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Hawranek C, Rosén A, Hajdarevic S. How hereditary cancer risk disclosure to relatives is handled in practice - Patient perspectives from a Swedish cancer genetics clinic. PATIENT EDUCATION AND COUNSELING 2024; 126:108319. [PMID: 38788311 DOI: 10.1016/j.pec.2024.108319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 04/14/2024] [Accepted: 05/10/2024] [Indexed: 05/26/2024]
Abstract
OBJECTIVES Hereditary cancer risks can be effectively managed if at-risk relatives enroll in surveillance and preventive care. Family-mediated risk disclosure has internationally been shown to be incomplete, selective and leave over a third of eligible at-risk individuals without access to genetic counseling. We explored patients handling of cancer risk information in practice. METHODS We conducted twelve semi-structured interviews with patients who had completed their genetic counseling and been asked to disclose risk information to relatives. Questions were designed to investigate lived experiences of communicating hereditary risk and focused on disclosure strategies, intrafamilial interactions and emotional responses. RESULTS Qualitative content analysis yielded five categories. These span personal fears, shared responsibilities, feeling of empowerment, innovative solutions and unmet needs. Patients put high value on collaboration with their genetic healthcare professionals but also solicited better overview of the counseling process and more personalized, case-tailored information. CONCLUSIONS Our results add novel insights about the practical strategies employed by genetic counselees and their motivations behind disclosing hereditary risk information to relatives. PRACTICE IMPLICATIONS A patient-centered cancer genetics care would clarify roles and responsibilities around risk disclosure, inform counselees about the process upfront and tailor information to offer case-specific data with the family's inheritance pattern explained.
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Affiliation(s)
- Carolina Hawranek
- Department of Diagnostics and Intervention, Oncology, Umeå University, Umeå, Sweden.
| | - Anna Rosén
- Department of Diagnostics and Intervention, Oncology, Umeå University, Umeå, Sweden
| | - Senada Hajdarevic
- Department of Nursing, Umeå University, Umeå, Sweden; Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, Umeå, Sweden
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Adler JM, Hesse-Biber S, Seven M, Dwyer AA. "Identity theft" in BRCA1/2: impact of positive genetic test results and risk-reducing interventions. Front Genet 2024; 15:1380637. [PMID: 39050256 PMCID: PMC11267581 DOI: 10.3389/fgene.2024.1380637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 06/20/2024] [Indexed: 07/27/2024] Open
Abstract
Individuals harboring breast cancer gene 1/2 (BRCA1/2) pathogenic variants are at increased lifetime risk for developing cancer. Learning one's BRCA1/2 carrier status is a watershed moment that can result in psychological distress, anxiety, and depression, as well as feelings of vulnerability and stigma. However, emotional and coping responses to learning one's BRCA1/2 carrier status and after risk-reducing interventions (i.e., preventative bilateral mastectomy) are variable, and existing literature reveals mixed and sometimes contradictory results. Drawing on the concept of narrative identity from the field of psychology, we sought to examine if "identity theft" (the sudden overtaking of one's narrative agency by an external force) may help explain the heterogeneity of emotional and coping responses following the revelation of BRCA carrier status and the subsequent medical intervention one may receive. This Perspective explores BRCA related identity theft using two case studies. Narrative analysis of qualitative interviews uncover the ways that patients experience the disintegration (theft) of their identity as well as their efforts to build and reintegrate a new BRCA carrier identity. This initial qualitative exploration provides preliminary support for the relevance of narrative identity and identity theft to hereditary cancer. We posit that applying the lens of identity theft may hold promise as a unifying concept, integrating across the variable emotional and coping responses among BRCA carriers. Employing a lens of identity theft may help inform the development of tailored narrative interventions as part of precision healthcare to support active coping and psychosocial wellbeing.
