"Social separation" among women under 40 years of age diagnosed with breast cancer and carrying a BRCA1 or BRCA2 mutation

A scoping review of parents' disclosure of BRCA1/2 genetic alteration test results to underage children

BACKGROUND

Individuals with BRCA1/2 mutations have a notably higher than average lifetime risk of developing cancer as adults. Some parents with BRCA1/2 mutations wish to share this information with their children, yet they struggle to know how, when, and what information to share.

OBJECTIVE

The objective of this review was to identify what communication strategies/interventions exist for parents communicating their BRCA1/2 status to their minor children, and what communication interventions do healthcare professionals use to support parents' disclosure process.

METHODS

Scoping review on six databases search for studies with parents and/or healthcare professionals' interventions on supporting communication from parents to children. The review aligned PRISMA guidelines for scoping reviews and used the PAGER recommendations to guide charting and reporting.

RESULTS

22 articles published from 2001 to 2020 were included. Multiple facilitators/motivators of disclosure, how and where parents disclosed, reactions to disclosure were identified. Also, there were no healthcare professionals' interventions in the disclosure process found.

CONCLUSIONS

The review summarizes research on parents' disclosure of their BRCA1/2 status to their underage children and demonstrates a paucity of communication interventions for guiding parents in this difficult process. Parents experience many obstacles communicating the results to their children.

PRACTICE IMPLICATIONS

These findings equip healthcare professionals in their efforts to develop and test interventions which support the communication of genetic risk information. Furthermore, it is evident there is a need for more research to understand how the disclosure process occurs in the families.

Relationship satisfaction and self-esteem in patients with breast cancer and healthy women: the role of expected and actual personal projects support from the partner

BACKGROUND

For breast cancer patients, the partner's support for personal projects can serve as a means of adaptation. We aimed to investigate the associations between the intimate partner's personal project support and women's well-being.

METHODS

A sample of 274 Hungarian women (breast cancer patients n = 137, control n = 137) took part in the study. Expected and actually received autonomy-, directive- and emotional project support was assessed by the procedure of Personal Project Assessment. Well-being was measured by the Relationship Assessment Scale and the Rosenberg Self-Esteem Scale. For investigating the associations between project support and well-being in a multivariate way, structural equation modelling was used.

RESULTS

Except for autonomy support, participants expected more support than they received. A path model indicated multiple associations between types of project support and relationship satisfaction and self-esteem. The partner's emotional project support was predictive of women's relationship satisfaction and self-esteem, while directive support was predictive of self-esteem only. The associations showed similar patterns in the subgroups of patients with breast cancer and control.

CONCLUSIONS

Our results highlight the importance of involving women's subjective perspectives regarding the partner's project support while also have implications for praxis. Teaching women how to communicate their needs to their partner effectively (whether it is the need for autonomy or directive guidance) can help close the gap between expected and received support, which may in turn enhance relationship satisfaction and self-esteem.

Trajectories and predictors of social avoidance in female patients with breast cancer

Background

Social avoidance plays an important role in influencing quality of life among patients with breast cancer. Social avoidance behaviors change with treatment periods. However, the trajectory patterns and the predictive factors have not been fully studied.

Objective

This study examined the growth trajectory of social avoidance and its predictors in patients with breast cancer.

Materials and methods

A total of 176 patients with breast cancer in a university hospital in Shaanxi Province, China, were followed up four times over 6 months following surgery, and data from the final 144 patients were analyzed. The growth mixed model (GMM) was used to identify the trajectory categories, and the predictive factors of the trajectory types were analyzed by logistic regression.

Results

The best-fit growth mixture modeling revealed three class models: persistent high social avoidance group (Class 1), social avoidance increased first and then decreased group (Class 2), and no social avoidance group (Class 3), accounting for 13.89, 31.94, and 54.17% of patients, respectively. Single-factor analysis showed that family income per capita, residence, and temperament type were related to the social avoidance trajectory. Logistic regression analysis showed that only temperament type was an independent predictor of the social avoidance trajectory, and patients with melancholia were more likely to have persistent high social avoidance.

Conclusion

Our study proved the heterogeneity of social avoidance behaviors and the influencing effect of temperament type on the development of social avoidance behaviors in Chinese patients with breast cancer. Health professionals should pay more attention to patients who are at higher risk of developing a persistent social avoidance pattern and provide target interventions.

Assessment of socio-relational self-efficacy in breast cancer patients: Italian validation of the social relationship coping efficacy scale (SRCE-I)

BACKGROUND

Social relationship coping efficacy (SRCE) represents the ability to maintain or enhance social relationships in the context of serious illness. The purpose of the current study was to confirm the factor structure, psychometric properties, and utility of the Italian version of the SRCE scale.

METHODS

181 breast cancer patients completed the SRCE-Italian (SRCE-I), the Cancer Behavior Inventory-Brief/Italian (CBI-B/I), quality of life (QOL) measures (EORTC QLQ-C30; EORTC QLQ-BR23), and the Hospital Anxiety and Depression Scale (HADS).

