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Zhang JQ, Dos Anjos CH, Sevilimedu V, Crown A, Amoroso KA, Pilewskie ML, Robson ME, Gemignani ML. Association of Moderate-Risk Breast Cancer Genes with Contralateral Prophylactic Mastectomy and Bilateral Disease. Ann Surg Oncol 2023; 30:6990-6999. [PMID: 37661222 PMCID: PMC11005956 DOI: 10.1245/s10434-023-14141-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 06/23/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND The impact of ATM, CHEK2, and PALB2, the three most prevalent moderate-risk breast cancer genes, on surgical decision making is not well known. METHODS Our retrospective study included patients with resectable non-metastatic breast cancer who underwent multigene panel testing between July 2014 and January 2020 with at least one genetic alteration (pathogenic or variant of uncertain significance [VUS] in ATM [n = 49], CHEK [n = 57], or PALB2 [n = 27]). Our objectives were to determine the rate of contralateral prophylactic mastectomy (CPM) and the rate of bilateral breast cancer. Univariable analyses (UVA) and multivariable analyses (MVA) were performed to identify factors associated with CPM and bilateral breast cancer. RESULTS The rate of CPM was 39% (n = 49/127), with 54% (n = 25/46) of patients with a pathogenic mutation and 30% (n = 24/81) of patients with a VUS choosing CPM. On MVA, premenopausal status (odds ratio [OR] 3.46) and a pathogenic alteration (OR 3.01) were associated with increased use of CPM. Bilateral disease was noted in 16% (n = 22/138). Patients with pathogenic mutations had a 22% (n = 11/51) incidence of bilateral breast cancer, while patients with VUS had a 13% (n = 11/87) incidence, although this was not statistically significant on UVA or MVA. On MVA, premenopausal status was associated with a decreased risk of bilateral disease (OR 0.33, p = 0.022). During follow-up, a breast cancer event occurred in 16% (n = 22/138). CONCLUSIONS Our study identified a high rate of CPM among those with ATM, CHEK2, and PALB2 alterations, including VUS. Further studies are needed to clarify reasons for CPM among patients with moderate-risk alterations.
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Affiliation(s)
- Jennifer Q Zhang
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Department of Surgery, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA, USA.
| | | | - Varadan Sevilimedu
- Biostatistics Service, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Angelena Crown
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Breast Surgery, True Family Women's Cancer Center, Swedish Cancer Institute, Seattle, WA, USA
| | - Kimberly A Amoroso
- Clinical Genetics Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Melissa L Pilewskie
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Mark E Robson
- Breast Medicine Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mary L Gemignani
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Bednar EM, Nitecki R, Krause KJ, Rauh-Hain JA. Interventions to improve delivery of cancer genetics services in the United States: A scoping review. Genet Med 2022; 24:1176-1186. [PMID: 35389342 DOI: 10.1016/j.gim.2022.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/25/2022] [Accepted: 03/02/2022] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Interventions that decrease barriers and improve clinical processes can increase patient access to guideline-recommended cancer genetics services. We sought to identify and describe interventions to improve patient receipt of guideline-recommended cancer genetics services in the United States. METHODS We performed a comprehensive search in Ovid MEDLINE and Embase, Scopus, and Web of Science from January 1, 2000 to February 12, 2020. Eligible articles reported interventions to improve the identification, referral, genetic counseling (GC), and genetic testing (GT) of patients in the United States. We independently screened titles and abstracts and reviewed full-text articles. Data were synthesized by grouping articles by clinical process. RESULTS Of 44 included articles, 17 targeted identification of eligible patients, 14 targeted referral, 15 targeted GC, and 16 targeted GT. Patient identification interventions included universal tumor testing and screening of medical/family history. Referral interventions included medical record system adaptations, standardizing processes, and provider notifications. GC interventions included supplemental patient education, integrated GC within oncology clinics, appointment coordination, and alternative service delivery models. One article directly targeted the GT process by implementing provider-coordinated testing. CONCLUSION This scoping review identified and described interventions to improve US patients' access to and receipt of guideline-recommended cancer genetics services.
