A randomized trial of breast cancer risk counseling: the impact on self-reported mammography use

The introduction of risk stratified screening into the NHS breast screening Programme: views from British-Pakistani women

BACKGROUND

UK national guidelines suggest women at high-risk of breast cancer should be offered more frequent screening or preventative medications. Currently, only 1 in 6 high-risk women are identified. One route to identify more high-risk women is via multifactorial risk assessment as part of the UK's NHS Breast Screening Programme (NHSBSP). As lower socioeconomic and minority ethnic populations continue to experience barriers to screening, it is important that any new service does not exacerbate issues further. To inform service development, this study explored views of women from underserved backgrounds regarding the introduction of risk stratification into the NHSBSP.

METHODS

Nineteen semi-structured interviews were conducted with British-Pakistani women from low socioeconomic backgrounds from East Lancashire, UK. Fourteen interviews were conducted via an interpreter.

RESULTS

Thematic analysis produced three themes. Attitudes toward risk awareness concerns the positive views women have toward the idea of receiving personalised breast cancer risk information. Anticipated barriers to accessibility emphasises the difficulties associated with women's limited English skills for accessing information, and their I.T proficiency for completing an online risk assessment questionnaire. Acceptability of risk communication strategy highlights the diversity of opinion regarding the suitability of receiving risk results via letter, with the option for support from a healthcare professional deemed essential.

CONCLUSIONS

The idea of risk stratification was favourable amongst this underserved community. To avoid exacerbating inequities, this new service should provide information in multiple languages and modalities and offer women the opportunity to speak to a healthcare professional about risk. This service should also enable completion of personal risk information via paper questionnaires, as well as online.

Discordance in perceived risk and epidemiological outcomes of prostate cancer among African American men

As guidelines for prostate cancer screening have changed from an annual screening recommendation starting at age 50 to discussing the benefits and harms of screening with health care providers, it is necessary to examine other types of factors that are important to prostate cancer screening decisions among African American men. Perceived risk of developing cancer has been shown to predict cancer control behaviors and is lower among African Americans. We characterized perceived risk of developing prostate cancer among African American men from November 2009 to 2011 and evaluated the relationship between prostate cancer risk perceptions and sociodemographic characteristics, health care experiences, and knowledge and exposure to health information about cancer. Chi square tests and logistic regression were employed to determine independent associations. Overall, men did not believe they were at increased risk of developing prostate cancer; they believed their risk was equivalent to or lower than men the same age. Perceived risk of prostate cancer was associated with income (OR = 0.59, 95% CI = 0.26, 1.34, p = 0.03), hypertension (OR = 2.68, 95% CI = 1.17, 6.16, p = 0.02), and beliefs about the association between race and cancer risk (OR = 2.54, 95% CI = 1.24, 5.20, p = 0.01). Clinic and community-based approaches to improve prostate cancer risk comprehension among African American men are needed to reduce the discordance between perceived risk and epidemiological data on prostate cancer risk factors. Risk education interventions that are developed for African American men may need to integrate information about susceptibility for multiple diseases as well as address strategies for risk reduction and prevention, and chronic disease management.

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Perceived risk was associated with income, hypertension and race and cancer risk.

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There is discordance in perceived risk for prostate cancer and risk outcomes data.

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Clinic and community-based approaches are needed to improve risk comprehension.

Effects of personalized colorectal cancer risk information on laypersons' interest in colorectal cancer screening: The importance of individual differences

OBJECTIVE

To evaluate how personalized quantitative colorectal cancer (CRC) risk information affects laypersons' interest in CRC screening, and to explore factors influencing these effects.

METHODS

An online pre-post experiment was conducted in which a convenience sample (N=578) of laypersons, aged >50, were provided quantitative personalized estimates of lifetime CRC risk, calculated by the National Cancer Institute Colorectal Cancer Risk Assessment Tool (CCRAT). Self-reported interest in CRC screening was measured immediately before and after CCRAT use; sociodemographic characteristics and prior CRC screening history were also assessed. Multivariable analyses assessed participants' change in interest in screening, and subgroup differences in this change.

RESULTS

Personalized CRC risk information had no overall effect on CRC screening interest, but significant subgroup differences were observed. Change in screening interest was greater among individuals with recent screening (p=.015), higher model-estimated cancer risk (p=.0002), and lower baseline interest (p<.0001), with individuals at highest baseline interest demonstrating negative (not neutral) change in interest.

CONCLUSION

Effects of quantitative personalized CRC risk information on laypersons' interest in CRC screening differ among individuals depending on prior screening history, estimated cancer risk, and baseline screening interest.

PRACTICE IMPLICATIONS

Personalized cancer risk information has personalized effects-increasing and decreasing screening interest in different individuals.

Genetic counseling content: How does it impact health behavior?

Women with hereditary breast-ovarian cancer face decisions about screening (transvaginal ultrasound, CA125, mammography, breast exams) and proactive (before cancer) or reactive (after cancer) surgery (oophorectomy, mastectomy). The content of genetic counseling and its relation to these key health behaviors is largely unexamined. Ashkenazi Jewish women (n = 78) were surveyed through the process of genetic testing and had audiorecorded counseling sessions available for Linguistic Inquiry and Word Count analysis. Proportions for participant and counselor cognitive and affective content during sessions were used as primary predictor variables in linear mixed models for change in intentions for screening and treatment and in self-reported screening. Cognitive and affective content were important predictors of behavior. Counselor cognitive content was associated with ovarian screening. An interaction effect also emerged for CA-125, such that counselor cognitive content plus participant cognitive content or counselor affective content were associated with more screening. Teasing out the factors in risk communication that impact decision-making are critical, and affect from a risk communicator can spur action, such as cancer screening.

Breast Cancer Risk Assessment Among Low-Income Women of Color in Primary Care: A Pilot Study

PURPOSE

The US Preventive Services Task Force recommends identifying candidates for breast cancer (BC) chemoprevention and referring them for genetic counseling as part of routine care. Little is known about the feasibility of implementing these recommendations or how low-income women of color might respond to individualized risk assessment (IRA) performed by primary care providers (PCPs).

METHODS

Women recruited from a federally qualified health center were given the option to discuss BC risk status with their PCP. Comprehensive IRA was performed using a software tool designed for the primary care environment combining three assessment instruments and providing risk-adapted recommendations for screening, prevention, and genetic referral. Logistic regression models assessed factors associated with wanting to learn and discuss BC risk with PCP.

RESULTS

Of 237 participants, only 12.7% (n = 30) did not want to discuss IRA results with their PCP. Factors associated with lower odds of wanting to learn results included having private insurance and reporting ever having had a mammogram. Factors associated with higher odds of wanting to learn results included older age (50 to 69 years) and increased BC worry. For all women wishing to learn results, IRA was successfully completed and delivered to the PCP immediately before the encounter for incorporation into the well-visit evaluation.

CONCLUSION

Incorporation of US Preventive Services Task Force recommendations as part of routine primary care is feasible. Interest in IRA seems high among underserved women. This approach warrants further investigation as a strategy for addressing disparities in BC mortality.

Development of a risk assessment tool for projecting individualized probabilities of developing breast cancer for Chinese women

The optimal approach regarding breast cancer screening for Chinese women is unclear due to the relative low incidence rate. A risk assessment tool may be useful for selection of high-risk subsets of population for mammography screening in low-incidence and resource-limited developing country. The odd ratios for six main risk factors of breast cancer were pooled by review manager after a systematic research of literature. Health risk appraisal (HRA) model was developed to predict an individual's risk of developing breast cancer in the next 5 years from current age. The performance of this HRA model was assessed based on a first-round screening database. Estimated risk of breast cancer increased with age. Increases in the 5-year risk of developing breast cancer were found with the existence of any of included risk factors. When individuals who had risk above median risk (3.3‰) were selected from the validation database, the sensitivity is 60.0% and the specificity is 47.8%. The unweighted area under the curve (AUC) was 0.64 (95% CI = 0.50-0.78). The risk-prediction model reported in this article is based on a combination of risk factors and shows good overall predictive power, but it is still weak at predicting which particular women will develop the disease. It would be very helpful for the improvement of a current model if more population-based prospective follow-up studies were used for the validation.

