BRCA carriers as they discuss BRCA positive results and their implications with relatives. We conducted a pilot study of 19 BRCA carriers identified through the University of California San Francisco Cancer Risk Program. Our study had two aims: 1) to assess the feasibility and acceptability of ShaRIT, and 2) describe characteristics associated with increased family communication and BRCA testing. Participants in our study were divided into two groups: those who had not received ShaRIT as part of their genetic counseling protocol (control group, n = 10) and those who received ShaRIT (n = 9).

Results

All 9 women who received ShaRIT reported that it was a useful resource. Characteristics associated with increased sharing and testing included: female gender, degree of relationship, and frequency of communication. Increased pedigree knowledge showed a trend toward higher rates of sharing.

Conclusions

Both participants and genetic counselors considered ShaRIT a well-received, comprehensive tool for disseminating individual risk information and clinical care guidelines to Hereditary Breast and Ovarian Cancer Syndrome families. Because of this, ShaRIT has been incorporated as standard of care at our institution. In the future we hope to evaluate the effects of ShaRIT on family communication and family testing in larger populations of BRCA positive families.

Direct-to-Consumer Genetic Testing

Genetics has fascinated societies since ancient times, and references to traits or behaviors that appear to be shared or different among related individuals have permeated legends, literature, and popular culture. Biomedical advances from the past century, and particularly the discovery of the DNA double helix, the increasing numbers of links that were established between mutations and medical conditions or phenotypes, and technological advances that facilitated the sequencing of the human genome, catalyzed the development of genetic testing. Genetic tests were initially performed in health care facilities, interpreted by health care providers, and included the availability of counseling. Recent years have seen an increased availability of genetic tests that are offered by companies directly to consumers, a phenomenon that became known as direct-to-consumer genetic testing. Tests offered in this setting range from the ones that are also provided in health care establishments to tests known as ‘recreational genomics,’ and consumers directly receive the test results. In addition, testing in this context often does not involve the availability of counseling and, when this is provided, it frequently occurs on-line or over the phone. As a field situated at the interface between biotechnology, biomedical research, and social sciences, direct-to-consumer genetic testing opens multiple challenges that can be appropriately addressed only by developing a complex, inter-disciplinary framework.

Unpacking the blockers: understanding perceptions and social constraints of health communication in hereditary breast ovarian cancer (HBOC) susceptibility families

Family communication is essential for accurate cancer risk assessment and counseling; family blockers play a role in this communication process. This qualitative analysis of social exchanges is an extension of earlier work characterizing those who are perceived by study participants as health information gatherers, disseminators, and blockers within families with Hereditary Breast and Ovarian Cancer (HBOC) susceptibility. Eighty-nine women, ages 23-56 years, enrolled in a Breast Imaging Study (BIS) and participated in a sub-study utilizing a social assessment tool known as the Colored Ecological Genetic Relational Map (CEGRM). Purposive sampling ensured that participants varied according to numbers of participating family members e.g., ranging from 1 to 6. Eighty-nine women from 42 families (1-8 relatives/family) participated. They collectively designated 65 blockers, both male and female. Situational factors, beliefs, attitudes and cultural traditions, privacy and protectiveness comprised perceived reasons for blocking intra-family health communications. Longitudinal data collected over 4 years showed families where blocking behavior was universally recognized and stable over time, as well as other families where blocking was less consistent. Self-blocking was observed among a significant minority of participating women. Blocking of health communications among family members with HBOC was variable, complex, and multifaceted. The reasons for blocking were heterogeneous; duration of the blocking appeared to depend on the reasons for blocking. Blocking often seemed to involve bi-directional feedback loops, in keeping with Lepore's Social Constraints and Modulation Theory. Privacy and protectiveness predominated as explanations for long-term blocking.

[Cognitive, emotional and behavioral impact of an uncertain outcome after study of BRCA1/2: review of the literature]

BACKGROUND

Recent advances in oncogenetics have enabled the development of tests for predisposition to breast and ovarian cancers. Where no mutation has been identified in the BRCA1 or 2 genes, the proband (first person tested in a family with a genetic risk) can receive an uncertain outcome: negative inconclusive or identification of a variant of unknown clinical significance. From the demonstration of such outcomes, their psychological impact has been studied among women concerned.

