Purpose
Introduction
Cancer Risk Assessment and Counseling

Genetic Counseling Cancer Risk Assessment Counseling

Components of the Risk Assessment Process

Assessment         Psychosocial assessment         Risk perception Clinical Evaluation         Personal health history         Physical examination         Family history Determining Cancer Risk         Analysis of the family history         Methods of quantifying cancer risk

Education and Counseling About Risk/Risk Communication

Methods of Risk Presentation Risk Communication Communication Strategies

The Option of Genetic Testing

Factors to Take into Consideration in Offering Testing         Indications for testing         Value of testing an affected family member first         Testing in families with evidence of an inherited susceptibility that have not had any genetic testing or in which genetic testing has not identified a mutation         Testing in families with a documented deleterious mutation         Genetic testing and assisted reproductive technology Determining the Test to be Used         Regulation of genetic tests Direct-to-Consumer Marketing of Genetic Tests         Trends in direct-to-consumer marketing of genetic tests         Concerns about marketing of direct-to-consumer genetic tests         Research examining the impact of direct-to-consumer marketing of genetic tests Informed Consent         Core elements of informed consent         Testing in children         Testing in vulnerable populations Importance of Pretest Counseling Psychological Impact of Genetic Information/Test Results on the Individual Psychological Impact of Genetic Information/Test Results on the Family         Exploration of potential risks, benefits, burdens, and limitations of genetic susceptibility testing         Posttest education and result notification

Ethical, Legal, and Social Implications

Bioethical Issues in Cancer Genetic Testing         Beneficence         Nonmaleficence         Autonomy         Justice Privacy and Confidentiality: Disclosure of Patient’s Genetic Information         Disclosure in research         “Duty to warn”: legal proceedings, federal/state legislation, and recommendations of professional organizations Employment and Insurance Discrimination         Legal proceedings, federal/state legislation, and recommendations of professional organizations         Professional guidelines and other resources

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Purpose

This PDQ cancer information summary for health professionals provides a framework for assessing and counseling clients about their chance of having an inherited susceptibility to cancer. This summary is reviewed regularly and updated as necessary by the PDQ Cancer Genetics Editorial Board.

Information about the following is included in this summary:

• Components of the risk assessment process.
• Strategies for communicating cancer risk.
• Aspects of genetic testing including considerations about whether genetic testing should be offered, which genetic test should be used, informed consent for genetic testing, and the psychological impact of genetic information or test results on the individual and family.
• Ethical, legal, and social implications of cancer risk assessment and counseling.

This summary does not provide formal guidelines or recommendations for making health care decisions. Information in this summary should not be used as a basis for reimbursement determinations.

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Introduction

 [Note: Many of the medical and scientific terms used in this summary are found in the NCI Dictionary of Genetics Terms. When a linked term is clicked, the definition will appear in a separate window.]

This summary describes current approaches to assessing and counseling people about their chance of having an inherited susceptibility to cancer. Genetic counseling is defined by the National Society of Genetic Counselors as the process of helping people understand and adapt to the medical, psychological, and familial implications of genetic contributions to disease. Several reviews present overviews of the cancer risk assessment, counseling and genetic testing process.[1-4].

Individuals are considered to be candidates for cancer risk assessment if they have a personal and/or family history in a maternal or paternal lineage with features suggestive of hereditary cancer.[5] These features vary by type of cancer and specific hereditary syndrome. Criteria have been published to help identify families who may benefit from a referral to genetic counseling.[2,6] The introductory sections of the PDQ cancer genetics information summaries on breast, ovarian, colorectal, prostate and medullary thyroid cancers describe the clinical features of hereditary syndromes associated with these cancers.

The following are features that suggest hereditary cancer:

• Unusually early age of cancer onset (e.g., premenopausal breast cancer).
• Multiple primary cancers in a single individual (e.g., colorectal and endometrial cancer).
• Bilateral cancer in paired organs, or multifocal disease (e.g., bilateral breast cancer or multifocal renal cancer).
• Clustering of the same type of cancer in close relatives (e.g., mother, daughter and sisters with breast cancer).
• Cancers occurring in multiple generations of a family (autosomal dominant inheritance).
• Occurrence of rare tumors (e.g., retinoblastoma, adrenocortical carcinoma, granulosa cell tumor of the ovary, ocular melanoma, hepatoma, or duodenal cancer).
• Unusual presentation of cancer (e.g., male breast cancer).
• Uncommon tumor histology (e.g., medullary thyroid carcinoma).
• Rare cancers associated with birth defects (e.g., Wilms tumor and genitourinary abnormalities).
• Geographic or ethnic populations known to be at high risk of hereditary cancers. Genetic testing candidates may be identified based solely on ethnicity when a strong founder effect is present in a given population (e.g., Ashkenazi heritage and BRCA1/BRCA2 mutations).[7,8]

As part of the process of genetic education and counseling, genetic testing may be considered when the following factors are present:

• An individual's personal history (including ethnicity) and/or family history is suspicious for a genetic predisposition to cancer.
• The genetic test has sufficient sensitivity and specificity to be interpreted.
• The test will impact the individual's diagnosis, cancer management or cancer risk management, and/or help clarify risk for family members.[9]

A candidate for genetic testing receives genetic education and counseling before testing to facilitate informed decision making and adaptation to the risk or condition.[10] Genetic education and counseling gives an individual time to consider the various medical uncertainties, diagnosis, or medical management based on varied test results, and the risks, benefits and limitations of genetic testing.

References

1. Petersen GM: Genetic testing. Hematol Oncol Clin North Am 14 (4): 939-52, 2000.  [PUBMED Abstract]
   
   
2. Kuschel B, Lux MP, Goecke TO, et al.: Prevention and therapy for BRCA1/2 mutation carriers and women at high risk for breast and ovarian cancer. Eur J Cancer Prev 9 (3): 139-50, 2000.  [PUBMED Abstract]
   
   
3. Schoen RE: Families at risk for colorectal cancer: risk assessment and genetic testing. J Clin Gastroenterol 31 (2): 114-20, 2000.  [PUBMED Abstract]
   
   
4. Trepanier A, Ahrens M, McKinnon W, et al.: Genetic cancer risk assessment and counseling: recommendations of the national society of genetic counselors. J Genet Couns 13 (2): 83-114, 2004.  [PUBMED Abstract]
   
   
5. Weitzel JN, Lagos VI, Cullinane CA, et al.: Limited family structure and BRCA gene mutation status in single cases of breast cancer. JAMA 297 (23): 2587-95, 2007.  [PUBMED Abstract]
   
   
6. Hampel H, Sweet K, Westman JA, et al.: Referral for cancer genetics consultation: a review and compilation of risk assessment criteria. J Med Genet 41 (2): 81-91, 2004.  [PUBMED Abstract]
   
   
7. Tobias DH, Eng C, McCurdy LD, et al.: Founder BRCA 1 and 2 mutations among a consecutive series of Ashkenazi Jewish ovarian cancer patients. Gynecol Oncol 78 (2): 148-51, 2000.  [PUBMED Abstract]
   
   
8. Beller U, Halle D, Catane R, et al.: High frequency of BRCA1 and BRCA2 germline mutations in Ashkenazi Jewish ovarian cancer patients, regardless of family history. Gynecol Oncol 67 (2): 123-6, 1997.  [PUBMED Abstract]
   
   
9. American Society of Clinical Oncology.: American Society of Clinical Oncology policy statement update: genetic testing for cancer susceptibility. J Clin Oncol 21 (12): 2397-406, 2003.  [PUBMED Abstract]
   
   
10. Genetic Counseling as a Profession. Chicago, IL: National Society of Genetic Counselors, 2006 Also available online. Last accessed September 5, 2007. 
    
    

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Cancer Risk Assessment and Counseling

Comprehensive cancer risk assessment is a consultative service that includes clinical assessment, genetic testing when appropriate, and risk management recommendations, delivered in the context of one or more genetic counseling sessions. Several professional organizations, including the American Society of Clinical Oncology,[1] Oncology Nursing Society, and the International Society of Nurses in Genetics, emphasize the importance of genetic counseling in the cancer risk assessment and genetic testing process.[2]

Genetic counseling informs the consultand about potential cancer risks and the benefits and limitations of genetic testing, and offers an opportunity to consider the potential medical, psychological, familial, and social implications of genetic information.[2-4] Descriptions of genetic counseling and the specialized practice of cancer risk assessment counseling are detailed below.

Genetic counseling has been defined by the American Society of Human Genetics as “a communication process which deals with the human problems associated with the occurrence, or risk of occurrence, of a genetic disorder in a family. The process involves an attempt by one or more appropriately trained persons to help the individual or family to:

1. comprehend the medical facts including the diagnosis, probable course of the disorder, and the available management;
2. appreciate the way that heredity contributes to the disorder, and to the risk of recurrence (occurrence), in specific relatives;
3. understand the alternatives for dealing with the risk of recurrence (occurrence);
4. choose a course of action which seems to them appropriate in view of their risk, their family goals, and their ethical and religious standards and act in accordance with that decision; and
5. make the best possible adjustment to the disorder in an affected family member and/or to the risk of recurrence (occurrence) of that disorder.”[5]

In 2006, the National Society of Genetic Counselors further refined the definition of genetic counseling to include the process of helping people understand and adapt to the medical, psychological and familial implications of genetic contributions to disease including integration of the following:

• Interpretation of family and medical histories to assess the chance of disease occurrence or recurrence.
• Education about inheritance, testing, management, prevention, resources and research.
• Counseling to promote informed choices and adaptation to the risk or condition.[2]

Additionally, understanding the potential impact of genetic testing facilitates discussion on how information might be transmitted and shared among family members.

Central to the philosophy and practice of genetic counseling are the principles of voluntary utilization of services, informed decision making, attention to psychosocial and affective dimensions of coping with genetic risk, and protection of patient confidentiality and privacy. This is facilitated through a combination of rapport building and information gathering; establishing or verifying diagnoses; risk assessment and calculation of quantitative occurrence/recurrence risks; education and informed consent processes; psychosocial assessment, support, and counseling appropriate to a family’s culture and ethnicity; and other relevant background characteristics.[6,7] The psychosocial assessment is especially important in the genetic counseling process because individuals most vulnerable to adverse effects of genetic information may include those who have had difficulty dealing with stressful life events in the past.[8] Variables that may influence psychosocial adjustment to genetic information include: individual and familial factors, cultural factors, and health system factors, such as the type of test, disease status and risk information.[8] Findings from a psychosocial assessment can be used to help guide the direction of the counseling session.[9] An important objective of genetic counseling is to provide an opportunity for shared decision-making when the medical benefits of one course of action are not demonstrated to be superior to another. The relationship between the availability of effective medical treatment for mutation carriers and the clinical validity of a given test affects the degree to which personal choice or physician recommendation is supported in counseling at-risk individuals.[10] Uptake of genetic counseling services among those referred is moderate (30%-40%). Efforts to decrease barriers to service utilization are ongoing (e.g., a patient navigator telephone call may increase utilization of these services by at-risk women).[11] Readers interested in the nature and history of genetic counseling are referred to a number of comprehensive reviews.[12-17]

The scope of genetic counseling practice has expanded over the past several years to address risk assessment and genetic testing for hereditary cancer predisposition. Cancer risk assessment counseling has emerged as a specialized practice that requires knowledge of genetics, oncology, and individual and family counseling skills that may be provided by health care providers with this interdisciplinary training.[18,19] Some centers providing cancer risk assessment services involve a multidisciplinary team, which may include a genetic counselor, a genetics advanced practice nurse, a medical geneticist or a physician such as an oncologist, surgeon, or internist, and a mental health professional. The Cancer Genetics Services Directory provides a partial list of individuals involved in cancer risk assessment, genetic counseling, testing, and other related services, and is available on the National Cancer Institute's Web site.

The need for advanced professional training in cancer genetics for genetics counselors, physicians, nurses, laboratory technicians, and others has been widely reported.[20-24] Despite these identified needs, the evidence indicates that competency in genetics and genomics remains limited across all health care disciplines with the exception of genetic specialists.[25] The National Coalition for Health Professional Education in Genetics (NCHPEG) was established in 1996 to enhance the level of general professional education about genetics. NCHPEG has published and updated core competencies for all health professionals. Building on this work, individual health professions such as nursing and physician assistants, have developed and published core competencies specific to their profession.[26,27] A number of other organizations have also published professional guidelines, and scopes and standards of practice.[28-33]

Traditionally, genetic counseling services have been delivered using individualized in-person appointments. However, other methodologies are being explored including group sessions and telephone counseling.[34-38] Additionally, computer programs designed to provide genetics education can be successful adjuncts to personal genetic counseling services in a computer-literate population.[39-41]

Some studies of patient satisfaction with cancer genetic counseling services have been published. For example, one survey of participants after the first year of operation of a cancer genetics program reported that the clinical services met the needs and expectations of most people.[42] Patients reported that the best parts of the experience were simply having a chance to talk to someone about cancer concerns, having personalized summary letters and family pedigrees, learning that cancer risk was lower than expected, or realizing that one had been justified in suspecting the inheritance of cancer in one’s family.

Several studies have since shown that the majority of individuals are satisfied with their genetic counseling experience.[43-46] However, one study of 61 women participating in a BRCA1/2 genetic testing program found that satisfaction with genetic counseling was influenced by psychological variables including optimism, family functioning, and general and cancer-specific distress.[47]

A meta-analysis of several controlled studies showed that outcomes of genetic counseling included improvement in cancer genetic knowledge (pooled short term difference – 0.70 U, 95% confidence interval, 0.15–1.26 U). Overall, no long term increases in general anxiety, cancer specific worry, distress or depression were detected as a consequence of genetic counseling. However, the impact of genetic counseling on risk perception is less clear, with some studies reporting no change in risk perception while others reported significant differences before and after counseling.[48]

Evidence regarding long-term recommendation recall as a consequence of genetic counseling is now emerging. One study of 41 women who underwent genetic education and counseling followed by a written summary of the recommendations found that the majority did not accurately recall the recommendations 4 to 6 months postcounseling.[46] Other data indicate that recall and interpretation of genetic test results may also be inaccurate. In a study of 24 individuals tested from 1998-2006, who were found to have a BRCA variant of uncertain significance (VUS), 29% recalled the result as being a deleterious mutation. In this study there was a difference between factual recall and subjective interpretation of the test results; the majority of those who accurately recalled the VUS as being uninformative still interpreted the result as conferring a predisposition to cancer.[49]

References

1. American Society of Clinical Oncology.: American Society of Clinical Oncology policy statement update: genetic testing for cancer susceptibility. J Clin Oncol 21 (12): 2397-406, 2003.  [PUBMED Abstract]
   
   
2. Resta R, Biesecker BB, Bennett RL, et al.: A new definition of Genetic Counseling: National Society of Genetic Counselors' Task Force report. J Genet Couns 15 (2): 77-83, 2006.  [PUBMED Abstract]
   
   
3. Lerman C, Peters JA, Ades T, et al.: Genetic counseling issues. Workshop No. 2. Cancer 80(3): 628-629, 1997. 
   
   
4. Resta RG: Defining and redefining the scope and goals of genetic counseling. Am J Med Genet C Semin Med Genet 142C (4): 269-75, 2006.  [PUBMED Abstract]
   
   
5. Genetic counseling. Am J Hum Genet 27 (2): 240-2, 1975.  [PUBMED Abstract]
   
   
6. Baty BJ, Kinney AY, Ellis SM: Developing culturally sensitive cancer genetics communication aids for African Americans. Am J Med Genet 118A (2): 146-55, 2003.  [PUBMED Abstract]
   
   
7. Jenkins JF, Lea DH: Nursing Care in the Genomic Era: A Case-Based Approach. Sudbury, Mass: Jones and Bartlett Publishers, 2005. 
   
   
8. Meiser B, Gaff C, Julian-Reynier C, et al.: International perspectives on genetic counseling and testing for breast cancer risk. Breast Dis 27: 109-25, 2006-2007.  [PUBMED Abstract]
   
   
9. Trepanier A, Ahrens M, McKinnon W, et al.: Genetic cancer risk assessment and counseling: recommendations of the national society of genetic counselors. J Genet Couns 13 (2): 83-114, 2004.  [PUBMED Abstract]
   
   
10. Burke W, Pinsky LE, Press NA: Categorizing genetic tests to identify their ethical, legal, and social implications. Am J Med Genet 106 (3): 233-40, 2001 Fall.  [PUBMED Abstract]
    
    
11. Rahm AK, Sukhanova A, Ellis J, et al.: Increasing utilization of cancer genetic counseling services using a patient navigator model. J Genet Couns 16 (2): 171-7, 2007.  [PUBMED Abstract]
    
    
12. Walker AP: The practice of genetic counseling. In: Baker DL, Schuette JL, Uhlmann WR, eds.: A Guide to Genetic Counseling. New York, NY: Wiley-Liss, 1998, pp 1-26. 
    
    
13. Bartels DM, LeRoy BS, Caplan AL, eds.: Prescribing Our Future: Ethical Challenges in Genetic Counseling. New York, NY: Aldine De Gruyter, 1993. 
    
    
14. Kenen RH: Genetic counseling: the development of a new interdisciplinary occupational field. Soc Sci Med 18 (7): 541-9, 1984.  [PUBMED Abstract]
    
    
15. Kenen RH, Smith AC: Genetic counseling for the next 25 years: models for the future. J Genet Couns 4(2): 115-124, 1995. 
    