Personalised risk communication for informed decision making about taking screening tests

BACKGROUND

There is a trend towards greater patient involvement in healthcare decisions. Although screening is usually perceived as good for the health of the population, there are risks associated with the tests involved. Achieving both adequate involvement of consumers and informed decision making are now seen as important goals for screening programmes. Personalised risk estimates have been shown to be effective methods of risk communication.

OBJECTIVES

To assess the effects of personalised risk communication on informed decision making by individuals taking screening tests. We also assess individual components that constitute informed decisions.

SEARCH METHODS

Two authors searched the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 3, 2012), MEDLINE (OvidSP), EMBASE (OvidSP), CINAHL (EbscoHOST) and PsycINFO (OvidSP) without language restrictions. We searched from 2006 to March 2012. The date ranges for the previous searches were from 1989 to December 2005 for PsycINFO and from 1985 to December 2005 for other databases. For the original version of this review, we also searched CancerLit  and Science Citation Index (March 2001). We also reviewed the reference lists and conducted citation searches of included studies and other systematic reviews in the field, to identify any studies missed during the initial search.

SELECTION CRITERIA

Randomised controlled trials incorporating an intervention with a 'personalised risk communication element' for individuals undergoing screening procedures, and reporting measures of informed decisions and also cognitive, affective, or behavioural outcomes addressing the decision by such individuals, of whether or not to undergo screening.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed each included trial for risk of bias, and extracted data. We extracted data about the nature and setting of interventions, and relevant outcome data. We used standard statistical methods to combine data using RevMan version 5, including analysis according to different levels of detail of personalised risk communication, different conditions for screening, and studies based only on high-risk participants rather than people at 'average' risk. 

MAIN RESULTS

We included 41 studies involving 28,700 people. Nineteen new studies were identified in this update, adding to the 22 studies included in the previous two iterations of the review. Three studies measured informed decision with regard to the uptake of screening following personalised risk communication as a part of their intervention. All of these three studies were at low risk of bias and there was strong evidence that the interventions enhanced informed decision making, although with heterogeneous results. Overall 45.2% (592/1309) of participants who received personalised risk information made informed choices, compared to 20.2% (229/1135) of participants who received generic risk information. The overall odds ratios (ORs) for informed decision were 4.48 (95% confidence interval (CI) 3.62 to 5.53 for fixed effect) and 3.65 (95% CI 2.13 to 6.23 for random effects). Nine studies measured increase in knowledge, using different scales. All of these studies showed an increase in knowledge with personalised risk communication. In three studies the interventions showed a trend towards more accurate risk perception, but the evidence was of poor quality. Four out of six studies reported non-significant changes in anxiety following personalised risk communication to the participants. Overall there was a small non-significant decrease in the anxiety scores. Most studies (32/41) measured the uptake of screening tests following interventions. Our results (OR 1.15 (95% CI 1.02 to 1.29)) constitute low quality evidence, consistent with a small effect, that personalised risk communication in which a risk score was provided (6 studies) or the participants were given their categorised risk (6 studies), increases uptake of screening tests. 

AUTHORS' CONCLUSIONS

There is strong evidence from three trials that personalised risk estimates incorporated within communication interventions for screening programmes enhance informed choices. However the evidence for increasing the uptake of such screening tests with similar interventions is weak, and it is not clear if this increase is associated with informed choices. Studies included a diverse range of screening programmes. Therefore, data from this review do not allow us to draw conclusions about the best interventions to deliver personalised risk communication for enhancing informed decisions. The results are dominated by findings from the topic area of mammography and colorectal cancer. Caution is therefore required in generalising from these results, and particularly for clinical topics other than mammography and colorectal cancer screening.

Effectiveness of interventions to increase screening for breast, cervical, and colorectal cancers: nine updated systematic reviews for the guide to community preventive services

CONTEXT

Screening reduces mortality from breast, cervical, and colorectal cancers. The Guide to Community Preventive Services previously conducted systematic reviews on the effectiveness of 11 interventions to increase screening for these cancers. This article presents results of updated systematic reviews for nine of these interventions.

EVIDENCE ACQUISITION

Five databases were searched for studies published during January 2004-October 2008. Studies had to (1) be a primary investigation of one or more intervention category; (2) be conducted in a country with a high-income economy; (3) provide information on at least one cancer screening outcome of interest; and (4) include screening use prior to intervention implementation or a concurrent group unexposed to the intervention category of interest. Forty-five studies were included in the reviews.

EVIDENCE SYNTHESIS

Recommendations were added for one-on-one education to increase screening with fecal occult blood testing (FOBT) and group education to increase mammography screening. Strength of evidence for client reminder interventions to increase FOBT screening was upgraded from sufficient to strong. Previous findings and recommendations for reducing out-of-pocket costs (breast cancer screening); provider assessment and feedback (breast, cervical, and FOBT screening); one-on-one education and client reminders (breast and cervical cancer screening); and reducing structural barriers (breast cancer and FOBT screening) were reaffirmed or unchanged. Evidence remains insufficient to determine effectiveness for the remaining screening tests and intervention categories.

CONCLUSIONS

Findings indicate new and reaffirmed interventions effective in promoting recommended cancer screening, including colorectal cancer screening. Findings can be used in community and healthcare settings to promote recommended care. Important research gaps also are described.

Cancer genetic risk assessment for individuals at risk of familial breast cancer

BACKGROUND

The recognition of an inherited component to breast cancer has led to an increase in demand for information, reassurance, and genetic testing, which has resulted in the creation of genetic clinics for familial cancer. The first step for patients referred to a cancer genetic clinic is a risk assessment.

OBJECTIVES

To evaluate the impact of cancer genetic risk-assessment services on patients at risk of familial breast cancer.

SEARCH METHODS

The specialised register maintained by the Cochrane Breast Cancer Group was searched on 16th February 2005. We also searched MEDLINE, EMBASE, CINAHL, PsycLIT, CENTRAL, DARE, ASSIA, Web of Science, SIGLE and LILACS. The original searches covered the period 1985 to February 2005. We also handsearched relevant journals. For this review update the search was repeated through to April 2011.

SELECTION CRITERIA

We considered trials looking at interventions for cancer genetic risk-assessment services for familial breast cancer for inclusion. Trials assessed outcomes such as understanding of risk, satisfaction and psychological well-being. We excluded studies if they concerned cancers other than breast cancer or if participants were not at risk of inherited breast cancer. We also excluded trials concerning the provision of general cancer genetic information or education as this review was concerned with the delivery of genetic risk assessment. Participants could be individuals of any age or gender, with or without a known BRCA mutation, but without a previous history of breast cancer or any other serious illness.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. Additional information was sought from investigators as necessary. Due to the heterogeneity of both the interventions and outcomes, we reported data descriptively.

MAIN RESULTS

In this review update, we included five new trials, bringing the total number of included studies to eight. The included trials (pertaining to 10 papers), provided data on 1973 participants and assessed the impact of cancer genetic risk assessment on outcomes including perceived risk of inherited cancer, and psychological distress. This review suggests that cancer genetic risk-assessment services help to reduce distress, improve the accuracy of the perceived risk of breast cancer, and increase knowledge about breast cancer and genetics. The health professional delivering the risk assessment does not appear to have a significant impact on these outcomes.

AUTHORS' CONCLUSIONS

This review found favourable outcomes for patients after risk assessment for familial breast cancer. However, there were too few papers to make any significant conclusions about how best to deliver cancer genetic risk-assessment services. Further research is needed assessing the best means of delivering cancer risk assessment, by different health professionals, in different ways and in alternative locations.

Breast cancer worry among women awaiting mammography: is it unfounded? Does prior counseling help?

