Assessing perceptions of cancer risk: does mode of assessment or numeracy matter?

Impact of numeracy on understanding of prostate cancer risk reduction in PSA screening

Prostate-specific antigen (PSA) screening for prostate cancer in men of average risk remains controversial. Patients' ability to incorporate risk reduction data into their decision-making may depend on their numeracy. We assessed the impact of patients' numeracy on their understanding of the risk reduction benefits of PSA screening. Men attending a general internal medicine clinic were invited to complete a survey. Four versions of the survey each included a three-item numeracy test and PSA risk reduction data, framed one of four ways: absolute (ARR) versus relative risk reduction (RRR), with or without baseline risk (BR). Respondents were asked to adjust their perceived risk of prostate-cancer mortality using the data presented. Accuracy of risk reduction was evaluated relative to how risk data were framed. Among a total of 200 respondents, a majority incorrectly answered one or more of the numeracy items. Overall accuracy of risk adjustment was only 20%. Accuracy varied with data framing: when presented with RRR, respondents were 13% accurate without BR and 31% accurate with BR; when presented with ARR, they were 0% accurate without BR and 35% accurate with BR. Including BR data significantly improved accuracy for both RRR (P = 0.03) and ARR groups (P < 0.01). Accuracy was significantly related to numeracy; numeracy scores of 0, 1, 2, and 3 were associated with accuracy rates of six, five, nine, and 36 percent, respectively (P < 0.01). Overall, numeracy was significantly associated with the accuracy of interpreting quantitative benefits of PSA screening. Alternative methods of communicating risk may facilitate shared decision-making in the use of PSA screening for early detection of prostate cancer.

Diabetes prevention among American Indians: the role of self-efficacy, risk perception, numeracy and cultural identity

Background

According to the Risk Perception Attitude (RPA) framework, classifying people according to their perceptions of disease risk and their self-efficacy beliefs allows us to predict their likelihood for engaging in preventive behaviors. Health interventions can then be targeted according to RPA group. We applied the framework to type 2 diabetes prevention behaviors among American Indians and expanded it to include culture and numeracy.

Methods

Using a cross-sectional study design, we surveyed a sample of Northern Plains American Indians in a reservation community setting on self-reported perceptions of diabetes risk, objective diabetes risk, self-efficacy, engagement in healthy behaviors, knowledge of diabetes risk factors, and covariates including demographics, numeracy, and cultural identity. We used the RPA framework to classify participants into four groups based on their perceptions of risk and self-efficacy. Analyses of variance and covariance estimated inter-group differences in behaviors associated with type 2 diabetes prevention.

Results

Among 128 participants, our only finding consistent with the RPA framework was that self-efficacy and risk perception predicted knowledge about diabetes risk factors. We found limited evidence for the influence of cultural identity within the RPA framework. Overall, participants had lower numeracy skills which tended to be associated with inaccurate perceptions of higher levels of risk.

Conclusions

The theoretical framework may benefit from inclusion of further contextual factors that influence these behaviors. Attention to numeracy skills stands out in our study as an important influence on the RPA framework, highlighting the importance of attending to numeracy when targeting and tailoring risk information to participants segmented by the RPA framework.

Great expectations: patient perspectives and anticipated utility of non-diagnostic genomic-sequencing results

The management of secondary findings is a challenge to health-care providers relaying clinical genomic-sequencing results to patients. Understanding patients' expectations from non-diagnostic genomic sequencing could help guide this management. This study interviewed 14 individuals enrolled in the eMERGE (Electronic Medical Records and Genomics) study. Participants in eMERGE consent to undergo non-diagnostic genomic sequencing, receive results, and have results returned to their physicians. The interviews assessed expectations and intended use of results. The majority of interviewees were male (64%) and 43% identified as non-Caucasian. A unique theme identified was that many participants expressed uncertainty about the type of diseases they expected to receive results on, what results they wanted to learn about, and how they intended to use results. Participant uncertainty highlights the complex nature of deciding to undergo genomic testing and a deficiency in genomic knowledge. These results could help improve how genomic sequencing and secondary findings are discussed with patients.

How Well Do Customers of Direct-to-Consumer Personal Genomic Testing Services Comprehend Genetic Test Results? Findings from the Impact of Personal Genomics Study

AIM

To assess customer comprehension of health-related personal genomic testing (PGT) results.

METHODS

We presented sample reports of genetic results and examined responses to comprehension questions in 1,030 PGT customers (mean age: 46.7 years; 59.9% female; 79.0% college graduates; 14.9% non-White; 4.7% of Hispanic/Latino ethnicity). Sample reports presented a genetic risk for Alzheimer's disease and type 2 diabetes, carrier screening summary results for >30 conditions, results for phenylketonuria and cystic fibrosis, and drug response results for a statin drug. Logistic regression was used to identify correlates of participant comprehension.