OBJECTIVE

The purpose of this article is to summarize the results of studies about the impact of delivering an uncertain BRCA1/2 genetic result on emotional (general or cancer specific distress), cognitive (perception of risk) and behavioral (decisions of medical care) reactions of consultants. It is also to identify factors particularly associated with personal or familial medical history that may alter this impact.

METHODOLOGY

A literature review was conducted from a key word search on the databases PsycINFO and PubMed (breast*, BRCA*, genetic*, familial, mutation, heredit*) crossed with terms related to the psychological impact and mutation status. Included papers are quantitative studies focused on the psychological impact of the uncertain genetic test result, compared to the impact resulting from positive or true negative result, or from test refusal.

RESULTS

The results of the eight selected articles generally suggest a less emotional distress and a lower perceived risk of predisposition or to develop cancer facing uncertain genetic result compared to positive result. Intentions of breast cancer surveillance are optimal, indicating the absence of "false reassurance", while demand for prophylactic surgery appears to be less frequent. Nevertheless risk factors of inappropriate psychological reactions may be highlighted as pretest clinical distress, a personal cancer history or multiple family history of cancer.

CONCLUSION

Current data suggest psychological reactions adapted to the clinical significance of uncertain genetic test results. These findings are preliminary given the small number of studies and their restriction to populations with similar sociocultural characteristics.

Distress and psychosocial needs of a heterogeneous high risk familial cancer population

In order to assess the levels of distress and psychosocial support needs of a high risk population, we undertook a study to look at both the objective and subjective levels of distress and the wants and needs of individuals from a high familial cancer risk population. Three hundred and eighteen individuals (160 affected, 158 unaffected) completed several distress and psychosocial needs questionnaires (including the Brief Symptom Inventory-18). Sixty key informants were also surveyed about their perspective on the support needs of this population. In the largely female (90%), largely HBOC syndrome group (approximately 90%), 20% had significant levels of generalized distress, with no significant differences between affected and unaffected individuals. Generalized distress was also not significantly different as a function of mutation status. Individuals who received inconclusive test results, however, were more likely to indicate somatic symptoms of distress. Those individuals who did not have social support were more likely to be those who had never had cancer and who either had a mutation, received inconclusive test results, or were not tested. Key informants were most likely to indicate that patients need more support. These results provide evidence for the importance of establishing regular psychosocial distress screening, including a focus on somatic symptoms, in such high risk populations.

Uptake of predictive testing among relatives of BRCA1 and BRCA2 families: a multicenter study in northeastern Spain

Identifying a BRCA mutation among families with hereditary breast and ovarian cancer enables distinguishing those who may benefit from a specific medical management. This study aimed to evaluate the uptake of predictive testing among close relatives of a proband in Spanish families with a BRCA1 or BRCA2 mutation, and to determine the associated demographic and clinical predictors. A retrospective cohort of families undergoing clinical genetic testing at four university hospitals in northeastern Spain was considered. From 108 unrelated BRCA1/2 families, 765 close relatives of probands were analyzed. Sixty percent of the first-degree and 28% of the second-degree relatives underwent predictive testing within a median time of 2 and 6 months, respectively, since the mutation disclosure to the proband. Relatives undergoing genetic testing were more likely to be female, first-degree, and belong to a family with a proband who had a high educational level. Relatives were also more likely to have offspring, a previous cancer diagnosis, and to be aged between 30 and 64 years. Among second-degree relatives, having a first-degree relative with cancer was highly correlated with uptake. In conclusion, uptake of BRCA1/2 predictive testing among close relatives was notably high and within a short period of time after disclosure of the mutation to the proband. Being female, a high educational level of the proband, and having a close relative with cancer were associated with uptake among relatives. Further studies are warranted to determine whether information is disseminated properly by probands and to learn about the reasons for those not undergoing testing.

Attitudes toward information about genetic risk for cognitive impairment after cancer chemotherapy: breast cancer survivors compared with healthy controls

PURPOSE

The trend toward personalized medicine will involve cancer treatment increasingly being tailored to the genetic characteristics of individuals. However, the availability of genetic information does not imply this information is desired or would impact treatment decision making.