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Affiliation(s)
- Jonathan M. Adler
- Department of Psychology, Olin College of Engineering, Needham, MA, United States
| | | | - Memnun Seven
- Elaine Marieb College of Nursing, University of Massachusetts Amherst, Amherst, MA, United States
| | - Andrew A. Dwyer
- William F. Connell School of Nursing, Boston College, Chestnut Hill, MA, United States
- P50 Massachusetts General Hospital–Harvard Center for Reproductive Medicine, Boston, MA, United States
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Minhinnick A, Santos-Gonzalez F, Wilson M, Lorgelly P. How is Value Defined in Molecular Testing in Cancer? A Scoping Review. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2024:10.1007/s40258-024-00901-4. [PMID: 38980555 DOI: 10.1007/s40258-024-00901-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/18/2024] [Indexed: 07/10/2024]
Abstract
OBJECTIVE To identify how value is defined in studies that focus on the value of molecular testing in cancer and the extent to which broadening the conceptualisation of value in healthcare has been applied in the molecular testing literature. METHODS A scoping review was undertaken using Joanna Briggs Institute (JBI) guidance. Medline, Embase, EconLit and Cochrane Library were searched in August 2023. Articles were eligible if they reported costs relative to outcomes, novel costs, or novel outcomes of molecular testing in cancer. Results were synthesised and qualitative content analysis was performed with deductive and inductive frameworks. RESULTS Ninety-one articles were included in the review. The majority (75/91) were conventional economic analyses (comparative economic evaluations and budget impact assessments) and undertaken from a healthcare system perspective (38/91). Clinical outcomes dominate the assessment of value (61/91), with quality-adjusted life-years (QALYs) the most common outcome measure (45/91). Other definitions of value were diverse (e.g. psychological impact, access to trials), inconsistent, and largely not in keeping with evolving guidance. CONCLUSIONS Broader concepts of value were not commonly described in the molecular testing literature focusing on cancer. Conventional approaches to measuring the health costs and outcomes of molecular testing in cancer prevail with little focus on non-clinical elements of value. There are emerging reports of non-clinical outcomes of testing information, particularly psychological consequences. Intrinsic attributes of the testing process and preferences of those who receive testing information may determine the realised societal value of molecular testing and highlight challenges to implementing such a value framework.
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Trevisan L, Godino L, Battistuzzi L, Innella G, Luppi E, Buzzatti G, Gismondi V, Blondeaux E, Bonelli LA, Turchetti D, Varesco L. Cascade testing in Italian Hereditary Breast Ovarian Cancer families: a missed opportunity for cancer prevention? Fam Cancer 2024; 23:197-207. [PMID: 37968543 DOI: 10.1007/s10689-023-00349-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 10/24/2023] [Indexed: 11/17/2023]
Abstract
Healthy carriers of BRCA1/2 pathogenic variants (PVs) may benefit from risk-reducing measures of proven efficacy. The main approach to identify these individuals is cascade testing, and strategies to support this complex process are under investigation. In Italy, cascade testing has received little attention; therefore, we analyzed the uptake and characteristics of BRCA1/2 cascade testing in families diagnosed with HBOC between 2017 and 2019 at two Italian genetics centers. All blood relatives aged 18 years or older at September 2022 and who could be involved in the first step of cascade testing (i.e., all the living relatives closest to the proband) were included. In addition to first-degree relatives, individuals who were second-, third- or fourth-degree relatives were included if the closest relative(s) was/were deceased. Overall, 213 families were included (103, Genoa; 110, Bologna). Most probands were women affected by breast and/or ovarian cancer (86.4%, Genoa; 84.5%, Bologna), and the branch segregating the PV was known/suspected in 62% of families (62.1%, Genoa; 60.9%, Bologna). Overall, the uptake of cascade testing was 22.8% (25.8%, Genoa; 19.9%, Bologna; OR = 0.59: 95%CI 0.43-0.82). It was strongly associated with female gender (OR = 3.31, 95%CI 2.38-4.59), age ≤ 70 years (< 30 years OR = 3.48, 95%CI 1.85-6.56; 30-70 years OR = 3.08, 95%CI 2.01-4.71), first-degree relationship with the proband (OR = 16.61, 95%CI 10.50-26.28) and segregation of the PV in both the maternal (OR = 2.54, 95%CI 1.72-3.75) and the paternal branch (OR = 4.62, 95%CI 3.09-6.91). These real-world data may be important to inform the design and implementation of strategies aimed at improving the uptake of HBOC cascade testing in Italy.