    
16. Biesecker BB: Goals of genetic counseling. Clin Genet 60 (5): 323-30, 2001.  [PUBMED Abstract]
    
    
17. Weil Jon: Psychosocial Genetic Counseling. New York, NY: Oxford University Press, 2000. 
    
    
18. Freedman AN, Wideroff L, Olson L, et al.: US physicians' attitudes toward genetic testing for cancer susceptibility. Am J Med Genet A 120A (1): 63-71, 2003.  [PUBMED Abstract]
    
    
19. Myers MF, Doksum T, Holtzman NA: Genetic services for common complex disorders: surveys of health maintenance organizations and academic genetic centers. Genet Med 1 (6): 272-85, 1999 Sep-Oct.  [PUBMED Abstract]
    
    
20. Cole DE, Gallinger S, McCready DR, et al.: Genetic counselling and testing for susceptibility to breast, ovarian and colon cancer: where are we today? CMAJ 154 (2): 149-55, 1996.  [PUBMED Abstract]
    
    
21. Calzone KA: Predisposition testing for breast and ovarian cancer susceptibility. Semin Oncol Nurs 13 (2): 82-90, 1997.  [PUBMED Abstract]
    
    
22. Mansoura MK, Collins FS: Medical implications of the genetic revolution. Journal of Health Care Law and Policy 1(2): 329-353, 1998. 
    
    
23. Holtzman NA, Watson MS, eds.: Promoting Safe and Effective Genetic Testing in the United States: Final Report of the Task Force on Genetic Testing. Baltimore, Md: Johns Hopkins Press, 1998. Also available online. Last accessed June 28, 2007. 
    
    
24. McInerney JD: Genetics education for health professionals: a context. J Genet Couns 17 (2): 145-51, 2008.  [PUBMED Abstract]
    
    
25. Harvey EK, Fogel CE, Peyrot M, et al.: Providers' knowledge of genetics: A survey of 5915 individuals and families with genetic conditions. Genet Med 9 (5): 259-67, 2007.  [PUBMED Abstract]
    
    
26. Jenkins J, Calzone KA: Establishing the essential nursing competencies for genetics and genomics. J Nurs Scholarsh 39 (1): 10-6, 2007.  [PUBMED Abstract]
    
    
27. Rackover M: Establishing essential physician assistant clinical competencies guidelines for genetics and genomics. The Journal of Physician Assistant Education 18 (2): 47-8, 2007. 
    
    
28. American College of Medical Genetics.: Genetic susceptibility to breast and ovarian cancer: assessment, counseling and testing guidelines. New York: New York State Department of Health, American College of Medical Genetics Foundation, 1999. Also available online. Last accessed March 8, 2007. 
    
    
29. McKinnon WC, Baty BJ, Bennett RL, et al.: Predisposition genetic testing for late-onset disorders in adults. A position paper of the National Society of Genetic Counselors. JAMA 278 (15): 1217-20, 1997.  [PUBMED Abstract]
    
    
30. Resource document for curriculum development in cancer genetics education. American Society of Clinical Oncology. J Clin Oncol 15 (5): 2157-69, 1997.  [PUBMED Abstract]
    
    
31. Points to consider: ethical, legal, and psychosocial implications of genetic testing in children and adolescents. American Society of Human Genetics Board of Directors, American College of Medical Genetics Board of Directors. Am J Hum Genet 57 (5): 1233-41, 1995.  [PUBMED Abstract]
    
    
32. ASHG statement. Professional disclosure of familial genetic information. The American Society of Human Genetics Social Issues Subcommittee on Familial Disclosure. Am J Hum Genet 62 (2): 474-83, 1998.  [PUBMED Abstract]
    
    
33. The National Action Plan on Breast Cancer (NAPBC) Hereditary Susceptibility Working Group and Education Subgroup.: Hereditary Susceptibility to Breast and Ovarian Cancer: An Outline of Fundamental Knowledge Needed by all Health Care Professionals. Washington D.C.: US Dept. of Health and Human Services, The Office on Women's Health, 2000. 
    
    
34. Ormond K: Recommendations for telephone counseling. J Genet Couns 9 (1): 63-71, 2000. 
    
    
35. Sangha K: Assessment of the effectiveness of genetic counseling by telephone compared to a clinic visit. J Genet Couns 12 (2): 171-84, 2003. 
    
    
36. Calzone KA, Prindiville SA, Jourkiv O, et al.: Randomized comparison of group versus individual genetic education and counseling for familial breast and/or ovarian cancer. J Clin Oncol 23 (15): 3455-64, 2005.  [PUBMED Abstract]
    
    
37. Jenkins J, Calzone KA, Dimond E, et al.: Randomized comparison of phone versus in-person BRCA1/2 predisposition genetic test result disclosure counseling. Genet Med 9 (8): 487-95, 2007.  [PUBMED Abstract]
    
    
38. Peshkin BN, Demarco TA, Graves KD, et al.: Telephone genetic counseling for high-risk women undergoing BRCA1 and BRCA2 testing: rationale and development of a randomized controlled trial. Genet Test 12 (1): 37-52, 2008.  [PUBMED Abstract]
    
    
39. Green MJ, Biesecker BB, McInerney AM, et al.: An interactive computer program can effectively educate patients about genetic testing for breast cancer susceptibility. Am J Med Genet 103 (1): 16-23, 2001.  [PUBMED Abstract]
    
    
40. Green MJ, McInerney AM, Biesecker BB, et al.: Education about genetic testing for breast cancer susceptibility: patient preferences for a computer program or genetic counselor. Am J Med Genet 103 (1): 24-31, 2001.  [PUBMED Abstract]
    
    
41. Wang C, Gonzalez R, Milliron KJ, et al.: Genetic counseling for BRCA1/2: a randomized controlled trial of two strategies to facilitate the education and counseling process. Am J Med Genet A 134 (1): 66-73, 2005.  [PUBMED Abstract]
    
    
42. Stadler MP, Mulvihill JJ: Cancer risk assessment and genetic counseling in an academic medical center: consultands' satisfaction, knowledge, and behavior in the first year. J Genet Couns 7(3): 279-297, 1998. 
    
    
43. Chen WY, Garber JE, Higham S, et al.: BRCA1/2 genetic testing in the community setting. J Clin Oncol 20 (22): 4485-92, 2002.  [PUBMED Abstract]
    
    
44. Nordin K, Lidén A, Hansson M, et al.: Coping style, psychological distress, risk perception, and satisfaction in subjects attending genetic counselling for hereditary cancer. J Med Genet 39 (9): 689-94, 2002.  [PUBMED Abstract]
    
    
45. Klemp JR, O'Dea A, Chamberlain C, et al.: Patient satisfaction of BRCA1/2 genetic testing by women at high risk for breast cancer participating in a prevention trial. Fam Cancer 4 (4): 279-84, 2005.  [PUBMED Abstract]
    
    
46. Bober SL, Hoke LA, Duda RB, et al.: Recommendation recall and satisfaction after attending breast/ovarian cancer risk counseling. J Genet Couns 16 (6): 755-62, 2007.  [PUBMED Abstract]
    
    
47. Tercyak KP, Demarco TA, Mars BD, et al.: Women's satisfaction with genetic counseling for hereditary breast-ovarian cancer: psychological aspects. Am J Med Genet A 131 (1): 36-41, 2004.  [PUBMED Abstract]
    
    
48. Braithwaite D, Emery J, Walter F, et al.: Psychological impact of genetic counseling for familial cancer: a systematic review and meta-analysis. J Natl Cancer Inst 96 (2): 122-33, 2004.  [PUBMED Abstract]
    
    
49. Vos J, Otten W, van Asperen C, et al.: The counsellees' view of an unclassified variant in BRCA1/2: recall, interpretation, and impact on life. Psychooncology 17 (8): 822-30, 2008.  [PUBMED Abstract]
    
    

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Components of the Risk Assessment Process

This section provides an overview of critical elements in the cancer risk assessment process.

A number of professional guidelines on the elements of cancer genetics risk assessment and counseling are available, such as the National Cancer Network Practice Guidelines for Genetic/Familial High Risk Assessment: Breast and Ovarian Cancer.[1-7] Except where noted, the discussion below is based on these guidelines.

The cancer risk assessment and counseling process, which may vary among providers, requires one or more consultative sessions and generally includes the following:

• A detailed, multifaceted assessment.
• A determination of the risk of cancer and/or indication for genetic testing based on evidence of an inherited cancer syndrome.
• Education and counseling.
• Establishment of a cancer risk management plan.

At the outset of the initial counseling session, eliciting and addressing the consultand's perceptions and concerns about cancer and his or her expectations of the risk assessment process helps to engage the consultand in the session. This also helps inform the provider about practical or psychosocial issues, and guides the focus of counseling and strategies for risk assessment.

The counseling process that takes place as part of cancer risk assessment can identify factors that contribute to the consultand's perception of cancer risk and motivations to seek cancer risk assessment and genetic testing, and can identify potential psychological issues that may need to be addressed during or beyond the session. Information collected before and/or during the session may include the following:

• Motivations for seeking cancer risk assessment.
• Beliefs about the causes of cancer.
• Experiences with cancer and feelings, perceptions, concerns, or fears related to those experiences.
• The influence of cancer experiences and perceptions on health behaviors and cancer screening practices.
• Cultural, religious, and socioeconomic background.
• General psychological issues, such as depression or anxiety.
• Coping mechanisms.
• Support systems.

Either alone or in consultation with a mental health provider, health care providers offering cancer risk counseling attempt to assess whether the individual's expectations of counseling are realistic and whether there are factors suggesting risk of adverse psychological outcomes after disclosure of risk and/or genetic status. In some cases, referral for psychotherapeutic treatment may be recommended prior to or in lieu of testing.[8]

One study has shown that the addition of a colored ecogenetic relationship map (CEGRM) to the psychosocial assessment is feasible for assessing the social milieu in which an individual resides.[9] The CEGRM is a psychosocial assessment tool that expands the family pedigree to include a family systems genogram and ecomap.[10]

The communication of risk involves the delivery of quantitative information regarding what the data indicate about the likelihood of developing illness given various preventive actions. More broadly, however, risk communication is an interactive process regarding the individual’s knowledge, beliefs, emotions, and behaviors associated with risk, as well as the risk message conveyed. Accordingly, the goal of risk communication may impact the individual’s knowledge of risk factors, risk likelihoods, potential consequences of risk, and the benefits and drawbacks of preventive actions.

Even before the provision of risk information, the provider may anticipate that the individual already has some sense of his or her own risk of cancer. The individual may have derived this information from multiple sources, including physicians, family members and the media.[11] This information may be more salient or emotional if a family member has recently died from cancer, or if there is a new family diagnosis.[12,13] Additionally, individuals may have beliefs about how genetic susceptibility works in their family.[14,15] The social-ecological context through which risk beliefs develop and are maintained are important as potential moderators of individuals’ receptivity to the cancer risk communication process, and also represent the context in which individuals will return to continue ongoing decision-making about how to manage their risk.[16,17] As such, individuals’ beliefs, and the social context of risk, are important to discuss in education and genetic risk counseling.

Perceived risk can play an important role in an individual’s decision to participate in counseling,[18] despite the fact that perceived risk often varies substantially from statistical risk estimates.[19-21]

Consideration of the consultand's personal health history is essential in cancer risk assessment, regardless of whether the individual has a personal history of cancer. Important information to obtain about the consultand's health history includes the following:

• Current age.
• Race and ethnicity.
• History of benign or malignant tumors, surgeries, biopsies, major illnesses, medications, and reproductive history (for women, this includes age at menarche, parity, age at first live birth, age at menopause, and history of exogenous hormone use).
• Environmental exposures.
• Diet and exercise practices.
• Complementary and alternative medicine practices.
• Past and current alcohol intake and tobacco use.
• Screening practices and date of last screening exams, including imaging and/or physical examinations to identify any problems with compliance.[4,6]

For consultands with a history of cancer, additional information collected includes the following:

• Site of primary tumor.
• Age at diagnosis.
• Tumor pathology.
• Treatment (surgery, chemotherapy, radiation therapy).
• Bilaterality of disease, if applicable.
• Current surveillance plan.[4]

In some cases a physical exam is conducted by a qualified medical professional to determine whether the individual has physical findings suggestive of a hereditary cancer predisposition syndrome or to rule out evidence of an existing malignancy. For example, a medical professional may look for the sebaceous adenomas seen in Muir-Torre syndrome, measure the head circumference or perform a skin exam to rule out benign cutaneous features associated with Cowden syndrome, or perform a clinical breast and lymph node exam on a woman undergoing a breast cancer risk assessment.

The family history is an essential tool for cancer risk assessment. The family history can be obtained via interview or written self-report; both have been found to result in equivalent information in a study that utilized a sample (n = 104) that varied widely in educational attainment.[22] Details of the family health history are best summarized in the form of a family tree, or pedigree. The pedigree, a standardized graphic representation of family relationships, facilitates identification of patterns of disease transmission, recognition of the clinical characteristics associated with specific hereditary cancer syndromes, and determination of the best strategies and tools for risk assessment.[23] Factors suggesting inherited cancer risk were previously discussed.

Standards of pedigree nomenclature have been established.[23] Refer to Figure 1 for common pedigree symbols.

Enlarge

Figure 1. Standard pedigree nomenclature. Common symbols are used to draw a pedigree (family tree). A pedigree shows relationships between family members and patterns of inheritance for certain traits and diseases.

Documentation of a family cancer history typically includes the following:

• A minimum of three generations of relatives on both the maternal and paternal sides of the family. Information on multiple generations helps to demonstrate inheritance patterns. Hereditary cancer can be inherited from either the maternal or paternal side of the family, and is often an adult-onset disease.
• Race, ancestry, and ethnicity of all grandparents. This may influence decisions about genetic testing because specific mutations in some genes are known to occur with increased frequency in some populations (founder effect).
• Information about seemingly unrelated conditions, such as birth defects, atypical skin bumps, or other nonmalignant conditions of children and adults that may aid in the diagnosis of a cancer susceptibility syndrome.
• Notation of adoption, nonpaternity, consanguinity, and use of assisted reproductive technology (e.g., donor egg or sperm), when available.

A three-generation family history includes the following:

• First-degree relatives (e.g., children, brothers and sisters, and parents).
• Second-degree relatives (e.g., grandparents, aunts and uncles, nieces and nephews, grandchildren).
• Third-degree relatives (e.g., first cousins, great aunts, and great uncles).
• Additional distant relatives are included if information is available, especially when there are known cancer histories among them.

For any relative with cancer, collect the following information:[24]

• Primary site of each cancer, with supportive documentation of key cancers to confirm primary site and histology (e.g., pathology reports, clinical documents, death certificates).
• Age at diagnosis for each primary cancer.
• Where the relative was diagnosed and/or treated.
• History of surgery or treatments that may have reduced the risk of cancer. For example, bilateral salpingo-oophorectomy in a premenopausal woman significantly reduces the risk of ovarian and breast cancers. This may mask underlying hereditary predisposition to these cancers since breast and ovarian cancer risk is substantially reduced following prophylactic surgery.
• Current age (if the individual is living).
• Age at death and cause of death (if the individual is deceased).
• Carcinogenic exposures (e.g., tobacco use, radiation exposure).
• Other significant health problems.

For relatives not affected with cancer, collect the following information:

• Current age or age at death.
• Cause of death (if deceased).
• History of any surgeries or treatments that may have reduced the risk of cancer.
• Cancer screening practices.
• Any nonmalignant features associated with the syndrome in question.
• Carcinogenic exposures.
• Other significant health problems.

The accuracy of the family history has a direct bearing on determining the differential diagnoses, selecting and interpreting results of the genetic tests, refining individual cancer risk estimates, and outlining screening and risk reduction recommendations. However, people often have incomplete or inaccurate information about the cancer history in their family.[23-29] Accuracy may also vary by site of cancer or degree of relatedness.[30] A 2004 review suggests that reporting of cancer family histories may be most accurate for breast cancer and less accurate for gynecologic malignancies.[31] Self-reported family histories may contain errors and, in rare instances, could be fictitious.[28,31,32] It is important to confirm the primary site of cancers in the family that will effect the calculation of hereditary predisposition probabilities and/or estimation of empiric cancer risks, especially if decisions such as risk-reducing surgery will be based on family history.[32] The most reliable documentation of cancer etiology and histology is the pathology report. Verification of cancers can also be made through other medical records, tumor registries, or death certificates.

It is also important to consider limited, missing or questionable information when reviewing a pedigree for cancer risk assessment. It is more difficult to identify features of hereditary disease in families with a truncated family structure due to loss of contact with relatives, small family size, deaths at an early age from unrelated conditions, or when there are few family members of the at-risk sex in a syndrome with primarily male or female specific disease manifestations such as prostate or ovarian cancer (e.g., few female members in a family at risk for hereditary breast and ovarian cancer syndrome). In addition, information collected on risk-reducing surgical procedures, such as oophorectomy, could significantly change prior probability estimation and the constellation of cancers observed in a family.[33] Other factors to clarify and document whenever possible are adoptions, use of donor egg or sperm, consanguinity, and uncertain paternity.

Additionally, family histories are dynamic. The occurrence of additional cancers may alter the likelihood of a hereditary predisposition to cancer, and consideration of differential diagnoses or empiric cancer risk estimates may change if additional cancers arise in the family. It is important to advise the consultand to take note of, confirm, and report cancer diagnoses or other pertinent family health history that occurs after completion of the initial risk assessment process. This is especially important if genetic testing was not performed or was uninformative.

Finally, the process of taking the family history has a psychosocial dimension. Discussing and documenting discrete aspects of family relationships and health brings the family into the session symbolically, even when a single person is being counseled. Problems that may be encountered in eliciting a family history and constructing a pedigree include difficulty contacting relatives with whom one has little or no relationship, differing views between family members about the value of genetic information, resistance to discussion of cancer and cancer-related illness, unanticipated discovery of previously unknown medical or family information, and coercion of one relative by another regarding testing decisions. In addition, unexpected emotional distress may be experienced by the consultand in the process of gathering family history information.

Because a family history of cancer is one of the important predictors of cancer risk, analysis of the pedigree constitutes one important aspect of risk assessment. This analysis might be thought of as a series of the following questions:

1. What is the evidence that a cancer susceptibility syndrome is present in this family?
2. If a syndrome is present, what is the most probable diagnosis?
3. What could make this family history difficult to interpret?
4. What is the most likely mode of inheritance, regardless of whether a syndrome diagnosis can be established?
5. What is the chance of a member of this family developing cancer, if an inherited susceptibility exists?
6. If no recognizable syndrome is present, what are the implications of other epidemiological risk factors?