RESULTS

Participants exhibited high overall comprehension (mean score: 79.1% correct). The highest comprehension (range: 81.1-97.4% correct) was observed in the statin drug response and carrier screening summary results, and lower comprehension (range: 63.6-74.8% correct) on specific carrier screening results. Higher levels of numeracy, genetic knowledge, and education were significantly associated with greater comprehension. Older age (≥ 60 years) was associated with lower comprehension scores.

CONCLUSIONS

Most customers accurately interpreted the health implications of PGT results; however, comprehension varied by demographic characteristics, numeracy and genetic knowledge, and types and format of the genetic information presented. Results suggest a need to tailor the presentation of PGT results by test type and customer characteristics.

Understanding patient and provider perceptions and expectations of genomic medicine

Advances in genome sequencing technology have fostered a new era of clinical genomic medicine. Genetic counselors, who have begun to support patients undergoing multi-gene panel testing for hereditary cancer risk, will review brief clinical vignettes, and discuss early experiences with clinical genomic testing. Their experiences will frame a discussion about how current testing may challenge patient understanding and expectations toward the evaluation of cancer risk and downstream preventive behaviors.

Effects of patient-provider race concordance and smoking status on lung cancer risk perception accuracy among African-Americans

BACKGROUND

Communication of lung cancer risk information between providers and African-American patients occurs in a context marked by race-based health disparities.

PURPOSE

A controlled experiment assessed whether perceived physician race influenced African-American patients' (n = 127) risk perception accuracy following the provision of objective lung cancer risk information.

METHODS

Participants interacted with a virtual reality-based, simulated physician who provided personalized cancer risk information.

RESULTS

Participants who interacted with a racially discordant virtual doctor were less accurate in their risk perceptions at post-test than those who interacted with a concordant virtual doctor, F(1,94) = 4.02, p = .048. This effect was amplified among current smokers. Effects were not mediated by trust in the provider, engagement with the health care system, or attention during the encounter.

CONCLUSIONS

The current study demonstrates that African-American patients' perceptions of a doctor's race are sufficient to independently impact their processing of lung cancer risk information.

Behavioral and psychosocial responses to genomic testing for colorectal cancer risk

We conducted a translational genomic pilot study to evaluate the impact of genomic information related to colorectal cancer (CRC) risk on psychosocial, behavioral and communication outcomes. In 47 primary care participants, 96% opted for testing of three single nucleotide polymorphisms (SNPs) related to CRC risk. Participants averaged 2.5 of 6 possible SNP risk alleles (10% lifetime risk). At 3-months, participants did not report significant increases in cancer worry/distress; over half reported physical activity and dietary changes. SNP risk scores were unrelated to behavior change at 3-months. Many participants (64%) shared their SNP results, including 28% who shared results with a physician. In this pilot, genomic risk education, including discussion of other risk factors, appeared to impact patients' health behaviors, regardless of the level of SNP risk. Future work can compare risk education with and without SNP results to evaluate if SNP information adds value to existing approaches.

Risk perception among Brazilian individuals with high risk for colorectal cancer and colonoscopy

Background

Risk perception is considered a motivating factor for adopting preventive behaviors. This study aimed to verify the demographic characteristics and cancer family history that are predictors of risk perception and to verify if risk perception is a predictor of colonoscopy adherence.

Methods

Individuals with a family colorectal cancer history as indicated by a proband with cancer were interviewed by telephone. They responded to a questionnaire covering demographic characteristics, colonoscopy history and four questions on risk perception. Tests of multiple linear regression and logistic regression were used to identify associations between dependent and independent variables.

Results

The 117 participants belonged to 62 families and had a mean age of 45.2 years. The majority of these individuals were female (74.4%) and from families who met the Amsterdam Criteria (54.7%). The average risk perception was 47.6%, with a median of 50%. The average population perception of individual risk was 55.4%, with a median of 50%. Variables associated with a higher risk perception were age, gender, religion, school level, income, and death of a family member. The variable predicting colonoscopy was receiving medical information regarding risk (odds ratio OR 8.40).

Conclusions

We found that family cancer history characteristics (number of relatives with cancer, risk classification) are associated with adequate risk perception. Risk perception does not predict colonoscopy in this sample. The only variable that predicted colonoscopy was receiving medical information recommending screening.

The general public's understanding and perception of direct-to-consumer genetic test results

BACKGROUND/AIMS

Direct-to-consumer (DTC) genetic testing allows consumers to discover their risk for common complex disorders. The extent to which consumers understand typical results provided by DTC genetic testing is currently unknown. Misunderstanding of the results could lead to negative consequences including unnecessary concern, false reassurance or unwarranted changes in screening behaviors. We conducted a study to investigate consumers' perceptions and understanding of DTC test results.