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Affiliation(s)
- Erica M Bednar
- Cancer Prevention and Control Platform, Moon Shots Program, The University of Texas MD Anderson Cancer Center, Houston, TX; Clinical Cancer Genetics, The University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Roni Nitecki
- Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kate J Krause
- Research Medical Library, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jose Alejandro Rauh-Hain
- Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
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Kritzik R, Usoro E, Peshkin BN, Isaacs C, Valdimarsdottir HB, Willey S, O’Neill S, DeMarco T, Nusbaum R, Jandorf L, Kelleher S, Schwartz MD. Psychosocial impact of proactive rapid genetic counseling following breast cancer diagnosis. Psychooncology 2022; 31:788-797. [PMID: 34921700 PMCID: PMC9920729 DOI: 10.1002/pon.5863] [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: 08/09/2021] [Revised: 11/22/2021] [Accepted: 12/06/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE As germline genetic referral becomes increasingly routine as part of the care of newly diagnosed breast cancer patients, it is important to understand the psychosocial impact of genetic counseling at the time of diagnosis. We examined the psychosocial and quality of life (QOL) impact of providing proactive rapid genetic counseling and testing (RGCT) in the immediate aftermath of a breast cancer diagnosis. METHODS We randomized 330 patients in a 2:1 ratio to proactive rapid genetic counseling (RGCT; N = 222) versus usual care (UC; N = 108). Participants completed a baseline telephone survey before randomization and definitive surgery and a follow-up survey at 1-month post-randomization. We evaluated the impact of RGCT versus UC on breast cancer genetic knowledge, distress, QOL, and decisional conflict. Given that 43% of UC participants and 86% of RGCT participants completed genetic counseling prior to the 1-month assessment, we also evaluated the impact of genetic counseling participation over and above group assignment. RESULTS The RGCT intervention led to increased breast cancer genetic knowledge relative to UC but did not differentially impact other study outcomes. Across groups patients who participated in genetic counseling had significantly increased knowledge and improved QOL compared to those who did not participate in genetic counseling. CONCLUSIONS While prior research has documented the impact of genetic counseling and testing on surgical decisions, these results confirm that participation in genetic counseling at the time of diagnosis can yield improvements in knowledge and QOL in the short-term.
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Affiliation(s)
- Rachel Kritzik
- Department of Oncology, Georgetown Lombardi Comprehensive Cancer, Georgetown University, Washington, DC, USA
| | - Edidiong Usoro
- Department of Biology, University of the District of Columbia, Washington, DC, USA
| | - Beth N. Peshkin
- Department of Oncology, Georgetown Lombardi Comprehensive Cancer, Georgetown University, Washington, DC, USA
| | - Claudine Isaacs
- Department of Oncology, Georgetown Lombardi Comprehensive Cancer, Georgetown University, Washington, DC, USA
| | - Heiddis B. Valdimarsdottir
- Department of Population Health Science and Policy, Center for Behavioral Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shawna Willey
- Breast Cancer Program, Schar Cancer Institute, INOVA Health System, Fairfax, VA, USA
| | - Suzanne O’Neill
- Department of Oncology, Georgetown Lombardi Comprehensive Cancer, Georgetown University, Washington, DC, USA
| | - Tiffani DeMarco
- Cancer Genetics Program, INOVA Health System, Fairfax, VA, USA
| | - Rachel Nusbaum
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Lina Jandorf
- Department of Population Health Science and Policy, Center for Behavioral Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sarah Kelleher
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Marc D. Schwartz
- Department of Oncology, Georgetown Lombardi Comprehensive Cancer, Georgetown University, Washington, DC, USA
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Jull J, Köpke S, Smith M, Carley M, Finderup J, Rahn AC, Boland L, Dunn S, Dwyer AA, Kasper J, Kienlin SM, Légaré F, Lewis KB, Lyddiatt A, Rutherford C, Zhao J, Rader T, Graham ID, Stacey D. Decision coaching for people making healthcare decisions. Cochrane Database Syst Rev 2021; 11:CD013385. [PMID: 34749427 PMCID: PMC8575556 DOI: 10.1002/14651858.cd013385.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Decision coaching is non-directive support delivered by a healthcare provider to help patients prepare to actively participate in making a health decision. 