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Tiller JM, Stott A, Finlay K, Boughtwood T, Madelli EO, Horton A, Winship I, Nowak K, Otlowski M. Direct notification by health professionals of relatives at-risk of genetic conditions (with patient consent): views of the Australian public. Eur J Hum Genet 2024; 32:98-108. [PMID: 37280361 PMCID: PMC10242214 DOI: 10.1038/s41431-023-01395-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/27/2023] [Accepted: 05/16/2023] [Indexed: 06/08/2023] Open
Abstract
Genetic risk information for medically actionable conditions has relevance for patients' blood relatives. However, cascade testing uptake in at-risk families is <50%, and the burden of contacting relatives is a significant barrier to dissemination of risk information. Health professionals (HPs) could notify at-risk relatives directly, with patients' consent. This practice is supported by international literature, including strong public support. However, there is little exploration of the Australian public's views about this issue. We surveyed Australian adults using a consumer research company. Respondents were provided a hypothetical scenario and asked about views and preferences regarding direct contact by HPs. 1030 members of the public responded, with median age 45 y and 51% female. The majority would want to be told about genetic risk for conditions that can be prevented/treated early (85%) and contacted directly by a HP (68%). Most preferred a letter that included specific information about the genetic condition in the family (67%) and had no privacy concerns about HPs sending a letter using contact details provided by a relative (85%). A minority (< 5%) had significant privacy concerns, mostly about use of personal contact information. Concerns included ensuring information was not shared with third parties. Almost 50% would prefer that a family member contacted them before the letter was sent, while about half did not prefer this or were unsure. The Australian public supports (and prefers) direct notification of relatives at risk of medically actionable genetic conditions. Guidelines would assist with clarifying clinicians' discretion in this area.
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Affiliation(s)
- Jane M Tiller
- Australian Genomics, Parkville, VIC, Australia.
- Murdoch Children's Research Institute, Parkville, VIC, Australia.
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Ami Stott
- Australian Genomics, Parkville, VIC, Australia
| | - Keri Finlay
- Australian Genomics, Parkville, VIC, Australia
- Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Tiffany Boughtwood
- Australian Genomics, Parkville, VIC, Australia
- Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Evanthia O Madelli
- Australian Genomics, Parkville, VIC, Australia
- Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Ari Horton
- Department of Paediatrics, Monash University, Clayton, VIC, Australia
- Department of Genomic Medicine, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Ingrid Winship
- Department of Genomic Medicine, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Kristen Nowak
- Office of Population Health Genomics, WA Department of Health, East Perth, WA, Australia
| | - Margaret Otlowski
- Centre for Law and Genetics, University of Tasmania, Hobart, TAS, Australia
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2
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Dheensa S, Feder G. Sharing information about domestic violence and abuse in healthcare: an analysis of English guidance and recommendations for good practice. BMJ Open 2022; 12:e057022. [PMID: 35710255 PMCID: PMC9207756 DOI: 10.1136/bmjopen-2021-057022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Over two million adults experience domestic violence and abuse (DVA) in England and Wales each year. Domestic homicide reviews often show that health services have frequent contact with victims and perpetrators, but healthcare professionals (HCPs) do not share information related to DVA across healthcare settings and with other agencies or services. AIM We aimed to analyse and highlight the commonalities, inconsistencies, gaps and ambiguities in English guidance for HCPs around medical confidentiality, information sharing or DVA specifically. SETTING The English National Health Service. DESIGN AND METHOD We conducted a desk-based review, adopting the READ approach to document analysis. This approach is a method of qualitative health policy research and involves four steps for gathering, and extracting information from, documents. Its four steps are: (1) Ready your materials, (2) Extract data, (3) Analyse data and (4) Distill your findings. Documents were identified by searching websites of national bodies in England that guide and regulate clinical practice and by backwards citation-searching documents we identified initially. RESULTS We found 13 documents that guide practice. The documents provided guidance on (1) sharing information without consent, (2) sharing with or for multiagency risk assessment conferences (MARACs), (3) sharing for formal safeguarding and (4) sharing within the health service. Key findings were that guidance documents for HCPs emphasise that sharing information without consent can happen in only exceptional circumstances; documents are inconsistent, contradictory and ambiguous; and none of the documents, except one safeguarding guide, mention how coercive control can influence patients' free decisions. CONCLUSIONS Guidance for HCPs on sharing information about DVA is numerous, inconsistent, ambiguous and lacking in detail, highlighting a need for coherent recommendations for cross-speciality clinical practice. Recommendations should reflect an understanding of the manifestations, dynamics and effects of DVA, particularly coercive control.