The following sections relate to the way that each of these questions might be addressed:

1. What is the evidence that a cancer susceptibility syndrome is present in this family?

   The clues to a hereditary syndrome are based on pedigree analysis and physical findings. The index of suspicion is raised by the following:

   • Multiple cancers in close relatives, particularly in multiple generations.
   • Early age of cancer onset (younger than age 40 to 50 years for adult-onset cancers).
   • Multiple cancers in a single individual.
   • Bilateral cancer in paired organs (e.g., breast, kidney).
   • Recognition of the known association between etiologically related cancers in the family.
   • Presence of congenital anomalies or precursor lesions that are known to be associated with increased cancer risk (e.g., presence of atypical nevi and risk of malignant melanoma).
   • Recognizable Mendelian inheritance pattern.

   Clinical characteristics associated with distinctive risk ranges for different cancer genetic syndromes have been clarified by the Society of Gynecologic Oncologists Education Committee.[34]

2. If a syndrome is present, what is the most probable diagnosis?

   Hundreds of inherited conditions are associated with an increased risk of cancer. These have been summarized in texts [35-37] and a concise review.[38] Diagnostic criteria for different hereditary syndromes incorporate different features from the list above, depending on the original purpose of defining the syndrome, e.g., for gene mapping, genotype- phenotype studies, epidemiological investigations, population screening, or clinical service. Thus, a syndrome such as Lynch syndrome (also called hereditary nonpolyposis colorectal cancer [HNPCC]) can be defined for research purposes by the Amsterdam Criteria as having three related individuals with colorectal cancer, spanning two generations, of which one person is younger than 50 years, better known as the 3-2-1 rule. These criteria have limitations in the clinical setting, however, in that they ignore endometrial and other extracolonic tumors known to be important features of Lynch syndrome. Revised published criteria that consider extracolonic cancers in establishing the diagnosis of Lynch syndrome have been subsequently developed and include the Amsterdam criteria II and the revised Bethesda guidelines.

3. What could make the family history difficult to interpret?

   Other factors may complicate recognition of basic inheritance patterns or represent different types of disease etiology. These factors include the following:

   • Small family size.
   • Deaths at particularly early ages.
   • Removal of the target organ, either as prevention or as a result of a medical condition (e.g., total abdominal hysterectomy and bilateral salpingo-oophorectomy due to history of uterine fibroids or endometriosis).
   • Misidentified parentage.
   • Late or variable onset.
   • Nonpenetrance.
   • Variable expression.
   • Genetic heterogeneity.
   • Genomic imprinting.
   • De novo mutation.
   • Mosaicism.
   • Mitochondrial inheritance.
   • Consanguinity.
   • Assisted reproductive technology (e.g., donor egg or sperm).
4. What is the most likely mode of inheritance, regardless of whether a syndrome diagnosis can be established?

   The mode of inheritance refers to the way that genetic traits are transmitted in the family. Mendel’s laws of inheritance posit that genetic factors are transmitted from parents to offspring as discrete units known as genes that are inherited independently from each other and are passed on from an older generation to the following generation. The most common forms of Mendelian inheritance are autosomal dominant, autosomal recessive, and X-linked. Non-Mendelian forms of inheritance include chromosomal, multifactorial, and mitochondrial. Researchers have learned from cancer and other inherited diseases that even Mendelian inheritance is modified by environmental and other genetic factors and that there are variations in the ways that the laws of inheritance work.[39-41]

   Most commonly, Mendelian inheritance is established by a combination of clinical diagnosis with a compatible, but not in itself conclusive, pedigree pattern.[42] Below is a list of inheritance patterns with clues to their recognition in the pedigree, followed by a list of situations that may complicate pedigree interpretation.

   Autosomal dominant

   • Autosomal dominant inheritance refers to disorders that are expressed in the heterozygote, i.e., the affected person has one copy of a mutated allele and one allele that is functioning normally. Autosomal dominant inheritance is characterized by the following:
     • Vertical occurrence, i.e., seen in successive generations.
     • Usually seen only on one side of the family, i.e., unipaternal or unimaternal.
     • Males and females may inherit and transmit the disorder to offspring.
     • Male-to-male transmission may be seen.
     • Offspring have a 50% chance of inheriting a mutation and a 50% chance of inheriting the normal allele.
     • The condition may appear to skip a generation due to incomplete penetrance, early death due to other causes, delayed age of onset, or paucity of females or males when the target organ is sex-specific.
     • Most currently known cancer susceptibility syndromes follow an autosomal dominant inheritance pattern. Examples include hereditary breast and ovarian cancer syndrome, Lynch syndrome, familial adenomatous polyposis, and von Hippel Lindau disease.
     • It is possible for an individual to have a mutation in a gene that has not previously been expressed as an autosomal dominant family history of cancer due to a variety of factors discussed above (see question #3).
     • It is possible for an individual to have a de novo (new) mutation. This person would be the first affected member of his or her family, but could transmit this trait in the normal autosomal dominant manner.

   Autosomal recessive

   • Autosomal recessive inheritance refers to an inheritance pattern in which an affected person must be homozygous, i.e., carry two copies of a mutant gene, one from each parent. Autosomal recessive inheritance is characterized by the following:
     • Horizontal occurrence, i.e., seen in one generation only; these conditions generally are not seen in successive generations.
     • Affected individuals usually cluster within one sibship.
     • Mutated genes must come from both sides of the family, i.e., biparental inheritance.
     • Parents are heterozygous carriers; each carries one mutated copy of the gene and one functional copy.
     • Parents usually do not express the trait or the full syndrome; in some cases, parents may show a mild version of some features.
     • Heterozygous parents have a 25% recurrence risk for future offspring being affected.
     • Some well-defined cancer susceptibility syndromes with an autosomal recessive inheritance pattern include Bloom syndrome, ataxia telangiectasia, and Fanconi anemia.

   X-linked

   • X-linked inheritance refers to inheritance of genes located on the X chromosome. Because males carry one Y and one X chromosome, genes on their X chromosome are hemizygous and may be expressed, regardless of whether dominant or recessive. X-linked recessive inheritance is more common than X-linked dominant and is characterized by the following:
     • Male and female offspring have a 50% chance of inheriting the mutated allele from the carrier.
     • Males in the maternal lineage (brothers and maternal uncles) are affected.
     • Females are rarely affected, and when they are, the effects are usually milder than they are in males.
     • No father-to-son transmission of the mutation occurs, i.e., a father cannot transmit an X-linked condition to his son because he gives the son his Y chromosome and not his X.
     • It is unusual for a cancer susceptibility syndrome to show X-linked transmission. One rare example is X-linked lymphoproliferative disorder.

   Chromosomal

   • Chromosomal disorders generally are not inherited conditions. Rather, they occur as a de novo error in meiosis at the time of conception of a given individual. Certain chromosomal anomalies confer a risk of malignancy; thus, inquiries about birth defects and mental retardation are worthwhile in taking a pedigree. Examples of chromosomal disorders with increased risk of malignancy include leukemia associated with Down syndrome (trisomy 21) and breast cancer associated with Klinefelter syndrome (47,XXY karyotype).

   Multifactorial

   • Multifactorial or complex disease inheritance is used to describe conditions caused by genetic and environmental factors. Thus, a condition may be caused by the expression of multiple genes or by the interaction of genes and environmental factors. Therefore, a single genetic locus is not responsible for the condition. Rather, the net effect of genetic, lifestyle, and environmental factors determines a person’s liability to be affected with a condition, such as cancer.

     Susceptibility or resistance shows a more or less normal distribution in the population. Most people have an intermediate susceptibility, with those at the tails of the distribution curve having unusually low or unusually high susceptibility. Affected individuals are presumably those who are past a point of threshold for being affected due to their particular combination of risk factors. Outside of the few known Mendelian syndromes that predispose to a high incidence of specific cancer, most cancers are probably multifactorial in etiology.

     Clustering of cancer among relatives is common, but teasing out the underlying causes when there is no clear pattern is more difficult. In some types of cancer susceptibility, such as lung cancer, an excess of cancers in relatives can be seen. These familial aggregations are now seen as being due to combinations of exposures to known carcinogens, such as tobacco smoke, as well as to mutations in high penetrance genes or alterations in genes with low penetrance that affect the metabolism of the carcinogens in question.

     The general practitioner is likely to encounter some families with a strong genetic predisposition to breast cancer and the recognition of cancer susceptibility may have dramatic consequences for a given individual's health. Although mutations in major cancer susceptibility genes lead to recognizable Mendelian inheritance patterns, they are uncommon, and any given gene accounts for no more than 1% to 5% of cases of a particular cancer type. Mutations in these genes confer high relative risk as well as high absolute risk. The attributable risk is low, however, because they are so rare.

     In contrast, scientists now know of polymorphisms or alterations in deoxyribonucleic acid which are very common in the general population. Each polymorphism may confer low relative and absolute risks, but collectively they may account for high attributable risk because they are so common. Development of clinically significant disease in the presence of certain polymorphic types is highly dependent on environmental exposure to a potent carcinogen. People carrying polymorphisms associated with weak disease susceptibility may constitute a target group for whom avoidance of carcinogen exposure may be highly useful in preventing full-blown disease from occurring.

     For more information about specific low-penetrance genes, please refer to the summaries on genetics of specific types of cancer.

     In a pedigree showing multifactorial inheritance, one might see the following:

     • Males and females affected (unless the target organ is sex-specific).
     • A few cancers, without clear-cut vertical transmission or sibship clusters.
     • No set pattern of inheritance.
     • May appear to skip generations.
     • Risks to immediate family members of affected individuals are usually twofold to fourfold greater than the general population risk.
5. What is the chance of developing cancer if an inherited susceptibility exists?

   These probabilities vary by syndrome, family, gene, and mutation, with different mutations in the same gene sometimes conferring different cancer risks, or the same mutation being associated with different clinical manifestations in different families. These phenomena relate to issues such as penetrance and expressivity discussed elsewhere.

6. If no recognizable syndrome is present, what are the implications of other epidemiological risk factors?

   A positive family history may sometimes provide risk information in the absence of a specific genetically determined cancer syndrome. For example, the risk associated with having a single affected relative with breast or colorectal cancer can be estimated from data derived from epidemiologic and family studies. Examples of empiric risk estimates of this kind are provided in the PDQ summaries on Genetics of Breast and Ovarian Cancer and Genetics of Colorectal Cancer.

The overarching goal of cancer risk assessment is to individualize cancer risk management recommendations based on personalized risk. Methods to calculate risk utilize health history information, and risk factor and family history data often in combination with emerging biologic and genetic/genomic evidence, to establish predictions.[43] Multiple methodologies are used to calculate risk including statistical models, prevalence data from specific populations, penetrance data when a documented deleterious mutation has been identified in a family, Mendelian inheritance, and Bayesian analysis. All models have distinct capabilities, weaknesses and limitations based on the methodology, sample size, and/or population used to create the model. Methods to individually quantify risk encompass two primary areas: the probability of harboring a deleterious mutation in a cancer susceptibility gene and the risk of developing a specific form of cancer.[43]

The decision to offer genetic testing for cancer susceptibility is complex and can be aided in part by objectively assessing an individual's and/or family's probability of harboring a mutation.[44] Predicting the probability of harboring a mutation in a cancer susceptibility gene can be done using several strategies including empiric data, statistical models, population prevalence data, Mendel’s laws, Bayesian analysis, and specific health information such as tumor specific features.[44,45] All of these methods are gene specific or cancer-syndrome specific and are employed only after a thorough assessment has been completed and genetic differential diagnoses have been established.

If a gene or hereditary cancer syndrome is suspected, models specific to that disorder can be used to determine whether genetic testing may be informative. (Refer to the PDQ summary on the Genetics of Breast and Ovarian Cancer or the Genetics of Colorectal Cancer for more information about cancer syndrome-specific probability models.) The key to using specific models or prevalence data is to apply the model or statistics only in the population best suited for its use. For instance, a model or prevalence data derived from a population study of individuals older than 35 years may not accurately be applied in a population aged 35 years and younger. When utilizing models, careful attention must be given to what the model calculates, the probability of a mutation in the family (e.g., the Couch model ), or the individual, even if they he or she has no evidence of cancer (e.g., the BRCAPro or MMRPro model).[45] Other important considerations include critical family constructs which can significantly impact model reliability, such as small family size or male-dominated families when the cancer risks are predominately female in origin, adoption, and early deaths from other causes.[45,46] In addition, most models provide gene and/or syndrome-specific probabilities but do not account for the possibility that the personal and/or family history of cancer may be conferred by an as-yet-unidentified cancer susceptibility gene.[47] In the absence of a documented mutation in the family, critical assessment of the personal and family history is essential in determining the usefulness and limitations of probability estimates used to aide in the decisions regarding indications for genetic testing.[44,45,47]

When a deleterious mutation has been identified in a family and a test report documents that finding, prior probabilities can be ascertained with a greater degree of reliability. In this setting, probabilities can be calculated based on the pattern of inheritance associated with the gene in which the mutation has been identified. In addition, critical to the application of Mendelian inheritance is the consideration of integrating Bayes Theorem, which incorporates other variables, such as current age, into the calculation for a more accurate age-dependent probability.[4,48] This is especially useful in individuals who have lived to be older than the age at which cancer is likely to develop based on the mutation identified in their family, and therefore would have a lower likelihood of harboring the family mutation when compared with the probability based on their relationship to the mutation carrier in the family.

Even in the case of a documented mutation on one side of the family, careful assessment and evaluation of the individual’s personal and family history of cancer is essential to rule out cancer risk or suspicion of a cancer susceptibility gene mutation on the other side of the family (maternal or paternal, as applicable).[49] Segregation of more than one mutation in a family is possible (e.g., in circumstances in which a cancer syndrome has founder mutations associated with families of common ancestral origin).

Unlike mutation probability models that predict the likelihood that a given personal and/or family history of cancer could be associated with a mutation in a specific gene(s), other methods and models can be used to estimate the risk of developing cancer over time. Similar to mutation probability assessments, cancer risk calculations are also complex and necessitate a detailed health history and family history. In the presence of a documented deleterious mutation, cancer risk estimates can be derived from peer reviewed penetrance data.[4] Penetrance data are constantly being refined and many gene mutations have variable penetrance because other variables may impact the absolute risk of cancer in any given patient. Modifiers of cancer risk in mutation carriers include the mutation's effect on the function of the gene/protein, (e.g., mutation type and position), the contributions of modifier genes, and personal and environmental factors (e.g., the impact of bilateral salpingo-oophorectomy performed for other indications in a woman who harbors a BRCA mutation).[50] When there is evidence of an inherited susceptibility to cancer but genetic testing has not been performed, analysis of the pedigree can be used to estimate cancer risk. This type of calculation uses the probability the individual harbors a gene mutation and gene mutation-specific penetrance data to calculate cancer risk.[4]

In the absence of evidence of a hereditary cancer syndrome, several methods can be utilized to estimate cancer risk. Relative risk data from studies of specific risk factors provide ratios of observed versus expected cancers associated with a given risk factor. However, utilizing relative risk data for individualized risk assessment can have significant limitations: relative risk calculations will differ based on the type of control group and other study-associated biases, and comparability across studies can vary widely.[48] In addition, relative risks are lifetime ratios and do not provide age-specific calculations, nor can the relative risk be multiplied by population risk to provide an individual's risk estimate.[48,51]

Given these limitations, disease-specific cumulative risk estimates are most often employed in clinical settings. These estimates usually provide risk for a given time interval and can be anchored to cumulative risks of other health conditions in a given population (e.g., the 5-year risk by the Gail model).[48,51] It is important to note that cumulative risk models have limitations that may underestimate or overestimate risk. For example, the Gail model excludes paternal family histories of breast cancer.[45] Furthermore, many of these models were constructed from data derived from predominately Caucasian populations and may have limited validity when used to estimate risk in other ethnicities.[52]

Cumulative risk estimates are best used when evidence of other underlying significant risk factors have been ruled out. Careful evaluation of an individual's personal health and family history can identify other confounding risk factors that may outweigh a risk estimate derived from a cumulative risk model. For example, a woman with a prior biopsy showing lobular carcinoma in situ (LCIS) whose mother was diagnosed with breast cancer at age 65 years has a greater lifetime risk from her history of LCIS than her cumulative lifetime risk of breast cancer based on one first-degree relative. In this circumstance, recommendations for cancer risk management would be based on the risk associated with her LCIS. Unfortunately, there is no reliable method for combining all of an individual's relevant risk factors for an accurate absolute cancer risk estimate, nor are individual risk factors additive.