'Healthcare providers' are considered to be all people who are engaged in actions whose primary intent is to protect and improve health (e.g. nurses, doctors, pharmacists, social workers, health support workers such as peer health workers). Little is known about the effectiveness of decision coaching. OBJECTIVES To determine the effects of decision coaching (I) for people facing healthcare decisions for themselves or a family member (P) compared to (C) usual care or evidence-based intervention only, on outcomes (O) related to preparation for decision making, decisional needs and potential adverse effects. SEARCH METHODS We searched the Cochrane Library (Wiley), Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), CINAHL (Ebsco), Nursing and Allied Health Source (ProQuest), and Web of Science from database inception to June 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs) where the intervention was provided to adults or children preparing to make a treatment or screening healthcare decision for themselves or a family member. Decision coaching was defined as: a) delivered individually by a healthcare provider who is trained or using a protocol; and b) providing non-directive support and preparing an adult or child to participate in a healthcare decision. Comparisons included usual care or an alternate intervention. There were no language restrictions. DATA COLLECTION AND ANALYSIS Two authors independently screened citations, assessed risk of bias, and extracted data on characteristics of the intervention(s) and outcomes. Any disagreements were resolved by discussion to reach consensus. We used the standardised mean difference (SMD) with 95% confidence intervals (CI) as the measures of treatment effect and, where possible, synthesised results using a random-effects model. If more than one study measured the same outcome using different tools, we used a random-effects model to calculate the standardised mean difference (SMD) and 95% CI. We presented outcomes in summary of findings tables and applied GRADE methods to rate the certainty of the evidence. MAIN RESULTS Out of 12,984 citations screened, we included 28 studies of decision coaching interventions alone or in combination with evidence-based information, involving 5509 adult participants (aged 18 to 85 years; 64% female, 52% white, 33% African-American/Black; 68% post-secondary education). The studies evaluated decision coaching used for a range of healthcare decisions (e.g. treatment decisions for cancer, menopause, mental illness, advancing kidney disease; screening decisions for cancer, genetic testing). Four of the 28 studies included three comparator arms. For decision coaching compared with usual care (n = 4 studies), we are uncertain if decision coaching compared with usual care improves any outcomes (i.e. preparation for decision making, decision self-confidence, knowledge, decision regret, anxiety) as the certainty of the evidence was very low. For decision coaching compared with evidence-based information only (n = 4 studies), there is low certainty-evidence that participants exposed to decision coaching may have little or no change in knowledge (SMD -0.23, 95% CI: -0.50 to 0.04; 3 studies, 406 participants). There is low certainty-evidence that participants exposed to decision coaching may have little or no change in anxiety, compared with evidence-based information. We are uncertain if decision coaching compared with evidence-based information improves other outcomes (i.e. decision self-confidence, feeling uninformed) as the certainty of the evidence was very low. For decision coaching plus evidence-based information compared with usual care (n = 17 studies), there is low certainty-evidence that participants may have improved knowledge (SMD 9.3, 95% CI: 6.6 to 12.1; 5 studies, 1073 participants). We are uncertain if decision coaching plus evidence-based information compared with usual care improves other outcomes (i.e. preparation for decision making, decision self-confidence, feeling uninformed, unclear values, feeling unsupported, decision regret, anxiety) as the certainty of the evidence was very low. For decision coaching plus evidence-based information compared with evidence-based information only (n = 7 studies), we are uncertain if decision coaching plus evidence-based information compared with evidence-based information only improves any outcomes (i.e. feeling uninformed, unclear values, feeling unsupported, knowledge, anxiety) as the certainty of the evidence was very low. AUTHORS' CONCLUSIONS Decision coaching may improve participants' knowledge when used with evidence-based information. Our findings do not indicate any significant adverse effects (e.g. decision regret, anxiety) with the use of decision coaching. It is not possible to establish strong conclusions for other outcomes. It is unclear if decision coaching always needs to be paired with evidence-informed information. Further research is needed to establish the effectiveness of decision coaching for a broader range of outcomes.