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Affiliation(s)
- Sandi Dheensa
- Domestic Violence and Abuse Health Research Group, Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Gene Feder
- Domestic Violence and Abuse Health Research Group, Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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"Being proactive, not reactive": exploring perceptions of genetic testing among White, Latinx, and Pacific Islander Populations. J Community Genet 2021; 12:617-630. [PMID: 34415555 DOI: 10.1007/s12687-021-00542-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 07/25/2021] [Indexed: 12/20/2022] Open
Abstract
Genetic testing is becoming an integral part of healthcare, but evidence suggests that both race and ethnicity influence access to and utilization of genetic testing. Given this barrier, data are needed on the perceptions of genetic testing in racial and ethnic minority groups. The purpose of this study was to explore the perceptions of three types of genetic testing (genetic testing for adult-onset conditions, prenatal screening, and newborn screening) in a sample of US participants who identified as White, Pacific Islander, and Latinx (10 dyads from each group for 60 participants total). Data were collected through semi-structured dyadic interviews and assessed using thematic analysis. The major themes were knowledge as empowering, knowledge as stressful, and predictive nature of prenatal testing and newborn screening. Some differences were seen in themes by race and ethnicity. A sense of collective and familial health appeared to be a more important theme for Pacific Islander and Latinx participants compared to White participants. Adult-onset genetic testing was viewed variously across all groups with some noting how it may increase anxiety, particularly if the disease screened for was unable to be prevented with action. All three groups reported on the positives of prenatal testing and newborn screening yet often were confused on the differences between them. This study presents novel perceptions of genetic testing in participants from diverse communities across three types of genetic testing. Genetic healthcare providers should incorporate participants' perceptions, values, and beliefs into their counseling delivery as a way to engage with diverse communities.
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Informing relatives at risk of inherited cardiac conditions: experiences and attitudes of healthcare professionals and counselees. Eur J Hum Genet 2019; 27:1341-1350. [PMID: 31053782 DOI: 10.1038/s41431-019-0410-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 04/02/2019] [Accepted: 04/16/2019] [Indexed: 02/08/2023] Open
Abstract
Inherited cardiac conditions (ICCs) can lead to sudden cardiac death at young age, even without previous symptoms, yet often remain undetected. To prevent sudden cardiac death, cardiac monitoring and/or predictive DNA testing is advised for at-risk relatives. Probands in whom a causal variant is detected are asked to inform their relatives about the possibility of testing, often supported by a family letter. This qualitative study investigates experiences with and attitudes toward this family-mediated approach in ICCs and explores whether and how improvements can be made. Two online focus groups were conducted with 28 healthcare professionals (HCPs) from various disciplines, as were 25 face-to-face semi-structured interviews with counselees (10 probands; 15 relatives). Data were analysed by two researchers independently using a thematic approach. Participants, both HCPs and counselees, preferred that probands inform relatives about genetic risks in ICCs, but both groups struggled with the dependency on and burden on probands to inform their relatives. To overcome this, HCPs do see a more active role for themselves in informing relatives, but prefer uniformity in procedures in order to maintain their workload. Counselees, on the other hand, prefer a tailored information provision strategy adjusted to family dynamics and the personality characteristics of relatives. In conclusion, although it is generally preferred that probands inform relatives themselves, a more active role of HCPs could be considered to overcome the dependency and burden on probands. Further research is needed to study how HCPs can engage more actively in informing at-risk relatives in current clinical genetic practise.
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d'Audiffret Van Haecke D, de Montgolfier S. Genetic diseases and information to relatives: practical and ethical issues for professionals after introduction of a legal framework in France. Eur J Hum Genet 2018; 26:786-795. [PMID: 29487415 PMCID: PMC5974143 DOI: 10.1038/s41431-018-0103-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 01/15/2018] [Accepted: 01/17/2018] [Indexed: 11/08/2022] Open
Abstract
Health professionals have a role to play in assisting patients to communicate genetic information to their relatives. In France, a specific unique legal framework has been implemented concerning this issue. We questioned professionals about their practice and how it has evolved in this new frame. The French law has opted to lay responsibility for disclosure on the person concerned by a positive test result, without totally excluding some responsibility on the part of the professionals involved, in the information to be disclosed and in the transmission of the information if a patient refuses to do it themselves (indirect disclosure). We designed and validated an online survey to be sent out to healthcare professionals to explore their practice and how they went about implementing the legal provisions. We also sought to determine how healthcare professionals dealt with a patient's refusal to disclose information to their relatives, and whether the legal framework was helpful. We carried out a statistical analysis of the responses to questionnaires to interpret the results by professional category, field of medicine and genetic disorder. The results show that professionals agreed on the relevance of disclosure to relatives. However, they show a range of practices and varying representations of the genetic issue in the framework of disclosure to relatives according to their medical field, their role in the health system and their own interpretations. They indicated a lack of resources, raised some ethical issues and put forward some arguments against contacting relatives themselves.
