Abstract P5-19-04: Psychosocial impact of a multi-modality surveillance program for women at high-risk for breast cancer

Purpose: To evaluate the psychosocial impact of semi-annual dynamic contrast enhanced magnetic resonance imaging (DCE-MRI) screening in women at high-risk for breast cancer.

Background: For women with BRCA1 and BRCA2 mutations and/or a personal or family history of breast cancer, annual breast MRI has shown improved sensitivity and cancer detection compared to mammography. However, MRI's heightened sensitivity may lead to increased: false positives requiring additional follow-up biopsy/imaging; iatrogenic risk; and psychosocial distress, which all may negatively impact women's overall health-related quality of life.

Methods: Between 2004 and 2016, we assembled a prospective cohort of high-risk women undergoing semi-annual DCE-MRI and annual mammography. We reviewed a subset of this group. Participants completed psychosocial assessments at baseline and 6-month visits using the following measures: coping (MBSS); state/trait anxiety (STAI-S/T); depression (BDI-II); risk perception; and mental health (SF-36). Participants were classified according to Monitor or Blunter coping style. Mixed-effects logistic regressions models examined effects of demographics on psychosocial changes over time.

Results: 295 women were recruited to the study; 44% of the study participants had pathogenic mutations in BRCA1 or BRCA2 genes. 232 of 295 enrolled participants (78.6%) completed psychosocial assessments. For the total population: median age 44y (range: 21-73), 71% ≥college/post-graduate education; 84% Caucasian; 8% African American; 2% Latino; 99% with health insurance; 72% annual income of >$60,000. One third of women had a personal cancer history. Participants were evenly split between baseline Monitoring and Blunting coping style (49% and 51%, respectively). No significant differences were found between demographics (age, race, income, mutation, cancer type, cancer history) or psychosocial factors (baseline trait anxiety (p =0.64), depression (p =0.65), SF36 global health (p=0.66). After adjusting for education, race, cancer history and coping, women with ≥$60,000 income had lower trait anxiety (p<0.000) and greater mental health (p<0.001) than those with <$60,000 income. Over time, change in trait anxiety varied by coping (p=0.0006): Blunters did not experience significant changes in trait anxiety (p=0.072) while Monitors had significant diminished trait anxiety over time (p<0.001). For depression, women with ≥$60,000 income and college educated had lower BDI-II depression (p<0.000). Yet, women with a cancer history had significantly greater BDH-II depression (p= 0.048). Mental health over time varied by race as non-whites had greater gains in mental health (p=0.001) over time than whites (p=0.03).

Conclusion: Semi-annual DCE-MRI did not cause a significantly elevated state anxiety or depression, nor was there a significant decline in mental health over time for groups regardless of cancer history and genetic mutation status. Coping style may have an impact on psychosocial outcomes for those undergoing heightened surveillance over time.

Citation Format: Amico AL, Fang R, Raoul A, Wroblewski K, Nielsen S, Weipert C, Abe H, Sheth D, Romero I, Kulkarni K, Schacht D, Patrick-Miller L, Verp M, Bradbury AR, Hlubocky F, Olopade OI. Psychosocial impact of a multi-modality surveillance program for women at high-risk for breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-19-04.

Patient Perceptions of Care as Influenced by a Large Institutional Pharmacogenomic Implementation Program

Despite growing clinical use of genomic information, patient perceptions of genomic-based care are poorly understood. We prospectively studied patient-physician pairs who participated in an institutional pharmacogenomic implementation program. Trust/privacy/empathy/medical decision-making (MDM)/personalized care dimensions were assessed through patient surveys after clinic visits at which physicians had access to preemptive pharmacogenomic results (Likert scale, 1 = minimum/5 = maximum; mean [SD]). From 2012-2015, 1,261 surveys were issued to 507 patients, with 792 (62.8%) returned. Privacy, empathy, MDM, and personalized care scores were significantly higher after visits when physicians considered pharmacogenomic results. Importantly, personalized care scores were significantly higher after physicians used pharmacogenomic information to guide medication changes (4.0 [1.4] vs. 3.0 [1.6]; P < 0.001) compared with prescribing visits without genomic guidance. Multivariable modeling controlling for clinical factors confirmed personalized care scores were more favorable after visits with genomic-influenced prescribing (odds ratio [OR] = 3.26; 95% confidence interval [CI] = (1.31-8.14); P < 0.05). Physicians seem to individualize care when utilizing pharmacogenomic results and this decision-making augmentation is perceived positively by patients.