The purpose of this study was to explore the prevalence of breast cancer anxiety and risk counseling in women undergoing mammography, and the association with known risk factors for cancer. Women awaiting mammography were surveyed regarding anxiety, prior breast cancer risk counseling, demographic and risk factors. Anxiety was assessed via 7-point Likert-type scale (LS). Risk was defined by Gail model or prior breast cancer. Data were analyzed by nonparametric methods; significance determined at alpha = 0.05. Of 227 women surveyed, 54 were classified "higher risk". Counseling prevalence was similar (52%) for all ethnic groups, but higher (72%, P<0.001) for "higher risk" women. On average, women awaiting screening/diagnostic mammography were somewhat worried (median LS = 4). Worry was significantly higher (P<0.05) in "higher risk" women (LS = 5), and in women living outside Honolulu (LS = 6). Counseling by primary care physicians (PCP) did not correlate with lower worry scores. It was concluded that most women awaiting mammography are not unduly anxious. Additionally, the findings showed a correlation between a woman's concern about developing cancer with known risk factors and rural residence.

"I have always believed I was at high risk..." The role of expectation in emotional responses to the receipt of an average, moderate or high cancer genetic risk assessment result: a thematic analysis of free-text questionnaire comments

It is well-recognised that receipt of cancer genetic risk information can evoke a mix of both positive and negative emotional responses. Objective risk itself is not necessarily predictive of emotional response to receipt of risk information and the Cue Adaptive Reasoning Account (CARA; Renner, 2004) suggests that that the degree to which level of risk is consistent with expectations may influence emotional responses. This paper reports a thematic analysis of the free-text data structured around responses to the three risk labels: average, moderate or high. Data is reported from both 123 women and 15 men, including those with a past or current cancer diagnosis. Reactions to risk information appear to be dependent upon participants' pre-conceived expectations about their level of cancer risk. Many average risk respondents questioned the accuracy of their result, whereas high risk information was often expected. Findings are discussed in relation to the CARA model and clinical implications.

Risky feelings: why a 6% risk of cancer does not always feel like 6%

OBJECTIVE

Emotion plays a strong role in the perception of risk information but is frequently underemphasized in the decision-making and communication literature. We sought to discuss and put into context several lines of research that have explored the links between emotion and risk perceptions.

METHODS

In this article, we provide a focused, "state of the science" review of research revealing the ways that emotion, or affect, influences people's cancer-related decisions. We identify illustrative experimental research studies that demonstrate the role of affect in people's estimates of cancer risk, their decisions between different cancer treatments, their perceptions of the chance of cancer recurrence, and their reactions to different methods of presenting risk information.

RESULTS

These studies show that people have strong affective reactions to cancer risk information and that the way risk information is presented often determines the emotional gist people take away from such communications.

CONCLUSION

Cancer researchers, educators and oncologists need to be aware that emotions are often more influential in decision making about cancer treatments and prevention behaviors than factual knowledge is.

PRACTICE IMPLICATIONS

Anticipating and assessing affective reactions is an essential step in the evaluation and improvement of cancer risk communications.

Unwanted effects of risk notification for breast cancer regarding intention toward mammography utilization

OBJECTIVE

This study was conducted to explore the possible influence of risk notification regarding breast cancer on the intention of women to undergo mammography.

METHODS

This study employed an uncontrolled before-after design. A baseline survey was conducted in a random sample of 1000 women to examine the sociodemographic variables, breast cancer risk factors, and screening-related variables. All subjects received the findings of a personalized health-risk appraisal (HRA) following the baseline interview. After 2 months of the baseline survey, a survey was conducted in 855 women to assess whether the intention of undergoing mammography had changed. Thus, the modification in the intention by communicating the individual risk status was assessed.

RESULTS

There was an overall increase from baseline to post-intervention in the number of subjects with the intention of undergoing mammography. Women in the contemplation and action stages who had intention toward mammography utilization at baseline showed decreased intention regarding mammography. After intervention in the form of HRA to promote mammography utilization, it was determined that young age, being married, being in neither the precontemplation nor the relapse stage, and having one or more risk factors of breast cancer were the predictors of intention to undergo mammography.

CONCLUSIONS

Our findings indicate that communicating the risk status by HRA service can have a negative effect in the promotion of health-conscious behavior. The selection of the appropriate type of intervention using HRA to promote mammography utilization in the target group will be enhanced by taking into account the risk status of each client.

Impact of an informed choice invitation on uptake of screening for diabetes in primary care (DICISION): trial protocol

Background

Screening invitations have traditionally been brief, providing information only about population benefits. Presenting information about the limited individual benefits and potential harms of screening to inform choice may reduce attendance, particularly in the more socially deprived. At the same time, amongst those who attend, it might increase motivation to change behavior to reduce risks. This trial assesses the impact on attendance and motivation to change behavior of an invitation that facilitates informed choices about participating in diabetes screening in general practice. Three hypotheses are tested:

1. Attendance at screening for diabetes is lower following an informed choice compared with a standard invitation.

2. There is an interaction between the type of invitation and social deprivation: attendance following an informed choice compared with a standard invitation is lower in those who are more rather than less socially deprived.

3. Amongst those who attend for screening, intentions to change behavior to reduce risks of complications in those subsequently diagnosed with diabetes are stronger following an informed choice invitation compared with a standard invitation.

Method/Design

1500 people aged 40–69 years without known diabetes but at high risk are identified from four general practice registers in the east of England. 1200 participants are randomized by households to receive one of two invitations to attend for diabetes screening at their general practices. The intervention invitation is designed to facilitate informed choices, and comprises detailed information and a decision aid. A comparison invitation is based on those currently in use. Screening involves a finger-prick blood glucose test. The primary outcome is attendance for diabetes screening. The secondary outcome is intention to change health related behaviors in those attenders diagnosed with diabetes. A sample size of 1200 ensures 90% power to detect a 10% difference in attendance between arms, and in an estimated 780 attenders, 80% power to detect a 0.2 sd difference in intention between arms.

Discussion

The DICISION trial is a rigorous pragmatic denominator based clinical trial of an informed choice invitation to diabetes screening, which addresses some key limitations of previous trials.

Trial registration

Current Controlled Trials ISRCTN73125647

Stability and change in health-related behaviors of midlife Swedish women

We investigated the dimensions and stability in health-related behaviors (HRBs) among midlife Swedish women, and the factors that predicted change in those behaviors. At age 43, 569 women from a representative longitudinal sample completed questionnaires about lifestyle (diet, exercise, smoking, alcohol) and participated in medical screening. Four years later we mailed a follow-up questionnaire. HRBs clustered in two dimensions: healthy eating and addictions. There was a high degree of stability in HRBs; all women slightly increased their HRBs over time. After controlling for previous HRBs, we found that education, marital status, and having children at home were significant predictors of HRBs 4 years later.

Client-directed interventions to increase community demand for breast, cervical, and colorectal cancer screening a systematic review

Most major medical organizations recommend routine screening for breast, cervical, and colorectal cancers. Screening can lead to early detection of these cancers, resulting in reduced mortality. Yet not all people who should be screened are screened, either regularly or, in some cases, ever. This report presents the results of systematic reviews of effectiveness, applicability, economic efficiency, barriers to implementation, and other harms or benefits of interventions designed to increase screening for breast, cervical, and colorectal cancers by increasing community demand for these services. Evidence from these reviews indicates that screening for breast cancer (mammography) and cervical cancer (Pap test) has been effectively increased by use of client reminders, small media, and one-on-one education. Screening for colorectal cancer by fecal occult blood test has been increased effectively by use of client reminders and small media. Additional research is needed to determine whether client incentives, group education, and mass media are effective in increasing use of any of the three screening tests; whether one-on-one education increases screening for colorectal cancer; and whether any demand-enhancing interventions are effective in increasing the use of other colorectal cancer screening procedures (i.e., flexible sigmoidoscopy, colonoscopy, double contrast barium enema). Specific areas for further research are also suggested in this report.