RESULTS

The SRCE-I was internally consistent (Cronbach alpha = .95) and factor analysis confirmed that the SRCE-I was a unidimensional construct. In terms of validity, the SRCE-I was correlated with QOL (EORTC QLQ-30, Social Functioning, r = .33, Emotional Functioning, r = .57, and Global Health/Quality of Life; r = .54) and scales of the EORTC QLQ-BR23 (e.g., Future Perspective, r = .38; Breast Symptoms, -.31). SRCE-I was also correlated negatively with the HADS (r = -.72) and positively with the CBI-B/I (r = .79), a measure of coping efficacy (all ps < .001). Mediation analyses confirmed the utility of the SRCE-I scale as a mediating mechanism in enhancing social functioning and QOL.

CONCLUSIONS

The SRCE-I is a structurally sound, reliable, and valid measure that assesses the ability to maintain or enhance social support and mitigate the loss of social support. The SRCE-I can be used as a screening measure to assess low efficacy for maintaining social support or as a measure to detect the change in efficacy for enhancing social support in interventions to improve the QOL of patients.

Outcomes of support groups for carriers of BRCA 1/2 pathogenic variants and their relatives: a systematic review

People tested positive for BRCA1/2 face an increased risk of cancer; to help them cope with the genetic information received, support to BRCA1/2 families should be continued after testing. Nonetheless how such support should be provided has not been established yet. As a potentially valuable option is represented by support groups, the aim of this systematic review was to assess studies exploring the outcomes of support groups for BRCA1/2 carriers. This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and was registered in the International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42021238416). Peer-reviewed papers published between January 1995 and February 2021 were searched for, using four databases. Among 1586 records identified, 34 papers were reviewed in full-text and eleven were included in the qualitative synthesis of the results. Three themes emerged as major focuses of support groups: risk management decisions, family dynamics and risk communication, and psychosocial functioning. Our findings show that support groups proved helpful in supporting women's decision-making on risk-reducing options. Moreover, during those interventions, BRCA1/2 carriers had the opportunity to share thoughts and feelings, and felt that mutual support through interacting with other mutation carriers help them release the emotional pressure. However, no significant impact was reported in improving family communication. Overall, a high level of satisfaction and perceived helpfulness was reported for support group. The findings suggest that support groups represent a valuable tool for improving BRCA1/2 families care.

A review of psychological impact of breast cancer in women below 50 years old

A breast cancer diagnosis is a critical event with a potentially traumatic nature. In recent years there has been an increase of this illness in women aged under-fifty, a group of particular scientific interest. In this article the authors review the recent scientific literature on psychological impact of breast cancer experiences in under-50 women. Our results highlight three trajectories: clinical psychological risks; feminine-specific concerns; resources between individual and relational aspects. This overview illustrates the complexity of the effects of breast cancer in under-50women allowing to think about theoretical and psychosocial models to provide support for under-50 women during the illness experience.

Genetic testing for pheochromocytoma and paraganglioma: SDHx carriers' experiences

Pheochromocytoma and paraganglioma are frequently hereditary tumors commonly associated with succinate dehydrogenase (SDHx) pathogenic variants (PV). Genetic testing is recommended to relatives of patients carrying SDHx PV. This study aims to explore the experiences associated with genetic testing for this hereditary condition. Semi-structured interviews with 38 SDHx PV (tumor-affected and non-affected) carriers were transcribed and content-analyzed. Four ways of living with this genetic alteration emerged from the interviews: 'living as if not knowing', 'preventing others from going through this', 'feeling privileged', and 'still suffering'. Within each, negative, neutral, and positive reactions to the actual test result emerged initially, in addition to blame and guilt. Recognition of the importance of the genetic test and of the follow-up occurred in all four, but views on fecundity were divided between having and not having children. Consideration for the four different meanings of carrying an SDHx PV can improve participants' experiences and clinical practice.

Mainstreamed genetic testing in ovarian cancer: patient experience of the testing process

OBJECTIVE

Pathogenic BRCA variants account for 5.8-24.8% of ovarian cancers. The identification of such a variant can have a significant impact on the affected individual and their relatives, determining eligibility for targeted therapies, predicting treatment response, and granting access to disease prevention strategies. Cancer services are responding to the increased demand for genetic testing with the introduction of mainstreamed genetic testing via oncology clinics. This study aimed to evaluate patient experience of the mainstreamed genetic testing pathway at a tertiary referral center in London, UK.

METHODS

Study participants were patients diagnosed with high-grade non-mucinous ovarian cancer, tested via a mainstreamed genetic testing pathway at the tertiary referral center between February 2015 and June 2017. Eligible participants were invited to complete the retrospective study questionnaire. Five quantitative measures with additional free-text items were used to evaluate the patient experience of mainstreamed genetic testing.