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Affiliation(s)
- Janet Jull
- School of Rehabilitation Therapy, Faculty of Health Sciences, Queen's University, Kingston, Canada
| | - Sascha Köpke
- Institute of Nursing Science, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | | | - Meg Carley
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Jeanette Finderup
- Department of Renal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Research Centre for Patient Involvement, Aarhus University & the Central Denmark Region, Aarhus, Denmark
| | - Anne C Rahn
- Institute of Social Medicine and Epidemiology, Nursing Research Unit, University of Lubeck, Lubeck, Germany
| | - Laura Boland
- Integrated Knowledge Translation Research Network, The Ottawa Hospital Research Institute, Ottawa, Canada
- Western University, London, Canada
| | - Sandra Dunn
- BORN Ontario, CHEO Research Institute, School of Nursing, University of Ottawa, Ottawa, Canada
| | - Andrew A Dwyer
- William F. Connell School of Nursing, Boston University, Chestnut Hill, Massachusetts, USA
- Munn Center for Nursing Research, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jürgen Kasper
- Department of Nursing and Health Promotion, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Simone Maria Kienlin
- Faculty of Health Sciences, Department of Health and Caring Sciences, University of Tromsø, Tromsø, Norway
- The South-Eastern Norway Regional Health Authority, Department of Medicine and Healthcare, Hamar, Norway
| | - France Légaré
- Department of Family Medicine and Emergency Medicine, Université Laval, Québec City, Canada
| | - Krystina B Lewis
- School of Nursing, University of Ottawa, Ottawa, Canada
- University of Ottawa Heart Institute, University of Ottawa, Ottawa, Canada
| | | | - Claudia Rutherford
- School of Psychology, Quality of Life Office, University of Sydney, Camperdown, Australia
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, Camperdown, Australia
| | - Junqiang Zhao
- School of Nursing, University of Ottawa, Ottawa, Canada
| | - Tamara Rader
- Canadian Agency for Drugs and Technologies in Health (CADTH), Ottawa, Canada
| | - Ian D Graham
- Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology, Public Health and Preventative Medicine, University of Ottawa, Ottawa, Canada
| | - Dawn Stacey
- School of Nursing, University of Ottawa, Ottawa, Canada
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Preoperative diagnosis of BRCA1/2 mutation impacts decision-making for risk-reducing mastectomy in breast cancer patients. Sci Rep 2021; 11:14747. [PMID: 34285295 PMCID: PMC8292311 DOI: 10.1038/s41598-021-94195-4] [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: 03/21/2021] [Accepted: 07/05/2021] [Indexed: 11/08/2022] Open
Abstract
Decision to undergo risk-reducing mastectomy (RRM) needs to consider several factors, including patient's preference, surgeon's preference, family history, and genetic predisposition. The aim of this study was to examine whether preoperative diagnosis of BRCA1/2 mutation status could influence surgical decision-making in newly diagnosed breast cancer patients. We retrospectively reviewed ipsilateral breast cancer patients with BRCA1/2 mutation who underwent primary surgery between January 2008 and November 2019 at a single institution in Korea. Of 344 eligible patients, 140 (40.7%) patients were aware of their mutation status 'prior to surgery', while 204 (59.3%) did not. Contralateral RRM rate was significantly higher in the group with BRCA1/2 mutation status identified 'prior to surgery' compared to the group with mutation status identified 'after surgery' [45.0% (63/140) vs. 2.0% (4/204)] (p < 0.001). Reduced turnaround time of BRCA1/2 testing (p < 0.001) and the use of neoadjuvant chemotherapy (p < 0.001) were associated with BRCA1/2 mutation status identified prior to surgery. Although not statistically significant, higher incidence of developing contralateral breast cancer for BRCA1/2 mutation carriers who underwent ipsilateral surgery-only compared to those who underwent contralateral RRM was observed [12.1% (95% CI: 7.7-17.7%)] (p = 0.1618). Preoperative diagnosis of BRCA1/2 mutation could impact surgical decision-making for breast cancer patients to undergo risk-reducing surgery at the time of initial surgery.
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Effect of a health literacy training program for surgical oncologists and specialized nurses on disparities in referral to breast cancer genetic testing. Breast 2021; 58:80-87. [PMID: 33933926 PMCID: PMC8105680 DOI: 10.1016/j.breast.2021.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 04/20/2021] [Accepted: 04/21/2021] [Indexed: 01/04/2023] Open
Abstract
Background There is an underuse of genetic testing in breast cancer patients with a lower level of education, limited health literacy or a migrant background. We aimed to study the effect of a health literacy training program for surgical oncologists and specialized nurses on disparities in referral to genetic testing. Methods We conducted a multicenter study in a quasi-experimental pre-post (intervention) design. The intervention consisted of an online module and a group training for surgical oncologists and specialized nurses in three regions in the Netherlands. Six months pre- and 12 months post intervention, clinical geneticists completed a checklist with socio-demographic characteristics including the level of health literacy of each referred patient. We conducted univariate and logistic regression analysis to evaluate the effect of the training program on disparities in referral to genetic testing. Results In total, 3179 checklists were completed, of which 1695 were from hospital referrals. No significant differences were found in educational level, level of health literacy and migrant background of patients referred for genetic testing by healthcare professionals working in trained hospitals before (n = 795) and after (n = 409) the intervention. The mean age of patients referred by healthcare professionals from trained hospitals was significantly lower after the intervention (52.0 vs. 49.8, P = 0.003). Conclusion The results of our study suggest that the health literacy training program did not decrease disparities in referral to genetic testing. Future research in a more controlled design is needed to better understand how socio-demographic factors influence referral to breast cancer genetic testing and what other factors might contribute. Study on the effect of a health literacy training on access to breast cancer genetic testing. Background characteristics of breast cancer patients pre- and post-intervention are compared. Mean age of patients referred by trained hospitals was significantly lower after intervention. The health literacy training did not decrease disparities in referral to genetic testing.