Predicting the use of individualized risk assessment for breast cancer

PURPOSE

The purpose of this study was to investigate the decision to obtain individualized risk assessment (IRA) after a breast cancer education session.

METHODS

A sample of both African American and Caucasian women was used to determine if there were differences by race/ethnicity in uptake of the assessment and differences in the variables that were most predictive of uptake. The sample included 166 women between the ages of 18 and 80. Sixty-two percent of the sample were African American women.

KEY FINDINGS

The results suggested that African American women and Caucasian women used different factors and used other factors differently to decide whether or not to obtain an IRA.

CONCLUSIONS AND IMPLICATIONS

These results are discussed within the context of health disparities among ethnic minority and Caucasian women with implications for breast cancer control programs. The results of this study suggest that knowledge alone does not lead to opting for a personalized risk assessment, and that African American and Caucasian women use different pieces of information, or information differently to make decision about getting more personalized information about risk.

The impact of breast cancer genetic risk assessment on intentions to perform cancer surveillance behaviors

One hundred and fifty-four women undergoing breast/ovarian cancer genetic risk assessment completed questionnaires at entry into the Cancer Genetic Service for Wales (CGSW) assessment program and following risk provision, mapping the strength of intentions to engage in a number of preventive/surveillance behaviors, including seeing specialists, breast self-examination, and involvement in screening programs, including mammography. A number of potential predictors of intentions were also assessed, including participants' mood and emotional response to receiving risk information, the perceived benefits (in terms of reassurance and early disease detection) of engaging in each preventive behavior, and the perceived desires of their family and General Practitioner. Intentions to self-examine did not change following risk provision, although strength of intentions to engage in some other preventive behaviors did lessen. Family and General Practitioners appeared to be strong social influences on behavioral intentions, as were the perceived benefits of gaining reassurance and/or early detection of disease.

Cancer genetic risk assessment for individuals at risk of familial breast cancer

BACKGROUND

The recognition of an inherited component to breast cancer has led to an increase in demand for information, reassurance, and genetic testing, resulting in the creation of genetics clinics for familial cancer. The first step for patients referred to a cancer genetic clinic is a risk assessment.

OBJECTIVES

To evaluate the impact of cancer genetic risk assessment services on patients at risk of familial breast cancer.

SEARCH STRATEGY

The specialised register maintained by the Cochrane Breast Cancer Group was searched. We also searched MEDLINE, EMBASE, CINAHL, PsycLIT, CENTRAL, DARE, ASSIA, Web of Science, SIGLE and LILACS. The searches covered the period 1985 to February 2005. We also hand-searched relevant journals.

SELECTION CRITERIA

Trials looking at interventions for cancer genetic risk assessment delivery for familial breast cancer were considered for inclusion. Trials assessed outcomes such as understanding of risk, satisfaction and psychological well-being. Studies were excluded if they concerned cancers other than breast cancer or if participants were not at risk of breast cancer. Trials concerning the provision of information or education were also excluded as it was intended to review these separately. Participants could be individuals of any age or gender, with or without a known BRCA mutation, but without a previous history of breast cancer or any other serious illness.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. Additional information was sought from investigators as necessary. Due to the heterogeneity of both the interventions and outcomes, data were analysed descriptively.

MAIN RESULTS

Fifty-eight papers were identified as relevant to the review, 54 of these were subsequently excluded. The three included trials (pertaining to five papers), provide data on 1251 participants and assessed the impact of cancer genetic risk assessment on outcomes including perceived risk, and psychological distress. This review suggests that cancer genetic risk assessment services help to reduce distress, improve the accuracy of the perceived risk of, and increase knowledge about, breast cancer and genetics. The health professional delivering the risk assessment does not appear to have a significant impact on these outcomes.

AUTHORS' CONCLUSIONS

This review found favourable outcomes for patients' risk assessment for familial breast cancer. However, there were too few papers to make any significant conclusions about how best to deliver cancer genetic risk assessment services. Further research is needed assessing the best means of delivering cancer risk assessment, by different health professionals, in different ways and in alternative locations.

Validity of Self-Reports of Return for Routine Repeat Screening in an Ovarian Cancer Screening Program: Table 1

Cancer screening research relies on reliable and valid measurement of cancer screening behavior. Self-reports of screening constitute a cost-effective approach to measuring screening behavior; however, demonstration of suitable validity of these self-reports is critical. We evaluated the validity of self-report of return for repeat, routine, annual transvaginal sonography (TVS) screening for ovarian cancer. Participants (n = 535) in a university-based ovarian cancer screening program for asymptomatic, average risk women completed a telephone interview 18 months following an initial, baseline TVS screening test. Self-reports of return for a repeat, routine ovarian cancer screening test since baseline were obtained and compared with objective records of repeat screening from the screening program database. Overall agreement of self-reports and objective records of ovarian cancer screening was 97.57% (kappa = 0.94). Sensitivity was 0.98, specificity was 0.96, positive predictive value was 0.98, and negative predictive value was 0.96. The month of last screening was accurately identified by 80% of participants. It was concluded the validity of self-reports of TVS screening for ovarian cancer is very high and may even exceed the validity of self-reports of participation in breast, cervical, and colorectal cancer screening over similar recall periods. Consequently, self-reports of TVS screening may serve as a cost-effective substitute for more objective methods of assessing TVS screening behavior.

Results of a randomized study of telephone versus in-person breast cancer risk counseling

OBJECTIVE

Women of all risk levels have reported high interest in obtaining genetic testing for breast cancer risk. Breast cancer risk counseling may help women to learn about their risk and appropriate options of testing. This study measured the effects of an intervention in-person and by telephone, compared to a control group.

METHODS

Participants were 340 women, recruited through a network of primary care physicians. They received a baseline questionnaire in the mail, were randomized to one of the three study arms, and completed a follow-up survey 3 months later.

RESULTS

Both types of counseling were very well received. The counseling decreased women's cancer worry, risk perceptions, and intentions to pursue genetic testing. There were similar effects for both in-person and telephone counseling.

CONCLUSION

Genetic counseling can be used to inform women at all risk levels about their breast cancer risk.

PRACTICE IMPLICATIONS

Breast cancer risk counseling can be done in-person and by telephone--thereby reaching women in remote areas.

Personalised risk communication for informed decision making about taking screening tests

BACKGROUND

There is a trend towards greater patient involvement in healthcare decisions. Adequate discussion of the risks and benefits associated with different choices is often required if involvement is to be genuine and effective. Achieving both the adequate involvement of consumers and informed decision making are now seen as important goals for any screening programme. Personalised risk estimates have been shown to be effective methods of risk communication in general, but the effectiveness of different strategies has not previously been examined.

OBJECTIVES

To assess the effects of different types of personalised risk communication for consumers making decisions about taking screening tests.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2004), MEDLINE (1985 to December 2005), EMBASE (1985 to December 2005), CINAHL (1985 to December 2005), and PsycINFO (1989 to December 2005). Follow-up searches involved hand searching Preventive Medicine, citation searches on seven authors, and searching reference lists of articles. For the original version of this review (Edwards 2003c) we also searched CancerLit (1985 to 2001) and Science Citation Index Expanded (searched March 2002).

SELECTION CRITERIA

Randomised controlled trials addressing the decision by consumers of whether or not to undergo screening, incorporating an intervention with a 'personalised risk communication element' and reporting cognitive, affective, or behavioural outcomes. A 'personalised risk communication element' is based on the individual's own risk factors for a condition (such as age or family history). It may be calculated from an individual's risk factors using formulae derived from epidemiological data, and presented as an absolute or relative risk or as a risk score, or it may be categorised into, for example, high, medium or low risk groups. It may be less detailed still, involving a listing, for example, of a consumer's risk factors as a focus for discussion and intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed each trial for quality and extracted data. We extracted data about the nature and setting of the intervention, and relevant outcome data, along with items relating to methodological quality. We then used standard statistical methods of the Consumers and Communication Review Group to combine data using MetaView, including analysis according to different levels of detail of personalised risk communication, different condition for screening, and studies based only on high risk participants rather than people at 'average' risk.