RESULTS

The tertiary referral center tested 170 ovarian cancer patients. Twenty-three pathogenic BRCA mutations were identified (23/170, 13.5%). One-hundred and six patients (106/170, 62.4%) met the study inclusion criteria. Twenty-nine of those invited to participate (29/106, 27.4%) returned the retrospective study questionnaire. Pathogenic BRCA1/2 variants were identified within four respondents (4/29, 13.8%). Motivations for genetic testing related to improved medical management, and the ability to provide relatives with genetic information. Participants did not appear to be adversely affected by result disclosure post-mainstreamed genetic testing. Two individuals with a pathogenic variant reported that the support provided by the tertiary referral center post-result disclosure could have been improved.

CONCLUSION

Results of the current study support further psychosocial research into the expansion of the mainstreamed genetic testing pathway. The results, although promising, have also highlighted the importance of genetic awareness within the multi-disciplinary team and the provision of timely psychological support from genetic specialists.

Social relationship coping efficacy: A new construct in understanding social support and close personal relationships in persons with cancer

OBJECTIVE

Social relationship coping efficacy (SRCE) is the confidence to engage in behaviors that can maintain or enhance close social relationships in the context of illness. This study focused on psychometric analyses of the SRCE scale and its role in maintaining or enhancing personal relationships, social support, and quality of life (QOL).

METHOD

A mixed diagnosis sample (N = 151) of cancer patients completed a variety of measures: physical debilitation, received emotional and instrumental support, SRCE, and QOL.

RESULTS

The SRCE scale is a 10-item, one-factor, internally reliable (α = 0.965) measure with strong concurrent validity in relation to measures of social support. SRCE fully mediated the relationship between physical debilitation and both instrumental and emotional received support. SRCE also was directly related to both social/family well-being and psychological distress, and this relationship was also partially mediated by social support.

CONCLUSIONS

The results corroborated that SRCE might account for changes in both instrumental and emotional support. Also, the direct and indirect relationship (mediated by social support) of SRCE with both social/family well-being and distress indicated that interventions to increase SRCE with those at risk for social support loss may bolster social support in personal relationships as well as enhance emotional well-being and quality of life.

Loneliness in Professional Caring Relationships, Health, and Recovery

This study investigated patients' experiences of loneliness in professional caring relationships and their associations with perceived recovery, health, psychological distress, and general loneliness in life. The sample consisted of 406 patients who had undergone breast cancer or heart surgery 6 months earlier. The data were collected in May 2014-March 2015 using a postal survey including the Caring Loneliness Scale (CARLOS), questions concerning perceived health and recovery, 12-item General Health Questionnaire (GHQ-12), and a question concerning perceived general loneliness in life. Data analysis was done using Mann-Whitney U test and Kruskal-Wallis test. The variables showing a statistically significant association with professional caring loneliness were perceived health, recovery, psychological distress, and general loneliness in life. It is necessary for health care professionals to identify the phenomenon of this dimension of loneliness because it is bound to affect patients' experiences. Further studies with different patient groups are required.

Preparing young people for future decision-making about cancer risk in families affected or at risk from hereditary breast cancer: A qualitative interview study

PURPOSE

Women carrying the mutated BRCA gene, have approximately an 80% life-time risk of developing breast cancer with 50% risk of their children inheriting the gene mutation. Many parents find it difficult to know when and how to disclose this information to their children and how such disclosure might affect their child's future decision-making.

METHOD

This study explored the communication of genetic risk information in families using qualitative semi-structured interviews conducted with parents, children (7-11years) and young people (12-18years) affected or at risk from a BRCA gene mutation. Thematic analysis was applied to coded transcripts producing four themes; family communication, perception of cancer risks, risk management strategies and impact of genetic risk communication in children and young people's decision making.

RESULTS

Twenty-seven individuals from 11 families took part, recruited through purposive sampling techniques. Cancer risk caused by a BRCA gene mutation induced a sense of fear in parents about their children's future. As a result, parents with hereditary breast cancer disclosed limited information about the risks associated with prophylactic surgery and/or the psychological and emotional impacts of surgery on body image. This had implications to children and young people's perceptions of prophylactic procedures, which were already influenced by cultural understandings of the 'desirable body' and increasing acceptance and proliferation cosmetic surgery.

CONCLUSION

Lack of risk management information and the acculturation of cosmetic surgery combined to limit children and young people's understanding of the impact of hereditary breast cancer; reducing their ability to actualise the physiological, psychological and emotional consequences of surgery.