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Affiliation(s)
| | - Sandrine de Montgolfier
- Institut de Recherche Interdisciplinaire sur les enjeux Sociaux (IRIS), UMR 8156 CNRS - 997 Inserm-EHESS-UP 13, UFR SMBH 74 rue Marcel-Cachin, 93017 Bobigny Cedex 33, Créteil, France.
- Université Paris Est Créteil (UPEC), Créteil, France.
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Rainey L, van der Waal D, Jervaeus A, Wengström Y, Evans DG, Donnelly LS, Broeders MJM. Are we ready for the challenge of implementing risk-based breast cancer screening and primary prevention? Breast 2018. [PMID: 29529454 DOI: 10.1016/j.breast.2018.02.029] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Increased knowledge of breast cancer risk factors provides opportunities to shift from a one-size-fits-all screening programme to a personalised approach, where screening and prevention is based on a woman's risk of developing breast cancer. However, potential implementation of this new paradigm could present considerable challenges which the present review aims to explore. METHODS Bibliographic databases were searched to identify studies evaluating potential implications of the implementation of personalised risk-based screening and primary prevention for breast cancer. Identified themes were evaluated using thematic analysis. RESULTS The search strategy identified 5699 unique publications, of which 59 were selected for inclusion. Significant changes in policy and practice are warranted. The organisation of breast cancer screening spans several healthcare delivery systems and clinical settings. Feasibility of implementation depends on how healthcare is funded and arranged, and potentially varies between countries. Piloting risk assessment and prevention counselling in primary care settings has highlighted implications relating to the need for extensive additional training on risk (communication) and prevention, impact on workflow, and professionals' personal discomfort breaching the topic with women. Additionally, gaps in risk estimation, psychological, ethical and legal consequences will need to be addressed. CONCLUSION The present review identified considerable unresolved issues and challenges. Potential implementation will require a more complex framework, in which a country's healthcare regulations, resources, and preferences related to screening and prevention services are taken into account. However, with the insights gained from the present overview, countries expecting to implement risk-based screening and prevention can start to inventory and address the issues that were identified.
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Affiliation(s)
- Linda Rainey
- Radboud Institute for Health Sciences, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Daniëlle van der Waal
- Radboud Institute for Health Sciences, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Anna Jervaeus
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet & Theme Cancer, Karolinska University Hospital, Alfred Nobels allé 23, 23300, 14183, Huddinge, Sweden
| | - Yvonne Wengström
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet & Theme Cancer, Karolinska University Hospital, Alfred Nobels allé 23, 23300, 14183, Huddinge, Sweden
| | - D Gareth Evans
- Prevent Breast Cancer Research Unit, The Nightingale Centre, Manchester University NHS Foundation Trust, Southmoor Road, Manchester M23 9LT, United Kingdom; Genomic Medicine, Division of Evolution and Genomic Sciences, Manchester Academic Health Sciences Centre, Manchester University NHS Foundation Trust, Manchester M13 9WL, United Kingdom; The Christie NHS Foundation Trust, Withington, Manchester M20 4BX, United Kingdom
| | - Louise S Donnelly
- Prevent Breast Cancer Research Unit, The Nightingale Centre, Manchester University NHS Foundation Trust, Southmoor Road, Manchester M23 9LT, United Kingdom
| | - Mireille J M Broeders
- Radboud Institute for Health Sciences, Radboud University Medical Center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands; Dutch Expert Center for Screening, PO Box 6873, 6503 GJ Nijmegen, The Netherlands
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Derbez B, de Pauw A, Stoppa-Lyonnet D, de Montgolfier S. Supporting disclosure of genetic information to family members: professional practice and timelines in cancer genetics. Fam Cancer 2018; 16:447-457. [PMID: 28293859 DOI: 10.1007/s10689-017-9970-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Disclosure of genetic information within families is one of the longstanding questions under scrutiny in the field of genetics. Most of the probands entrusted with family disclosure succeed in this task, but there are still many problematic cases where it proves difficult. How can professionals help probands disclose this information? What levers can they activate to foster the diffusion of genetic information within families? In the context of a new legal framework concerning this question in France, this paper offers a comprehensive view of the process of genetic counselling in a cancer genetics department. Based on an ethnographic study, it focuses on the interactions between professionals and probands during each step of the testing procedures in order to identify key times when the issue can be addressed. The results show that the question of family disclosure needs to be addressed before, during and after the test. Greater awareness of this continuum among professionals could help them foster family disclosure by supporting the probands at each stage of the testing procedure.