Abstract P2-09-01: Patient reported outcomes of multiplex breast cancer susceptibility testing utilizing a tiered-binned counseling and informed consent model in BRCA1/2 negative patients

Background:The risks, benefits and utilities of multiplex panels for breast cancer susceptibility are unknown and new counseling and informed consent models are needed. We sought to obtain patient reported outcomes of multiplex testing in BRCA1/2 negative patients utilizing a novel, previously piloted tiered-binned counseling model for multiplex testing. Methods:BRCA1/2 negative participants completed pre(V1) and post-test counseling(V2) and surveys evaluating cognitive, affective and behavioral responses to a 25-gene multiplex testing panel. We used linear regressions with estimation by GEE where appropriate. Results:376 patients have been approached. To date, 124 participants(33%) have consented to the study, 21(6%) declined and 231(61%) are considering. Of 95 who have completed pre-test counseling(V1), 88(93%) elected to proceed with 25-gene panel testing and (81%) were classified as making an informed choice after tiered-binned counseling. 6/53(11%) participants received a positive result, including 1 mutation in MSH2 and 5 in moderate penetrance genes (2 ATM, 1 BARD1, 1 CHEK2, 1 PALB2). 22/53(42%) participants received a variant of unknown significance(VUS). General anxiety and perceived utility decreased significantly with pre-test counseling and after results (Table 1). Knowledge increased with pre-test counseling; cancer worry increased after receipt of multiplex results. Higher cancer worry was associated only with lower income (2.6 points/income category, p&lt;0.01). Those with a VUS had greater decreases in perceived utility compared to negative (p=0.01) or positive (p=0.003) results. To date, there are no other significant differences in knowledge, distress or uncertainty by test result. Medical management recommendations for the proband changed in 3/6 with a positive result. Cascade testing in the family was discussed as an option in 3/6 with a positive result. Conclusions:Many BRCA1/2-negative patients proceed with 25-gene cancer susceptibility testing if offered and most make informed choices utilizing a tiered-binned genetic counseling model. The tiered-binned counseling model is associated with increased knowledge, decreases in general anxiety and uncertainty after pre-test counseling and disclosure of results, but an increase in cancer worry after result disclosure. The clinical utility, long-term outcomes and differences in patient reported outcomes by test result remain unknown.

Table 1 Baseline, Mean(SD)After V1, Mean(SD)After V2, Mean(SD) N=75ˆ;N=49ˆˆN=75ˆ;N=49ˆˆN=49ˆˆGeneral Anxiety (range 0-21)6.4(3.9)*;6.9(3.9)**6.0(4.3)*;6.6(4.2)**5.8(4.5)**General Depression (range 0-212.8(2.9);3.1(3.2)3.0(3.5);3.1(3.6)3.0(3.7)State Anxiety (range 20-80)35.5(11.2);36.6(11.9)35.5(11.8);36.8(11.9)36.1(12.2)Cancer Worry (range 0-75)18.2(13.5);20.1(13.8)**16.7(12.5);17.2(11.9)**21.0(13.9)**Knowledge (range 17-82)65.7(5.0)**;66.5(5.0)**68.0(5.7)**;68.4(5.6)**67.3(4.9)**Uncertainty (range 0-15)5.8(3.9);6.2(4.3)5.6(3.7);5.4(3.2)5.6(3.5)Perceived Utility (range 24-120)75.2(14.0)*;75.9(14.0)**73.0(14.1)*;74.1(13.4)**68.4(16.9)***p≤0.05 **p≤0.01. ˆcompleted V1. ˆˆcompleted V1 & V2. To date, 53 have received results and 49 have completed post-disclosure surveys.