`I'm like you': establishing and protecting a common ground in focus groups with Huntington disease caregivers

Focus group research reflects content contributed by participants and the influence of interactions among participants. Analysis of interactions provides insights into focus group dynamics and the contextual meaning of focus group topics. The aim of this report is to analyse interactions that establish or protect a common ground in focus groups of family members caring for adults with Huntington disease (HD). HD tends to stigmatise persons with the disease, as well as their families. Thus, many of the topics in these groups were sensitive. Establishing a common ground was of paramount importance to group members. Participants used interactional processes that combined validations and challenges across assertions of knowledge or expertise, and disclosure of personally painful or socially sanctioned thoughts or feelings. Participants couched their contributions in ways that established similarity with others and when disagreements arose, group members developed processes to sustain their common ground. These behaviours served to facilitate group solidarity and may have influenced the information provided by group members. Awareness of interactions to facilitate maintenance of a common ground allows leaders to recognise the importance of such interactions for the group's functioning, and provides insights for researchers into meanings of focus group findings.

Living With Genetic Vulnerability: a Life Course Perspective

This is the second article of a two part series about utilizing the life course perspective (LCP) in genetic counseling. Secondary data analysis was conducted on a grounded theory, longitudinal study which provided a wide focus on living with hereditary breast and ovarian cancer (HBOC) risk. The aim of this analysis was to explore the longitudinal data for both the temporal and social context of living with BRCA mutation genetic test results. Sixteen women from two previous studies were interviewed on multiple occasions over an 8 year time period. The LCP was used to direct a thematic analysis of the data. Families experience the consequences of knowing they carry a BRCA1 or BRCA2 gene mutation long after the initial diagnosis. These women's experiences across time reflect the concepts of the LCP and show how life is changed when families know they live with a genetic vulnerability to an adult-onset and potentially life-threatening disease. Different emphases on concepts from the LCP were evident across the different age groups. For example, the group of 40-50 year old women emphasized the concept of linked lives, those in their 30's focused on human agency and women in their 20's were more focused on timing of events. This study helps give direction to healthcare providers counseling women living with a BRCA mutation.

Exploration of Male Attitudes on Partnerships and Sexuality with Female BRCA1/2 Mutation Carriers

Women with BRCA mutations are inundated with decisions about managing cancer risks and childbearing considerations. Decisions become more complicated when women face disclosing their mutation and risk-reduction options to a romantic partner. This study identifies the concerns and perspectives of male romantic partners regarding these unique decisions. Twenty-five male participants completed an online survey posted to cancer support group message boards. Participants reported relationship changes regarding intimacy levels (n = 9), attraction (n = 2), and communication (n = 22) after mutation disclosure. Participants whose partners had not undergone prophylactic mastectomy (n = 14) reported concerns regarding sexual relations (n = 5), post-surgical appearance (n = 2), post-surgical attraction (n = 5), and health/lifespan (n = 9). Participants did not express attitude changes toward childbearing. While mutation disclosure conversations and surgical options are concerns for many BRCA mutation carriers in relationships, male partners share these concerns. Aspects of the relationship may change, but male study participants continued to support their partners. This information can benefit female BRCA mutation carriers, their current or future partners, and genetic counselors working with this particular population.

Striking a balance in communicating pharmacogenetic test results: promoting comprehension and minimizing adverse psychological and behavioral response

OBJECTIVE

Pharmacogenetic (PGx) testing can provide information about a patient's likelihood to respond to a medication or experience an adverse event, and be used to inform medication selection and/or dosing. Promoting patient comprehension of PGx test results will be important to improving engagement and understanding of treatment decisions.

METHODS

The discussion in this paper is based on our experiences and the literature on communication of genetic test results for disease risk and broad risk communication strategies.

RESULTS

Clinical laboratory reports often describe PGx test results using standard terminology such as 'poor metabolizer' or 'ultra-rapid metabolizer.' While this type of terminology may promote patient recall with its simple, yet descriptive nature, it may be difficult for some patients to comprehend and/or cause adverse psychological or behavioral responses.

CONCLUSION

The language used to communicate results and their significance to patients will be important to consider in order to minimize confusion and potential psychological consequences such as increased anxiety that can adversely impact medication-taking behaviors.

PRACTICE IMPLICATIONS

Due to patients' unfamiliarity with PGx testing and the potential for confusion, adverse psychological effects, and decreased medication adherence, health providers need to be cognizant of the language used in discussing PGx test results with patients.

Maximising survival: the main concern of women with hereditary breast and ovarian cancer who undergo genetic testing for BRCA1/2

PURPOSE

Little is known about how women with hereditary breast and/or ovarian cancer who test positive for a BRCA gene manage the impact of a positive test result on their everyday lives and in the longer term. This study defined the experience and needs of women with hereditary breast and ovarian cancer and a positive BRCA test over time.

METHODS

A grounded theory approach was taken using qualitative interviews (n = 49) and reflective diaries. Data collected from December 2006 until March 2010 was analysed using the constant comparative technique to trace the development of how women manage their concerns of inherited cancer.

RESULTS

A four stage substantive theory of maximising survival was generated that defines the experience of women and how they resolve their main concerns. The process of maximising survival begins prior to genetic testing in women from high risk families as they expect to get a cancer diagnosis at some time. Women with cancer felt they had experienced the worst with a cancer diagnosis and altruistically tested for the sake of their children but a positive test result temporarily shifted their focus to decision-making around their personal health needs.