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Affiliation(s)
- Benjamin Derbez
- Institut de Recherche Interdisciplinaire sur les enjeux Sociaux (IRIS), UMR 8156 CNRS - 997 Inserm - EHESS - UP 13, 190 avenue de France, Paris Cedex 13, 75244, France
| | - Antoine de Pauw
- Service de Génétique Oncologique, Institut Curie, Paris, France
| | - Dominique Stoppa-Lyonnet
- Service de Génétique Oncologique, Institut Curie, Paris, France.,INSERM U830, Paris, France.,Université Paris Descartes, Paris, France
| | - Sandrine de Montgolfier
- Institut de Recherche Interdisciplinaire sur les enjeux Sociaux (IRIS), UMR 8156 CNRS - 997 Inserm - EHESS - UP 13, 190 avenue de France, Paris Cedex 13, 75244, France. .,Université Paris Est Créteil (UPEC), Créteil, France.
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8
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Dheensa S, Lucassen A, Fenwick A. Limitations and Pitfalls of Using Family Letters to Communicate Genetic Risk: a Qualitative Study with Patients and Healthcare Professionals. J Genet Couns 2017; 27:689-701. [PMID: 29094272 PMCID: PMC5943374 DOI: 10.1007/s10897-017-0164-x] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 10/03/2017] [Indexed: 12/31/2022]
Abstract
European genetic testing guidelines recommend that healthcare professionals (HCPs) discuss the familial implications of any test with a patient and offer written material to help them share the information with family members. Giving patients these “family letters” to alert any relatives of their risk has become part of standard practice and has gone relatively unquestioned over the years. Communication with at-risk relatives will become an increasingly pressing issue as mainstream and routine practice incorporates broad genome tests and as the number of findings potentially relevant to relatives increases. This study therefore explores problems around the use of family letters to communicate about genetic risk. We conducted 16 focus groups with 80 HCPs, and 35 interviews with patients, recruited from across the UK. Data were analyzed thematically and we constructed four themes: 1) HCPs writing family letters: how to write them and why?, 2) Patients’ issues with handing out family letters, 3) Dissemination becomes an uncontrolled form of communication, and 4) When the relative has the letter, is the patient’s and HCP’s duty discharged? We conclude by suggesting alternative and supplementary methods of communication, for example through digital tools, and propose that in comparison to communication by family letter, direct contact by HCPs might be a more appropriate and successful option.
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Affiliation(s)
- Sandi Dheensa
- Clinical Ethics and Law, Southampton General Hospital, South Academic Block, University of Southampton, Room AB 203, MP 801, Tremona Road, Southampton, SO16 6YD, 02381 205082, UK.
| | - Anneke Lucassen
- Clinical Ethics and Law, Southampton General Hospital, South Academic Block, University of Southampton, Room AB 203, MP 801, Tremona Road, Southampton, SO16 6YD, 02381 205082, UK.,Wessex Clinical Genetics Service, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Angela Fenwick
- Clinical Ethics and Law, Southampton General Hospital, South Academic Block, University of Southampton, Room AB 203, MP 801, Tremona Road, Southampton, SO16 6YD, 02381 205082, UK
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Dheensa S, Fenwick A, Lucassen A. Approaching confidentiality at a familial level in genomic medicine: a focus group study with healthcare professionals. BMJ Open 2017; 7:e012443. [PMID: 28159847 PMCID: PMC5293977 DOI: 10.1136/bmjopen-2016-012443] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Clinical genetics guidelines from 2011 conceptualise genetic information as confidential to families, not individuals. The normative consequence of this is that the family's interest is the primary consideration and genetic information is shared unless there are good reasons not to do so. We investigated healthcare professionals' (HCPs') views about, and reasoning around, individual and familial approaches to confidentiality and how such views influenced their practice. METHOD 16 focus groups with 80 HCPs working in/with clinical genetics services were analysed, drawing on grounded theory. RESULTS Participants raised seven problems with, and arguments against, going beyond the individual approach to confidentiality. These problems fell into two overlapping categories: 'relationships' and 'structures'. Most participants had never considered ways to-or thought it was impossible to-treat familial genetic information and personal information differently. They worried that putting the familial approach into practice could disrupt family dynamics and erode patient trust in the health service. They also thought they had insufficient resources to share information and feared that sharing might change the standard of care and make them more vulnerable to liability. CONCLUSIONS A familial approach to confidentiality has not been accepted or adopted as a standard, but wider research suggests that some of the problems HCPs perceived are surmountable and sharing in the interest of the family can be achieved. However, further research is needed to explore how personal and familial genetic information can be separated in practice. Our findings are relevant to HCPs across health services who are starting to use genome tests as part of their routine investigations.