Citation Format: Bradbury AR, Patrick-Miller L, Egleston BE, Maxwell KN, Brandt A, Brower J, DiGiovanni L, Long JM, Powers J, Stopfer J, Nathanson KL, Domchek SM. Patient reported outcomes of multiplex breast cancer susceptibility testing utilizing a tiered-binned counseling and informed consent model in BRCA1/2 negative patients. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-09-01.

Abstract P6-08-01: Perceptions of breast cancer risk, psychological adjustment and behaviors in adolescent girls at high-risk and population-risk for breast cancer

BACKGROUND: Preliminary evidence suggests that many girls from breast cancer (BC) families are aware of their increased risk for BC. How this awareness impacts their psychosocial adjustment and health behaviors remains unknown.

METHODS: 11–19 YO girls at high-risk (HR) or population-risk (PR) for BC completed self-administered quantitative surveys informed by the Self-Regulation Theory of Health Behavior. Girls with a first or second-degree relative with BC were classified as HR. For hypothesis testing, we used simple linear and logistic regressions. To account for correlation of responses within families, we used robust (cluster-corrected) standard errors or Generalized Estimating Equations.

RESULTS: 47 PR and 89 HR girls have completed surveys. Age did not differ between groups (Mage = 15.6; SD=2.4). 30% of HR girls have a mother with BC. 67% of HR girls vs. 30% of PR girls reported self-perceived risk for adult BC to be “higher than other girls my age,” (p = &lt;0.01, Table 1).

Genetic counselor opinions of, and experiences with telephone communication of BRCA1/2 test results

BRCA1/2 test disclosure has, historically, been conducted in-person by genetics professionals. Given increasing demand for, and access to, genetic testing, interest in telephone and Internet genetic services, including disclosure of test results, has increased. Semi-structured interviews with genetic counselors were conducted to determine interest in, and experiences with telephone disclosure of BRCA1/2 test results. Descriptive data are summarized with response proportions. One hundred and ninety-four genetic counselors completed self-administered surveys via the web. Although 98% had provided BRCA1/2 results by telephone, 77% had never provided pre-test counseling by telephone. Genetic counselors reported perceived advantages and disadvantages to telephone disclosure. Thirty-two percent of participants described experiences that made them question this practice. Genetic counselors more frequently reported discomfort with telephone disclosure of a positive result or variant of uncertain significance (p < 0.01) than other results. Overall, 73% of participants reported interest in telephone disclosure. Many genetic counselors have provided telephone disclosure, however, most, infrequently. Genetic counselors identify potential advantages and disadvantages to telephone disclosure, and recognize the potential for testing and patient factors to impact patient outcomes. Further research evaluating the impact of testing and patient factors on cognitive, affective, social and behavioral outcomes of alternative models of communicating genetic information is warranted.

Should Minors Be Offered BRCA1/2 Testing for Hereditary Breast Cancer? Opinions of Parents Who Have Undergone BRCA1/2 Testing

Background: Professional societies recommend against the genetic testing of minors for hereditary cancer syndromes that present in adulthood. Yet, many adolescent specialists indicate that they would consider BRCA1/2 testing of minor children. We conducted interviews with parents who have had BRCA1/2 testing, to evaluate their opinions regarding the genetic testing of minors for BRCA1/2. Methods: 244 parents, including 67 BRCA1/2 mutation carriers (MCs), 140 parents with uninformative negative results (UN), 14 with true negative results (TN) & 23 with a variant of uncertain significance (VUS), from two cancer risk assessment programs completed semi-structured interviews. We used multiple logistic regressions to evaluate the associations among biomedical factors, demographic factors and support of testing minors. Wald tests and likelihood ratio tests were used to assess statistical significance for binary covariates and nominal covariates. Results: 38% of parents supported testing minors for BRCA1/2 in response to a dichotomous (Y/N) question. Support was greatest among parents with TN (64%) and UN (40%) results and lower among MCs (31%) and parents with a VUS (26%). In a multivariable analysis, support was greatest among parents who tested negative (p=0.02), were of minority race (p=0.06) and among fathers (&lt;0.01). Responses to open-ended questions suggest that 27% of parents unconditionally support testing of minors, and 25% support testing only in certain situations. Psychological risks, a lack of medical necessity and the insufficient maturity of minors, were frequent concerns of those opposed. The potential to positively impact minors' health behaviors was the most reported reason for supporting testing. Conclusions: Up to 52% of parents who have undergone BRCA1/2 testing support pediatric testing for BRCA1/2. Given willingness among general and pediatric practitioners and interest among parents, further research is necessary to formally evaluate the risks and benefits of providing genetic testing to minors for adult-onset hereditary cancer syndromes in order to inform clinical practice and public policy that will ensure optimal psychosocial and medical outcomes for all members of families at risk for hereditary cancer.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4071.