In summary, careful ascertainment and review of personal health and cancer family history are essential adjuncts to the use of prior probability models and cancer risk assessment models to assure that critical elements influencing risk calculations are considered.[44] Influencing factors include the following:

• Differential diagnosis that is consistent with the personal and cancer family history.
• Consideration of factors that influence how informative the family history may be.
• Population that is best suited for the use of the model.
• Tumor-specific features that may be suspicious for an inherited predisposition or modify individual cancer risk predictions.
• Model-specific limitations that can overestimate or underestimate calculations.[47]

A number of investigators are developing health care provider decision support tools such as the Genetic Risk Assessment on the Internet with Decision Support (GRAIDS),[53] but at this time, clinical judgment remains a key component of any prior probability or absolute cancer risk estimation.[44]

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44. Lindor NM, Lindor RA, Apicella C, et al.: Predicting BRCA1 and BRCA2 gene mutation carriers: comparison of LAMBDA, BRCAPRO, Myriad II, and modified Couch models. Fam Cancer 6 (4): 473-82, 2007.  [PUBMED Abstract]
    
    
45. Domchek SM, Eisen A, Calzone K, et al.: Application of breast cancer risk prediction models in clinical practice. J Clin Oncol 21 (4): 593-601, 2003.  [PUBMED Abstract]
    
    
46. Weitzel JN, Lagos VI, Cullinane CA, et al.: Limited family structure and BRCA gene mutation status in single cases of breast cancer. JAMA 297 (23): 2587-95, 2007.  [PUBMED Abstract]
    
    
47. Kauff ND, Offit K: Modeling genetic risk of breast cancer. JAMA 297 (23): 2637-9, 2007.  [PUBMED Abstract]
    
    
48. Offit K, Brown K: Quantitating familial cancer risk: a resource for clinical oncologists. J Clin Oncol 12 (8): 1724-36, 1994.  [PUBMED Abstract]
    
    
49. Apicella C, Andrews L, Hodgson SV, et al.: Log odds of carrying an Ancestral Mutation in BRCA1 or BRCA2 for a Defined personal and family history in an Ashkenazi Jewish woman (LAMBDA). Breast Cancer Res 5 (6): R206-16, 2003.  [PUBMED Abstract]
    
    
50. Chenevix-Trench G, Milne RL, Antoniou AC, et al.: An international initiative to identify genetic modifiers of cancer risk in BRCA1 and BRCA2 mutation carriers: the Consortium of Investigators of Modifiers of BRCA1 and BRCA2 (CIMBA). Breast Cancer Res 9 (2): 104, 2007.  [PUBMED Abstract]
    
    
51. Hoskins KF, Stopfer JE, Calzone KA, et al.: Assessment and counseling for women with a family history of breast cancer. A guide for clinicians. JAMA 273 (7): 577-85, 1995.  [PUBMED Abstract]
    
    
52. Adams-Campbell LL, Makambi KH, Palmer JR, et al.: Diagnostic accuracy of the Gail model in the Black Women's Health Study. Breast J 13 (4): 332-6, 2007 Jul-Aug.  [PUBMED Abstract]
    
    
53. Emery J, Morris H, Goodchild R, et al.: The GRAIDS Trial: a cluster randomised controlled trial of computer decision support for the management of familial cancer risk in primary care. Br J Cancer 97 (4): 486-93, 2007.  [PUBMED Abstract]
    
    

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Education and Counseling About Risk/Risk Communication

Specific clinical programs for risk management may be offered to persons with an increased genetic risk of cancer. These programs may differ from those offered to persons of average risk in several ways: screening may be initiated at an earlier age or involve shorter screening intervals; screening strategies not in routine use, such as screening for ovarian cancer, may be offered; and interventions to reduce cancer risk, such as risk-reducing surgery, may be offered. Such programs are generally based on expert opinion. Current recommendations are summarized in the PDQ summaries addressing genetics of specific cancers.

The goal of genetic education and counseling is to help individuals understand their personal risk status, their options for cancer risk management, and to explore feelings regarding their personal risk status. Counseling focuses on obtaining and giving information, promoting autonomous decision-making, and facilitating informed consent if genetic testing is pursued.

Optimally, education and counseling about cancer risk includes providing the following information:

• Purpose, strengths and limitations of cancer risk assessment.
• Basic genetics and patterns of inheritance.
• Genetic basis of cancer.
• Clinical features of relevant hereditary cancer syndromes.
• Evidence of a hereditary cancer syndrome from the consultand's personal and family history.
• Options for clarifying cancer risk, including genetic testing, if indicated.
• Options available for risk management, including data (or lack of data) on the efficacy of different measures for early detection and risk reduction.
• Signs and symptoms of cancer.

Strategies available for risk management (including their efficacy, risk, and psychological implications) may be an important factor in decisions about pursuing genetic testing.

For individuals choosing to pursue genetic testing, education and counseling typically includes the following:

• Risk of having a mutation, as well as patterns of transmission.
• Alternatives to genetic testing.
• Risks, benefits and limitations of genetic testing, including psychological and discriminatory risks.
• Possible test outcomes, including likelihood of uninformative results and identifying variants of uncertain significance.
• Accuracy of the genetic test.
• Health care management options based on possible test results.
• Implications for children and other family members based on pattern of transmission.
• Dissemination of risk and genetic information to family members.
• Cost associated with testing, counseling, medical management, and options for insurance coverage.
• How genetic information and genetic test results will be recorded in the medical record.
• Specimen storage and reuse, if applicable.

If a second session is held to disclose and interpret genetic test results, education and counseling focuses on:

• Interpretation of test results.
• Assessment of the practical and emotional responses to genetic test results.
• Recommendations for coping and communication strategies to address issues related to cancer risk.
• Cancer risk management recommendations.
• Risk analysis and dissemination of risk results to family members.

The process of counseling may require more than one visit to address medical, genetic testing, and psychosocial support issues. Additional case-related preparation time is spent before and after the consultation sessions to obtain and review medical records, complete case documentation, seek information about differential diagnoses, identify appropriate laboratories for genetic tests, find patient support groups, research resources, and communicate with or refer to other specialists.[1]

Information about inherited risk of cancer is growing rapidly. Many of the issues discussed in a counseling session may need to be revisited as new information emerges. At the end of the counseling process, individuals are typically reminded of the possibility that future research may provide new options and/or new information on risk. Individuals may be advised to check in with the health care provider periodically to determine whether new information is sufficient to merit an additional counseling session. The obligation of health care providers to recontact individuals when new genetic testing or treatment options are available is controversial, and standards have not been established.

The usage of numerical probabilities to communicate risk may overestimate the level of risk certainty, especially when wide confidence intervals exist to the estimates, or when the individual may differ in important ways from the sample on which the risk estimate was derived. As well, numbers are often inadequate for expressing gut-level or emotional aspects of risk. Finally, there are wide variations in individuals’ level of understanding of mathematical concepts (i.e. numeracy). For all the above reasons, conveying risk in multiple ways, both numerically and verbally, with discussion of important caveats, may be a useful strategy to increase risk comprehension. The numerical format that facilitates the best understanding is natural frequencies, because frequencies include information concerning the denominator, or the reference group to which the individual may refer. In general logarithmic scales are to be avoided.[2] Additionally, important “contextual” risks may be included with the frequency in order to increase risk comprehension, and these may include how the person’s risk compares with those who do not have the risk factor in question, as well as the risks associated with common hazards, such as being in a car accident. Additional suggestions include being consistent in risk formats (do not mix odds and percentages), using the same denominator across risk estimates, avoiding decimal points, including base rate information, and providing more explanation if the risk is less than one percent.

The communication of risk may be numerical, verbal, or visual. Use of multiple strategies may increase comprehension and retention of cancer genetic risk information.[2] Recently, use of visual risk communication strategies has increased, e.g., histograms, pie charts, and Venn diagrams. Visual depictions of risk may be very useful in avoiding problems with comprehension of numbers, but research that confirms this is lacking.[3,4]

The purpose of risk counseling is to provide individuals with accurate information about their risk, help them understand and interpret their risk, assist them as they use this information to make important health care decisions, and help them make the best possible adjustment to their situation. A systematic review of 28 studies that evaluated communication interventions showed that risk communication benefits users cognitively by increasing their knowledge and understanding of risk perception, and does not negatively influence affect (anxiety, cancer-related worry and depression). Risk communication does not appear to result in a change in use of screening practices and tests. Users received the most benefit from an approach utilizing risk communication along with genetic counseling.[5,6] Perceptions of risk are affected by the manner in which risk information is presented, difficulty understanding probability and heredity,[7,8] and other psychological processes on the part of individuals and providers.[9] Risk may be communicated in many ways (e.g., with numbers, words, or graphics; alone or in relation to other risks; as the probability of having an adverse event; in relative or absolute terms; and through combinations of these methods). The way in which risk information is communicated may affect the individual’s perception of the magnitude of that risk. In general, relative risk estimates (e.g., "You have a threefold increased risk of colorectal cancer") are perceived as less informative than absolute risk (e.g., "You have a 25% risk of colorectal cancer") [10] or risk information presented as a ratio (e.g., 1 in 4).[8] A strong preference for having BRCA1/2 mutation risk estimates expressed numerically is reported by women considering testing.[11] Individuals associate widely differing quantitative risks with qualitative descriptors of risk such as “rare” or “common.”[12] More research is needed on the best methods of communicating risk in order to help individuals develop an accurate understanding of their cancer risks.

Recent descriptive examination of the process of cancer genetic counseling has found that counseling sessions are predominantly focused on the biomedical teaching required to inform clients of their choices and to put genetic findings in perspective, but that attention to psychosocial issues does not detract from teaching goals, and may enhance satisfaction in clients undergoing counseling. For instance, one study of communication patterns in 167 pretest counseling sessions for BRCA1 found the sessions to have a predominantly biomedical and educational focus;[13] however this approach was client focused, with the counselor and client contributing equally to the dialogue. These authors note that there was a marked diversity in counselor styles, both between counselors, and within different sessions for each counselor. The finding of a didactic style was corroborated by other researchers who examined observer-rated content checklists and videotape of 51 counseling sessions for breast cancer susceptibility.[14] Of note, genetic counselors seemed to rely on demographic information and breast cancer history to tailor genetic counseling sessions rather than client’s self-reported expectations or psychosocial factors.[15] Concurrent provision of a combination of psychosocial and scientific information (e.g., breast cancer genetics topics) may be important in reducing worry in the context of teaching about cancer genetics topics.[16] An increasing appreciation of language choices may contribute to enhanced understanding and reduced anxiety levels in the session; for example, it was noted that patients may appreciate synonymic choices for the word “mutation,” such as “altered gene”.[17] Baty and colleagues provide recommendations for cultural tailoring of educational materials for the African-American population, such as a large flip chart, including the use of simple language and pictures, culturally identifiable figures, bright colors and humor.[18]

A literature is developing that examines novel channels to communicate genetic cancer risk information and deliver psychosocial support, and to standardize the genetic counseling process for individuals at increased risk for cancer.[19-26] Much of this literature has attempted to make the genetic counseling session more efficient, or to limit the need for the counselor to address basic genetic principles in the session to free up time for the client’s personal and emotional concerns about his or her risk. These include the development of checklists, CD-ROM programs, and interactive computer programs. Checklists have been developed to ensure coverage of important topics in the counseling session, and include those completed by observers or by the patients themselves to clarify their goals and needs in the counseling session. For instance, a checklist for diverse risk communication topics covered in genetic counseling for completion by outside observers had good interobserver reliability assessing the content covered in the sessions.[20] Another study compared a feedback checklist completed by 197 women attending a high-risk breast clinic prior to the counseling session to convey prior genetic knowledge and misconceptions to aid the counselor in tailoring the session for that client.[21] The use of the feedback checklist led to gains in knowledge from the counseling session, but did not reduce genetic counseling time, perhaps because the genetic counseling chose to spend time discussing topics such as psychosocial issues. Use of the checklist did decrease the time spent with the medical oncologist, however. The feedback checklist was compared to a CD-ROM that outlined basic genetic concepts and the benefits and limitations of testing, and found that those viewing the CD-ROM did spend less time with counselors, and were less likely to choose to undergo genetic counseling. The CD-ROM did not lead to increased knowledge of genetic concepts as did use of the checklist.

Other innovative strategies include educational materials and interactive computer technology. In one study, a 13-page color communication aid using a diverse format for conveying risk, including graphic representations and verbal descriptions, was developed.[22] The authors evaluated the influence of the communication aid in 27 women at high risk for a BRCA1 mutation, and compared those who had read the aid to a comparison sample of 107 women who received standard genetic counseling. Improvements in genetic knowledge and accuracy of risk perception were documented in those who had read the aid, with no differences in anxiety or depression between groups. Personalized, interactive computerized education materials have also been developed to aid in these efforts.[23,24] In one study, an interactive computer education program available prior to the genetic counseling session was compared with genetic counseling alone in women undergoing counseling for BRCA1/2 testing.[24] Use of the computer program prior to genetic counseling reduced face-time with the genetics counselor, particularly for those at lower risk of BRCA1/2 mutation. Many of the counselors reported that their client’s use of the computer program allowed them to be more efficient, and to reallocate time spent in the sessions to clients’ unique concerns.

Videoconferencing is another innovative strategy to facilitate genetic counseling sessions with clients who cannot travel to specialized clinic settings. In 37 individuals in the United Kingdom, real-time video conferencing was compared with face-to-face counseling sessions; both methods were found to improve knowledge and reduce anxiety levels.[25] Similarly, teleconferencing sessions, in which the client and genetic specialists were able to talk with each other in real time, was also used in rural Maine communities [26] in the pediatric context to convey genetic information and findings for developmental delays, and were found to be comparable to in-person consultations in terms of decision-making confidence and satisfaction with the consultations.

References

1. Baker DL, Schuette JL, Uhlmann WR, eds.: A Guide to Genetic Counseling. New York, NY: Wiley-Liss, 1998. 
   
   
2. Lipkus IM: Numeric, verbal, and visual formats of conveying health risks: suggested best practices and future recommendations. Med Decis Making 27 (5): 696-713, 2007 Sep-Oct.  [PUBMED Abstract]
   
   
3. Ancker JS, Senathirajah Y, Kukafka R, et al.: Design features of graphs in health risk communication: a systematic review. J Am Med Inform Assoc 13 (6): 608-18, 2006 Nov-Dec.  [PUBMED Abstract]
   
   
4. Schapira MM, Nattinger AB, McHorney CA: Frequency or probability? A qualitative study of risk communication formats used in health care. Med Decis Making 21 (6): 459-67, 2001 Nov-Dec.  [PUBMED Abstract]
   
   
5. Edwards A, Gray J, Clarke A, et al.: Interventions to improve risk communication in clinical genetics: systematic review. Patient Educ Couns 71 (1): 4-25, 2008.  [PUBMED Abstract]
   
   
6. Edwards A, Unigwe S, Elwyn G, et al.: Personalised risk communication for informed decision making about entering screening programs. Cochrane Database Syst Rev (1): CD001865, 2003.  [PUBMED Abstract]
   
   
7. Marteau TM, van Duijn M, Ellis I: Effects of genetic screening on perceptions of health: a pilot study. J Med Genet 29 (1): 24-6, 1992.  [PUBMED Abstract]
   
   
8. Hopwood P, Howell A, Lalloo F, et al.: Do women understand the odds? Risk perceptions and recall of risk information in women with a family history of breast cancer. Community Genet 6 (4): 214-23, 2003.  [PUBMED Abstract]
   
   
9. Redelmeier DA, Koehler DJ, Liberman V, et al.: Probability judgement in medicine: discounting unspecified possibilities. Med Decis Making 15 (3): 227-30, 1995 Jul-Sep.  [PUBMED Abstract]
   
   
10. Malenka DJ, Baron JA, Johansen S, et al.: The framing effect of relative and absolute risk. J Gen Intern Med 8 (10): 543-8, 1993.  [PUBMED Abstract]
    
    
11. Winer E, Winer N, Bluman L, et al.: Attitudes and risk perceptions of women with breast cancer considering testing for BRCA1/2. [Abstract] Proceedings of the American Society of Clinical Oncology 16: A1937, 537a, 1997. 
    
    
12. Mazur DJ, Hickam DH: Patients' interpretations of probability terms. J Gen Intern Med 6 (3): 237-40, 1991 May-Jun.  [PUBMED Abstract]
    
    
13. Ellington L, Baty BJ, McDonald J, et al.: Exploring genetic counseling communication patterns: the role of teaching and counseling approaches. J Genet Couns 15 (3): 179-89, 2006.  [PUBMED Abstract]
    
    
14. Pieterse AH, van Dulmen S, van Dijk S, et al.: Risk communication in completed series of breast cancer genetic counseling visits. Genet Med 8 (11): 688-96, 2006.  [PUBMED Abstract]
    
    
15. Lobb EA, Butow PN, Meiser B, et al.: Tailoring communication in consultations with women from high risk breast cancer families. Br J Cancer 87 (5): 502-8, 2002.  [PUBMED Abstract]
    
    
16. Appleton S, Watson M, Rush R, et al.: A randomised controlled trial of a psychoeducational intervention for women at increased risk of breast cancer. Br J Cancer 90 (1): 41-7, 2004.  [PUBMED Abstract]
    
    
17. Hodgson J, Hughes E, Lambert C: "SLANG"--Sensitive Language and the New Genetics--an exploratory study. J Genet Couns 14 (6): 415-21, 2005.  [PUBMED Abstract]
    
    
18. Baty BJ, Kinney AY, Ellis SM: Developing culturally sensitive cancer genetics communication aids for African Americans. Am J Med Genet 118A (2): 146-55, 2003.  [PUBMED Abstract]
    
    
19. Green MJ, Peterson SK, Baker MW, et al.: Effect of a computer-based decision aid on knowledge, perceptions, and intentions about genetic testing for breast cancer susceptibility: a randomized controlled trial. JAMA 292 (4): 442-52, 2004.  [PUBMED Abstract]
    
    
20. Fransen M, Meertens R, Schrander-Stumpel C: Communication and risk presentation in genetic counseling. Development of a checklist. Patient Educ Couns 61 (1): 126-33, 2006.  [PUBMED Abstract]
    
    
21. Wang C, Gonzalez R, Milliron KJ, et al.: Genetic counseling for BRCA1/2: a randomized controlled trial of two strategies to facilitate the education and counseling process. Am J Med Genet A 134 (1): 66-73, 2005.  [PUBMED Abstract]
    
    
22. Lobb EA, Butow PN, Moore A, et al.: Development of a communication aid to facilitate risk communication in consultations with unaffected women from high risk breast cancer families: a pilot study. J Genet Couns 15 (5): 393-405, 2006.  [PUBMED Abstract]
    
    
23. Mackay J, Schulz P, Rubinelli S, et al.: Online patient education and risk assessment: project OPERA from Cancerbackup. Putting inherited breast cancer risk information into context using argumentation theory. Patient Educ Couns 67 (3): 261-6, 2007.  [PUBMED Abstract]
    
    
24. Green MJ, Peterson SK, Baker MW, et al.: Use of an educational computer program before genetic counseling for breast cancer susceptibility: effects on duration and content of counseling sessions. Genet Med 7 (4): 221-9, 2005.  [PUBMED Abstract]
    
    
25. Coelho JJ, Arnold A, Nayler J, et al.: An assessment of the efficacy of cancer genetic counselling using real-time videoconferencing technology (telemedicine) compared to face-to-face consultations. Eur J Cancer 41 (15): 2257-61, 2005.  [PUBMED Abstract]
    
    
26. Lea DH, Johnson JL, Ellingwood S, et al.: Telegenetics in Maine: Successful clinical and educational service delivery model developed from a 3-year pilot project. Genet Med 7 (1): 21-7, 2005.  [PUBMED Abstract]
    
    

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The Option of Genetic Testing

Factors to Take into Consideration in Offering Testing

Indications for testing

Experts recommend offering genetic testing when a risk assessment suggests the presence of an inherited cancer syndrome for which specific genes have been identified. The American Society of Clinical Oncology (ASCO) Policy Statement on Genetic Testing for Cancer Susceptibility proposes that genetic testing be offered when the following conditions apply:

• An individual has a personal or family history suggestive of a genetic cancer susceptibility syndrome.
• The results of the test can be interpreted.
• Testing will influence medical management.[1]

Characteristics used in making this determination are discussed in the PDQ summaries on specific cancers. Even when individual and family history characteristics indicate a possible inherited cancer syndrome, individuals may elect not to proceed with testing after discussion of potential risks, benefits, and limitations as discussed below. Conversely, individuals whose pedigrees are incomplete or uninformative due to very small family size, early deaths, or incomplete data on key family members may elect to pursue genetic testing in an attempt to better define their risk status. In these situations, it is particularly important that the pretest counseling fully explore the limitations of the testing process.