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Affiliation(s)
- Sandi Dheensa
- Faculty of Medicine, Clinical Ethics and Law, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Angela Fenwick
- Faculty of Medicine, Clinical Ethics and Law, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Anneke Lucassen
- Faculty of Medicine, Clinical Ethics and Law, University of Southampton, Southampton General Hospital, Southampton, UK
- Wessex Clinical Genetics Service, Princess Anne Hospital, University Hospitals Southampton Foundation Trust, Southampton, UK
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Stol YH, Schermer MHN, Asscher ECA. Omnipresent Health Checks May Result in Over-responsibilization. Public Health Ethics 2016. [DOI: 10.1093/phe/phw034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Himes DO, Clayton MF, Donaldson GW, Ellington L, Buys SS, Kinney AY. Breast Cancer Risk Perceptions among Relatives of Women with Uninformative Negative BRCA1/2 Test Results: The Moderating Effect of the Amount of Shared Information. J Genet Couns 2016; 25:258-69. [PMID: 26245632 PMCID: PMC4799250 DOI: 10.1007/s10897-015-9866-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 07/08/2015] [Indexed: 02/07/2023]
Abstract
The most common result of BRCA1/2 mutation testing when performed in a family without a previously identified mutation is an uninformative negative test result. Women in these families may have an increased risk for breast cancer because of mutations in non-BRCA breast cancer predisposition genes, including moderate- or low-risk genes, or shared environmental factors. Genetic counselors often encourage counselees to share information with family members, however it is unclear how much information counselees share and the impact that shared information may have on accuracy of risk perception in family members. We evaluated 85 sisters and daughters of women who received uninformative negative BRCA1/2 results. We measured accuracy of risk perception using a latent variable model where accuracy was represented as the correlation between perceived risk (indicators = verbal and quantitative measures) and calculated risk (indicators = Claus and BRCAPRO). Participants who reported more information was shared with them by their sister or mother about her genetic counseling session had greater accuracy of risk perception (0.707, p = 0.000) than those who reported little information was shared (0.326, p = 0.003). However, counselees shared very little information; nearly 20 % of family members reported their sister or mother shared nothing with them about her genetic counseling. Family members were generally not aware of the existence of a genetic counseling summary letter. Our findings underscore the need for effective strategies that facilitate counselees to share information about their genetic counseling sessions. Such communication may help their relatives better understand their cancer risks and enhance risk appropriate cancer prevention.
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Affiliation(s)
- Deborah O Himes
- College of Nursing, Brigham Young University, 500 Spencer W. Kimball Tower, Provo, UT, 84602, USA.
| | | | - Gary W Donaldson
- College of Nursing, University of Utah, Salt Lake City, UT, USA
- Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Lee Ellington
- College of Nursing, University of Utah, Salt Lake City, UT, USA
- Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Saundra S Buys
- Department of Medicine, Huntsman Cancer Institute, Salt Lake City, UT, USA
| | - Anita Y Kinney
- Division of Epidemiology, Biostatistics and Prevention, Department of Internal Medicine, University of New Mexico, Albuquerque, NM, USA
- University of New Mexico Cancer Center, Albuquerque, NM, USA
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12
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Dheensa S, Fenwick A, Lucassen A. 'Is this knowledge mine and nobody else's? I don't feel that.' Patient views about consent, confidentiality and information-sharing in genetic medicine. JOURNAL OF MEDICAL ETHICS 2016; 42:174-9. [PMID: 26744307 PMCID: PMC4789809 DOI: 10.1136/medethics-2015-102781] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 11/09/2015] [Accepted: 12/07/2015] [Indexed: 05/24/2023]
Abstract
In genetic medicine, a patient's diagnosis can mean their family members are also at risk, raising a question about how consent and confidentiality should function in clinical genetics. This question is particularly pressing when it is unclear whether a patient has shared information. Conventionally, healthcare professionals view confidentiality at an individual level and 'disclosure without consent' as the exception, not the rule. The relational joint account model, by contrast, conceptualises genetic information as confidential at the familial level and encourages professionals to take disclosure as the default position. In this study, we interviewed 33 patients about consent and confidentiality and analysed data thematically. Our first theme showed that although participants thought of certain aspects of genetic conditions--for example, the way they affect day-to-day health--as somewhat personal, they perceived genetic information--for example, the mutation in isolation--as familial. Most thought these elements were separable and thought family members had a right to know the latter, identifying a broad range of harms that would justify disclosure. Our second theme illustrated that participants nonetheless had some concerns about what, if any, implications there would be of professionals treating such information as familial and they emphasised the importance of being informed about the way their information would be shared. Based on these results, we recommend that professionals take disclosure as the default position, but make clear that they will treat genetic information as familial during initial consultations and address any concerns therein.