METHODS

One hundred sixty breast cancer survivors (BC group) and 205 healthy controls (HC group) were randomly assigned to respond to two different clinical scenarios varying in genetic-related risk of cognitive impairment (CI; little v very likely) and severity of CI (little v moderate problem) after chemotherapy. Ratings of the importance of being told this genetic information (information importance) and the likelihood this information would affect their decision to receive chemotherapy (information impact) were obtained.

RESULTS

Results indicated the importance ascribed to genetic information was greatest when CI likelihood and severity were both high or low (P < .05). Information impact ratings were not sensitive to differences in CI likelihood or severity; the BC group was less likely to indicate genetic information would affect their decision to receive chemotherapy than the HC group (P < .001).

CONCLUSION

Results suggest lessened enthusiasm for genetic information that maintains or increases uncertainty about a specific course of action and highlight the importance of including clinically relevant groups in treatment decision-making research that employs hypothetical scenarios. Although women generally believe it is important to receive genetic information, they might benefit from assistance (eg, decision aid) in the difficult task of integrating information about survival and risk for adverse late effects from cancer treatment.

Social sharing of genetic information in the family: a study on hereditary breast and ovarian cancers

The present study assessed how preventive medical information about hereditary breast and ovarian cancer is spread within the family before actual genetic test results. Forty-two women (19 had a breast or ovarian tumor and 23 did not) were asked to fill out a questionnaire about: (1) the spread within the family of the medical information received during the consultation; and (2) the reasons for sharing this information. Results indicate that all of the women socially shared medical information with an immediate family member for preventive purposes, and generally not for seeking emotional or informative social support.

A systematic review of literature about the genetic testing of adolescents

PURPOSE

Mapping of the human genome raises interest in and concern about the genetic testing of adolescents. Our purpose was to determine the attitudes and knowledge adolescents and their parents have about genetic testing.

DESIGN AND METHOD

This paper is a report of a systematic review of the research literature (n = 56) about the attitudes and knowledge adolescents and their parents have about genetic testing.

RESULTS

The majority of studies, which were descriptive in design, focused on a specific heritable disorder, were conducted in the United States, and over-sampled well-educated White females.

PRACTICE IMPLICATIONS

Results suggest that adolescents and their families have relatively positive attitudes about genetic testing and may experience both harms and benefits from testing. Nurses may be in positions to assist adolescents and their families in making decisions about genetic testing, remaining sensitive to family dynamics and issues of privacy and autonomy.

Additional patient outcomes and pathways in evaluations of testing

Before medical tests are introduced into practice, they should be properly evaluated. Randomized trials and other comprehensive evaluations of tests and test strategies can best be designed based on an understanding of how tests can benefit or harm patients. Tests primarily affect patients' health by guiding clinical decision making and downstream management, such as the decision to order more tests or to start, stop, or modify treatment. In this article, the authors demonstrate that tests can have additional effects on patient outcome, which may be cognitive, emotional, social, or behavioral. They present a framework to help researchers and policy makers consider the cognitive, emotional, social, and behavioral effects of testing. These additional effects may be important themselves and may also influence the clinical outcomes of testing through different pathways. The authors provide examples from test evaluations in the literature to illustrate how these additional effects can be important in the evaluation of testing or indeed any health intervention.

Risk perception after genetic counseling in patients with increased risk of cancer

Background

Counselees are more aware of genetics and seek information, reassurance, screening and genetic testing. Risk counseling is a key component of genetic counseling process helping patients to achieve a realistic view for their own personal risk and therefore adapt to the medical, psychological and familial implications of disease and to encourage the patient to make informed choices [1,2].

The aim of this study was to conceptualize risk perception and anxiety about cancer in individuals attending to genetic counseling.

Methods

The questionnaire study measured risk perception and anxiety about cancer at three time points: before and one week after initial genetic counseling and one year after completed genetic investigations. Eligibility criteria were designed to include only index patients without a previous genetic consultation in the family. A total of 215 individuals were included. Data was collected during three years period.

Results

Before genetic counseling all of the unaffected participants subjectively estimated their risk as higher than their objective risk. Participants with a similar risk as the population overestimated their risk most. All risk groups estimated the risk for children's/siblings to be lower than their own. The benefits of preventive surveillance program were well understood among unaffected participants.

The difference in subjective risk perception before and directly after genetic counseling was statistically significantly lower in all risk groups. Difference in risk perception for children as well as for population was also statistically significant. Experienced anxiety about developing cancer in the unaffected subjects was lower after genetic counseling compared to baseline in all groups. Anxiety about cancer had clear correlation to perceived risk of cancer before and one year after genetic investigations.