Parent perceptions of offspring responses to parental communication of BRCA1/2 test results

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Background: Many BRCA1/2 mutation carriers report sharing their genetic test results with their minor children. The impact of this communication on offspring remains unknown. Methods: 163 parents who had BRCA1/2 testing completed qualitative interviews regarding their experiences with communication of their genetic test results to offspring. Descriptive responses were coded and response proportions utilized to summarize results. We used multiple regressions fit by GEE to test associations with disclosure. We controlled for parent mutation status in each regression. Results: 163 parents (52 BRCA1/2 mutation carriers) reported on 323 offspring 5 to 25 years old at the time of parent genetic testing. 107 (66%) parents reported disclosing to at least one offspring. Child age (p < 0.001) and parent cancer history (p = 0.004) were positively associated with disclosure. Parents without a BRCA1/2 mutation were more likely to communicate test results than parents with a mutation (p = 0.007). Among parents who disclosed, few (14%) reported they perceived their offspring to have had an initial negative affective or behavioral response. Others (13%) reported offspring concern for self and family. Reports of initial negative responses and concern were more frequent among parents with a mutation or a variant of uncertain significance. Many parents reported that the communication had no significant impact (39%) or a positive impact (36%) on their offspring. Conclusions: Many parents report sharing BRCA1/2 test results with their offspring. Parent self-reports suggest that they do not perceive most offspring to experience adverse reactions to this communication. Self-reports suggest that offspring learning of a BRCA1/2 mutation or a variant of uncertain significance may be more susceptible to initial negative reactions. Further research is necessary to explore psychosocial and behavioral responses to learning of hereditary risk during childhood and adolescence, and to inform the development of interventions to optimize adaptive response.

No significant financial relationships to disclose.

Telephone disclosure of BRCA1/2 test results: a survey of genetic counselors

Abstract #1098

Disclosure of BRCA1/2 test results has historically been conducted in person by a certified genetic counselor (GC) and/or other health care professional. Due to increasing demand for and access to BRCA1/2 testing, there has been interest in providing genetic counseling services, including disclosure of test results, by telephone and internet. The practice of telephone disclosure among certified genetic counselors has not been described. We conducted semi-structured interviews with GCs to determine current prevalence of, and future interest in, telephone disclosure (TD) of BRCA1/2 test results. Surveys were self-administered and completed via a secure web site. Participants were recruited through the NSGC Cancer Special Interest Group. 195 GCs completed the survey (25% response rate). 23% of respondents have provided pre-test counseling by telephone. 98% reported having provided genetic test results by telephone, although many (48%) conduct TD rarely (&lt;25% of the time). 33% reported TD experiences that had made them question TD as a practice. Comfort with TD varied by test result (37% comfortable with TD for positive test results, 77% for true negative results, 49% for indeterminate results and 33% for VUS results). The majority of GCs do not include a physician (85%) in the TD. Many report encouraging in-person follow-up with a GC (44%) and/or physician (30%). Overall, 42% reported being very interested in TD and 73% felt TD could be an acceptable standard practice. These results suggest many genetic counselors have provided genetic test results by phone and are interested in including telephone disclosure of BRCA1/2 test results in their practice. Given provider interest and the expansion of testing for BRCA1/2 and other hereditary cancer syndromes, further research evaluating the cognitive, affective and behavioral responses to telephone disclosure is warranted. Understanding the impact of telephone disclosure on factors such as, comprehension, risk perception, communication and performance of risk reducing behaviors and their mediators will be critical for the development of telephone disclosure policy and procedures that will optimize adaptive responses to receiving genetic test results via telephone or internet.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1098.