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Affiliation(s)
- Sandi Dheensa
- Clinical Ethics and Law, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Angela Fenwick
- Clinical Ethics and Law, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Anneke Lucassen
- Clinical Ethics and Law, Faculty of Medicine, University of Southampton, Southampton, UK
- Wessex Clinical Genetics Service, University Hospital Southampton NHS Foundation Trust
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Mendes Á, Paneque M, Sousa L, Clarke A, Sequeiros J. How communication of genetic information within the family is addressed in genetic counselling: a systematic review of research evidence. Eur J Hum Genet 2016; 24:315-25. [PMID: 26264439 PMCID: PMC4755382 DOI: 10.1038/ejhg.2015.174] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 06/20/2015] [Accepted: 07/03/2015] [Indexed: 11/09/2022] Open
Abstract
Supporting consultands to communicate risk information with their relatives is key to obtaining the full benefits of genetic health care. To understand how health-care professionals address this issue in clinical practice and what interventions are used specifically to assist consultands in their communication of genetic information to appropriate relatives, we conducted a systematic review. Four electronic databases and four subject-specific journals were searched for papers published, in English, between January 1997 and May 2014. Of 2926 papers identified initially, 14 papers met the inclusion criteria for the review and were heterogeneous in design, setting and methods. Thematic data analysis has shown that dissemination of information within families is actively encouraged and supported by professionals. Three overarching themes emerged: (1) direct contact from genetic services: sending letters to relatives of mutation carriers; (2) professionals' encouragement of initially reluctant consultands to share relevant information with at-risk relatives and (3) assisting consultands in communicating genetic information to their at-risk relatives, which included as subthemes (i) psychoeducational guidance and (ii) written information aids. Findings suggest that professionals' practice and interventions are predicated on the need to proactively encourage family communication. We discuss this in the context of what guidance of consultands by professionals might be appropriate, as best practices to facilitate family communication, and of the limits to non-directiveness in genetic counselling.
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Affiliation(s)
- Álvaro Mendes
- i3S –Instituto de Investigação e Inovação em Saúde, and Centre for Predictive and Preventive Genetics, IBMC –Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, Portugal
- Department of Health Sciences, University of Aveiro, Aveiro, Portugal
| | - Milena Paneque
- i3S –Instituto de Investigação e Inovação em Saúde, and Centre for Predictive and Preventive Genetics, IBMC –Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, Portugal
- ICBAS, University of Porto, Porto, Portugal
| | - Liliana Sousa
- CINTESIS, Center for Health Technology and Services Research, University of Aveiro, Aveiro, Portugal
| | - Angus Clarke
- Institute of Cancer and Genetics, School of Medicine, Cardiff University, Wales, UK
| | - Jorge Sequeiros
- i3S –Instituto de Investigação e Inovação em Saúde, and Centre for Predictive and Preventive Genetics, IBMC –Instituto de Biologia Molecular e Celular, Universidade do Porto, Porto, Portugal
- ICBAS, University of Porto, Porto, Portugal
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14
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Heaton TJ, Chico V. Attitudes towards the sharing of genetic information with at-risk relatives: results of a quantitative survey. Hum Genet 2016; 135:109-20. [PMID: 26612611 PMCID: PMC4698294 DOI: 10.1007/s00439-015-1612-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 11/06/2015] [Indexed: 01/19/2023]
Abstract
To investigate public attitudes towards receiving genetic information arising from a test on a relative, 955 University of Sheffield students and staff were surveyed using disease vignettes. Strength of attitude was measured on whether, in the event of relevant information being discovered, they, as an at-risk relative, would want to be informed, whether the at-risk relative's interest should override proband confidentiality, and, if they had been the proband, willingness to give up confidentiality to inform such relatives. Results indicated considerably more complexity to the decision-making than simple statistical risk. Desire for information only slightly increased with risk of disease manifestation [log odds 0.05 (0.04, 0.06) per percentage point increase in manifestation risk]. Condition preventability was the primary factor increasing desire [modifiable baseline, non-preventable log odds -1.74 (-2.04, -1.44); preventable 0.64 (0.34, 0.95)]. Disease seriousness also increased desire [serious baseline, non-serious log odds -0.89 (-1.19, -0.59); fatal 0.55 (0.25, 0.86)]. Individuals with lower education levels exhibited much greater desire to be informed [GCSE log odds 1.67 (0.64, 2.66)]. Age did not affect desire. Our findings suggest that attitudes were influenced more by disease characteristics than statistical risk. Respondents generally expressed strong attitudes demonstrating that this was not an issue which people felt ambivalent about. We provide estimates of the British population in favour/against disclosure for various disease scenarios.