MAIN RESULTS

Twenty-two studies were included, nine of which were added in the 2006 update of this review. There was weak evidence, consistent with a small effect, that personalised risk communication (whether written, spoken or visually presented) increases uptake of screening tests (odds ratio (OR) 1.31 (random effects, 95% confidence interval (CI) 0.98 to 1.77). In three studies the interventions showed a trend towards more accurate risk perception (OR 1.65 (95% CI 0.96 to 2.81), and three other trials with heterogenous outcome measures showed improvements in knowledge with personalised risk interventions. There was little other evidence from these studies that the interventions promoted or achieved informed decision making by consumers about participation in screening. More detailed personalised risk communication may be associated with a smaller increase in uptake of tests. That is, for personalised risk communication which used and presented numerical calculations of risk, the OR for test uptake was 0.82 (95% CI 0.65 to 1.03). For risk estimates or calculations which were categorised into high, medium or low strata of risk, the OR was 1.42 (95% CI 1.07 to 1.89). For risk communication that simply listed personal risk factors the OR was 1.42 (95% CI 0.95 to 2.12). Over half of the included studies assessed interventions in the context of mammography. These studies showed similar effects to the overall dataset. The five studies examining risk communication in high risk individuals (individuals at higher risk due to, for example, a family history of breast cancer or other conditions) showed larger odds ratios for uptake of tests than the other studies (random effects OR 1.74; 95% CI 1.05 to 2.88). There were insufficient data from the included studies to report odds ratios on other key outcomes such as: intention to take tests, anxiety, satisfaction with decisions, decisional conflict, knowledge and resource use.

AUTHORS' CONCLUSIONS

Personalised risk communication (as currently implemented in the included studies) may have a small effect on increasing uptake of screening tests, and there is only limited evidence that the interventions have promoted or achieved informed decision making by consumers.

Psychological impact of genetic counseling for familial cancer: a systematic review and meta-analysis

BACKGROUND

Identification of a genetic basis underlying certain types of cancer has led to an increase in demand for genetic counseling about individual risks of the disease. We conducted a systematic review of the literature to determine the quality and strength of evidence relating to psychological outcomes of genetic counseling for familial cancer.

METHODS

Six electronic databases were searched to identify controlled trials and prospective studies that examined the effect of genetic counseling on risk perception, knowledge, anxiety, cancer-specific worry, depression, and cancer surveillance. Twenty-one studies from 25 papers met inclusion criteria, including five controlled trials and 16 prospective studies. Analysis of each outcome was stratified by short-term (</=1 month) and long-term (>/=3 months) follow-up. Trial evidence was assessed with standardized differences of the means at follow-up between intervention and comparison groups, and these data were pooled by use of random-effects meta-analysis.

RESULTS

Meta-analysis of controlled trials showed that genetic counseling improved knowledge of cancer genetics (pooled short-term difference=0.70 U, 95% confidence interval (CI)=0.15 to 1.26 U) but did not alter the level of perceived risk (pooled short-term difference=-0.10 U, 95% CI=-0.23-0.04 U). Prospective studies reported improvements in the accuracy of perceived risk. No effect was observed in controlled trials on general anxiety (pooled long-term effect=0.05 U, 95% CI=-0.21-0.31 U) or cancer-specific worry (pooled long-term difference=-0.14 U, 95% CI=-0.35-0.06 U), although several prospective studies demonstrated short-term reductions in these outcomes. Few studies examined cancer surveillance behaviors, and no studies attempted to measure informed choice.

CONCLUSIONS

Genetic counseling for familial cancer is associated with improvement in knowledge but does not have an adverse effect on affective outcomes. We urge further investigation of these findings through well-designed, well-reported, randomized controlled trials with suitable comparison groups and additional outcome measures [J Natl Cancer Inst 2004; 96:122-33].

Does worry about breast cancer predict screening behaviors? A meta-analysis of the prospective evidence

OBJECTIVE

Many women worry about the possibility of developing breast cancer, but there is conflicting evidence concerning whether cancer worry acts as a facilitator or inhibitor of breast cancer screening.

METHOD

We conducted a meta-analysis of 12 prospective studies that measured worry about breast cancer at baseline and subsequent breast self-examination (BSE) or mammography utilization among 3342 high-risk and general population women.

RESULTS

The data consistently show that breast cancer worry has a small but reliable (r = 0.12) association with breast cancer screening behavior, such that greater worry predicts a greater likelihood of screening. We also found that the means for breast cancer worry were consistently in the lower third of the scales, despite differences in measurement approaches, sample utilization, or the date that the study was conducted.

CONCLUSION

The meta-analysis supports the contention that breast cancer worry may motivate screening behavior, and that high levels of breast cancer worry are uncommon.

BRCA1/2 testing in hereditary breast and ovarian cancer families III: Risk perception and screening

This study aimed to ascertain whether cancer risk perception changed following the offer and subsequent receipt of BRCA1/2 results and to evaluate breast and ovarian screening practices in testers and non-testers. Members of thirteen HBOC families were offered BRCA1/2 testing for a known family mutation. Perceived risk for developing breast cancer, ovarian cancer or for carrying the familial BRCA1/2 mutation, was assessed at baseline and again at 6-9 months following the receipt of test results. Breast and ovarian cancer screening data were obtained at both time-points. A total of 138 women participated and 120 (87%) chose to be tested for a known familial mutation. Twenty-eight women (24%) were identified as carriers and their perceived ovarian cancer risk and their perception of being a mutation carrier increased (P = 0.01 for both). Those testing negatives had a significant decrease in all dimensions of risk perception (P < 0.01). Regression analysis showed test results to be strong predictors of follow-up risk perception (P = 0.001), however, they were not predictors of screening practices at follow-up. Testers were more likely to have completed a clinical breast exam following testing than decliners. Mammography was positively associated with baseline adherence, age, and intrusive thoughts. Ovarian cancer worries only predicted pelvic ultrasound screening post-testing. Baseline practices and psychological factors appear to be stronger predictors of health behavior than test results.

How making a risk estimate can change the feel of that risk: shifting attitudes toward breast cancer risk in a general public survey

Counseling women about breast cancer risks has been found to decrease screening compliance. We investigated whether women's reactions to risk information are an artifact of requiring women to estimate the risk of breast cancer prior to receiving risk information. Three hundred and fifty-six women were randomized to either make or not make a risk estimate prior to receiving risk information. Outcome measures were participants' estimates of the average woman's breast cancer risk and their emotional response to the risk information. Women overestimated the lifetime risk of breast cancer (M = 46%). Women who made risk estimates felt more relieved about the risk and perceived the risk as being lower than women who did not make estimates (p's < 0.001). Asking people to estimate risks influenced their subsequent perceptions of the risk of breast cancer.

A randomised comparison of UK genetic risk counselling services for familial cancer: psychosocial outcomes

The aim of the study was to compare psychosocial outcomes for 50 new clinic attendees, referred for cancer genetic counselling to five UK centres. The centres represented England, Scotland and Wales, and were randomly selected from groups ranked by different levels of clinical activity in cancer genetics practice. Questionnaires assessed demographic data, risk perception, mental health and use of health services pre-consultation and at 1 and 12 months follow-up. Satisfaction was measured for attendees and referring doctors at follow-up. A total of 256 unaffected adults fulfilled the study criteria. The five centres varied widely with respect to service organisation and activity, but all had a greater proportion of unaffected attendees with a breast cancer risk (61–91%) than either a bowel cancer risk (0–33%) or ovarian cancer risk (3–25%). There were no significant differences in the psychosocial data between centres pre-counselling. No significant change over time occurred for any of the centres for risk perception or general psychological distress. There were significant differences between centres in reduction of cancer worry from baseline to 12 months and with the number of women who were recommended to have mammographic surveillance who had not received this. Overall, one-third of women for whom mammography had been recommended had not been screened within 1 year of follow-up. Subsequent attendance at the GP, but not at a hospital, was associated with risk level, but differences between centres could not be analysed. Satisfaction differed significantly between centres for 4 : 14 aspects of service provision and with 3 : 17 items concerning communication; satisfaction was high overall. Over 90% of referring doctors were moderately/very satisfied with the service, but 23% were dissatisfied with waiting times and 19% with access to preventive treatment. Results differed significantly between centres for doctor's satisfaction with the provision of referral criteria and prescribing information. In conclusion, there were relatively few significant differences in psychosocial outcomes between centres, considering the wide variation in service organisation and activity. These significant differences were not consistent across the centres, therefore, differences could not be linked to specific aspects of service provision.