Tobacco use among individuals presenting for cancer risk assessment

1547

Background: An important component of cancer risk assessment (CRA) is the evaluation of exposures and preventive health behaviors. Tobacco use (TU) remains a significant contributor to cancer risk and decreasing tobacco use is a major national health objective. Methods: Clinical charts were reviewed to evaluate the incidence of TU and characteristics of tobacco users (TUs) among individuals presenting to the University of Chicago Cancer Risk Clinic for cancer risk assessment (CRA). Results: Among 98 individuals (97% female) presenting for CRA from 12/05–10/06, 51% (50/98) reported no TU, 38% (37/98) reported prior TU and 11% (11/98) reported current TU. Current tobacco users included 10% (7/73) of whites and 18% (4/22) of blacks with no TU among other racial groups (0/3). 45% of TUs (5/11) had a personal history of cancer. 45% of TUs reported compliance with self-breast examination, 73% with cervical cancer screening. Among TUs over 40 years old (YO), 67% (6/9) reported a mammogram in the last year and the 2 TUs over 50 YO reported a screening colonoscopy. All TUs reported interest in tobacco cessation interventions. Conclusions: Tobacco use among individuals presenting for CRA is lower than reported general population rates of TU (23%). Despite this, a proportion of individuals presenting for CRA report current TU, despite engaging in other cancer prevention behaviors. Continued review of clinical encounters from 2004- 06 (n=425) will allow for multi-variate analysis of predictors of current TU, which will inform future research employing cancer risk assessment encounters as “teachable moments” to optimize tobacco cessation outcomes.

No significant financial relationships to disclose.

Health-related quality of life among high-risk women in an MRI surveillance study

1522

Background: The quality of life (QOL) and psychological impact of incorporating MRI into breast cancer screening programs for high-risk women (HRW) has not been well studied. Psychological and biological risk factors, e.g. cancer history, BRCA mutation, imaging recall, generalized anxiety or clinical depression may mediate QOL outcomes. Methods: 100 HRW undergoing intensive surveillance including yearly mammography, semiannual breast ultrasound and breast MRI have completed QOL (SF-36), anxiety (STAI) and depression (Beck) questionnaires at semi-annual visits. 56 HRW have completed 3 screenings. Differences in QOL measures over time were evaluated using longitudinal regression models. Differences between participants and population norms (PN), women with/without a history of cancer and with/without a BRCA mutation were assessed using t-tests. Results: QOL scores increased over time and were statistically significant for the general health (GH) subscale (p=0.016). All QOL subscales were higher than PN at baseline and were significantly higher than PN at 12 months. Mean GH score at 12 months = 80.0, PN 72.7 (SD14.2, p<0.01). Mean mental health score at 12 months = 78.9, PN 73.4 (SD14.9, p<0.01). At baseline, BRCA carriers had lower QOL scores than non-carriers and women with a history of cancer had higher QOL scores than unaffected participants, although these differences were not statistically significant. Conclusions: These data suggest that intensive breast cancer screening incorporating breast MRI may have a positive effect among HRW. Continued enrollment will allow for multi-variate characterization of psychological and biological predictors of change in QOL and psychological well-being among high-risk women undergoing intensive screening.

No significant financial relationships to disclose.

Content and method of parental disclosure of genetic risk to young adult and minor children in BRCA families

1536

Background: Prior research has found that many BRCA mutation carriers report discussing their genetic test results with their minor children. The content, method and process of this communication have not been previously described. Methods: 20 parents (yielding 42 parent-offspring pairs, POP) have completed a 62-item questionnaire regarding the content and methods of communication of genetic risk to offspring. Results: Of 19 (45%) POP where parents reported disclosure of their BRCA mutation to offspring in response to a binary (yes/no) question, all reported telling their children about the genetic mutation itself, as well as the parents’ risk for cancer. In 74% of POP the offspring’s chance of inheriting the mutation or risk for cancer were said to have been communicated. In 53% of POP parents reported discussion of parental risk reduction measures, and in only 37% of POP parents reported communication of offspring risk reduction measures. Of the POP where parents reported some communication of cancer risk, 22% described incorporating written materials. In 75% of POP parents reported communication through multiple conversations over time (1 -20 conversations, up to 4 years). Conclusions: Although many BRCA carriers report discussing their genetic mutation with offspring, the content and extent of parental communication is variable, often including information regarding the genetic mutation, but less frequently the offspring’s risk of inheriting the gene and infrequently communication regarding risk reduction measures. Further research on this expanding cohort will allow for analyses of parent and child factors associated with disclosure content in order to guide the development of interventions to facilitate age and content-appropriate communication of genetic risk to at-risk offspring.