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Affiliation(s)
- Timothy J Heaton
- School of Mathematics and Statistics, University of Sheffield, Hicks Building, Hounsfield Road, Sheffield, S. Yorkshire, S3 7RH, UK.
| | - Victoria Chico
- School of Law, Bartolome House, University of Sheffield, Winter Street, Sheffield, S. Yorkshire, S3 7ND, UK
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15
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Dheensa S, Fenwick A, Shkedi-Rafid S, Crawford G, Lucassen A. Health-care professionals' responsibility to patients' relatives in genetic medicine: a systematic review and synthesis of empirical research. Genet Med 2015; 18:290-301. [PMID: 26110233 PMCID: PMC4823639 DOI: 10.1038/gim.2015.72] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 04/20/2015] [Indexed: 01/02/2023] Open
Abstract
Purpose: The extent of the responsibility of health-care professionals (HCPs) to ensure that patients' relatives are told of their risk is unclear. Current international guidelines take confidentiality to the individual patient as the default position, but some suggest that disclosure could be default and genetic information could be conceptualized as familial. Genet Med18 4, 290–301. Methods: Our systematic review and synthesis of 17 studies explored the attitudes of HCPs, patients, and the public regarding the extent of HCPs' responsibility to relatives with respect to disclosure. Genet Med18 4, 290–301. Results: Health-care professionals generally felt a responsibility to patients' relatives but perceived a variety of reasons why it would be difficult to act on this responsibility. Public/patient views were more wide-ranging. Participants identified several competing and overlapping arguments for and against HCP disclosure: guidelines do not permit/mandate it, privacy, medical benefit, impact on family dynamics, quality of communication, and respecting autonomy. Genet Med18 4, 290–301. Conclusion: We argue that HCPs can sometimes share genetic information without breaching confidentiality and that they could factor into their considerations the potential harm to family dynamics of nondisclosure. However, we need more nuanced research about their responsibilities to relatives, particularly as genomic tests are used more frequently in clinical practice. Genet Med18 4, 290–301.
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Affiliation(s)
- Sandi Dheensa
- Clinical Ethics and Law, University of Southampton, Southampton, UK
| | - Angela Fenwick
- Clinical Ethics and Law, University of Southampton, Southampton, UK
| | - Shiri Shkedi-Rafid
- Clinical Ethics and Law, University of Southampton, Southampton, UK.,Wessex Clinical Genetics Service, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - Gillian Crawford
- Clinical Ethics and Law, University of Southampton, Southampton, UK.,Wessex Clinical Genetics Service, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - Anneke Lucassen
- Clinical Ethics and Law, University of Southampton, Southampton, UK.,Wessex Clinical Genetics Service, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
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16
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Vavolizza RD, Kalia I, Erskine Aaron K, Silverstein LB, Barlevy D, Wasserman D, Walsh C, Marion RW, Dolan SM. Disclosing Genetic Information to Family Members About Inherited Cardiac Arrhythmias: An Obligation or a Choice? J Genet Couns 2014; 24:608-15. [PMID: 25400212 DOI: 10.1007/s10897-014-9783-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 09/29/2014] [Indexed: 12/01/2022]
Abstract
Inherited cardiac arrhythmias such as long QT syndrome and Brugada syndrome, present clinical as well as ethical, legal, and social challenges. Many individuals who carry a deleterious mutation are largely asymptomatic and therefore may not be diagnosed until after the occurrence of a personal or family member's cardiac event. The familial nature of inherited genetic information raises numerous ethical, legal, and social issues regarding the sharing of genetic information, particularly when an individual found to carry a deleterious mutation refuses to disclose his or her results to at-risk family members who could benefit from life-saving treatments. This qualitative study sought to understand the experiences with genetic testing for individuals (n = 50) with a personal or family history of cardiac events or sudden death. Unstructured in-person focus groups or interviews were conducted for each participant in the study. The recordings of these interviews were transcribed verbatim and subsequently analyzed and coded. Participants' comments regarding sharing of genetic information centered around four main themes: (1) motivation to disclose; (2) extent of disclosure; (3) effect of disclosure on family dynamics; and (4) reasons for not sharing genetic information. The majority of individuals believed that affected individuals are obligated to disclose genetic information to family members. In the era of personalized medicine, the disclosure of genetic information provides individuals the opportunities to learn about the genetics, disease characteristics, and treatment options in order to reduce morbidity and mortality in themselves and their family members. Further research is necessary to identify and explore the barriers to sharing genetic information with at-risk family members.