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Peshkin BN, Ladd MK, Isaacs C, Segal H, Jacobs A, Taylor KL, Graves KD, O'Neill SC, Schwartz MD. The Genetic Education for Men (GEM) Trial: Development of Web-Based Education for Untested Men in BRCA1/2-Positive Families. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2021; 36:72-84. [PMID: 31402434 PMCID: PMC7010546 DOI: 10.1007/s13187-019-01599-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Cascade testing for hereditary breast/ovarian cancer is an important public health priority. Increasing attention has been paid to the relevance of testing for men within BRCA1/2-positive families given that such testing may provide important information about their cancer risks, particularly for prostate cancer, and risks to their offspring. However, men are much less likely to seek genetic counseling and testing than their at-risk female relatives. To facilitate access to pre-test information and testing, we developed a web-based intervention (WI) for men that we are evaluating in a pilot randomized controlled trial (RCT). This paper describes three phases of research in the development of the WI: (1) formative (qualitative) research among men from BRCA1/2 families to assess needs and preferences for education; (2) a detailed description of the organization, format, and content of the WI; and (3) usability testing. We discuss the aims and hypotheses of the pilot RCT in which the WI is being compared with an enhanced usual care condition among at-risk men. We expect that the WI described here will foster informed decisions and lead to increased use of BRCA1/2 counseling and testing, potentially yielding improved cancer control outcomes for this understudied group, and for their at-risk relatives.
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Affiliation(s)
- Beth N Peshkin
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA.
| | - Mary Kate Ladd
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA
- Jess and Mildred Fisher Center for Hereditary Cancer and Clinical Genomics Research, Georgetown University, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA
| | - Claudine Isaacs
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA
- Jess and Mildred Fisher Center for Hereditary Cancer and Clinical Genomics Research, Georgetown University, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA
| | - Hannah Segal
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA
- Jess and Mildred Fisher Center for Hereditary Cancer and Clinical Genomics Research, Georgetown University, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA
| | - Aryana Jacobs
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA
- Jess and Mildred Fisher Center for Hereditary Cancer and Clinical Genomics Research, Georgetown University, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA
| | - Kathryn L Taylor
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA
- Jess and Mildred Fisher Center for Hereditary Cancer and Clinical Genomics Research, Georgetown University, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA
| | - Kristi D Graves
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA
- Jess and Mildred Fisher Center for Hereditary Cancer and Clinical Genomics Research, Georgetown University, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA
| | - Suzanne C O'Neill
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA
- Jess and Mildred Fisher Center for Hereditary Cancer and Clinical Genomics Research, Georgetown University, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA
| | - Marc D Schwartz
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA
- Jess and Mildred Fisher Center for Hereditary Cancer and Clinical Genomics Research, Georgetown University, 3300 Whitehaven Street, NW, Suite 4100, Washington, DC, 20007, USA
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Biesecker BB, Lillie SE, Amendola LM, Donohue KE, East KM, Foreman AKM, Gilmore MJ, Greve V, Liangolou B, O'Daniel JM, Odgis JA, Rego S, Rolf B, Scollon S, Suckiel SA, Zepp J, Joseph G. A review and definition of 'usual care' in genetic counseling trials to standardize use in research. J Genet Couns 2021; 30:42-50. [PMID: 33278053 PMCID: PMC7882019 DOI: 10.1002/jgc4.1363] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/30/2020] [Accepted: 10/21/2020] [Indexed: 01/16/2023]
Abstract
The descriptor 'usual care' refers to standard or routine care. Yet, no formal definition exists. The need to define what constitutes usual care arises in clinical research. Often one arm in a trial represents usual care in comparison with a novel intervention. Accordingly, usual care in genetic counseling research appears predominantly in randomized controlled trials. Recent standards for reporting genetic counseling research call for standardization, but do not address usual care. We (1) inventoried all seven studies in the Clinical Sequencing Evidence-Generating Consortium (CSER) about how genetic counseling was conceptualized, conducted, and whether a usual care arm was involved; (2) conducted a review of published randomized control trials in genetic counseling, comparing how researchers describe usual care groups; and (3) reviewed existing professionally endorsed definitions and practice descriptions of genetic counseling. We found wide variation in the content and delivery of usual care. Descriptions frequently detailed the content of usual care, most often noting assessment of genetic risk factors, collecting family histories, and offering testing. A minority included addressing psychological concerns or the risks versus benefits of testing. Descriptions of how care was delivered were vague except for mode and type of clinician, which varied. This significant variation, beyond differences expected among subspecialties, reduces the validity and generalizability of genetic counseling research. Ideally, research reflects clinical practice so that evidence generated can be used to improve clinical outcomes. To address this objective, we propose a definition of usual care in genetic counseling research that merges common elements from the National Society of Genetic Counselors' practice definition, the Reciprocal Engagement Model, and the Accreditation Council for Genetic Counselors' practice-based competencies. Promoting consistent execution of usual care in the design of genetic counseling trials can lead to more consistency in representing clinical care and facilitate the generation of evidence to improve it.