The affected participants overestimated their children's risk as well as risk for anyone in population. Difference in risk perception for children/siblings as for the general population was significant between the first and second measurement time points. Anxiety about developing cancer again among affected participants continued to be high throughout this investigation.

Conclusion

The participant's accuracy in risk perception was poor, especially in low risk individuals before genetic counseling. There was a general trend towards more accurate estimation in all risk groups after genetic counseling. The importance of preventive programs was well understood. Cancer anxiety was prevalent and associated with risk perception, but decreased after genetic counseling.

[1] National Society of Genetic Counselors (2005), Genetic Counseling as a Profession. Available at (accessed November 25th 2007)

[2] Julian-Reynier C., Welkenhuysen M-, Hagoel L., Decruyenaere M., Hopwood P. (2003) Risk communication strategies: state of the art and effectiveness in the context of cancer genetic services. Eur J of Human Genetics 11, 725-736.

Guidelines for genetic risk assessment of hereditary breast and ovarian cancer: early disagreements and low utilization

BACKGROUND

BRCA1/2 testing is one of the most well-established genetic tests to predict cancer risk. Guidelines are available to help clinicians determine who will benefit most from testing.

OBJECTIVE

To identify women at high risk of hereditary breast and ovarian cancer and estimate their awareness of and experience with genetic testing for cancer risk.

DESIGN

Analyses of the 2000 and 2005 National Health Interview Surveys.

PARTICIPANTS

Women with no personal history of breast or ovarian cancer (n = 35,116).

MEASUREMENTS

Risk of hereditary breast or ovarian cancer based on self-reported family history of cancer and national guidelines; self-reported awareness of genetic testing for cancer risk; discussion of genetic testing for cancer risk with a health professional; having undergone genetic testing for breast/ovarian cancer risk.

RESULTS

Using guideline criteria, 0.96% of women were identified as being at high risk of hereditary breast and ovarian cancer. Among high-risk women, 54.04% were aware of genetic testing for cancer risk, 10.39% had discussed genetic testing with a health professional, and 1.41% had undergone testing for breast/ovarian cancer risk. Adjusting for survey year, high-risk women were more likely than average-risk women to have heard of genetic testing for cancer risk (RR, 1.3, 95% CI 1.2-1.4), to have discussed genetic testing with a health professional (RR 5.2, 95% CI 3.6-7.4), and to have undergone genetic testing for breast/ovarian cancer risk (RR 6.8, 95% CI 2.6-18.0).

CONCLUSIONS

We find low provision of guideline-recommended advice to women for whom testing may be appropriate and of significant clinical benefit.

Risk perception and cancer worries in families at increased risk of familial breast/ovarian cancer

While families at increased risk for familial breast/ovarian cancer continue to overestimate their cancer risk with increased cancer worries about the future, few studies have examined factors that affect inherited cancer risk perception and cancer worries in both survivors and unaffected female relatives. The purpose of this study was to examine variables that may affect cancer worries and risk perceptions from a family-based perspective in a racially diverse, community-based, random sample of 146 dyads consisting of adult female breast and/or ovarian cancer survivors and their unaffected female relatives (N=292). Results indicated that coping style, self-efficacy, partner's income, family role relationship, and cancer risk perception were significant contributors to the survivors' and their unaffected relatives' cancer worries. Significant variables for perception of cancer risk for both survivors and relatives included income, race, family history of cancer, and cancer worries. Relatives had a higher perception of cancer risk, whereas survivors had more cancer worries. Additionally, the level of cancer worries reported by one member of the dyad was related to the amount of worries reported by the other. The results from this study underscore the importance of clinicians addressing concerns of both affected and unaffected members of families at increased risk of cancer to assist them in managing cancer worries and having realistic risk appraisals to make informed decisions about their own and their family's health surveillance options.