CONCLUSION

This study adds to clinical practice through raising awareness and adding insights into how women cope with living with inherited cancer risk and the personal and familial ramifications that ensue from it. A clear multi-professional structured care pathway for women from genetic testing result disclosure to undergoing risk-reducing surgery and/or surveillance should be developed.

Genetic testing: when prediction generates stigmatization

Using grounded theory methodology, this study examined the experiences of six BRCA1/2 gene mutation carriers (mean age = 38.5 years). Three types of stigmatization were identified: stigmatization by anticipation, stigmatization through rejection, and stigmatization by affiliation. Participants described potential impacts on their womanhood, felt threatened by others, and revealed fears that their children would inherit their stigmatization. These findings indicate the importance of psychological support in the follow-up of such patients.

Theory development from studies with young women with breast cancer who are BRCA mutation negative

Researchers and practitioners can use inductively derived theory to direct their research and practice. This article describes the ongoing development of a theory that can assist in explaining experiences of young women with breast cancer who have genetic testing for the BRCA mutation. Seventeen BRCA-negative women with breast cancer from a larger grounded theory study were interviewed. While receiving a negative BRCA mutation test result subsequent to a breast cancer diagnosis was described as a relief, the information was also confusing. The author's published Theory of Genetic Vulnerability is expanded to incorporate the outcomes of this analysis.

A multi-case report of the pathways to and through genetic testing and cancer risk management for BRCA mutation-positive women aged 18-25

Much of the extant literature addressing the psychosocial aspects of BRCA1/2 mutation testing and risk management aggregates mutation carriers of all ages in study recruitment, data analysis, and interpretation. This analytic strategy does not adequately address the needs of the youngest genetic testing consumers, i.e., women aged 18-25. Despite low absolute cancer risk estimates before age 30, BRCA1/2 mutation-positive women aged 18-25 feel vulnerable to a cancer diagnosis but find themselves in a management quandary because the clinical utility of screening and prevention options are not yet well defined for such young carriers. We present three cases, selected from a larger study of 32 BRCA1/2 mutation-positive women who completed or considered genetic testing before age 25, to demonstrate the unique developmental, relational and temporal influences, as well as the challenges, experienced by very young BRCA mutation-positive women as they complete genetic testing and initiate cancer risk management. The first case describes the maturation of a young woman whose family participated in a national cancer registry. The second addresses the experiences and expectations of a young woman who completed genetic testing after learning that her unaffected father was a mutation carrier. The third case highlights the experiences of a young woman parentally bereaved in childhood, who presented for genetic counseling and testing due to intense family pressure. Together, these cases suggest that BRCA1/2-positive women aged 18-25 are challenged to reconcile their burgeoning independence from their families with risk-related support needs. Loved ones acting in ways meant to care for these young women may inadvertently apply pressure, convoluting family support dynamics and autonomous decision-making. Ongoing support from competent healthcare professionals will enable these young women to remain informed and receive objective counsel about their risk-management decisions.

Incidence and predictors of positive and negative effects of BRCA1/2 genetic testing on familial relationships: a 3-year follow-up study

PURPOSE

Little is known about the long-term impact of BRCA1/2 testing on the relationships between family members. We assessed the incidence of positive and negative family relationship effects of BRCA1/2 testing in the 3 years after result disclosure and identified predictors of these effects.

METHODS

A total of 485 women and 67 men who had undergone BRCA1/2 testing were asked 3 years later whether having been tested had improved and/or disrupted relationships with their relatives. The associations with sociodemographic, medical, and psychosocial characteristics were assessed.

RESULTS

Globally, 85.1% did not report any positive or negative effects of genetic testing on family relationships. Positive and negative effects were reported by 13.2% and 3.7% of participants, respectively. Reporting positive relationship effects was associated with older age, intolerance for uncertainty, cancer-specific distress, and more social support. Low education, positive attitude toward prophylactic mastectomy, and low social support increased the likelihood of negative effects.

CONCLUSION

Our findings do not support the belief that family relationships are frequently disrupted by BRCA1/2 testing. Understanding that most family relationships are unchanged long term by genetic testing may help genetic service providers encourage those considering testing to overcome hesitancy related to potential difficulties of communicating results to relatives.

Working toward an understanding of the impact of hereditary cancers

Hereditary diffuse gastric cancer is a genetically inherited aggressive form of stomach cancer. Once the person is diagnosed as having this gene, they have a 75%-80% chance of inheriting the cancer. People who are at risk of this genetic mutation have to meet many challenges relating to the implications of the disease. An understanding is required by nurses to guide them in the provision of care for those afflicted with this inherited form of gastric cancer. A review of literature has been undertaken relating to other genetically inherited cancers including hereditary nonpolyposis colon cancer, familial adenomatous polyposis, and hereditary lobular breast cancer. The findings from the literature assist nurses in understanding the physical and psychological implications of genetically inherited cancer; however, further study is required to gain a complete understanding of the implications of hereditary diffuse gastric cancer.