Genetic education and counseling including the interpretation of genetic test results, will vary depending on whether a previous attempt at genetic testing has been made (see Figure 2). In general, there are two primary circumstances in which genetic testing is performed:

• Families with evidence of an inherited susceptibility that have not had any genetic testing or in which genetic testing has not identified a mutation.
• Families with a documented deleterious mutation.

Enlarge

Figure 2. This genetic testing algorithm depicts the multistep process of testing for cancer susceptibility.

Genetic susceptibility testing generally yields the most useful information when a living family member affected with the cancer of concern is tested first to determine whether a genetic basis for the cancer in the family can be established. Three possible outcomes for this form of testing include the following (see Figure 2):

• Deleterious mutation detected.
• No mutation detected.
• Variant of uncertain significance detected.

If a mutation that is documented to be deleterious (associated with cancer risk) is identified, risks are based on penetrance data for mutations of that specific gene. In addition, other family members may be tested for the presence or absence of this specific mutation. If no mutation is found in an affected family member, testing is considered uninformative and thus there is no basis for testing unaffected relatives. Failure of the laboratory to detect a mutation in an affected family member does not rule out an inherited basis for the cancer in that family. Reasons why testing could be uninformative include the following:

• The cancer in the family may be associated with a cancer susceptibility gene other than the gene that was tested.
• The cancer in the family may be associated with a gene mutation but the cancer in the specific family member who underwent testing is not associated with that mutation. This can occur especially with cancers that are common in the general population such as breast cancer or prostate cancer. The family member who is affected with the disease but is not a carrier of the mutated gene associated with the inherited predisposition to cancer in the family is considered a phenocopy.
• Identifying a gene mutation may not be possible given the limited sensitivity of the laboratory techniques used to detect mutations.
• The function of the gene could be altered by a mutation in a different gene.

Lastly, testing may reveal a variant of uncertain significance. This result means that a gene mutation has been found, however, the extent that this mutation increases cancer risk, or whether it is associated with the history of cancer in the family, is uncertain. In this circumstance, some clues as to the significance of the mutation can be derived from the following:

• The location of the mutation in relation to regions and function.
• The specific change; since many variants are missense mutations, not all amino acid substitutions are as significant.
• Whether the variant has been documented in the presence of a documented deleterious mutation.
• Whether the mutation is associated with the branch in the family with the cancer and/or whether the variant tracks with the cancers in the family.

Unfortunately, even with this information, there is often insufficient evidence to document the significance of a specific variant and further clarifying research is required.

If there is no close, living, affected relative to undergo testing, or the living affected relative declines testing, other options may be discussed with the patient and the testing laboratory. These generally involve weighing the availability and reliability of testing the stored tissue of a deceased relative or testing an unaffected person without prior testing of an affected family member. Tests done on stored tissue are technically difficult and may not yield a definitive result. Testing an unaffected person without prior testing of an affected relative often is uninformative because a negative test does not rule out the presence of a cancer susceptibility gene in the family or the subject.

The goal of genetic testing in the absence of a documented mutation in the family member is to determine for each individual family whether the cancer in the family is attributable to a mutation in a specific gene.

Genetic susceptibility testing for a documented deleterious mutation in the family can be very informative and will yield one of the following two results (see Figure 2):

• Positive for the mutation in the family.
• Negative for the mutation in the family.

If the mutation in the family is detected in a family member, cancer risks are based on penetrance data for mutations in that specific gene. If the documented mutation is not found in a family member, the risk of cancer in that individual is equivalent to cancer risk in the general population. However, other risk factors and family history from the side of the family not associated with the documented mutation may increase the cancer risk above the general population levels.

In summary, genetic education and counseling includes identifying the most informative person in the family to test, which may be an affected family member rather than the individual seeking genetic services. In addition, counseling includes a discussion of the limitations of the test and all possible test outcomes, as well as the consequences of receiving a test result showing a variant of unknown clinical significance.[2]

Advances in reproductive technology have enabled predisposition cancer genetic testing to be performed in the prenatal setting using chorionic villi or amniotic fluid cell sampling and for preimplantation diagnosis to inform embryo selection before implantation.[3,4] A literature review coupled with a brief survey found 55 case reports of prenatal or preimplantation diagnosis performed for cancer predisposition for more than 12 familial cancer syndromes.[3] In a telephone survey of thirteen centers listed in an online resource as providing preimplantation genetic diagnosis, nine reported they provided this service for cancer predisposition.[3]

Reproductive medicine used in the context of predisposition genetic testing for cancer risk raises important ethical, legal and social issues. A proposed analytic framework recommends considering the following issues:

1. Does the cancer syndrome include childhood malignancies or significant morbidity or mortality at an early age?
2. What is the penetrance associated with the gene mutation?
3. How severe is the syndrome phenotype?
4. Are there interventions available that decrease the mutation-associated cancer risk or are proven to detect cancer early when it is in a treatable form?[4]

When counseling cancer susceptibility gene mutation carriers who are considering childbearing, it is important to address the issues listed above while maintaining sensitivity to the parents' personal beliefs.[4]

Genetic testing is highly specialized. A given test is usually performed in only a small number of laboratories. There are also multiple molecular testing methods available, each with its own costs, strengths, and weaknesses. Depending on the method employed and the extent of the analysis, different tests for the same gene will have varying levels of sensitivity and specificity. Even assuming high analytic validity, genetic heterogeneity makes test selection challenging. A number of different genetic syndromes may underlie the development of a particular cancer type. For example, hereditary colon cancer may be due to familial adenomatous polyposis (FAP), Lynch syndrome, Peutz-Jeghers syndrome, juvenile polyposis syndrome, or other syndromes. Each of these has a different genetic basis. In addition, different genes may be responsible for the same condition, e.g., Lynch syndrome can be due to mutations in one of several mismatch repair genes. Also, allelic heterogeneity, i.e., different mutations within the same gene, can confer different risks or be associated with a different phenotype. For example, though the general rule is that adenomatous polyposis coli (APC) gene mutations are associated with hundreds or thousands of colonic polyps and colon cancer of the classical FAP syndrome, some APC mutations cause a milder clinical picture, with fewer polyps and lower colorectal cancer risk. In addition, other disorders may be part of the FAP spectrum. Mutations in a certain portion of the APC gene also predispose to retinal changes, for example, whereas mutations in a different region of APC predispose to desmoid tumors. Thus, selection of the appropriate genetic test for a given individual requires considerable knowledge of genetic diagnostic methods, correlation between clinical and molecular findings, and access to information about rapidly changing testing options. These issues are addressed in detail in PDQ summaries on the genetics of specific cancers. (Refer to the Genetics of Breast and Ovarian Cancer, Genetics of Colorectal Cancer, and Genetics of Medullary Thyroid Cancer summaries for more information.)

Government regulation of genetic tests to date remains extremely limited in terms of both analytic and clinical validity with little interagency coordination.[5] The Centers for Medicare & Medicaid Services using the Clinical Laboratory Improvement Act (CLIA) regulates all clinical human laboratory testing performed in the United States for the purposes of generating diagnostic or other health information. CLIA regulations address personnel qualifications, laboratory quality assurance standards, as well as documentation and validation of tests and procedures.[6] For laboratory tests themselves, CLIA categorizes tests based on the level of complexity into waived tests, moderate complexity, or high complexity. Genetic tests are considered high complexity which indicates that a high degree of knowledge and skill is required to perform or interpret the test. Laboratories conducting high complexity tests must undergo proficiency testing at specified intervals, which consists of an external review of the laboratories' ability to accurately perform and interpret the test.[5,7] However, a specialty area specific for molecular and biologic genetic tests has yet to be established; therefore, specific proficiency testing of genetic testing laboratories is not required by CLIA.[5]

In regard to analytic validity, genetic tests fall into two primary categories; test kits and laboratory-developed tests (previously called home brews). Test kits are manufactured for use in laboratories performing the test and include all the reagents necessary to complete the analysis, as well as instructions, performance outcomes, and details on which mutations can be detected. The U.S. Food and Drug Administration (FDA) regulates test kits as medical devices; however, despite more than 1,000 available genetic tests, there are fewer than 10 FDA-approved test kits.[7] Laboratory-developed tests are performed in a laboratory that assembles its own testing materials in house [7] and this category represents the most common form of genetic testing. Laboratory-developed tests are subject to the least amount of oversight as neither CLIA nor the FDA evaluate the laboratories' proficiency in performing the test or clinical validity relative to the accuracy of the test to predict a clinical outcome.[5,7] The FDA does regulate manufactured analyte-specific reagents (ASRs) as medical devices. These small molecules are used to conduct laboratory-developed tests, but can also be made by the laboratory. ASRs made in the laboratory are not subject to FDA oversight. For laboratory-developed tests utilizing manufactured commercially available ASRs, the FDA requires that the test be ordered by a health professional or other individual authorized to order the test by state law. However, this regulation does not distinguish between health providers caring for the patient or health providers who work for the laboratory offering the test.[7]

In addition to classical clinical genetic tests is the regulatory oversight of research genetic testing. Laboratories performing genetic testing on a research basis are exempt from CLIA oversight if the laboratory does not report patient-specific results for the diagnosis, prevention, or treatment of any disease or impairment or the assessment of the health of individual patients.[5] However, there are anecdotal reports of research laboratories providing test results for clinical purposes with the caveat that the laboratory recommends that testing be repeated in a clinical CLIA-approved laboratory. In addition, there is no established mechanism that determines when a test has sufficient analytic and clinical validity to be offered clinically.[7] Currently, the decision to offer a genetic test clinically is at the discretion of the laboratory director.

Evidence regarding the implications of this narrow regulatory oversight of genetic tests is limited and consists predominately of laboratory director responses to quality assurance surveys. A survey of 133 laboratory directors performing genetic tests found that 88% of laboratories employed one or more American Board of Medical Genetics (ABMG)-certified or ABMG-eligible professional geneticists and 23% had an affiliation with at least one doctorally prepared geneticist. Eight percent of laboratories did not employ and were not affiliated with doctoral-level genetics professionals. Laboratory-developed tests were performed in 70% of laboratories. Sixty-three percent of laboratories provided an interpretation of the test result as part of the test report.[8] Another survey of 190 laboratory directors found that 97% were CLIA-certified for high complexity testing. Sixteen percent of laboratories reported no specialty area certification and those without specialty certification represented laboratories with the most volume of tests performed and offered the most extensive test selection.[5] Of laboratories with specialty certification, not all had certification relevant to genetic tests, with 48% reporting pathology certification, 46% chemistry certification and 41% clinical cytogenetics certification. Sixteen percent of directors reported participation in no formal external proficiency testing program, although 77% performed some informal proficiency testing when a formal external proficiency testing program was not available.

The most frequent reason cited for lack of proficiency testing participation was lack of available proficiency testing programs. Laboratory directors estimated that in the past 2 years 37% issued three or fewer incorrect reports, and 35% issued at least four incorrect reports. Analytic errors such as faulty reagent, equipment failure, or human error, increased 40% with each decrease in level of proficiency training completed.[5] An international genetic testing laboratory director survey involving 18 countries found that 64% of the 827 laboratories responding accepted samples from outside their country.[9] Similar to the U.S. study, 74% reported participation in some form of proficiency testing. Fifty-three percent of the laboratories required a copy of the consent to perform the test and 72% of laboratories retained specimens indefinitely that were submitted for testing.[9]

The U.S. Department of Health and Human Services Secretary’s Advisory Committee on Genetics, Health, and Society has published a detailed report regarding the adequacy and transparency of the current oversight system for genetic testing in the United States. The Committee identified gaps in the following areas:

• Regulations governing clinical laboratory quality.
• Oversight of the clinical validity of genetic tests.
• The number and identification of laboratories performing genetic tests and the specific genetic tests being performed.
• Level of current knowledge about the clinical usefulness of genetic tests.
• Educational preparation in genetics of health providers, the public health community, patients, and consumers.

Over the last decade there has been a marked increase in companies advertising or providing genetic services directly to the consumer.[10-12] Accordingly, it is inevitable that an increasing number of patients will approach physicians and genetic counselors armed with information, or genetic test results from direct-to-consumer (DTC) companies. In the next sections, information is provided about: (1) trends in DTC marketing of genetic tests; (2) concerns about DTC marketing of genetic tests; and (3) research examining the impact of DTC marketing of genetic tests.

In 2002, a search of Internet based studies found 14 genetic testing companies advertising adult health related susceptibility testing, with only three companies actually offering actual testing directly to the public.[10,11] A 2005 and 2006 study identified 24 internet-based companies providing DTC testing.[12] The companies survey offered diverse types of testing, including diagnostic tests for single high-penetrance diseases such as Huntington disease, risk assessment tests for polygenic diseases such as breast cancer and Alzheimer disease, and testing for many low penetrance genes that may have ramifications for health or well being such as nutrigenic or nutragenomic tests (genetic testing for multiple genes associated with common diseases such as heart disease along with information on diet and lifestyle choices) or cardiovascular profiles. About one quarter (24%) offered diagnostic and risk assessment tests, 21% offered all genetic tests, 21% offered enhancement tests only, 17% offered risk assessment and enhancement tests, 13% diagnostic tests only, and one company (4%) offered risk assessment tests only. This study also examined the content of the internet information and found that companies offering diagnostic and risk assessment tests were much more likely to indicate that a physician associated with the company would be involved in interpreting the tests than companies offering enhancement testing. Of these companies, eight did not require a physician to be involved in ordering tests or interpreting the results.[12] More than 75% of the 24 companies stated that they recommended or provided phone based genetic counseling services. When genetic counseling was offered there was no information provided about the qualifications or quality of the counselors.

Several professional organizations have released professional position statements or recommendations cautioning against DTC advertising and provision of genetic tests. The main concerns that are expressed within these statements include:

1. Patients may lack knowledge in key areas such as the purpose and appropriateness of testing, accuracy, follow-up implications, and clinical significance of results for themselves and other family members, or the reliability of the laboratory, and
2. the lack of required health care provider involvement, as well as the lack of stated qualifications of the health care providers utilized by the companies themselves, directs the onus on the patients to interpret complex findings or to take the initiative to seek other opinions.

In 2004, The American College of Medical Genetics Board of Directors asserted that genetic testing for susceptibility to disease are medical tests; therefore, these tests should be provided to the public through qualified health care professionals only. Given the complexities of genetic testing and counseling, that telephone or Internet orders or home testing kits are potentially harmful. Potential harms noted include inappropriate test use, misinterpretation of results, as well as lack of follow-up. More recently, the American Society of Human Genetics (ASHG) [13] provided a policy statement concerning the need for improved oversight of DTC genetic testing by the FDA and Federal Trade Commission (FTC), and stating that there is inadequate oversight of laboratory assessments in order to provide reliable tests. The ASHG statement [13] recommended a series of standards in the area of transparency, provider education, and test and laboratory quality, and concluded that further research and federal oversight are needed in this rapidly changing field. In 2006, the FTC and Centers for Disease Control and Prevention issued a joint statement to consumers regarding the limitations of DTC genetic tests.