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Affiliation(s)
- Lucia Trevisan
- Unit of Hereditary Cancer, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Lea Godino
- Unit of Medical Genetics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Linda Battistuzzi
- Unit of Hereditary Cancer, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Giovanni Innella
- Unit of Medical Genetics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | - Elena Luppi
- Unit of Medical Genetics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | - Giulia Buzzatti
- Unit of Hereditary Cancer, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Viviana Gismondi
- Unit of Hereditary Cancer, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Eva Blondeaux
- U.O. Epidemiologia Clinica, IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, Genova, 16132, Italy.
| | - Luigina Ada Bonelli
- U.O. Epidemiologia Clinica, IRCCS Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, Genova, 16132, Italy
| | - Daniela Turchetti
- Unit of Medical Genetics, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Dipartimento di Scienze Mediche e Chirurgiche, Università di Bologna, Bologna, Italy
| | - Liliana Varesco
- Unit of Hereditary Cancer, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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Cragun DL, Hunt PP, Dean M, Weidner A, Shields AK, Tezak A, Pal T. Applying the framework for developing and evaluating complex interventions to increase family communication about hereditary cancer. PEC INNOVATION 2023; 2:100133. [PMID: 37214492 PMCID: PMC10194404 DOI: 10.1016/j.pecinn.2023.100133] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 01/30/2023] [Accepted: 02/01/2023] [Indexed: 05/24/2023]
Abstract
Objective Evaluate an intervention to increase family communication (FC) of positive hereditary cancer test results using the Framework for Developing and Evaluating Complex Interventions (FDECI). Methods We developed 'programme theory' during the FDECI development phase by aligning intervention components with behavior change techniques (BCTs) and theoretical factors expected to improve FC. During the feasibility phase, we obtained feedback from 12 stakeholder interviews. Results Intervention components aligned with a total of 14 unique BCTs for which prior evidence links the BCT to theoretical factors that influence behavior change. Constructive stakeholder feedback included: more information desired, rewording to support autonomy by highlighting options, and improvements to navigation, visuals, and audio. Positive comments included: comprehensiveness of materials, modeling of conversations, and usefulness of the materials for helping a person prepare to share positive test results. Conclusion The first FDECI phases were helpful for improving the intervention and planning our ongoing effectiveness and future implementation phases. Innovation Our application of the FDECI is novel, including plans to test our 'programme theory' using coincidence analysis (CNA) to determine who accesses which intervention materials, how utilizing certain materials impact the aligned theoretical factors, and whether these in turn make a difference in the behavioral outcome.