Men in the women's world of hereditary breast and ovarian cancer--a systematic review

Little is known about men seeking genetic counseling for hereditary breast and ovarian cancer (HBOC). We review the sparse literature on men attending such genetic consultations. Two main themes are identified: the women's influence on the genetic counseling process, and the psychological impact on men. The women in the HBOC families have an influence on the men's decision to request genetic testing, and they take the leading role in communicating genetic information. With respect to psychological impact, the men suffer from grief and fear of developing cancer, and they seem to use avoidance as a coping strategy. Carrier males experience feelings of guilt because they might have passed on a mutation to their children. Non-carriers experience test-related stress if their siblings tested positive. Mutation status may have an impact on reproductive issues. These findings are discussed in light of gender issues and literature concerning men's health behavior. Further studies are needed to provide optimal care for men seeking genetic counseling for hereditary breast and ovarian cancer.

The withdrawal from oncogenetic counselling and testing for hereditary and familial breast and ovarian cancer. A descriptive study of an Italian sample

BACKGROUND

Oncogenetic counselling is seldom followed through, even when individuals are eligible according to the test criteria. The basic variables which influence the decision to undergo the genetic counselling process are: risk perception, expected benefit or limitations of genetic testing, general psychological distress or cancer-specific distress, lack of trust in one's emotional reactions when faced with negative events, expected level of family support and communications within the family. The aim of this study was to describe the psychosocial variables of an Italian sample that forgoes genetic counselling.

METHODS

From May 2002 to December 2006 a psychological questionnaire was sent out to one hundred and six subjects, who freely requested a first genetic informative consultation, and never asked to have a second visit and the family tree drawn up in order to inquire about their eligibility for genetic testing. Statistical analysis was performed by Pearson chi-square test, t-test and Spearman RHO coefficient.

RESULTS

The survey presents a lack of emotional cohesion and structured roles and rules within the family system and a positive correlation between the number of children, anxiety and risk perception. The main reasons for giving up on counselling were a sense that testing was a waste of time and the inability to emotionally handle the negative consequences of the test outcome. The subjects who maintained that test and an early diagnosis were a "waste of time" experienced more anxiety.

CONCLUSION

The study revealed the importance to ac knowledging the whole persona and their family system as well as provide information highlighting usefulness of early diagnosis.

The trajectory of psychological impact in BRCA1/2 genetic testing: does time heal?

BACKGROUND

Most research on adjustment of women undergoing genetic testing for breast cancer susceptibility has not followed women for more than 6 months after result receipt and has not evaluated curvilinear patterns in general and cancer-specific adjustment.

PURPOSE

This study's primary goal was to examine the trajectory of psychological status in women at risk for breast and ovarian cancer prior to undergoing genetic testing through 1 year after BRCA1/2 result receipt.

METHODS

Women in the UCLA Familial Cancer Registry completed questionnaires assessing psychological status (i.e., depressive symptoms, negative and positive mood, anxiety, and cancer-related distress) prior to testing and at 1, 6, and 12 months after result receipt.

RESULTS

Of 155 women tested, 117 were BRCA1/2- (96 uninformative negative and 21 true negative) and 38 were BRCA1/2+. Linear mixed model analyses revealed a consistent pattern in adjustment indicators, such that the groups did not differ at baseline, but mutation carriers endorsed significantly more depressive symptoms, negative mood, and cancer-specific distress relative to non-mutation carriers at 1 and 6 months after test result receipt (and less positive mood at 6 months only). At 12 months, negative and positive mood returned to baseline levels for mutation carriers, and depressive symptoms approached baseline. At 12 months, the groups differed significantly only on cancer-specific distress, owing to declining distress in non-carriers. Neither having a previous cancer diagnosis nor receiving a true negative versus uninformative negative result predicted reactions to genetic testing.

CONCLUSIONS

Genetic testing prompted an increase in general and cancer-specific distress for BRCA1/2+ women, which remitted by 1 year after result receipt.

Psychological and behavioural impact of genetic testing smokers for lung cancer risk: a phase II exploratory trial

The behavioural and psychological impact of genetic testing for lung cancer susceptibility was examined among smokers (N = 61) who were randomly allocated to a GSTM1 genetic testing group (with GSTM1-missing or GSTM1-present result) or no-test control group. The GSTM1-missing (higher risk) group reported greater motivation to quit smoking, and both genetic testing groups reported lower depression than the control group at one-week follow-up (p < .05 for all). Differences were not significant at two months follow-up. This study indicates the feasibility of much-needed research into the risks and benefits for individuals of emerging lifestyle-related genetic susceptibility tests.