However, proponents of DTC marketing and provision of genetic tests often assert the putative "right to information," which they argue promotes patient autonomy.[14] DTC marketing may increase patients’ feelings of empowerment to discuss their care with their physicians. Patients may also develop an increased awareness of the importance of family history, the relationship between risk and family history, and the role of genetics in disease, as well as a better understanding of the value of genetic counseling.[15] While the issue of privacy is also emphasized in DTC marketing and testing claims, it may not be as salient after testing, given that those found to be positive will, for the most part, want their physician involved early in identifying measures to mitigate risk.[16]

Marketing of DTC genetic tests includes diverse strategies for increasing awareness and market demand for genetic testing services by for-profit companies. There are two approaches to targeting consumers with information about DTC genetic tests. The first is called DTC advertising which promotes the availability of a genetic test to the public, but requires involvement of a health care provider to order the test and disseminate the results to the consumer. The second approach, direct-to-consumer genetic testing, is discussed below.[17] While numerous position papers, review articles and commentaries have been published, there are few empirical examples about the impact of DTC advertising of genetic tests on patients, providers, or the health care system. The most studied example to date is the Myriad Genetics campaign to increase awareness of BRCA1/2 mutation testing through multiple mass media (print, radio, and television). In 2002, Myriad launched its first marketing direct-to-consumer marketing campaign in the cities of Denver and Atlanta. The target audience for this campaign was the general population of women age 25–54 years. In May of 2002, Myriad began with educational outreach to providers in the two cities in anticipation of patient requests for information spurred by the DCT campaign that ran from September 2002 to February of 2003. The campaign included television, radio, and print advertisements that were expected to reach greater than 90% of the target audience, an average of 16 times during the 5 month period.[18,19] Subsequently, these DTC campaigns have been conducted in the Northeast, Texas, and Florida. These campaigns were immediately criticized for providing incomplete, manipulative information.[20,21]

Empirical research was conducted immediately following the 2002 campaign with women in target cities (Denver, Atlanta) and comparison cities.[22] A random digit dialing survey of 1,635 women in the campaign cities and two control cities found increased levels of awareness of BRCA1/2 mutation testing in target cities. However, no significant differences were observed in perceived knowledge about testing, concern about breast cancer, or interest in testing. There was no evidence that knowledge was differentially increased in those women with strong family histories of breast cancer, who would most benefit from consideration of testing.[22] No overall increase in anxiety or confusion about testing was reported, with 63% of women who reported exposure to the DTC advertisement reporting no anxiety at all and 76% reported no confusion.[18] More recently, a smaller study of 315 women from the Denver area found that women at increased risk of breast cancer were more knowledgeable about BRCA testing and more likely to recall the advertisement. However, an equal number of high and low risk women felt they would benefit from genetic testing and were interested in testing.[23]

The impact of the advertising campaign on physicians also was a focus of investigation. Physicians in target cities were more likely to remember hearing an advertisement for testing, but did not have increased knowledge compared with physicians in control cities. Physicians in target cities reported increases in patients’ questions about genetic testing, genetic counseling referrals, and requests for testing.[22,24] In summary, physicians might have been more likely to make a referral for testing based on the patient’s interest in testing, whether or not the doctor is informed enough to consider whether the test is appropriate. The most severe documented problem with this campaign was that the company targeted the general population, even though mutation testing for BRCA1/2 is only appropriate for a subgroup of women.[18]

In addition to the data from the Myriad campaign, one international study examined the impact of a DTC campaign for genetic testing by a group of researchers in partnership with a popular Polish women’s magazine (Twoj Styl). Genetic testing was offered to 5,000 women through an announcement placed in Twoj Styl in October 2001. A total of 5,024 women who qualified received a free genetic test for three BRCA1 mutations which are common in Poland. Genetic counseling was offered only to women with a positive test or with a significant family history of breast or ovarian cancer. The great majority of women who took part in the program expressed a high degree of satisfaction and after one year approximately two-thirds of identified mutation carriers had complied with breast cancer screening recommendations.[25] No follow-up was conducted with women who received a negative test to assess understanding of their results or subsequent follow-up with population screening recommendations.

Direct-to-consumer genetic testing is advertised directly to consumers, purchased directly by the consumer, and the results are delivered directly to the consumer without the involvement of the consumer’s health care provider.[17] DTC genetic tests promise heightened privacy, as well as the potential that individuals will be more informed – and more able to take an active decision-making role, in their medical options.[26]

A 2006 study of consumer and physician awareness of DTC nutrigenomic tests found that 14% of consumers and 44% of physicians had heard of the tests, but actual utilization was exceedingly low (0.6% of consumers had used one).[27] Of those consumers who had heard of DTC nutrigenomic tests, 46% had heard about them from television, 35% from magazines, 29% from newspapers, and only 13% from health professionals. There was great variation in the extent to which background information concerning the disease in question was presented, for example, more than half offered information about disease etiology, but far fewer offered information about diagnosis and treatment or prevention. Companies providing tests of little clinical utility (such as enhancement tests) tended to provide more detailed information, although the information provided about the diseases and genetics in general was not always accurate, as clinical validity claims were supported by peer-reviewed literature in only approximately half the companies. The trend identified in this survey of available companies indicates that the tests with the least clinical utility are provided with the least professional oversight and counseling services.

Consensus exists among experts that a process of informed consent should be an integral part of the pretest counseling process.[28] This view is driven by several ethical dilemmas that can arise in genetic susceptibility testing that, taken together, constitute a difference in kind from other noninvasive, diagnostic, or screening tests. The most commonly cited concern is the possibility of insurance or employment discrimination if a test result, or even the fact that an individual has sought or is seeking testing, is disclosed. Although many states have legislated against inappropriate use of genetic information, it is not clear whether or how such legislation will apply to underwriting based on family history or genetic test results, or to self-insured health care plans. Existing federal legislation leaves many loopholes. A related issue involves stigmatization that may occur when an individual who may never develop the condition in question, or may not do so for decades, receives genetic information and is labeled or labels himself or herself as ill. Finally, in the case of genetic susceptibility testing, medical information given to one individual has immediate implications for biologic relatives. These implications include not only the medical risks, but also disruptions in familial relationships. The possibility for coercion exists when one family member wants to be tested but, to do so optimally, must first obtain genetic material or information from other family members.

Inclusion of an informed consent process in counseling, including the signing of an informed consent document prior to genetic testing, helps support patient autonomy.[29] It may also reduce the potential for misunderstanding between patient and provider. Many protocols provide opportunities for individuals to review their informed consent during the genetic testing and counseling process. The initial informed consent document provides a comprehensive overview of the process, but relevant issues are raised again at strategic points, for instance, prior to notification of results.

Some programs use a second informed consent process prior to disclosure to the individual of his or her genetic test results. This process allows for the possibility that a person may change his or her mind about receiving test results. After the test result has been disclosed, a third informed consent discussion often occurs. This discussion concerns issues regarding sharing the genetic test result with health providers and/or interested family members, currently or in the future. Obtaining written permission to provide the test result to others in the family who are at risk can avoid vexing problems in the future should the individual not be available to release his or her results.

Meaningful informed consent can enhance preparedness for testing, including careful weighing of benefits and limitations of testing, minimization of adverse psychosocial outcomes, appropriate use of medical options, and a strengthened provider-patient relationship based on honesty, support, trust, and beneficence.

Major elements of an informed consent discussion can be inferred from the preceding discussion. The critical elements, as described in the literature,[30-32] include the following:

• Elicitation and discussion of a person’s expectations, beliefs, goals, and motivations.
• Explanation of how inheritance of genetic factors may affect cancer susceptibility.
• Clarification of a person’s increased risk status.
• Discussion of potential benefits, risks, and limitations of testing.
• Discussion of costs and logistics of testing and follow-up.
• Discussion of possible outcomes of testing, e.g., positive, negative, variant of uncertain significance, uninterpretable, true positive, false positive.
• Discussion of medical options available for those who choose to test; for those who choose not to test, and for those who have positive, negative, or inconclusive results.
• Data on efficacy of methods of cancer prevention and early detection.
• Discussion of possible psychological, social, economic, and family ramifications of testing or not testing.
• Consideration of how the person’s screening or other behaviors might change depending on the test result.
• Discussion of alternatives to genetic testing, e.g., tissue banking, risk assessment.
• Attainment of verbal and written informed consent or clarification of the decision to decline testing.
• Consideration of personal acceptability of screening and risk reduction options.

All individuals considering genetic testing should be informed that they have several options even after the genetic testing has been completed. They may decide to receive the results at the posttest meeting, delay result notification, or less commonly, not receive the results of testing. They should be informed that their interest in receiving results will be addressed at the beginning of the posttest meeting (see below), and time will be available to review their concerns and thoughts on notification. It is important that individuals receive this information during the pretest counseling to ensure added comfort with the decision to decline or defer result notification even when testing results become available.

Genetic testing for mutations in cancer susceptibility genes in children is particularly complex. Many experts have argued that unless there is evidence that the test result will influence the medical management of the child or adolescent, genetic testing should be deferred until legal adulthood (age 18 years or older) because of concerns about individual decision making, discrimination risks, and potentially adverse psychosocial effects.[33-35] A number of cancer syndromes include childhood disease risk such as retinoblastoma, multiple endocrine neoplasia (MEN) types 1 and 2 (MEN1 and MEN2), neurofibromatosis types 1 and 2 (NF1 and NF2), Beckwith–Wiedemann syndrome, Fanconi anemia, FAP, and Von Hippel-Lindau disease (VHL).[36,37] However, some well recognized adult onset cancer syndromes have thus far not demonstrated increases in childhood cancer risk, such as hereditary breast/ovarian cancer syndrome.[38] As a consequence, decisions about genetic testing in children are made in the context of a specific gene in which a mutation is suspected. The ASCO statement on genetic testing for cancer susceptibility maintains that the decision to consider offering childhood genetic testing should take into account not only the risk of childhood malignancy but also the evidence associated with risk reduction interventions for that disorder.[1] Specifically, ASCO recommends that:

• When screening or preventive strategies during childhood are available (e.g., MEN, FAP), testing should be encouraged on clinical grounds.
• When no risk reduction strategies are available in childhood and the probability of developing a malignancy during childhood is very low (e.g., hereditary breast/ovarian cancer syndrome), testing should not be offered.
• Some patients may be at risk of developing a malignancy during childhood without the availability of validated risk-reduction strategies (e.g., TP53 mutations). The decision to test in such circumstances is particularly controversial.[1]

Special considerations are required when genetic counseling and testing for mutations in cancer susceptibility genes are considered in children. The first issue is the age of the child. Young children, especially those younger than 10 years, may not be involved or may have limited involvement in the decision to be tested, and some may not participate in the genetic counseling process. In these cases, the child’s parents or other legal surrogate will be involved in the genetic counseling and ultimately be responsible for making the decision to proceed with testing.[1,39] Counseling under these circumstances incorporates a discussion of how test results will be shared with the child when he or she is older.[1] Children aged 10 to 17 years may have more involvement in the decision-making process.[40] In a qualitative study of parents and children aged 10 to 17 years assessing decision-making for genetic research participation, older more mature children and families with open communication styles were more likely to have joint decision-making. The majority of children in this study felt that they should have the right to make the final decision for genetic research participation though many would seek input from their parents.[40] While this study is specific to genetic research participation, the findings allude to the importance children aged 10 to 17 years place on personal decision-making regarding factors that impact them. Unfortunately cognitive and psychosocial development may not consistently correlate with the age of the child.[39] Therefore, careful assessment of the child’s developmental stage may help in the genetic counseling and testing process to facilitate parent and child adaptation to the test results. Another critical factor includes risks for discrimination. Testing in childhood may impact insurability as an adult due to evidence of a pre-existing condition, or potentially influence future employers such as the military, which may consider a gene mutation reason to deny eligibility for military service.[33,41]

The consequences of genetic testing in children have been reviewed.[39] In contrast to observations in adults, young children in particular are vulnerable to changes in parent and child bonding based on test results. Genetic testing could interfere with the development of self-concept and self-esteem. Children may also be at risk of developing feelings of survivor guilt or heightened anxiety. All children are especially susceptible to not understanding the testing, results, or implications for their health. As children mature, they begin to have decreased dependency on their parents while developing their personal identity. This can be altered in the setting of a serious health condition or an inherited disorder. Older children are beginning to mature physically and develop intimate relationships while also changing their idealized view of their parents. All of this can be influenced by the results of a genetic test.[39]

In summary, the decision to proceed with testing in children is based on the use of the test for medical decision-making for the child, the ability to interpret the test, and evidence that changes in medical decision-making in childhood can positively impact health outcomes. Deferral of genetic testing is suggested when the risk of childhood malignancy is low or absent and/or there is no evidence that interventions can reduce risk.[1] When offering genetic testing in childhood, consideration of the child’s developmental stage is used to help determine his or her involvement in the testing decision, and who has legal authority to provide consent. In addition, careful attention to intrafamilial issues and potential psychosocial consequences of testing in children can enable the provider to deliver support that facilitates adaptation to the test result. (See the Genetics of Breast and Ovarian Cancer, Genetics of Colorectal Cancer, and Genetics of Medullary Thyroid Cancer summaries for more information on psychosocial research done in children being tested for specific cancer susceptibility gene mutations.)

Genetic counseling and testing requires special considerations when used in vulnerable populations. In 1995, the American Society of Human Genetics published a position statement on the ethical, legal, and psychosocial implications of genetic testing in children and adolescents as a vulnerable population.[34] However, vulnerable populations encompass more than just children. Federal policy applicable to research involving human subjects, 45 CFR Code of Federal Regulations part 46 Protection Of Human Subjects, considers the following groups as potentially vulnerable populations: prisoners, traumatized and comatose patients, terminally ill patients, elderly/aged persons who are cognitively impaired and/or institutionalized, minorities, students, employees, and individuals from outside the United States. Specific to genetic testing, the International Society of Nurses in Genetics further expanded the definition of vulnerable populations to also include individuals with hearing and language deficits or conditions limiting communication (for example, language differences and concerns with reliable translation), cognitive impairment, psychiatric disturbances, clients undergoing stress due to a family situation, those without financial resources; clients with acute or chronic illness and in end-of-life, and those in whom medication may impair reasoning. What constitutes a vulnerable population can be broadened to include: any individual, family, community or population in which coercion and/or undue influence could exist; those deemed to be at greater risk for experiencing adverse outcomes; patients, families, communities, and populations with some impairment; patients, families, communities, and populations in which a condition such as HIV exists that is associated with social stigma, an acute or chronic illness exists or a situation in life is present, such as belonging to a specific ethnic or economically and/or educationally disadvantaged group.

Genetic counseling and testing in vulnerable populations raises special considerations. The aim of genetic counseling is to help people understand and adapt to the medical, psychological, and familial implications of genetic contributions to disease, which in part involves the meaningful exchange of factual information.[42] In a vulnerable population, health care providers need to be sensitive to factors that can impact the ability of the individual to comprehend the discussion. In particular in circumstances of cognitive impairment or intellectual disability, special attention is paid to whether the individual’s legally authorized representative should be involved in the counseling, informed consent, and testing process.

Providers need to assess all patients for their ability to make an uncoerced, autonomous informed decision prior to proceeding with genetic testing. Populations that do not seem vulnerable, for example, legally adult college students, may actually be deemed vulnerable because of undue coercion for testing by their parents, or the threat of withholding financial support by their parents based on a testing decision inconsistent with the parent’s wishes. Alteration of the genetic counseling and testing process may be necessary depending on the situation, such as counseling and testing in terminally ill individuals who opt for testing for the benefit of their children but given their impending death, results may have no impact on their own health care nor may results be available before their death. In summary, genetic counseling and testing requires that the health care provider assess all individuals for any evidence of vulnerability, and if present, be sensitive to those issues, modify genetic counseling based on the specific circumstances, and avoid causing additional harm.

The complexity of genetic testing for cancer susceptibility has led experts to suggest that careful, in-depth counseling should precede any decision about the use of testing in keeping with the accepted principles for the use of genetic testing.[43] For example, New York State guidelines specify that “When an increased risk for hereditary susceptibility is identified through the individual or family history, the clinician should initiate discussion or refer the patient for information concerning genetic testing and its potential benefits and burdens. The clinician who opts to take on this responsibility must provide the depth of content and time required to ensure that the patient can make an informed testing choice.”[31]

Qualitative and quantitative research studies indicate that families hold a variety of beliefs about the inheritance of characteristics within families; some of these beliefs are congruent with current scientific understanding whereas others are not.[44-46] These beliefs may be influenced by education, personal and family experiences, and cultural background. Because behavior is likely to be influenced by these beliefs, the usefulness of genetic information may depend on recognizing and addressing the individual’s pre-existing cognitions. This process begins with initial discussion and continues throughout the genetic counseling process.

An accurate assessment of psychosocial functioning and emotional factors related to testing motivation and potential impact and utilization is an important part of pretest counseling.[47-51] Generally, a provider inquires about a person’s emotional response to the family history of cancer and also about a person’s response to his or her own risk of developing cancer. People have various coping strategies for dealing with stressful circumstances such as genetic risk. Identifying these strategies and ascertaining how well or poorly they work will have implications for the support necessary during posttest counseling, and will help personalize the discussion of anticipated risks and benefits of testing. Taking a brief history of past and current psychiatric symptoms (e.g., depression, extreme anxiety, suicidality) will allow for an assessment of whether this individual is at particular risk of adverse effects following disclosure of results. In such cases, further psychological assessment may be indicated.

In addition, cognitive deficits in the person being counseled may significantly limit understanding of the genetic information provided and hinder the ability to give informed consent, and may also require further psychological assessment. Emotional responses to cancer risk may also affect overall mood and functioning in other areas of life such as home, work, and personal health management, including cancer screening practices.[52] Education and genetic counseling sessions provide an opportunity for ongoing informal assessment of the affective as well as cognitive aspects of the health communication process. Since behavioral factors influence adherence to screening and surveillance recommendations, consideration of emotional barriers is important in helping a person choose prevention strategies and in discussing the potential utility of genetic testing.[53,54]

The discussion of issues such as history of depression, anxiety, and suicidal thoughts or tendencies requires sensitivity to the individual. The individual must be assured that the counseling process is a collaborative effort to minimize intrusiveness while maximizing benefits. Determining whether the individual is currently receiving treatment for major psychiatric illness is an important part of the counseling process. Consultation with a mental health professional familiar with psychological assessments may be useful to help the provider develop the strategies for these discussions. It also may be beneficial for the individual to be given standard psychological self-report instruments that assess levels of depression, anxiety, and other psychiatric difficulties that he or she may be experiencing. This step provides objective comparisons with already established normative data.[55,56]

In addition to the clinical assessment of psychological functioning, several instruments for cancer patients and people at increased risk of cancer have been utilized to assess psychological status. These include the Center for Epidemiological Studies-Depression scale,[57] the Profile of Mood States,[58] the Hospital Anxiety and Depression Scale,[59] and the Brief Symptom Inventory.[60] Research programs have included one or more of these instruments as a way of helping refine the selection of people at increased risk of adverse psychosocial consequences of genetic testing. Psychological assessments are an ongoing part of genetic counseling. Some individuals with symptoms of increased distress, extreme avoidance of affect, or other marked psychiatric symptoms may benefit from a discussion with, or evaluation by, a mental health professional. It may be suggested to some people (generally a very small percentage of any population) that testing be postponed until greater emotional stability has been established.