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Affiliation(s)
- Barbara B Biesecker
- Genomics, Bioinformatics and Translation, RTI International, Washington, DC, USA
| | - Sarah E Lillie
- Center for Communication Science, RTI International, Research Triangle Park, NC, USA
| | - Laura M Amendola
- Division of Medical Genetics, University of Washington, Seattle, WA, USA
| | - Katherine E Donohue
- Institute for Genomic Health, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kelly M East
- HudsonAlpha Institute for Biotechnology, Huntsville, AL, USA
| | | | - Marian J Gilmore
- Department of Translational and Applied Genomics, Kaiser Permanente - Center for Health Research, Portland, OR, USA
| | - Veronica Greve
- HudsonAlpha Institute for Biotechnology, Huntsville, AL, USA
| | | | | | - Jacqueline A Odgis
- Institute for Genomic Health, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shannon Rego
- Institute for Human Genetics, University of California, San Francisco, CA, USA
| | - Bradley Rolf
- Division of Medical Genetics, University of Washington, Seattle, WA, USA
| | - Sarah Scollon
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Sabrina A Suckiel
- Institute for Genomic Health, The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jamilyn Zepp
- Department of Translational and Applied Genomics, Kaiser Permanente - Center for Health Research, Portland, OR, USA
| | - Galen Joseph
- Department of Humanities and Social Sciences, University of California, San Francisco, CA, USA
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9
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Metcalfe KA, Eisen A, Poll A, Candib A, McCready D, Cil T, Wright F, Lerner-Ellis J, McCuaig J, Graham T, Sun P, Akbari M, Narod SA. Rapid Genetic Testing for BRCA1 and BRCA2 Mutations at the Time of Breast Cancer Diagnosis: An Observational Study. Ann Surg Oncol 2020; 28:2219-2226. [PMID: 32989658 DOI: 10.1245/s10434-020-09160-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 09/01/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND This study aimed to evaluate the impact of rapid genetic testing (RGT) for BRCA1 and BRCA2 at the time of breast cancer diagnosis on treatment choices. Bilateral mastectomy for the treatment of breast cancer in women with a BRCA1 or BRCA2 mutation offers a reduction in the risk of contralateral breast cancer. It is unclear whether offering RGT at the time of breast cancer diagnosis has an impact on women's surgical decision-making. METHODS Women with breast cancer diagnosed between June 2013 and May 2018 were recruited from four academic health sciences centers in Toronto, Canada. The participants completed a questionnaire before genetic testing, then one week and one year after disclosure of the genetic test result. Before surgery, RGT was performed. Diagnostic, pathologic, and treatment data were compared between those with and those without a BRCA mutation. RESULTS The study enrolled 1007 women who consented to RGT. The mean age of the participants was 46.3 years, and the median time to result disclosure was 10 days. A BRCA mutation was found in 6% of the women. The women with a BRCA mutation were significantly more likely to elect for bilateral mastectomy than the women without a BRCA mutation (p < 0.0001). Of the BRCA-positive patients, 95.7% reported that they used their genetic test result to make a surgical decision. CONCLUSIONS The women provided with RGT at the time of breast cancer diagnosis use the genetic information to make treatment decisions, and the majority of those identified with a BRCA mutation elect for a bilateral mastectomy.