Can self-esteem, mastery and perceived stigma predict long-term adjustment in women carrying a BRCA1/2-mutation? Evidence from a multi-center study

Little is known about protective and vulnerability factors of long-term adjustment with BRCA1/2 carrier status. Specifically, the role of personal resources and perceptions of stigmatization have not been studied in the context of adjustment with hereditary breast cancer. The present study, therefore, explored associations of personal resources and stigma with cancer-specific anxiety in female BRCA1/2-carriers within a cross-sectional multi-center study. Participants (n = 237) had received carrier notification between 4 months and 8 years before data collection and experienced a low level of cancer-related anxiety on average. Younger age was associated with both higher perceptions of stigma (P = .002) and cancer-specific anxiety (P = .034). Time since receiving test results, affected status, having undergone prophylactic mastectomy or prophylactic oophorectomy was not associated with demographic or psychological variables. Global self-esteem (P = .002) and mastery (P < .001) were associated with fewer intrusive and avoidant thoughts, whereas stigma was associated with more (P < .001). Time since test result receipt did not moderate relations of self-esteem, mastery or stigma and cancer-specific anxiety. Cancer-specific anxiety did not vary as a function of time since carrier notification. Hence cancer-specific distress may be explained by past and ongoing experiences of cancer in the family rather than by the time point of carrier notification. Psychological interventions may benefit from specifically addressing feelings of stigmatization, and promoting self-worth and personal control in order to affect cancer-specific anxiety.

Hospice nurses and genetics: implications for end-of-life care

AIM

The overall aim of this study is to determine hospice nurses' perception of the importance of genetics to hospice care provision and their personal level of confidence in carrying out genetics-related activities within an end-of-life care context.

BACKGROUND

Hospices nurses regularly care for patients and their families affected by inherited genetic conditions (e.g. some cancers). Therefore, nurses need knowledge and awareness of the implications of genetic conditions and confidence in their abilities to provide appropriate care and support for patients and families.

DESIGN

Survey.

METHOD

Questionnaires were sent to a stratified sample of hospice nurses (n = 1149) in England and Wales. Using Likert scales, nurses were asked to rate the importance of and their confidence in undertaking a range of scenario-based activities that accompany caring for a patient and family affected by a genetic condition in the hospice setting. Open questions invited comments on their experiences of nursing patient/family in similar situations. Follow-up telephone interviews were carried out with hospice nurse educators to explore emerging issues.

RESULTS

Response rate was 29% (n = 328). Hospice nurses felt that all aspects of genetics-related care were 'very important' to hospice care, but lacked confidence in their ability to carry out the activities. Many respondents had not considered the relevance of genetics to hospice-care prior to completing the questionnaire but now considered it essential to end-of-life care even if they were not confident to provide it.

CONCLUSION

Hospice nurses' need genetics education focusing on the psychosocial implications of caring for patients and families affected by genetic conditions to enable them to provide the complex care and support in face of the difficult issues that arise in practice.

RELEVANCE TO CLINICAL PRACTICE

This study highlights the genetics education needs of hospice nurses in providing end-of life care for patients and their families affected by inherited genetic conditions.

Women's constructions of the 'right time' to consider decisions about risk-reducing mastectomy and risk-reducing oophorectomy

BACKGROUND

Women who are notified they carry a BRCA1/2 mutation are presented with surgical options to reduce their risk of breast and ovarian cancer, including risk-reducing mastectomy (RRM) and risk-reducing oophorectomy (RRO). Growing evidence suggests that a sub-group of women do not make decisions about RRM and RRO immediately following genetic testing, but rather, consider these decisions years later. Women's perspectives on the timing of these decisions are not well understood. Accordingly, the purpose of this research was to describe how women construct the 'right time' to consider decisions about RRM and RRO.

METHODS

In-depth interviews were conducted with 22 BRCA1/2 carrier women and analyzed using qualitative, constant comparative methods.

RESULTS

The time that lapsed between receipt of genetic test results and receipt of RRM or RRO ranged from three months to nine years. The findings highlighted the importance of considering decisions about RRM and RRO one at a time. The women constructed the 'right time' to consider these decisions to be when: (1) decisions fit into their lives, (2) they had enough time to think about decisions, (3) they were ready emotionally to deal with the decisions and the consequences, (4) all the issues and conflicts were sorted out, (5) there were better options available, and (6) the health care system was ready for them.

CONCLUSIONS

These findings offer novel insights relevant to health care professionals who provide decision support to women considering RRM and RRO.