In addition to making an assessment of the family history of cancer, the family as a social system may also be assessed as part of the process of cancer genetic counseling. Hereditary susceptibility to cancer may affect social interactions and attitudes toward the family.[61]

In assessing families, characteristics that may be relevant are the organization of the family (including recognition of individuals who propose to speak for or motivate other family members), patterns of communication within the family, cohesion or closeness of family members (or lack thereof), and the family beliefs and values that affect health behaviors. Cultural factors may also play an important role in guiding behavior in some families.

Assessment also evaluates the impact of the family’s prior experience with illness on their attitudes and behaviors related to genetic counseling and testing. Prior experience with cancer diagnosis and treatment, loss due to cancer, and the family members’ interaction with the medical community may heavily influence attitudes toward receiving genetic information and may play a major role in the emotional state of individuals presenting for genetic services.

The practitioner may use the above framework to guide inquiries about the relationship of the individual to (1) the affected members of the family or (2) others who are considering or deciding against the consideration of genetic counseling or testing. Inquiries about how the family shares (or does not share) information about health, illness, and genetic susceptibility may establish whether the individual feels under pressure from other family members or anticipates difficulty in sharing genetic information obtained from counseling or testing. Inquiries about the present health (new diagnoses or deaths from cancer) or relationship status (divorce, marriage, grieving) of family members may inform the provider about the timing of the individual’s participation in counseling or testing and may also reveal possible contraindications for testing at present.

In addition to using a pedigree to evaluate family health history, tools such as the genogram and ecomap can provide specific information regarding the nature of interpersonal relationships within the family and the connections with social networks outside of the family.[62-64]

More specific information about family functioning in coping with hereditary cancers can be found in the psychosocial or counseling sections of PDQ summaries on the genetics of specific types of cancer. (Refer to the Genetics of Breast and Ovarian Cancer and Genetics of Colorectal Cancer summaries for more information.)

There is substantial evidence that many people do not understand the potential limitations of genetic testing and may give too much weight to the potential benefits.[65-67] Counseling provides the opportunity to present a balanced view of the potential risks and benefits of testing and to correct misconceptions. It may be helpful to ask individuals to identify their perceptions about the pros and cons of testing as part of this discussion.

1. Potential burdens of a test result that is uninformative or of uncertain significance.

   In the absence of a known mutation in the family, a negative test result is not informative. In this situation, the tested person’s risk status remains the same as it was prior to testing. One study of 183 women with an uninformative BRCA test result found that most women understood the implications of the test result, and it did not alter their intention to undergo a high-risk screening regimen.[68,69] If the test identifies a new mutation of unknown clinical significance, the test result is of uncertain significance and cannot be used to revise the tested person’s risk estimate. Subsequent research, however, may provide information about the mutation’s effect (or lack of effect) on cancer risk.

   Potential burdens

   • Need to evaluate other family members to determine the significance of mutations not known to be disease related.
   • Persistent uncertainty about risk status, which may result in a recommendation for intensive monitoring if a hereditary predisposition cannot be ruled out with certainty.
   • Lack of evidence-based guidance regarding prevention or surveillance strategies.
   • Continuing anxiety, frustration, and other adverse psychological sequelae associated with uncertainty because no definitive answer has been provided.
   • High monetary cost of testing.
2. Potential benefits and burdens of a positive test in an unaffected, at-risk individual when a disease-related mutation has been previously identified in the family.

   Potential benefits

   • Elimination of uncertainty about inherited susceptibility for an individual.
   • Potential for reduction in future morbidity and mortality through enhanced cancer risk management strategies (i.e., increased screening, adoption of a healthy lifestyle, and avoidance of risk factors).
   • Opportunity to reduce cancer risk through chemoprevention and risk-reducing surgery.
   • Opportunity to inform relatives about the likelihood that they have the family mutation and about the availability of genetic testing, cancer risk assessment, and management services.

   Potential burdens

   • Neglect of screening and surveillance resulting from increased anxiety about being a mutation carrier.
   • Psychological distress, including anxiety, depression, reduced self-esteem.
   • Increased worry about cancer due to unproven effectiveness of current interventions to reduce risk.
   • Risks and costs of increased screening or prophylaxis.
   • Strained/altered relationships within family.
   • Guilt about possible transmission of genetic risk to children.
   • Potential insurance, employment, or social discrimination.
3. Potential benefits and burdens of a negative test result when a disease-related mutation has been identified in the family.

   Potential benefits

   • Reassurance and reduction of anxiety about personal cancer risk due to heredity.
   • Avoidance of unnecessary intensive monitoring and prevention strategies.
   • Avoidance of aggressive interventions such as risk-reducing surgery.
   • Relief that children are not at increased risk.

   Potential burdens

   • Neglect of routine surveillance resulting from misunderstanding of a negative test result. The patient remains at the general population risk and may be at increased risk depending on his or her personal risk factors and any risk associated with the other branch of the family.
   • Adjustment to the change in expected life course.
   • Survivor guilt.
   • Strained relationship with others in family.
   • Regret over previous decisions (e.g., having had risk-reducing surgery prior to being tested).
4. Potential benefits and burdens of a positive test result in an individual who is the first identified mutation carrier in a family.[70]

   Potential benefits

   • No need to rely on other family members for informative test results.
   • Potential for risk reduction in future morbidity and mortality through enhanced cancer risk management strategies (i.e., increased screening and surveillance, adoption of a healthy lifestyle, and avoidance of risk factors).
   • Opportunity to reduce cancer risk through chemoprevention and risk-reducing surgery.
   • Opportunity to inform relatives about the likelihood that they have the family mutation and about the availability of genetic testing, cancer risk assessment, and management services.

   Potential burdens

   • Confronting ethical dilemmas about who should receive the information, what should be conveyed, and when it should be conveyed to specific family members.
   • Coping with potential personal distress in conveying the information.
   • Coping with family members' potential distress and reaction to the information.
   • Feeling unprepared for the tasks associated with disseminating genetic information through the family.
   • Loss of privacy.

The primary component of the posttest session is result notification. An individual may change his or her mind about receiving results, however, until the moment of results disclosure. Therefore, one typically begins the disclosure session by confirming that test results are still desired. Some people may decline or delay receipt of test results. The percentage of people who will make this decision is unknown. Such people need ongoing follow-up and the opportunity to receive test results in the future.

Once confirmed, people appreciate direct, immediate reporting of the results; they often describe the wait for results as one of the most stressful aspects of undergoing testing.[71] Often, people need a few minutes of privacy to gather their composure after hearing their test results. Sometimes this precludes all but the briefest discussion at the initial posttest visit. Usually, individuals who have been properly prepared through the pretest counseling process do not exhibit disabling distress. Although it is rare that an acute psychological reaction will occur at disclosure, it is useful for providers of genetic test results to establish a relationship with a mental health provider who can be consulted should extreme reactions occur, or who can be available by referral for people seeking further exploration of emotional issues.

Either at the time of disclosure or shortly thereafter, a session for the provider and the individual to consider the genetic, medical, psychological, and social ramifications of the test result is advisable. Despite having extensive pretest education, people may still be confused about the implications and meaning of the test results. Examples of frequently documented misconceptions include the belief that a positive result means that cancer is present or certain to develop; the belief that a negative result means that cancer will never occur; and failure to understand the uncertainty inherent in certain test results, as when only a limited mutation panel was examined. Regarding medical implications, it is important to inform the person of risk implications and management options for all of the cancer types in an inherited syndrome and to revisit options for risk management.

Posttest counseling may include consideration of the implications of the test results for other family members. It has been suggested that some individuals affected by an inherited disorder agree to have genetic testing performed in order to acquire information that could be shared with family members. There is evidence that implementation of a follow-up counseling program with the index patient, after test results are revealed, will significantly increase the proportion of relatives informed of their genetic risk. Follow-up counseling may include telephone conversations with the index patient verifying which family members have been contacted and an offer to assist with conveying information to family members.[72] Some experts have suggested that if a test result is positive, plans should be made at this time for the notification, education, and counseling of other relatives based on the test result of the individual. Written materials, brochures, or personal letters may aid people in informing the appropriate relatives about genetic risk.

When a test result is negative, the posttest session may be briefer. It is important, however, to discuss genetic, medical, and psychological implications of a negative result in a family with a known mutation as well. For example, it is essential that the person understand that the general population risks for relevant cancer types still apply and that the person’s individual risk of cancer may still be influenced by other risk factors and family history from the other side of the family. Furthermore, people are often surprised to feel distress even when a test is negative. This outcome has been documented in a variety of hereditary conditions and may also be anticipated in cancer susceptibility testing. Posttest results discussion of such distress may lead to referral for additional counseling in some cases.

Many individuals benefit from follow-up counseling and consultation with medical specialists after disclosure of test results. This provides an opportunity for further discussion of feelings about their risk status, options for risk management including screening and detection procedures, and implications of the test results for other family members.

References

1. American Society of Clinical Oncology.: American Society of Clinical Oncology policy statement update: genetic testing for cancer susceptibility. J Clin Oncol 21 (12): 2397-406, 2003.  [PUBMED Abstract]
   
   
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24. Myers MF, Chang MH, Jorgensen C, et al.: Genetic testing for susceptibility to breast and ovarian cancer: evaluating the impact of a direct-to-consumer marketing campaign on physicians' knowledge and practices. Genet Med 8 (6): 361-70, 2006.  [PUBMED Abstract]
    
    
25. Gronwald J, Huzarski T, Byrski T, et al.: Direct-to-patient BRCA1 testing: the Twoj Styl experience. Breast Cancer Res Treat 100 (3): 239-45, 2006.  [PUBMED Abstract]
    
    
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27. Goddard KA, Moore C, Ottman D, et al.: Awareness and use of direct-to-consumer nutrigenomic tests, United States, 2006. Genet Med 9 (8): 510-7, 2007.  [PUBMED Abstract]
    
    
28. Geller G, Botkin JR, Green MJ, et al.: Genetic testing for susceptibility to adult-onset cancer. The process and content of informed consent. JAMA 277 (18): 1467-74, 1997.  [PUBMED Abstract]
    
    
29. Geller G, Doksum T, Bernhardt BA, et al.: Participation in breast cancer susceptibility testing protocols: influence of recruitment source, altruism, and family involvement on women's decisions. Cancer Epidemiol Biomarkers Prev 8 (4 Pt 2): 377-83, 1999.  [PUBMED Abstract]
    
    
30. Statement of the American Society of Clinical Oncology: genetic testing for cancer susceptibility, Adopted on February 20, 1996. J Clin Oncol 14 (5): 1730-6; discussion 1737-40, 1996.  [PUBMED Abstract]
    
    
31. American College of Medical Genetics.: Genetic susceptibility to breast and ovarian cancer: assessment, counseling and testing guidelines. New York: New York State Department of Health, American College of Medical Genetics Foundation, 1999. Also available online. Last accessed March 8, 2007. 
    
    
32. McKinnon WC, Baty BJ, Bennett RL, et al.: Predisposition genetic testing for late-onset disorders in adults. A position paper of the National Society of Genetic Counselors. JAMA 278 (15): 1217-20, 1997.  [PUBMED Abstract]
    
    
33. Nelson RM, Botkjin JR, Kodish ED, et al.: Ethical issues with genetic testing in pediatrics. Pediatrics 107 (6): 1451-5, 2001.  [PUBMED Abstract]
    
    
34. Points to consider: ethical, legal, and psychosocial implications of genetic testing in children and adolescents. American Society of Human Genetics Board of Directors, American College of Medical Genetics Board of Directors. Am J Hum Genet 57 (5): 1233-41, 1995.  [PUBMED Abstract]
    
    
35. Wertz DC, Fanos JH, Reilly PR: Genetic testing for children and adolescents. Who decides? JAMA 272 (11): 875-81, 1994.  [PUBMED Abstract]
    
    
36. Field M, Shanley S, Kirk J: Inherited cancer susceptibility syndromes in paediatric practice. J Paediatr Child Health 43 (4): 219-29, 2007.  [PUBMED Abstract]
    
    
37. Tischkowitz M, Rosser E: Inherited cancer in children: practical/ethical problems and challenges. Eur J Cancer 40 (16): 2459-70, 2004.  [PUBMED Abstract]
    
    
38. Brooks GA, Stopfer JE, Erlichman J, et al.: Childhood cancer in families with and without BRCA1 or BRCA2 mutations ascertained at a high-risk breast cancer clinic. Cancer Biol Ther 5 (9): 1098-102, 2006.  [PUBMED Abstract]
    
    
39. Fanos JH: Developmental tasks of childhood and adolescence: implications for genetic testing. Am J Med Genet 71 (1): 22-8, 1997.  [PUBMED Abstract]
    
    
40. Bernhardt BA, Tambor ES, Fraser G, et al.: Parents' and children's attitudes toward the enrollment of minors in genetic susceptibility research: implications for informed consent. Am J Med Genet A 116 (4): 315-23, 2003.  [PUBMED Abstract]
    
    
41. Genetics Perspectives on Policy Seminar - Genes in Uniform: Don't Test, Don't Tell. Washington DC, The Genetics and Public Policy Center, 2006 Available online. Last accessed September 5, 2007. 
    
    
42. Resta R, Biesecker BB, Bennett RL, et al.: A new definition of Genetic Counseling: National Society of Genetic Counselors' Task Force report. J Genet Couns 15 (2): 77-83, 2006.  [PUBMED Abstract]
    
    
43. National Research Council Committee for the Study of Inborn Errors of Metabolism.: Genetic Screening Programs, Principles, and Research. Washington, D.C.: National Academy of Sciences, 1975. 
    
    
44. Tessaro I, Borstelmann N, Regan K, et al.: Genetic testing for susceptibility to breast cancer: findings from women's focus groups. J Womens Health 6 (3): 317-27, 1997.  [PUBMED Abstract]
    
    
45. Richards M: Families, kinship and genetics. In: Marteau T, Richards M, eds.: The Troubled Helix: Social and Psychological Implications of the New Human Genetics. Cambridge, England: Cambridge University Press, 1996, pp 249-273. 
    
    
46. Hallowell N, Statham H, Murton F: Women's understanding of their risk of developing breast/ovarian cancer before and after genetic counseling. J Genet Couns 7(4): 345-364, 1998. 
    
    
47. Baum A, Friedman AL, Zakowski SG: Stress and genetic testing for disease risk. Health Psychol 16 (1): 8-19, 1997.  [PUBMED Abstract]
    
    
48. Peters JA, Stopfer JE: Role of the genetic counselor in familial cancer. Oncology (Huntingt) 10 (2): 159-66, 175; discussion 176-6, 178, 1996.  [PUBMED Abstract]
    
    
49. Richards M: Families, kinship and genetics. In: Marteau T, Richards M, eds.: The Troubled Helix: Social and Psychological Implications of the New Human Genetics. Cambridge, England: Cambridge University Press, 1996, pp 264-265. 
    
    
50. Croyle RT, Achilles JS, Lerman C: Psychologic aspects of cancer genetic testing: a research update for clinicians. Cancer 80 (3 Suppl): 569-75, 1997.  [PUBMED Abstract]
    
    
51. Kessler S: Psychological aspects of genetic counseling, X: advanced counseling techniques. J Genet Couns 6(4): 379-392, 1997. 
    
    
52. van Dooren S, Rijnsburger AJ, Seynaeve C, et al.: Psychological distress and breast self-examination frequency in women at increased risk for hereditary or familial breast cancer. Community Genet 6 (4): 235-41, 2003.  [PUBMED Abstract]
    
    
53. Lerman C, Schwartz MD, Lin TH, et al.: The influence of psychological distress on use of genetic testing for cancer risk. J Consult Clin Psychol 65 (3): 414-20, 1997.  [PUBMED Abstract]
    
    
54. Shoda Y, Mischel W, Miller SM, et al.: Psychological interventions and genetic testing: facilitating informed decisions about BRCA1/2 cancer susceptibility. J Clin Psychol Med Settings 5(1): 3-17, 1998. 
    
    
55. Patenaude AF: Genetic Testing for Cancer: Psychological Approaches for Helping Patients and Families. Washington, DC: American Psychological Association, 2005. 
    
    
56. Vadaparampil ST, Miree CA, Wilson C, et al.: Psychosocial and behavioral impact of genetic counseling and testing. Breast Dis 27: 97-108, 2006-2007.  [PUBMED Abstract]
    
    
57. Radloff LS: The CES-D scale: a self-report depression scale for research in the general population. Applied Psychological Measurement 1(3): 385-401, 1977. 
    
    
58. McNair D, Lorr M, Droppelman L, et al.: Profile of Mood States. San Diego, Calif: Educational and Industrial Testing Service, 1971. 
    