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Affiliation(s)
- Deborah L. Cragun
- University of South Florida, College of Public Health, Tampa, FL, United States of America
| | - Paige Phillips Hunt
- University of South Florida, College of Public Health, Tampa, FL, United States of America
| | - Marleah Dean
- University of South Florida, Department of Communication, Tampa, FL; Health Outcomes & Behavior Program, Moffitt Cancer Center, Tampa, FL, United States of America
- Moffitt Cancer Center, Health Outcomes & Behavior Program, Tampa, FL, United States of America
| | - Anne Weidner
- Vanderbilt University Medical Center, Department of Medicine; Vanderbilt-Ingram Cancer Center, Nashville, TN, United States of America
| | - Andrea K. Shields
- University of South Florida, College of Public Health, Tampa, FL, United States of America
| | - Ann Tezak
- Vanderbilt University Medical Center, Department of Medicine; Vanderbilt-Ingram Cancer Center, Nashville, TN, United States of America
| | - Tuya Pal
- Vanderbilt University Medical Center, Department of Medicine; Vanderbilt-Ingram Cancer Center, Nashville, TN, United States of America
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Barnoy S, Dagan E, Kim S, Caiata-Zufferey M, Katapodi MC. Privacy and utility of genetic testing in families with hereditary cancer syndromes living in three countries: the international cascade genetic screening experience. Front Genet 2023; 14:1109431. [PMID: 37229185 PMCID: PMC10203600 DOI: 10.3389/fgene.2023.1109431] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 04/17/2023] [Indexed: 05/27/2023] Open
Abstract
Background: Hereditary breast and ovarian cancer and Lynch syndrome are associated with increased lifetime risk for common cancers. Offering cascade genetic testing to cancer-free relatives of individuals with HBOC or LS is a public health intervention for cancer prevention. Yet, little is known about the utility and value of information gained from cascade testing. This paper discusses ELSI encountered during the implementation of cascade testing in three countries with national healthcare systems: Switzerland, Korea, and Israel. Methods: A workshop presented at the 5th International ELSI Congress discussed implementation of cascade testing in the three countries based on exchange of data and experiences from the international CASCADE cohort. Results: Analyses focused on models of accessing genetic services (clinic-based versus population-based screening), and models of initiating cascade testing (patient-mediated dissemination versus provider-mediated dissemination of testing results to relatives). The legal framework of each country, organization of the healthcare system, and socio-cultural norms determined the utility and value of genetic information gained from cascade testing. Conclusion: The juxtaposition of individual versus public health interests generates significant ELSI controversies associated with cascade testing, which compromise access to genetic services and the utility and value of genetic information, despite national healthcare/universal coverage.
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Affiliation(s)
- Sivia Barnoy
- Department of Nursing, Tel-Aviv University, Tel-Aviv, Israel
| | - Efrat Dagan
- The Cheryl Spencer Department of Nursing, University of Haifa, Haifa, Israel
| | - Sue Kim
- College of Nursing, Yonsei University, Seoul, South Korea
| | - Maria Caiata-Zufferey
- Department of Business Economics, Health and Social Care, University of Applied Sciences and Arts of Southern Switzerland, Manno, Switzerland
| | - Maria C. Katapodi
- Department of Clinical Research, University of Basel, Basel, Switzerland
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Stefka J, Streff H, Liu P, Towne M, Smith HS. Cascade testing after exome sequencing: Retrospective analysis of linked family data at 2 US laboratories. Genet Med 2023; 25:100818. [PMID: 36852743 DOI: 10.1016/j.gim.2023.100818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 02/16/2023] [Accepted: 02/22/2023] [Indexed: 02/26/2023] Open
Abstract
PURPOSE Cascade testing, the process of testing a proband's at-risk relatives, is integral to realizing the full value of genomic sequencing. However, there is little empirical evidence on the uptake of cascade testing after a positive exome sequencing (ES) result in a population of probands with diverse clinical indications. METHODS We retrospectively reviewed administrative data from 2 US clinical laboratories that perform ES. For each proband with a positive ES result, we used linked family data to describe the frequency of relatives' cascade testing performed at the same laboratory, variant detection yield of cascade tests, and characteristics of probands and relatives categorized on the basis of cascade testing completion. RESULTS Among the 3723 positive ES results across both laboratories, 426 relatives of 282 probands completed cascade testing (uptake = 7.6%). An average of 1.5 relatives (SD = 0.9) were tested per proband. Of the 426 relatives tested, 200 had a variant of interest detected (variant detection yield = 47.0%). CONCLUSION In our real-world data analysis, a small proportion of probands with a positive ES result subsequently had relatives complete cascade testing at the same laboratory. However, approximately half of the tested relatives received a clinically significant result that could have implications for clinical management or reproductive planning. Additional research on ways to increase cascade testing uptake is warranted.