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Affiliation(s)
- Kelly A Metcalfe
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada. .,Women's College Research Institute, Toronto, Canada.
| | - Andrea Eisen
- Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Aletta Poll
- Women's College Research Institute, Toronto, Canada
| | | | | | - Tulin Cil
- Princess Margaret Hospital, Toronto, Canada
| | | | | | | | - Tracy Graham
- Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Ping Sun
- Women's College Research Institute, Toronto, Canada
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Underhill-Blazey M, Blonquist T, Chittenden A, Pozzar R, Nayak M, Lansang K, Hong F, Garber J, Stopfer JE. Informing models of cancer genetics care in the era of multigene panel testing with patient-led recommendations. J Genet Couns 2020; 30:268-282. [PMID: 32851753 DOI: 10.1002/jgc4.1317] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 07/15/2020] [Accepted: 07/17/2020] [Indexed: 12/23/2022]
Abstract
The study describes patient-reported experiences and recommendations to improve the genetic counseling and multigene panel testing (MGPT) process. A descriptive mixed-method study with concurrently collected and integrated qualitative and quantitative data was conducted. Eligible participants were English-speaking adults with a breast or gynecologic cancer diagnosis who had received genetic counseling and testing with a MGPT from one Comprehensive Cancer Center. Satisfaction with the genetic counseling, genetic knowledge using a recently validated scale (KnowGene), the multidimensional impact of cancer risk assessment (MICRA), family communication, and the association with demographic factors were evaluated. To supplement the large quantitative data set, qualitative focus group responses and open-ended text items were collected. Univariate and multivariable associations between each outcome of interest and personal characteristics were assessed. Qualitative data were content-analyzed. 603 participants completed the survey (48% response rate) and 10 individuals participated in the focus groups. Participants were mostly Caucasian, educated with a college degree or more, and female with median age 58 (24-91), and 78% of participants had a breast cancer diagnosis. Of all individuals undergoing genetic testing using a MGPT, 13% had a pathogenic variant identified, and 30% had a variant of uncertain significance (VUS). Overall, participants reported satisfaction with the genetic counseling and testing process (mean 36.9 [SD 4.7]). On average, participants had 7 incorrect answers out of 19 on the genetic knowledge scale (mean 12.3 [SD 3.4]). MICRA scores showed overall low levels of distress and uncertainty, as well as positive experiences, with wide variability (median 17 [0-84]). Age, marital status, education level, type of cancer diagnosis, and genetic testing results were significantly associated with outcomes. Most participants communicated genetic testing results to mainly female first-degree relatives. A wide range of individual preferences affecting overall satisfaction, or suggestions for improvement were shared. As new models of streamlined cancer genetic services are being clinically implemented, approaches should continue to assess and tailor the process based on patients' informational and emotional needs.
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Affiliation(s)
- Meghan Underhill-Blazey
- Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, MA, USA.,School of Nursing, University of Rochester, Rochester, NY, USA
| | - Traci Blonquist
- Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Anu Chittenden
- Cancer Genetics and Prevention Program, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Rachel Pozzar
- Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Manan Nayak
- Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Kristina Lansang
- Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Fangxin Hong
- Phyllis F. Cantor Center for Research in Nursing and Patient Care Services, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Judy Garber
- Cancer Genetics and Prevention Program, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jill E Stopfer
- Cancer Genetics and Prevention Program, Dana-Farber Cancer Institute, Boston, MA, USA
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Scott N, O'Sullivan J, Asgeirsson K, Macmillan D, Wilson E. Changing practice: moving to a specialist nurse-led service for BRCA gene testing. ACTA ACUST UNITED AC 2020; 29:S6-S13. [DOI: 10.12968/bjon.2020.29.10.s6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Some 5–10% of all breast cancers are associated with a pathogenic variant in a breast cancer-associated gene (BRCA1/BRCA2). Historically, with referral to the Nottingham University Hospitals NHS Trust's clinical genetics department for genetic testing, waiting times were on average 12–14 weeks for an initial appointment and 4–6 months to obtain results from the date of testing. A specialist, nurse-led mainstreaming cancer genetics (MCG) service was set up in the trust's Nottingham Breast Institute (NBI) to: reduce waiting times for the initial consultation, counselling, consent and obtaining results for BRCA1/BRCA2 gene testing; and to ensure appropriate patients with breast cancer were offered genetic testing. Two breast clinical nurse specialists were trained so they could counsel, consent and give results for the BRCA1/BRCA2 gene testing directly to patients. Average waiting times for results from the time of testing were reduced to 35.8 days under the nurse-led service, which enabled oncologists and patients to consider individual treatment options at an earlier time. The MCG service reduced waiting times, resulting in an improved, more streamlined service for patients undergoing genetic testing. The MCG service extended the scope of practice of the breast nurse clinical specialists, embedded an expert advanced nursing role in the breast multidisciplinary team and developed nurse mentoring opportunities.