METHODS

An online survey was posted on Facebook that included questions relating to 4 sample test results for risk of developing colorectal cancer, heart disease and skin cancer. Genetic counselors were used as a comparison group.

RESULTS

145 individuals from the general public and 171 genetic counselors completed the survey. A significant difference was found between the way the general public and genetic counselors interpreted the meaning of the DTC results. The general public respondents also believed that results in all 4 scenarios would be significantly more helpful than the genetic counselors did. Although the majority of general public respondents rated the results as easy to understand, they often misinterpreted them.

CONCLUSIONS

These findings imply that the general public has the potential to misinterpret DTC results without appropriate assistance. Further research is needed to explore optimal methods of providing DTC test results and ways to minimize the risk of negative consequences for consumers.

Uncertainty in assessing value of oncology treatments

Patients, clinicians, payers, and policymakers face an environment of significant evidentiary uncertainty as they attempt to achieve maximum value, or the greatest level of benefit possible at a given level of cost in their respective health care decisions. This is particularly true in the area of oncology, for which published evidence from clinical trials is often incongruent with real-world patient care, and a substantial portion of clinical use is for off-label indications that have not been systematically evaluated. It is this uncertainty in the knowledge of the clinical harms and benefits associated with oncology treatments that prevents postregulatory decision makers from making accurate assessments of the value of these treatments. Because of the incentives inherent in the clinical research enterprise, randomized control trials (RCTs) are designed for the specific purpose of regulatory approval and maximizing market penetration. The pursuit of these goals results in RCT study designs that achieve maximal internal validity at the expense of generalizability to diverse real-world patient populations that may have significant comorbidities and other clinically mitigating factors. As such, systematic reviews for the purposes of coverage and treatment decisions often find relevant and high-quality evidence to be limited or nonexistent. For a number of reasons, including frequent off-label use of medications and the expedited approval process for cancer drugs by the U.S. Food and Drug Administration, this situation is exacerbated in the area of oncology. This paper investigates the convergence of incentives and circumstances that lead to widespread uncertainty in oncology and proposes new paradigms for clinical research, including pragmatic clinical trials, methodological guidance, and coverage with evidence development. Each of these initiatives would support the design of clinical research that is more informative for postregulatory decision makers, and would therefore reduce uncertainty and provide greater confidence in conclusions about the value of these treatments.

Genetic counselling and genetic testing in hereditary gastrointestinal cancer syndromes

Up to 10% of cancers are caused by inherited mutations in single genes. The process of genetic counselling and genetic testing allows for identification of these high-risk individuals and their at risk family members and enrolment into appropriate screening protocols. The medical impact of genetic testing is evidenced by reduced morbidity and mortality, however, the impact on a personal or psychosocial level has been more difficult to evaluate. We present a review of the current literature regarding the role of genetic counselling and testing in the setting of gastrointestinal cancers and explore several related issues including risk perception and risk communication, family communication, psychosocial factors and decision making, and family planning. We also provide guidelines for referral to cancer genetics clinics and for promoting discussions about genetic counselling and genetic testing.

Cancer risk and risk communication in urban, lower-income neighborhoods

OBJECTIVES

Family history of cancer is an important risk factor for the disease, and communicating with family and physicians about family history is critical to cancer risk assessment. This study examined cancer risk communication with family and physicians.

METHODS

A telephone interview was administered to randomly selected participants (n=217) from 5 urban, lower-income communities in 2006 and 2007. A large proportion of the population were minorities and of lower socio-economic status (47% African American, 43% incomes <$25,000). Most (76%) believed family history was important, and approximately half talked to their family (50%) or their physician (49%) about their cancer risk.

RESULTS

Respondents were equally likely as family members to initiate discussions about cancer risk, but respondents were more likely to initiate discussions with physicians. Logistic regression models were fit to talk to family, talk to physician, and perceived risk. In multivariable analysis, higher income and greater worry were associated with talking to family about risk, and higher income was associated with talking to physician about risk. Gender, family history and worry were associated with greater perceived risk.

CONCLUSION

Efforts to decrease income barriers to cancer risk communication are needed.

Numeracy and communication with patients: they are counting on us

Patient-centered interactive communication between physicians and patients is recommended to improve the quality of medical care. Numerical concepts are important components of such exchanges and include arithmetic and use of percentages, as well as higher level tasks like estimation, probability, problem-solving, and risk assessment--the basis of preventive medicine. Difficulty with numerical concepts may impede communication. The current evidence on prevalence, measurement, and outcomes related to numeracy is presented, along with a summary of best practices for communication of numerical information. This information is integrated into a hierarchical model of mathematical concepts and skills, which can guide clinicians toward numerical communication that is easier to use with patients.