Development and Psychometric Testing of the Coping With Breast Cancer Threat Instrument

Women with a positive family history of breast cancer have a higher relative breast cancer risk. Research pertinent to this “at-risk” population has focused primarily on the early detection measures of breast self-exam, clinical breast exam, and mammography. Other specific primary prevention coping behaviors have received little research attention and, while there are instruments that measure general coping behaviors in the face of illness threat, there are no known instruments that measure coping behaviors specific to dealing with breast cancer threat. This study tested the psychometric properties of the Coping with Breast Cancer Threat instrument (CBCT). The CBCT was designed to measure primary prevention and early detection coping strategies used by women with family histories of breast cancer in response to their appraised breast cancer threat. The tool’s format was modeled after the Jalowiec Coping Scale (JCS) and included use and effectiveness scales. Internal consistency reliabilities and content and construct validity of the CBCT were assessed in a sample of 209 women with a family history of breast cancer. Alpha coefficients for the CBCT’s total use and effectiveness scales were .70 and .76, respectively. Principal components factor analysis with a varimax rotation revealed three conceptually relevant subcales that accounted for 52% of the variance in breast cancer threat coping behaviors. The CBCT was shown to be a reliable and valid measure of coping with breast cancer threat in a well-educated, European Amercian sample of middle-aged women.

Assessment of genetic testing and related counseling services: current research and future directions

With the recent completion of the sequencing of the Human Genome, genetic testing will increasingly become available for a greater number of medical conditions, many of which are those that manifest in adulthood (e.g., various cancers, cardiovascular disease, diabetes) or for which little or no treatments are available (e.g., Alzheimer disease). Genetic services, defined here as those relating to genetic testing and counseling, will be with helping more individuals deal with medical information that affects their health directly, as opposed to affecting primarily the health of their offspring. This paper reviews the existing research in the genetic testing and counseling literature and presents an evaluation framework outlining the intended outcomes of genetic services. The purpose of this framework is to provide an overview of the potential outcomes of these services and highlight constructs for future research in this area. In addition, other issues that will affect the assessment of genetic services are raised, using examples from the existing literature. Ultimately, the goal of this paper is to highlight and suggest directions researchers can take to produce the information needed to guide genetic testing and counseling practice. Moreover, as genetic knowledge is increasingly applied towards the prevention and treatment of various common, chronic disease conditions, genetic information will have implications for providers outside of the traditional medical genetics realm, such as primary care providers and public health practitioners. A better understanding of the outcomes of genetic testing and counseling will provide a basis from which to ensure an appropriate application of genetic information by all those who eventually provide care and "genetic" services.

Predictors of perceived breast cancer risk and the relation between perceived risk and breast cancer screening: a meta-analytic review

BACKGROUND

Perceived risk is a principal variable in theoretical models that attempt to predict the adoption of health-protective behaviors.

METHODS

This meta-analysis synthesizes findings from 42 studies, identified in PubMed and PsycInfo from 1985 onward. Studies examined demographic and psychological variables as predictors of perceived breast cancer risk and the relationship between perceived risk and breast cancer screening. Statistical relationships, weighted for sample size, were transformed to effect sizes and 95% CIs.

RESULTS

Women do not have accurate perceptions of their breast cancer risk (N = 5561, g = 1.10). Overall, they have an optimistic bias about their personal risk (g = 0.99). However, having a positive family history (N = 70660, g = 0.88), recruitment site, and measurement error confounded these results. Perceived risk is weakly influenced by age (N = 38000, g = 0.13) and education (N = 1979, g = 0.16), and is moderately affected by race/culture (N = 2192, g = 0.38) and worry (N = 6090, g = 0.49). There is an association between perceived risk and mammography screening (N = 52766, g = 0.19). It is not clear whether perceived risk influences adherence to breast self-examination. Women who perceived a higher breast cancer risk were more likely to pursue genetic testing or undergo prophylactic mastectomy.

CONCLUSION

Perceived breast cancer risk depends on psychological and cognitive variables and influences adherence to mammography screening guidelines.

Psychological impact of genetic counseling for familial cancer: a systematic review and meta-analysis

BACKGROUND

Identification of a genetic basis underlying certain types of cancer has led to an increase in demand for genetic counseling about individual risks of the disease. We conducted a systematic review of the literature to determine the quality and strength of evidence relating to psychological outcomes of genetic counseling for familial cancer.

METHODS

Six electronic databases were searched to identify controlled trials and prospective studies that examined the effect of genetic counseling on risk perception, knowledge, anxiety, cancer-specific worry, depression, and cancer surveillance. Twenty-one studies from 25 papers met inclusion criteria, including five controlled trials and 16 prospective studies. Analysis of each outcome was stratified by short-term (< or =1 month) and long-term (> or = 3 months) follow-up. Trial evidence was assessed with standardized differences of the means at follow-up between intervention and comparison groups, and these data were pooled by use of random-effects meta-analysis.

RESULTS

Meta-analysis of controlled trials showed that genetic counseling improved knowledge of cancer genetics (pooled short-term difference = 0.70 U, 95% confidence interval [CI] = 0.15 to 1.26 U) but did not alter the level of perceived risk (pooled short-term difference = -0.10 U, 95% CI = -0.23 to 0.04 U). Prospective studies reported improvements in the accuracy of perceived risk. No effect was observed in controlled trials on general anxiety (pooled long-term effect = 0.05 U, 95% CI = -0.21 to 0.31 U) or cancer-specific worry (pooled long-term difference = -0.14 U, 95% CI = -0.35 to 0.06 U), although several prospective studies demonstrated short-term reductions in these outcomes. Few studies examined cancer surveillance behaviors, and no studies attempted to measure informed choice.

CONCLUSIONS

Genetic counseling for familial cancer is associated with improvement in knowledge but does not have an adverse effect on affective outcomes. We urge further investigation of these findings through well-designed, well-reported, randomized controlled trials with suitable comparison groups and additional outcome measures.

Colon cancer: risk perceptions and risk communication

Members of a health maintenance organization (N=353) interacted with a computer program that provided personalized information about their risk of developing colon cancer in the next 20 years. Prior to computer feedback, most people greatly overestimated their numerical, absolute risk (chances per 1000) and also overestimated their relative risk compared to peers (e.g., "above average"). Their relative risk estimates were correlated with several risk factors, whereas their absolute risk estimates were not, suggesting that assessing individual risk perceptions with numerical, absolute risk scales may provide misleading information about what people believe. Computer feedback improved the accuracy of mean risk estimates, but about half of participants did not accept the personalized feedback as correct. In fact, correlations between actual and perceived risk were no greater among participants who received risk scores than among those who did not. Three possible explanations for resistance to lower-than-expected risk feedback are considered.

Effects of communicating individual risks in screening programmes: Cochrane systematic review

OBJECTIVE

To assess the effects of different types of individualised risk communication for patients who are deciding whether to participate in screening.

DESIGN

Systematic review.

DATA SOURCES

Specialist register of the Cochrane consumers and communication review group, scientific databases, and a manual follow up of references.