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Affiliation(s)
- Nicola Scott
- Breast Clinical Nurse Specialist and Specialist in Breast Family History, Nottingham Breast Institute, Nottingham University Hospitals NHS Trust
| | - Jackie O'Sullivan
- Breast Clinical Nurse Specialist and Specialist in Breast Family History, Nottingham Breast Institute, Nottingham University Hospitals NHS Trust
| | - Kristjan Asgeirsson
- Consultant Oncoplastic Breast Surgeon, Nottingham Breast Institute, Nottingham University Hospitals NHS Trust
| | - Douglas Macmillan
- Consultant Oncoplastic Breast Surgeon, Nottingham Breast Institute, Nottingham University Hospitals NHS Trust
| | - Emma Wilson
- Associate Professor in Public Health, University of Nottingham
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Ladd MK, Peshkin BN, Isaacs C, Hooker G, Willey S, Valdimarsdottir H, DeMarco T, O'Neill S, Binion S, Schwartz MD. Predictors of genetic testing uptake in newly diagnosed breast cancer patients. J Surg Oncol 2020; 122:134-143. [PMID: 32346886 DOI: 10.1002/jso.25956] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 04/18/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Many newly diagnosed breast cancer patients do not receive genetic counseling and testing at the time of diagnosis. We examined predictors of genetic testing (GT) in this population. METHODS Within a randomized controlled trial of proactive rapid genetic counseling and testing vs usual care, patients completed a baseline survey within 6 weeks of breast cancer diagnosis but before a definitive survey. We conducted a multinomial logistic regression to identify predictors of GT timing/uptake. RESULTS Having discussed GT with a surgeon was a dominant predictor (χ2 (2, N = 320) = 70.13; P < .0001). Among those who discussed GT with a surgeon, patients who had made a final surgery decision were less likely to receive GT before surgery compared with postsurgically (OR [odds ratio] = 0.24; 95% confidence interval [CI] = 0.12-0.49) or no testing (OR = 0.28; 95% CI = 0.14-0.56). Older patients (OR = 0.95; 95% CI = 0.91-0.99) and participants enrolled in New York/New Jersey (OR = 0.22; 95% CI = 0.07-0.72) were less likely to be tested compared with receiving results before surgery. Those with higher perceived risk (OR = 1.02; 95% CI = 1.00-1.03) were more likely to receive results before surgery than to not be tested. CONCLUSIONS This study highlights the role of patient-physician communication about GT as well as patient-level factors that predict presurgical GT.
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Affiliation(s)
- Mary K Ladd
- Georgetown Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC
| | - Beth N Peshkin
- Georgetown Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC
| | - Claudine Isaacs
- Georgetown Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC
| | - Gillian Hooker
- Georgetown Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC
| | - Shawna Willey
- Georgetown Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC
| | - Heiddis Valdimarsdottir
- Department of Population Health Science and Policy, Center for Behavioral Oncology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Tiffani DeMarco
- Georgetown Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC
| | - Suzanne O'Neill
- Georgetown Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC
| | - Savannah Binion
- Georgetown Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC
| | - Marc D Schwartz
- Georgetown Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC
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13
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Predictors of contralateral prophylactic mastectomy in genetically high risk newly diagnosed breast cancer patients. Breast Cancer Res Treat 2020; 180:177-185. [PMID: 31894446 DOI: 10.1007/s10549-019-05515-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 12/18/2019] [Indexed: 12/18/2022]
Abstract
PURPOSE Recent trends indicate increased use of contralateral prophylactic mastectomy (CPM) among newly diagnosed breast cancer patients, particularly those who test positive for a pathogenic variant in the BRCA1/2 genes. However, the rate of CPM among patients who test negative or choose not to be tested is surprisingly high. We aimed to identify patient predictors of CPM following breast cancer diagnosis among such patients. METHODS As part of a randomized controlled trial of rapid genetic counseling and testing vs. usual care, breast cancer patients completed a baseline survey within 6 weeks of diagnosis and before definitive surgery. Analyses focused on patients who opted against testing (n = 136) or who received negative BRCA1/2 test results (n = 149). We used multivariable logistic regression to assess the associations between sociodemographic, clinical- and patient-reported factors with use of CPM. RESULTS Among patients who were untested or who received negative test results, having discussed CPM with one's surgeon at the time of diagnosis predicted subsequent CPM. Patients who were not candidates for breast-conserving surgery and those with higher levels of cancer-specific intrusive thoughts were also more likely to obtain a CPM. CONCLUSION The strongest predictors of CPM in this population were objective clinical factors and discussion with providers. However, baseline psychosocial factors were also independently related to the receipt of CPM. Thus, although CPM decisions are largely guided by relevant clinical factors, it is important to attend to psychosocial factors when counseling newly diagnosed breast cancer patients about treatment options.
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