Psychological and social predictors of decisions about genetic testing for breast cancer in high-risk women

Predictors of recruited melanoma families into a behavioral intervention project

BACKGROUND

Examination of families represents an important priority in health research. In this paper we report on individual and family-level factors associated with enrollment in a cancer prevention research project. We approached families affected by melanoma for possible participation in a randomized controlled trial of a web-based communication and support intervention.

METHODS

We recruited three family members per family for assessment - the melanoma case, a first-degree relative (FDR), and a relative who is a parent of a child age 18 or younger. Recruitment involved three steps: requesting the physician's consent to approach the melanoma case, approaching the case to request their participation and family contact information, and they approaching the FDRs and parents.

RESULTS

Of the 1380 families approached, 313 were enrolled, 263 were excluded because we could not find or contact a family member (FDR or parent), 331 did not have eligible family members, and 473 refused. The most frequently noted reason for refusal was being too busy or having no time. The primary predictors of participation for cases (OR=1.6; CI=1.01-2.51) and FDRs (OR=2.15; CI=1.11-4.13) included higher educational attainment. FDRs were more likely to enroll if they were female (OR=1.77; CI=1.1-.85) and parents were more likely to enroll if the case had been diagnosed more recently (OR=3.3; CI=1.9-5.93), if the parent was partnered (OR=4.37; CI=1.86-10.26), and if the parent lived in the same city as the case (OR=2.88; CI=1.08-7.68).

CONCLUSIONS

The results can provide information on potential directions for future family recruitment.

Beating the biological clock: the compressed family life cycle of young women with BRCA gene alterations

Empirical and clinical literature suggests a temporal thread running through family narratives of hereditary disease, linking past experiences to current beliefs about risk. This study asked young women with elevated risk of developing hereditary breast or ovarian cancer (HBOC) how their family histories with cancer and their gene status inform meaning construction around cancer risk and family development. Twenty-three women aged 22-35 who carry a BRCA gene alteration completed illness genograms and open-ended, narrative interviews. Transcripts were analyzed using the Listening Guide, a narrative tool that emphasizes key themes, meanings, and relational structures. Data analysis revealed distinct priorities for (1) single versus partnered women and (2) women who wished to have children versus those who had completed childbearing or were not intending to have children. Findings suggest single women experience increased urgency at finding a life partner capable of handling the emotional strain of the cancer world and open to pursuing multiple paths toward parenthood. Further, participants' family experiences shaped beliefs about perceived time to achieve desired family goals, specifically having biological children, before a cancer diagnosis or the need for preventive surgery. Clinical practice and research implications are discussed.

Uptake rates for breast cancer genetic testing: a systematic review

PURPOSE

Individuals and families dealing with the possibility of hereditary cancer risk face numerous decisions, including whether to obtain genetic testing. The purpose of this article is to determine what is known about the rate at which people obtain cancer genetic testing.

METHODS

Using MEDLINE, CINAHL, and PSYCHINFO plus reviewing reference lists of relevant articles, we identified 40 studies in May 2002 that addressed breast cancer-related decisions, enrolled adult participants, were published in 1990 or more recently, were peer-reviewed primary clinical studies, addressed genetic testing either alone or in combination with genetic counseling, and reported rates at which participants showed interest in and/or underwent cancer genetic testing. Information regarding study design, participants, and genetic testing uptake rates was recorded. Each article was reviewed for methodologic quality using a flexible quality review system applicable to all study types.

RESULTS

Of the 40 studies, 25 provided information about hypothetical genetic testing decisions, 14 about real decisions, and 1 about both. Mean hypothetical uptake was 66% (range, 20-96%) and real uptake was 59% (range, 25-96%). Multivariate logistic regression analyses found that decision type (real/hypothetical), personal and family history of breast cancer, and variability in sampling strategy, recruitment setting, and criteria for real and hypothetical uptake were independently associated with uptake. Our systematic review identified additional explanations for uptake variability (investigator influences, small sample sizes, variability in target populations, lack of clearly described sampling strategies, sampling methods open to bias, and variability in reporting associated risk factors).

CONCLUSION

In addition to clinical characteristics, research methodologic issues are likely to be major determinants of variability in published breast cancer genetic testing uptake rates. An understanding of these issues will clarify to clinicians why their clinical experience may not be congruent with published rates and help guide future research.

Genetic susceptibility testing from a stress and coping perspective

Four theories of health behavior and of stress and coping are reviewed for their ability to illuminate interest in uptake and outcomes of genetic testing for adult-onset diseases. These theories are the Health Belief Model, the Theory of Planned Behavior (TPB), the Common Sense Model of Self-regulation (CSM), and the Transactional Model of Stress and Coping (TMSC). Basic concepts of each theory are discussed, followed by evidence from the literature supporting the relevance of these concepts to the understanding of genetic testing for four adult-onset diseases: Huntington's disease, Alzheimer's disease, hereditary breast/ovarian cancer, and hereditary colorectal cancer. Emphasis is placed on the finding that a decision to undergo genetic testing may be considered as a way to cope with both the cognitive and affective concerns that arise from living at increased risk of developing a disease in the future. The potential value of genetic testing for reducing uncertainty about and gaining a sense of control over one's risk of developing a chronic disease is highlighted. We argue that theories which focus on stress and coping provide a useful framework for future studies of genetic testing decisions for adult-onset disease risk.

Some problems with social cognition models: a pragmatic and conceptual analysis

Empirical articles published between 1997 and 2001 from 4 health psychology journals that tested or applied 1 or more social cognition models (theory of reasoned action, theory of planned behavior, health belief model, and protection motivation theory; N = 47) were scrutinized for their pragmatic and conceptual basis. In terms of their pragmatic basis, these 4 models were useful for guiding research. The analysis of their conceptual basis was less positive. First, these models do not enable the generation of hypotheses because their constructs are unspecific; they therefore cannot be tested. Second, they focus on analytic truths rather than synthetic ones, and the conclusions resulting from their application are often true by definition rather than by observation. Finally, they may create and change both cognitions and behavior rather than describe them.

Attitudes toward genetic testing in patients at risk for HNPCC/FAP and the German population

Adequate knowledge regarding hereditary diseases and genetics, as well as personal attitudes toward gene tests, are major determinants of optimal utilization of genetic testing. In the present study, we aimed to explore the general attitudes toward genetic testing in a sample representative of the German general population (n = 2,076) and to compare the attitudes of persons at risk for hereditary non-polyposis colorectal cancer/familial adenomatous polyposis (HNPCC/FAP) (n = 36) who had attended a university genetic counseling service, with a matched general population sample. We administered a subset of a questionnaire previously used in a Finnish study (Jallinoja et al., 1998). The 12 statements pertain to approval, disapproval, and concern for genetic testing. Overall, the results reveal high approval of genetic testing in the German population and in at-risk persons. In accordance with other studies, we find that the attitudes of individuals for whom hereditary disease is a salient issue of personal relevance and the attitudes of the general public are very similar. Only a few significant differences between these two samples emerged, indicating that at-risk persons hold a more favourable view of the testing. One intriguing finding was the high rate of "don't know" responses, especially in the general population sample. Compared to results from Finland, approval of genetic testing is lower in the German population, and endorsement of "don't knows" is remarkably higher. We argue for increased attention to the issue of attitude change after genetic counseling and for the need of comparative cross-cultural research on attitudes toward gene technology.