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Affiliation(s)
- Julie Stefka
- Genetic Counseling Program, School of Health Professions, Baylor College of Medicine, Houston, TX; Clinical Diagnostics, Ambry Genetics, Aliso Viejo, CA.
| | - Haley Streff
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
| | - Pengfei Liu
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX; Baylor Genetics, Houston, TX
| | - Meghan Towne
- Medical Sciences, Ambry Genetics, Aliso Viejo, CA
| | - Hadley Stevens Smith
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX; Precision Medicine Translational Research Center (PROMoTeR), Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
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Relatives from Hereditary Breast and Ovarian Cancer and Lynch Syndrome Families Forgoing Genetic Testing: Findings from the Swiss CASCADE Cohort. J Pers Med 2022; 12:jpm12101740. [PMID: 36294879 PMCID: PMC9605198 DOI: 10.3390/jpm12101740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/11/2022] [Accepted: 10/13/2022] [Indexed: 11/17/2022] Open
Abstract
Cascade genetic testing of relatives from families with pathogenic variants associated with hereditary breast and ovarian cancer (HBOC) or Lynch syndrome (LS) has important implications for cancer prevention. We compared the characteristics of relatives from HBOC or LS families who did not have genetic testing (GT (−) group) with those who had genetic testing (GT (+) group), regardless of the outcome. Self-administered surveys collected cross-sectional data between September 2017 and December 2021 from relatives participating in the CASCADE cohort. We used multivariable logistic regression with LASSO variable selection. Among n = 115 relatives who completed the baseline survey, 38% (n = 44) were in the GT (−) group. Being male (OR: 2.79, 95% CI: 1.10–7.10) and without a previous cancer diagnosis (OR: 4.47, 95% CI: 1.03–19.42) increased the odds of being untested by almost three times. Individuals from families with fewer tested relatives had 29% higher odds of being untested (OR: 0.71, 95% CI: 0.55–0.92). Reasons for forgoing cascade testing were: lack of provider recommendation, lack of time and interest in testing, being afraid of discrimination, and high out-of-pocket costs. Multilevel interventions designed to increase awareness about clinical implications of HBOC and LS in males, referrals from non-specialists, and support for testing multiple family members could improve the uptake of cascade testing.
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The Communication Chain of Genetic Risk: Analyses of Narrative Data Exploring Proband–Provider and Proband–Family Communication in Hereditary Breast and Ovarian Cancer. J Pers Med 2022; 12:jpm12081249. [PMID: 36013197 PMCID: PMC9409642 DOI: 10.3390/jpm12081249] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/24/2022] [Accepted: 07/26/2022] [Indexed: 11/21/2022] Open
Abstract
Low uptake of genetic services among members of families with hereditary breast and ovarian cancer (HBOC) suggests limitations of proband-mediated communication of genetic risk. This study explored how genetic information proceeds from healthcare providers to probands and from probands to relatives, from the probands’ perspectives. Using a grounded-theory approach, we analyzed narrative data collected with individual interviews and focus groups from a sample of 48 women identified as carriers of HBOC-associated pathogenic variants from three linguistic regions of Switzerland. The findings describe the “communication chain”, confirming the difficulties of proband-mediated communication. Provider–proband communication is impacted by a three-level complexity in the way information about family communication is approached by providers, received by probands, and followed-up by the healthcare system. Probands’ decisions regarding disclosure of genetic risk are governed by dynamic and often contradictory logics of action, interconnected with individual and family characteristics, eventually compelling probands to engage in an arbitrating process. The findings highlight the relevance of probands’ involvement in the communication of genetic risk to relatives, suggesting the need to support them in navigating the complexity of family communication rather than replacing them in this process. Concrete actions at the clinical and health system levels are needed to improve proband-mediated communication.
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