SELECTION OF STUDIES

Studies were randomised controlled trials addressing decisions by patients whether or not to undergo screening and incorporating an intervention with an element of "individualised" risk communication-based on the individual's own risk factors for a condition (such as age or family history).

OUTCOME MEASURES

The principal outcome was uptake of screening tests; further cognitive and affective measures were also assessed to gauge informed decision making.

RESULTS

13 studies were included, 10 of which addressed mammography programmes. Individualised risk communication was associated with an increased uptake of screening tests (odds ratio 1.5, 95% confidence interval 1.11 to 2.03). Few cognitive or affective outcomes were reported consistently, so it was not possible to conclude whether this increase in the uptake of tests was related to informed decision making by patients.

CONCLUSIONS

Individualised risk estimates may be effective for purposes of population health, but their effects on increasing uptake of screening programmes may not be interpretable as evidence of informed decision making by patients. Greater attention is required to ways of developing interventions for screening programmes that can achieve this.

Predictive genetics in primary care: expectations for the motivational impact of genetic testing affects the importance family physicians place on screening for familial cancer risk

PURPOSE

To investigate whether the importance family physicians place on familial cancer-risk screening is influenced by expectations for the motivational impact of a high-risk genetic test result.

METHODS

Mailed survey of the Massachusetts Academy of Family Physicians.

RESULTS

Respondents expected patients would increase pursuit of screening for cancer (99.6%) and other diseases (89.9%), quit smoking (93.6%), and improve diet/exercise (92.5%). The degree of motivational effect was significantly related to the importance they place on screening.

CONCLUSIONS

Family physicians believe that a high-risk cancer genetic-test result would motivate their patients to pursue risk-reduction behavior, and this belief is related to the importance they place on screening their patients for an inherited risk of cancer.

Prospective association between distress and mammography utilization among women with a family history of breast cancer

In this study we sought to evaluate the prospective association between psychological distress and mammography utilization among women with a family history of breast cancer. We evaluated the association of cancer worry, cancer-specific distress, and general distress with mammography utilization after controlling for potential confounders. The results revealed that 74% of our sample had obtained a mammogram within 12 months of the baseline assessment. Logistic regression models revealed that after controlling for potential confounding variables, cancer worry and general distress were independent predictors of mammography utilization. Specifically, women who reported higher levels of worry and/or distress at baseline were less likely to report having received a mammogram in the 12 months following the baseline assessment. These results are in contrast to the only other prospective study in this population. Additional research is needed to determine the prospective association between distress and adherence and to identify potential mechanisms for such an association.

Effecting behavior change: awareness of family history

This article explores the use of family history of disease as a public health tool for risk stratification and improved disease prevention by drawing from previous research on women at moderate risk of developing breast cancer because of a positive family history. About one quarter to one third of women do not appear to be aware of the added risk a family history of breast cancer poses, and many women with a family history overestimate their risk. It is unclear whether risk perceptions are causally related to breast cancer screening in women with a family history. Exaggerated risk perceptions may not hinder breast cancer screening, unless accompanied by distress. Studies suggest that counseling women with a family history of breast cancer about their risk has a small and short-term effect on risk comprehension, a small effect on breast cancer screening, psychological benefits for some women, and unintended negative effects on screening for other women. Future research needs to consider the psychological, individual difference, and cultural variables that moderate counseling effects, recruitment biases, the prospective relationship between perceived risk and breast cancer screening, and whether risk perceptions and comprehension need to match objective risk to be an effective tool to promote screening.

Personalised risk communication for informed decision making about entering screening programs

BACKGROUND

There is a trend towards greater patient involvement in health care decisions. Adequate discussion of the risks and benefits associated with different choices is often required if involvement is to be genuine and effective. Achieving adequate involvement of consumers and informed decision making are now seen as important goals for any screening programme. Individualised risk estimates have been shown to be effective methods of risk communication in general, but the effectiveness of different strategies has not previously been examined.

OBJECTIVES

To assess the effects of different types of individualised risk communication for consumers making decisions about participating in screening.

SEARCH STRATEGY

We searched the Cochrane Consumers and Communication Review Group specialised register (searched March 2001), MEDLINE (1985 to 2001), EMBASE (1985 to 2001), CancerLit (1985 to 2001), CINAHL (1985 to 2001), ClinPSYC (1989 to 2001), and the Science Citation Index Expanded (searched March 2002). Follow-up searches involved hand searching Preventive Medicine, citation searches on seven authors, and searching reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials addressing the decision by consumers of whether or not to undergo screening, incorporating an intervention with a 'personalised risk communication element' and reporting cognitive, affective, or behavioural outcomes. A 'personalised risk communication element' is based on the individual's own risk factors for a condition (such as age or family history). It may be calculated from an individual's risk factors using formulae derived from epidemiological data, and presented as an absolute risk or as a risk score, or it may be categorised into, for example, high, medium or low risk groups. It may be less detailed still, involving a listing, for example, of a consumer's risk factors as a focus for discussion and intervention.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Data about the nature and setting of the intervention, and the relevant outcome data were extracted, along with items relating to methodological quality.

MAIN RESULTS

Thirteen studies were included. Personalised risk communication (whether written, spoken or visually presented) was associated with increased uptake of screening tests (odds ratio (OR) 1.5 (95% confidence interval (CI) 1.11 to 2.03). There was no evidence from these studies that this increase in uptake of tests was related to informed decision making by consumers. More detailed personalised risk communication was associated with a smaller increase in uptake of tests. That is, for personalised risk communication which used and presented numerical calculations of risk, the OR for test uptake was 1.22 (95% CI 0.56 to 2.68). For risk estimates or calculations which were categorised into high, medium or low strata of risk, the OR was 1.42 (95% CI 1.07 to 1.88). For risk communication that simply listed risk personal risk factors the OR was 1.7 (95% CI 1.17 to 2.48). Most of the included studies addressed mammography programmes. These studies showed slightly smaller effects than the overall dataset, again with numerical calculated risk estimates being associated with lower ORs for uptake of tests (OR 1.13; 95% CI 0.98 to 1.29) than the other categories of (less detailed) personalised risk communication. The four studies examining risk communication in high risk individuals showed larger odds ratios for uptake of tests than the other studies. The OR for numerical calculated risk estimates was 1.48 (95% CI 1.06 to 2.07), compared to 4.66 (95% CI 2.24 to 9.69) for categorised risk estimates and 2.64 (95% CI 1.42 to 4.9) for listed personal risk factors. There were insufficient data from the included studies to report odds ratios on other key outcomes such as: intention to take tests, anxiety, satisfaction with decisions, decisional conflict, knowledge and risk perception.

REVIEWER'S CONCLUSIONS

Personalised risk communication (as currently implemented in the included studies) is associated with increased uptake of screening programmes, but this may not be interpretable as evidence of informed decision making by consumers.

What is the impact of genetic counselling in women at increased risk of developing hereditary breast cancer? A meta-analytic review

Meta-analytic methods were used to determine the impact of genetic counselling on women with a family history of breast cancer. Published studies with prospective designs and randomized controlled trials were included in the review, and the psychological outcomes assessed were generalized psychological distress, generalized anxiety, depression, and breast cancer anxiety. Other outcomes investigated were the accuracy of perceived risk of developing breast cancer, breast cancer genetics knowledge and breast cancer screening uptake. A meta-analysis was performed to estimate effect size, where sufficient data were available. A total of 12 studies, most of which measured several outcomes, met at least one of the inclusion criteria. A sufficiently large number of studies were available to assess the magnitude of effects on three outcomes: generalized psychological distress, generalized anxiety and accuracy of perceived risk of developing breast cancer. The quantitative synthesis showed that genetic counselling leads to statistically significant decreases in generalized anxiety, with an average weighted effect sizes of r = - 0.17 (p<0.01). In contrast, the reduction in psychological distress exhibited a trend towards statistical significance only, with r = -0.074 (p = 0.052). The impact of genetic counselling on the accuracy of perceived risk was associated with an effect size of r = 0.56 (p<0.01). Thus in this meta-analysis, we demonstrated the efficacy of genetic counselling in meeting two of its objectives: reducing women's anxiety levels and improving the accuracy of their perceived risk. This review highlighted that most research so far focused on generalized distress and anxiety and accuracy of perceived risk, to the exclusion of other, perhaps equally important, types of outcomes. Future studies are likely to lead to more comprehensive assessments if additional emotional, cognitive and behavioural outcomes are included in the assessment.