What facilitates or impedes family communication following genetic testing for cancer risk? A systematic review and meta-synthesis of primary qualitative research

To systematically review and meta-synthesise primary qualitative research findings regarding family communication following genetic testing of cancer risk, in order to inform development of effective interventions. Systematic searches of CINAHL, Embase, Medline, British Nursing Index and PsycINFO databases were undertaken and relevant studies identified using strict criteria. The selected primary qualitative studies were appraised for quality and relevance by three independent researchers and then synthesized using a "Framework" approach. Fourteen (4.3%) studies met the inclusion criteria. The following factors influenced family communication following genetic testing for late-onset hereditary cancer: the informant's feelings about informing relatives about genetic testing; the perceived relevance of the information to other family members and their anticipated reactions; the "closeness" of relationships within the family; family rules and patterns (e.g., who is best placed to share information with whom); finding the right time and level of disclosure; and the supportive role of heath care professionals. The themes identified in this review could provide practitioners with a useful framework for discussing family communication with those undergoing genetic testing. This framework focuses on helping health care professionals to facilitate family communication. The next step will be the development of an intervention to directly support people in talking to their relatives.

Living with genetic test results for hereditary breast and ovarian cancer

PURPOSE

To examine adaptation by nonsymptomatic individuals who knew the results of a genetic test for hereditary breast and ovarian cancer (HBOC) for at least 4 years.

DESIGN

Longitudinal grounded theory study.

METHODS

Follow-up interviews after a 3- to 4-year interval were conducted by telephone or e-mail with seven asymptomatic participants originally recruited for an earlier study of genetic testing experiences. A total of 14 interviews, 2 for each participant were conducted. Conceptual analysis on these 14 interviews focused on impact on daily life and health behavior decisions made in the intervening years.

FINDINGS

Participants described the impact of the result and adaptations made in relationships, sexuality, outlook, and plans for the future. Participants accepted recommended surveillance and preventative measures to maximize a healthy lifestyle and reported both the benefits of knowing their mutation status as well as challenges they had encountered since testing.

CONCLUSIONS

Adaptation to living with genetic test results indicating a disease-related mutation is an ongoing process of balancing the knowledge of risk with living a normal life. Over time, awareness of genetic risk does not appear to diminish.

CLINICAL RELEVANCE

Positive and negative long-term consequences of genetic testing for hereditary breast or ovarian cancer may influence many aspects of the personal lives and health care decisions of those tested.

Genetics: breast cancer as an exemplar

Genetic testing for adult-onset diseases is now available. One such test is for the mutations present in the BRCA gene that result in a significantly higher risk for the development of breast cancer or ovarian cancer. Women who have one of these mutations face difficult choices in terms of increased surveillance or prophylactic surgeries. Examining experiences of women with BRCA mutations can serve as an exemplar for other populations at risk for genetically associated adult-onset diseases.

The effect of BRCA gene testing on family relationships: A thematic analysis of qualitative interviews

Discovery of mutations in the breast and ovarian cancer susceptibility genes BRCA1 and BRCA2 can have emotional consequences for both the tested individual and his or her relatives. This secondary analysis study investigated how BRCA testing impacts family dynamics and relationships. For the original study, a grounded theory inquiry, participants were recruited from a hereditary breast/ovarian cancer syndrome support website and open-ended interviews were performed asking about individual and family experiences after BRCA testing. All 12 participants whose interviews were included in the secondary analysis had a BRCA mutation. For the secondary analysis, thematic analysis was conducted and revealed three main themes characterizing the effect of BRCA testing on family relationships: 1. That the first in the family to have testing or seek genetic counseling takes on a special family role that can be difficult for them; 2. That discussions in the family often change; and 3. That individuals may feel more or less connected to certain family members. These changes seemed to relate to family cancer history, relationships, coping strategies, communication patterns, and mutation status. Genetic counselors might find it useful to explore these issues in order to prepare clients before BRCA testing and to support them through shifts in family dynamics after disclosure of results.

Formal and informal support needs of young women with BRCA mutations

This qualitative investigation aims to identify the salient support concerns of young women with BRCA mutations, a frequently understudied population with unique developmental, psychosocial, and family needs. Twenty-three unaffected BRCA gene alteration carriers aged 21 to 36 completed illness genograms and open-ended interviews. Transcripts were analyzed using the Listening Guide to highlight key themes, relationships, and meaning structures. Results reveal existing social support networks composed of family, partners, friends, and coworkers are often inadequate and formal services unavailable or underutilized. These findings suggest an important role for clinicians in reducing isolation, bolstering existing support networks, and designing innovative, targeted interventions that address the challenges specific to this age group. Interventions, such as the multifamily support group, should be integrated into genetic counseling protocols to mitigate the risk of distress.

Survivorship considerations in adults with hereditary breast and ovarian cancer syndrome: state of the science

INTRODUCTION

Five to 10% of breast cancers are caused by inherited mutations of the BRCA1/2 genes. Knowledge of inherited risk for cancer has potential for psychosocial consequences. The purpose of this review is to determine the survivorship concerns of women with mutations of BRCA1/2; with and without a diagnosis of cancer.