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Affiliation(s)
- Rick D Vavolizza
- Department of Obstetrics and Gynecology and Women's Health, Albert Einstein College of Medicine/ Montefiore Medical Center, 1300 Morris Park Avenue, Block 634, Bronx, NY, 10461, USA
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17
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Silverstein LB, Stolerman M, Hidayatallah N, McDonald T, Walsh CA, Paljevic E, Cohen LL, Marion RW, Wasserman D, Dolan SM. Translating advances in cardiogenetics into effective clinical practice. QUALITATIVE HEALTH RESEARCH 2014; 24:1315-28. [PMID: 25114027 PMCID: PMC4487807 DOI: 10.1177/1049732314546754] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
In this article we describe a qualitative research study in which we explored individuals' subjective experiences of both genetic testing and cardiogenetic disorders. Using a grounded theory approach, we coded and analyzed interview and focus group transcripts from 50 participants. We found that just under half of the participants who received their diagnosis during the study reported difficulty understanding information about both the purpose of genetic testing and their cardiac disease. A high level of anxiety about genetic testing and cardiac symptoms exacerbated individuals' cognitive confusion. Participants reported both positive and negative interactions with the medical community, depending on health care professionals' knowledge of cardiogenetic disorders. Overall, participants expressed a range of attitudes--positive, negative, and ambivalent--toward genetic testing. We conclude with a discussion of the barriers to achieving effective clinical care for genetic conditions and offer suggestions for improving collaborative decision making between physicians and patients.
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18
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Menko FH, Aalfs CM, Henneman L, Stol Y, Wijdenes M, Otten E, Ploegmakers MMJ, Legemaate J, Smets EMA, de Wert GMWR, Tibben A. Informing family members of individuals with Lynch syndrome: a guideline for clinical geneticists. Fam Cancer 2014; 12:319-24. [PMID: 23535968 DOI: 10.1007/s10689-013-9636-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The diagnosis of Lynch syndrome can lead to the prevention of colorectal cancer through periodic colonoscopies and removal of premalignant lesions in susceptible individuals. Therefore, predisposed individuals identified by mutation analysis are advised to inform their at-risk relatives about the options of predictive DNA testing and preventive measures. However, it has now been established that more than half of these relatives do not receive the necessary information. Barriers in conveying information include family communication problems and variable attitudes and practice among clinical geneticists. In this complex field, both medical, psychological, ethical and juridical aspects deserve consideration. Here we summarize the development of a revised guideline for clinical geneticists that allows a more active role of the geneticist, aimed at improving procedures to inform family members in Lynch syndrome and other hereditary and familial cancer syndromes.
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Affiliation(s)
- Fred H Menko
- Department of Clinical Genetics, VU University Medical Center, Amsterdam, The Netherlands.
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Downsizing genomic medicine: approaching the ethical complexity of whole-genome sequencing by starting small. Genet Med 2011; 13:191-4. [PMID: 21311340 DOI: 10.1097/gim.0b013e31820f603f] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
As we look to a time when whole-genome sequencing is integrated into patient care, it is possible to anticipate a number of ethical challenges that will need to be addressed. The most intractable of these concern informed consent and the responsible management of very large amounts of genetic information. Given the range of possible findings, it remains unclear to what extent it will be possible to obtain meaningful patient consent to genomic testing. Equally unclear is how clinicians will disseminate the enormous volume of genetic information produced by whole-genome sequencing. Toward developing practical strategies for managing these ethical challenges, we propose a research agenda that approaches multiplexed forms of clinical genetic testing as natural laboratories in which to develop best practices for managing the ethical complexities of genomic medicine.
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