Psychological adjustment to familial-genetic risk assessment for ovarian cancer: predictors of nonadherence to surveillance recommendations

OBJECTIVE

To evaluate whether self-report measures of psychological distress and perceived risk were associated with nonadherence to recommended ovarian cancer surveillance.

METHODS

Eighty-three patients attending the Familial Ovarian Cancer Clinic (FOCC) at Princess Margaret Hospital were assessed psychosocially prior to and during initial familial-genetic assessment and then monitored for adherence with recommended follow-up surveillance over a period of 12-18 months. The assessment protocol included an investigator-designed clinic questionnaire, the State-Trait Anxiety Inventory (STAI), Center for Epidemiologic Studies Depression Scale (CESD), Life Orientation Test (LOT), Medical Outcomes Study Social Support Survey (MOSSS), Texas Inventory of Grief, and the COPE. Nonadherence was measured in terms of unexplained absences at one or two recommended and scheduled surveillance appointments following the familial-genetic assessment.

RESULTS

Univariate tests revealed a significant association between higher perception of ovarian cancer risk, as assessed immediately after the familial-genetic risk assessment in the clinic and nonadherence to physician-recommended surveillance (chi2 (2, N = 83) = 9.75, P < 0.008). Empirically based estimates of risk, conveyed by the clinic team to subjects, were not significantly associated with nonadherence (chi2 (2, N = 83) = 0.19, P = 0.91). Logistic regression analysis revealed that subjects who perceived themselves to be at high ovarian cancer risk were five times more likely to be nonadherent than participants who perceived themselves to be at low or medium ovarian cancer risk.

CONCLUSIONS

These results suggest that higher self-perceived risk may predict adherence difficulties to recommended surveillance in women attending a familial-genetic risk clinic.

Long-term outcomes of genetic counseling in women at increased risk of developing hereditary breast cancer

This multicenter study evaluated the impact of genetic counseling in 218 women at risk of developing hereditary breast cancer. Women were assessed prior to counseling and 12-month post-counseling using self-administered, mailed questionnaires. Compared to baseline, breast cancer genetics knowledge was increased significantly at follow-up, and greater increases in knowledge were associated with educational level. Breast cancer anxiety decreased significantly from baseline to follow-up, and these decreases were associated with improvements in perceived risk. A significant decrease in clinical breast examination was observed at the 12-month follow-up. Findings suggest that women with a family history of breast cancer benefit from attending familial cancer clinics as it leads to increases in breast cancer genetics knowledge and decreases in breast cancer anxiety. The lowered rates of clinical breast examination indicate that the content of genetic counseling may need to be reviewed to ensure that women receive and take away the right message.

Adherence to recommendations for clinical follow-up after benign breast biopsy

PURPOSE

Women who undergo a benign breast biopsy are at elevated risk for the subsequent development of breast cancer (BC). Therefore, appropriate clinical follow-up of a benign breast biopsy is important. The present study examines the extent and correlates of nonadherence with follow-up recommendations after a benign breast biopsy.

METHODS

Women (n = 114) who had undergone a benign breast biopsy completed an initial telephone interview within 50 days of their biopsy (mean = 21 days). Additional telephone interviews were completed at 4 and 8 months post-biopsy. Measures of BC risk perception, general and BC-specific distress, BC-related attitudes and beliefs, social support, optimism, and informational coping style were completed. Specific recommendations for clinical follow-up and evidence of actual follow-up were obtained from medical records.

RESULTS

Of 103 women given a specific recommendation for clinical follow-up, 34% were classified as nonadherent with follow-up recommendations. Logistic regression analyses indicated that nonadherent women were characterized by younger age, recommendations for follow-up by clinical breast examination alone, greater confidence in their ability to perform breast self-examination properly, higher perceived personal risk for BC, and greater BC-specific distress.

CONCLUSION

Despite the importance of appropriate clinical follow-up of a benign breast biopsy, about one-third of women did not adhere to recommended follow-up. Risk factors for nonadherence suggest potential avenues for interventions to enhance participation in appropriate clinical follow-up.

Mammography behavior after receiving a negative BRCA1 mutation test result in the Ashkenazim: a community-based study

PURPOSE

To define the impact of a negative BRCA1 test result on subsequent breast cancer screening behavior in women.

METHODS

Longitudinal study of a community-based sample of Ashkenazi Jews offered testing for the 185delAG BRCA1 mutation in 1996. Of 309 participants, 118 women were mutation negative, of average risk (based on family history of cancer), unaffected with breast cancer, and provided complete data at baseline, and Year 1 and Year 2 follow-up questionnaires.

RESULTS

Women age 50 and older had 91.7% compliance with mammography for the year prior to entry (baseline), 88.3% during Year 1, 91.7% during Year 2 (no significant change; P = 0.775). Women under age 50 demonstrated an increase in mammography (49.2% at baseline, 62.7% Year 1, and 67.1% Year 2; P = 0.035). Both groups demonstrated significant decreases in breast cancer worry and perceived risk. Logistic regression analysis on having a mammogram at Year 2 showed that age, physician recommendation, worry, and perceived risk were all significant.

CONCLUSION

Receipt of negative BRCA1 test results in a cohort of Ashkenazi Jewish women did not have a negative impact on mammography behavior 2 years after genetic testing.

Cancer screening decisions

This review focuses on why people decide to obtain or to avoid screening for cancer. We discuss three topics: (a) physician prompts that may elicit compliant screening behavior, (b) the independent and joint effects of risk perceptions and worry, and (c) the costs and benefits of getting screened. Overall, the data suggest that each of these factors will influence screening. So, for example, people are more likely to seek screening if a physician recommends the behavior, if they feel personally vulnerable and worry a little about cancer, if insurance covers the screening, and if they believe that the test is an effective early detection procedure. Future research needs include studies comparing theories, longitudinal rather than cross-sectional studies, and true experiments. We also need to know more about why physicians are such powerful change agents and the trade-offs of increasing personal risk versus exacerbating worry. Practical recommendations for promoting cancer screening include encouraging physician interventions, explaining risk, and lowering the costs while emphasizing the benefits of screening.

Risk perception and risk communication for cancer screening behaviors: a review

This review summarizes and synthesizes research findings on risk perception and risk communication related to cancer screening behaviors. The focus is on cancers for which there is evidence that screening reduces mortality, i.e., cervical, breast, and colorectal cancers. The following questions are addressed: 1) Is perceived risk associated with relevant cancer screening behaviors? 2) What factors are associated with perceived risk? 3) Is the relationship between perceived risk and cancer screening behaviors modified by other factors? 4) Have interventions to change perceived risk been effective in modifying risk perceptions? 5) Are these changes related to subsequent cancer screening behaviors? Methodologic issues are discussed, and future research needs are identified. There was consistent evidence that perceived risk was associated with mammography screening, but there were insufficient data on these associations for cervical or colorectal cancer screening behaviors. There was some evidence that perceived risk mediated the association between other variables and screening behaviors; however, because of the small number of studies, the findings are best viewed as hypothesis generating. Studies of interventions to modify risk perceptions provided some support for the view that they are modifiable, but there was conflicting evidence that these changes were related to subsequent cancer screening. Methodologic studies of how best to measure perceived risk are needed. Because most data on the correlates of perceived risk were cross-sectional, it is difficult to determine whether perceived risk is a cause or an effect in relation to cancer screening. Longitudinal studies that measure perceived risk in defined populations with different cancer screening histories and that include follow-up for screening and repeated measurements of risk perception are needed to clarify this relationship.