No significant financial relationships to disclose.

It's long-term stressors that take a toll: comment on Cohen et al. (1998)

In an extremely well-controlled study, Cohen et al. (1998) add to prior knowledge of stress-illness relationships by showing that self-reports of stress occurrence and duration of 1 month or more, rather than estimates of stressor severity, predict susceptibility to experimentally induced colds (i.e., viral replication and cold symptoms). Although ruling out obvious behavioral and personality factors as causes of the association of stressors to colds, they were unable to identify mediational immune factors, a deficit attributable to the difficulty of assessing the multi-layered, dynamic physiological processes within the bidirectional connections of the nervous (stress) and immune systems. The findings provide an interesting complement to data, showing that people use stressor duration in evaluating the illness implications of somatic symptoms (Cameron et al., 1995), and suggest caution with regard to overestimating the prevalence of stress-induced colds in natural settings.

It's long-term stressors that take a toll: comment on Cohen et al. (1998)

In an extremely well-controlled study, Cohen et al. (1998) add to prior knowledge of stress-illness relationships by showing that self-reports of stress occurrence and duration of 1 month or more, rather than estimates of stressor severity, predict susceptibility to experimentally induced colds (i.e., viral replication and cold symptoms). Although ruling out obvious behavioral and personality factors as causes of the association of stressors to colds, they were unable to identify mediational immune factors, a deficit attributable to the difficulty of assessing the multi-layered, dynamic physiological processes within the bidirectional connections of the nervous (stress) and immune systems. The findings provide an interesting complement to data, showing that people use stressor duration in evaluating the illness implications of somatic symptoms (Cameron et al., 1995), and suggest caution with regard to overestimating the prevalence of stress-induced colds in natural settings.

Negative affect relates to cross-sectional but not longitudinal symptom reporting: data from elderly adults

To test hypotheses about the relationship between negative affect and symptom reports, symptom reports of 4 groups of elderly participants (N = 76; mean age = 73.5 years) were compared: those high on measures of both depression and anxiety, those high on one measure and low on the other, and those low on both measures. Symptom reports were obtained before and after 3 simultaneously given active inoculations (influenza; tetanus toxoid; and keyhole limpet hemocyanin, a neoantigen) and 3 similarly given placebo injections. Cross-sectional analyses replicated associations between negative affect and reports of elevated systemic (flulike) symptoms. Local symptoms (sore arm and redness at injection site) increased significantly from before to after active inoculations. Reports of systemic symptoms declined from before to after for both active and placebo inoculations regardless of affect groups. The results add to previous research showing that negative affect is related to cross-sectional symptom reporting but not to increases in symptom reporting from before to after a symptom-producing inoculation procedure.

Negative affect relates to cross-sectional but not longitudinal symptom reporting: data from elderly adults

To test hypotheses about the relationship between negative affect and symptom reports, symptom reports of 4 groups of elderly participants (N = 76; mean age = 73.5 years) were compared: those high on measures of both depression and anxiety, those high on one measure and low on the other, and those low on both measures. Symptom reports were obtained before and after 3 simultaneously given active inoculations (influenza; tetanus toxoid; and keyhole limpet hemocyanin, a neoantigen) and 3 similarly given placebo injections. Cross-sectional analyses replicated associations between negative affect and reports of elevated systemic (flulike) symptoms. Local symptoms (sore arm and redness at injection site) increased significantly from before to after active inoculations. Reports of systemic symptoms declined from before to after for both active and placebo inoculations regardless of affect groups. The results add to previous research showing that negative affect is related to cross-sectional symptom reporting but not to increases in symptom reporting from before to after a symptom-producing inoculation procedure.