METHODS

The search strategy included a search of CINAHL, PsycINFO, Medline, Pubmed, and Cochrane databases to identify research reports with specific aims of determining physical, psychosocial or spiritual outcomes of genetic testing for breast and ovarian cancer syndrome in adults at high risk for BRCA1/2 mutations. The identified studies were analyzed by design, sampling, and outcome measures. They were categorized by domain and main findings by domain are summarized.

RESULTS

One systematic review, ten qualitative and 27 quantitative studies met the inclusion criteria. Four theoretical frameworks were identified.

DISCUSSION/CONCLUSIONS

Survivorship concerns were multidimensional and included issues related to risk reduction procedures, psychological and emotional impacts, and impact on family and social relationships. Many adults experience temporary distress after receipt of positive BRCA1/2 testing. Usually the distress is not clinically significant, however support is desired from health professionals, others who have a BRCA1/2 mutation, and family as decisions are made regarding screening and risk-reducing options. Social relationships are impacted as information is communicated to family members. Limitations of the current state of the science, opportunities to build evidence for the future and implications for nursing practice and education are identified.

Sisters in hereditary breast and ovarian cancer families: communal coping, social integration, and psychological well-being

OBJECTIVE

We investigated the association between psychological distress and indices of social integration and communal coping among sisters from hereditary breast and ovarian cancer (HBOC) families.

SAMPLE AND METHODS

Sixty-five sisters from 31 HBOC families completed the Brief Symptom Inventory-18 and the Colored Eco-Genetic Relationship Map, which identified members of participants' social support networks. Hierarchical linear models were used for all analyses to account for the clustering of sisters within families.

RESULTS

Intra-family correlation coefficients suggested that sisters shared perceptions of breast cancer risk and worry, but not ovarian cancer risk and worry. Further, sisters demonstrated shared levels of anxiety and somatization, but not depressive symptoms. Communal coping indices quantifying shared support resources were negatively related to anxiety and somatization. The number of persons with whom cancer risk information was shared exhibited a positive trend with somatization. Social integration, as measured by the size of participants' emotional support network, was negatively associated with anxiety. Lower depression scores were observed among participants with more persons playing multiple support roles and fewer persons providing tangible assistance.

CONCLUSION

Understanding how support relationships impact well-being among persons adjusting to HBOC risk, and the particular role of family in that process, will facilitate developing appropriate management approaches to help cancer-prone families adjust to their cancer risk.

The emotional effects of genetic diseases: implications for clinical genetics

The aim of this qualitative study was to explore the emotional effects that may be common to many genetic conditions, or risk of genetic conditions, that could be appropriately targeted by clinical genetics services. The study sample comprised 52 individuals. Seven focus groups with patients of clinical genetics services, their representatives from patient support organizations and genetics healthcare providers were conducted. Focus groups were supplemented by 19 face-to-face interviews with patients and patient group representatives. Focus groups and interviews were audio taped, transcribed in full, and analyzed using the constant comparative method. Eight emotional effects of genetic diseases were identified: anxiety, worry about risks to children, guilt, anger, uncertainty, sadness and grief, depression, and redemptive adjustment. Two factors were identified that could modify the emotional effects; these were variability of genetic diseases, and lack of diagnosis/inappropriate care. Despite many negative effects of genetic disease being identified, results also suggest that redemptive adjustment is possible where a genetic condition is present in a family. Interventions designed to (1) adjust the modifying conditions and (2) help manage the emotional effects may facilitate adjustment and improve patient outcomes.

Focus group approach for developing written patient information in oncogenetics

We report our experience in developing written patient information in the field of genetic oncology using a focus group approach. A scientific document addressing the issue about the finding of negative (i.e., inconclusive) results in BRCA1/2 diagnostic genetic testing was elaborated in three stages. The initial version written by a scientific committee was discussed in two focus group sessions, and then rewritten to incorporate the comments and suggestions collected. The discussions during focus group meetings were analyzed using a specific analysis grid exploring five dimensions. The input provided from the focus group greatly improved the initial version, leading to the production of a document containing appropriate scientific information that was accessible to patients. Focus groups are useful tools for developing good-quality documents in the complex setting of genetic oncology.

Picking a frame for communicating about genetics: stigmas or challenges

Currently, one may describe awareness of genomics as limited, but growing in the US. Although awareness is limited, the US public expresses great concern that genomics could result in stigmatization and discrimination (Reproductive genetic testing: What America thinks. Washington, DC: Genetics and Public Policy Center, 2004). This situation provides a rare opportunity to think carefully about how to design communication to a general public in ways that galvanize positive sentiments around genomics instead of stimulate stigmas. This manuscript provides a synthesis of communication theories relevant to framing genomics in stigma and challenge formats, the details necessary to understand what such messages look like, and an illustration of the two frames. Many people in different roles are engaging in these conversations in many different contexts. Through the growing exposure and interest in genomics, the opportunity to proactively script messages to form beliefs and attitudes about genomics, instead of managing pre-existing ones, may disappear quickly.