    
59. Ford S, Lewis S, Fallowfield L: Psychological morbidity in newly referred patients with cancer. J Psychosom Res 39 (2): 193-202, 1995.  [PUBMED Abstract]
    
    
60. Derogatis LR, Melisaratos N: The Brief Symptom Inventory: an introductory report. Psychol Med 13 (3): 595-605, 1983.  [PUBMED Abstract]
    
    
61. Rolland JS: Families, Illness, and Disability: An Integrative Treatment Model. New York, NY: BasicBooks, 1994. 
    
    
62. Olsen S, Dudley-Brown S, McMullen P: Case for blending pedigrees, genograms and ecomaps: nursing's contribution to the 'big picture'. Nurs Health Sci 6 (4): 295-308, 2004.  [PUBMED Abstract]
    
    
63. Peters JA, Hoskins L, Prindiville S, et al.: Evolution of the colored eco-genetic relationship map (CEGRM) for assessing social functioning in women in hereditary breast-ovarian (HBOC) families. J Genet Couns 15 (6): 477-89, 2006.  [PUBMED Abstract]
    
    
64. Peters JA, Kenen R, Giusti R, et al.: Exploratory study of the feasibility and utility of the colored eco-genetic relationship map (CEGRM) in women at high genetic risk of developing breast cancer. Am J Med Genet A 130 (3): 258-64, 2004.  [PUBMED Abstract]
    
    
65. Lerman C, Narod S, Schulman K, et al.: BRCA1 testing in families with hereditary breast-ovarian cancer. A prospective study of patient decision making and outcomes. JAMA 275 (24): 1885-92, 1996.  [PUBMED Abstract]
    
    
66. Lerman C, Biesecker B, Benkendorf JL, et al.: Controlled trial of pretest education approaches to enhance informed decision-making for BRCA1 gene testing. J Natl Cancer Inst 89 (2): 148-57, 1997.  [PUBMED Abstract]
    
    
67. Bluman LG, Rimer BK, Berry DA, et al.: Attitudes, knowledge, and risk perceptions of women with breast and/or ovarian cancer considering testing for BRCA1 and BRCA2. J Clin Oncol 17 (3): 1040-6, 1999.  [PUBMED Abstract]
    
    
68. van Dijk S, Otten W, Timmermans DR, et al.: What's the message? Interpretation of an uninformative BRCA1/2 test result for women at risk of familial breast cancer. Genet Med 7 (4): 239-45, 2005.  [PUBMED Abstract]
    
    
69. Dorval M, Patenaude AF, Schneider KA, et al.: Anticipated versus actual emotional reactions to disclosure of results of genetic tests for cancer susceptibility: findings from p53 and BRCA1 testing programs. J Clin Oncol 18 (10): 2135-42, 2000.  [PUBMED Abstract]
    
    
70. Hallowell N, Foster C, Eeles R, et al.: Balancing autonomy and responsibility: the ethics of generating and disclosing genetic information. J Med Ethics 29 (2): 74-9; discussion 80-3, 2003.  [PUBMED Abstract]
    
    
71. Bennett RL: The Practical Guide to the Genetic Family History. New York, NY: Wiley-Liss, 1999. 
    
    
72. Forrest LE, Burke J, Bacic S, et al.: Increased genetic counseling support improves communication of genetic information in families. Genet Med 10 (3): 167-72, 2008.  [PUBMED Abstract]
    
    

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Ethical, Legal, and Social Implications

Having an understanding of the ethical, legal, and social implications (ELSI) regarding cancer genetic testing may influence the clinician’s response to the complex questions and issues that may arise during the process of risk assessment and counseling. This section discusses biomedical ethics codes, legal and social issues relevant to privacy, and fair use in the interpretation of genetic information. In order to integrate the different perspectives of bioethics, law, and psychosocial influences, case scenarios are offered to illustrate dilemmas encountered in the clinical setting. (Refer to the Determining the Test to Be Used section of this summary for more information about the regulation of genetic tests.)

Bioethical tenets can guide health care providers in dealing with the complex issues surrounding predictive testing for hereditary cancer. The tenets of beneficence, nonmaleficence, autonomy, and justice are part of a framework needed to balance the complex and potentially conflicting factors surrounding a clinician’s role in respecting privacy, confidentiality and fair use of genetic information obtained from cancer genetic testing.

The concept of beneficence dictates that the primary goal of medical care is to provide benefit through appropriate health care.[1] In the field of oncology, this translates into using early detection and effective treatment protocols to improve outcomes. Providing beneficent care may go beyond medical outcomes of treatment to encompass the patient’s life circumstances, expectations, and values.[1] Consideration of the patient’s psychological and emotional ability to handle the testing and results disclosure process can help avoid doing harm.[2] (Refer to the Psychological Impact of Genetic Testing/Test Results on the Individual section of this summary for more information.)

Nonmaleficence is the bioethical code that directs health care providers to do no harm, inclusive of physical and emotional harm, and acknowledges that medical care involves risks as well as benefits.[1] Particular to the field of oncology, adherence to this construct includes taking measures to minimize the adverse effects of cancer prevention, treatment, and control. This may encompass taking precautionary measures to prevent inadvertent disclosure of sensitive information.[2]

Autonomous decision-making respects patient preferences by incorporating informed consent and education.[1] In the field of oncology, the patient has the right to choose or decline services by comparing different medical approaches’ risks and benefits of predictive testing services that may have similar medical outcomes or to decline those services. Additionally, it is beneficial to consider the sociocultural and family dynamics to ensure medical decision-making takes places without coercion or interference.[1]

Justice refers to the equitable distribution of the benefits and risks of health care.[1] A goal in oncology is ensuring access to cancer genetic services. The availability of predictive genetic testing should not be dependent on ethnic background, geographical location, or ability to pay. Genetic discrimination should not be a result of predictive testing.[2] Equitable distribution balances individual rights with responsibilities of community membership.[1]

A strong provider-patient relationship is founded on respect for the patient’s privacy and confidentiality; therefore, protecting the patient’s personal information from third parties is key to building trust.[2,3] Predictive testing for cancer susceptibility presents a challenge because of the hereditary nature of the diseases being tested and the implications of genetic risk for family members. Physicians are faced with a duty to warn or to act to prevent foreseeable harm.[4] One practical suggestion for facilitating family-based communication is providing patients with education and information materials to facilitate disease susceptibility discussions with family members.[1] The next section discusses the legal, legislative, and ethical basis for balancing patient confidentiality with duty to warn.

Privacy and confidentiality also applies to research, for example, population screening for genetic diseases. The U.S. Department of Health and Human Services authorizes the use of Certificates of Confidentiality to researchers.[5] This certificate issued by the National Institutes of Health protects the researcher from having to reveal the identity of any research subject “in any Federal, State, or local civil, criminal, administrative, legislative, or other proceedings.” The protections offered by the certificate of confidentiality are limited to personally identifiable information collected beginning on the date of issuance and ending on the expiration date, which matches the date of study completion. The NIH Office of Extramural Research policy and guidance on Certificates of Confidentiality notes that any personally identifiable information collected during that time interval is protected in perpetuity. In regard to family-based recruitment strategies, the Cancer Genetics Network Bioethics Committee assembled a group of experts to develop recommendations for researchers to use in approaching family members.[6] Due to the wide spectrum of research strategies, there are different levels of concern. Essential to family-based recruitment strategies is informing potential research participants how their personal information was obtained by the researcher, why the researcher is approaching them, what the researcher knows about them, and for what purpose the information will be used, whether or not they decide to participate.[6]

“Duty to warn” requires balancing the bioethical constructs of beneficence and autonomy with other factors such as case proceedings, legislation and professional societies’ recommendations. As of September 2008, the National Council of State Legislatures lists 27 states that have legislation requiring consent to disclose genetic information. Genetic information can vary depending on the legal case and the language used in state and federal legislation, but may include direct and indirect genetic testing and family history information; it does not apply to current conditions. Genetic diagnosis can be done through direct genetic tests (direct mutation analysis) for disorders linked to a specific mutation and indirect genetic tests (indirect mutation analysis) for disorders in which the specific mutations are not known or there are multiple different mutations.[7] There are four state case laws that apply to duty to warn.[8] Two cases deal directly with testing for cancer genetics, one case deals with a psychotherapist's duty to warn a relative of imminent threat, and another with genetic testing as a tool for reproductive decisions. Table 1 summarizes the cases.

At the federal level there are strict nondisclosure policies governing private health information.[8] The Standards for Privacy of Individually Identifiable Health Information (Privacy Rule), which summarizes the Health Insurance Portability and Accountability Act (HIPAA) of 1996, finds it permissible to disclose health information without consent when the public interest is at risk;[15,16] therefore, under certain conditions, there are exceptions to the nondisclosure policy include the following:

1. There is serious or imminent threat to the health or safety of a person or the public.
2. The threat constitutes an imminent, serious threat to an identifiable third party.
3. The physician has the capacity to avert significant harm.

Professional societies and government advisory agencies have published their different positions and recommendations on communication between a physician and a patient's relatives in regard to disclosure of genetic disease.[4,8,17]

The Council on Ethical and Judicial Affairs of the American Medical Association (AMA) and the American Society of Clinical Oncology (ASCO) [18] encourage discussing the importance of patients sharing genetic information with family members.[4] Specifically the Council on Ethical and Judicial Affairs of the American Medical Association states “Physicians …should identify circumstances under which they would expect patients to notify biological relatives of the availability of information related to risk of disease…(and) physicians should make themselves available to assist patients in communicating with relatives to discuss opportunities for counseling and testing, as appropriate.” ASCO’s position is that providers “should remind patients of the importance of communicating test results to family members… ASCO believes that the cancer care provider’s obligations (if any) to at-risk relatives are best fulfilled by communication of familial risk to the person undergoing testing, emphasizing the importance of sharing this information with family members so that they may also benefit.”[18] These organizations recommend that family members disclose genetic information.

The National Society of Genetic Counselors,[19] the Great Lakes Regional Genetic Group, and the International Society of Nurses in Genetics [20] support disclosure to relatives with the patient's consent.[4] One of the tenets of genetic counseling is to maintain information received from clients as confidential, unless released by the client or consent for disclosure is provided as required by law.[4,19]

Similar to the Privacy Rule, the U.S. Bioethics Commission,[21] American Society of Human Genetics,[22] and National Human Genome Research Institute (NHGRI) recommend the following guidelines to identify exceptional circumstances under which it is ethically acceptable to breach confidentiality.[4,8]

1. There is a high likelihood of harm if the relative is not warned.[4,21,22]
2. The patient, despite encouragement, refuses to inform family members.[4,21,22]
3. The relative is identifiable.[22]
4. The harm of nondisclosure is greater than the harm of disclosure.[22]
5. Current medical technology renders the disease preventable, treatable or manageable.[22]
6. Only the information necessary to prevent harm is released.[4,23]
7. There is no other reasonable way to avert harm.[4]

At an international level the World Health Organization and World Medical Association have similar guidelines.[4] Additionally, Australia, Canada, Germany, Japan, the Netherlands, and the United Kingdom have guidelines supporting the disclosure of genetic information to relatives under similar exceptional circumstances.[4]

Genetic information obtained from genetic susceptibility tests may have medical, economic, and psychosocial implications for the individual tested and his or her family members. Fear of employment and insurance discrimination are considerations for individuals considering genetic testing. A review of ethical controversies in cancer genetics clinics included a phone interview of over 300 members of genetics support groups;13% of the study participants reported being denied or dismissed from a job and 22% reported being refused life insurance because of a genetic disorder in the family.[10,12,24] (See the Informed Consent and Exploration of Potential Risks, Benefits, Burdens, and Limitations of Genetic Susceptibility Testing sections of this summary for more information on discrimination issues related to cancer genetics services.)

A legal case example at the federal district court level involves the Burlington Northern Santa Fe Railroad. The U.S. Equal Employment and Opportunities Commission requested that Burlington Northern Santa Fe Railroad not be allowed to use medical information obtained from genetic tests for employment decisions.[23]

In the last 15 years, state and federal legislation statutes have been developed to prevent the use of genetic information for employment practices, such as hiring, promotion, and salary decisions; and insurance policies, including life and health coverage, by employers, schools, government agencies, and insurers.[12] According to Executive Order 13145, federal departments and agencies are prohibited from discriminating against employees on the basis of genetic testing results or information about a request for genetic testing services.[23] Employers and insurers are prohibited from intentionally lowering policy rates by using practices such as screening for individuals who are at risk of becoming ill or dying due to genetic disease susceptibility, such as cancer.[23] Federal laws, including the Genetic Information Nondiscrimination Act (GINA), do not cover employer-provided life and disability; however, some states do have legislation addressing the use of genetic information for life and disability policies. The National Conference of State Legislatures (NCSL) [25,26] summarized current health legislation of the U.S. Congress. Examples of relevant legislation regarding genetic information include, GINA, HIPAA, Americans with Disabilities Act (ADA), and Employee Retirement Income Security Act (ERISA).

GINA 2008 protects the provision of health insurance and employment against discrimination based on genetic information as follows:

• Prohibits access to individuals’ personal genetic information by insurance companies and by employers.[28]
• Prohibits insurance companies from requesting that applicants for group or individual health coverage plans be subjected to genetic testing or screening, and prohibits them from discriminating against health plan applicants based on individual genetic information.[28]
• Does not prohibit medical underwriting based on current health status.[29]
• Does not mandate coverage for medical tests or treatments.[29]
• Does not interfere or limit treating health care providers, including those employed or affiliated with health plans, from requesting or notifying individuals about genetic tests.[29]
• Prohibits employers from using genetic information to refuse employment, and prohibits them from collecting employees’ personal genetic information without their explicit consent.[28]
• Does not prohibit occupational testing for toxic monitoring programs, employer-sponsored wellness programs, administration of federal and state Family and Medical Leave Laws and certain cases of inadvertent acquisition of genetic information.[29]

GINA amends and/or extends coverage of HIPAA, ADA, and ERISA by including genetic information under medical privacy and confidentiality legislation and employment and insurance determinations.[25] Additionally, with the passage of GINA, researchers and clinicians can encourage participation in clinical trials and appropriate genetic testing knowing that there are federal protections against discrimination based on the results of genetic testing. GINA established the minimum protection level that must be met in all states. However, for states with more robust legislation in place, GINA does not weaken existing protections provided by state law.

However, GINA has several limitations.

1. GINA does not apply to members of the United States military, to veterans obtaining health care through the Veteran’s Administration, or to the Indian Health Service, because the laws amended by GINA do not apply to these groups and programs.
2. The legislation does not apply to life insurance, long-term care, or disability insurance. Even though GINA does not provide protection for employer-provided disability and life insurance, some states do encompass these arenas in addition to employment, genetic privacy, health insurance, health insurance enforcement, life, disability, and long term care.[23,30] NCSL has links to tables summarizing what each state determines genetic information to encompass and the relevant state regulations. Thirty-five states have legislation covering genetic discrimination in hiring, firing, and/or terms, conditions or privileges of employment. Seven states have varying legislation covering genetic discrimination in life, disability and/or long-term care insurance. Some states mention life, disability or long-term care as exclusions to their genetic nondiscrimination legislation.[30]

GINA and other state and federal protections do not extend to genetic testing of active duty military personnel or genetic information obtained from active duty military personnel.[31,32] In the military, genetic testing provides medical information that is to be used to protect military personnel from harmful duty or other exposures that could stimulate or aggravate a health problem. For example, use of certain antimalaria medication in individuals with glucose 6-phosphate dehydrogenase deficiency can result in red blood cell rupture. Therefore, some genetic information is critical for maintaining the health and safety of military personnel given the possible stressful occupational environments they face. In addition, all military personnel provide a DNA sample to be maintained in a repository that can be used for identification purposes.

Results of genetic tests for disease predisposition could influence military eligibility for new enlistments, and for current military personnel, genetic test results could influence worldwide eligibility, assignments, and promotions. For example, a young woman found to carry a BRCA mutation may not be considered eligible for deployment for 12-15 months because access to recommended health care may not be easily accessible, such as breast MRI, a recommended screening modality for BRCA mutation carriers. Active duty military personnel with less than eight years of active duty service are especially vulnerable in the event they become disabled and must go before the medical board to establish benefit eligibility. In 2006, Department of Defense Instruction Number 1332.38 (DODINST 1332.38) redefined pre-existing condition as a result of two cases brought by service members who each had a hereditary condition that presented later in their military career. The disability instructions state that any injury or disease discovered after a Service member enters active duty -- with the exception of congenital and hereditary conditions -- is presumed to have been incurred in the line of duty. Any hereditary and/or genetic disease shall be presumed to have been incurred prior to entry into active duty. However, DODINST 1332.38 further states that any aggravation of that disease, incurred in the line of duty, beyond that determined to be due to natural progression, shall be deemed service aggravated. As a result of these two cases, the 8-year active duty service limit was established. This means that after 8 or more years of military service the natural progression of a genetic condition would be deemed aggravated by military service. Therefore, the presence of a congenital or hereditary condition would not be considered a pre-existing condition in disability decision-making for those with 8 or more years of service.

There are multiple psychosocial, ethical, and legal issues to consider in cancer genetic testing. Genetic tests for germline mutations have social and family implications. In addition to prevention and surveillance options, genetic testing should be offered in conjunction with genetic education and counseling.[18] A comprehensive strategy for dealing with ethical dilemmas can incorporate a shared approach to decision-making including open discussion, planning, and involvement of the family.[5] To integrate the different perspectives of bioethics, law, and psychosocial influences, the following scenarios can help health care providers become familiar with commonly encountered dilemmas; it is imperative, however, that the clinician evaluate each patient and his or her situation on a case-by-case basis. These case scenarios were adopted from “Counseling about Cancer: Strategies for Genetic Counseling;” the in-depth case examples are extensively discussed in the original text.[2]

A patient with known family history of breast cancer is interested in testing for BRCA1 and BRCA2 mutation. In reviewing her family history, the health care provider realizes that the patient is not aware of an additional rare but hereditary cancer mutation in a second-degree relative, which the health center tested and confirmed in the past. After talking with her family, the patient is unable to confirm the details of the second cancer and again expresses interest in BRCA1/2 testing. Does the health care provider have a “duty to warn” the patient of the unknown cancer susceptibility gene in the family, at the risk of disclosing private patient information? The following issues are important to consider in resolving this case.

1. Preserving the confidentiality of the relative and informing the patient of her cancer risk are both important goals. In general, the health care professional has a “Duty to warn” when there is a high likelihood of harm if not warned, the person at risk is identifiable, the harm of nondisclosure is greater than disclosure, and only the information necessary to prevent harm is released. (Refer to the Privacy and Confidentiality: Disclosure of Patient’s Genetic Information section of this summary for more information.)
2. It is possible that the benefit outweighs the harm of informing the patient of the second cancer syndrome because the monitoring and management of the rare cancer are different from guidelines for the general population. Additionally both parties are identifiable. An option is to contact the relative for permission to disclose the genetic test result to the patient in question.
3. If it is not possible to obtain permission to disclose, it is possible to inform the patient that she meets clinical criteria for the hereditary cancer syndrome without releasing specific information about the genetic test results of the relative.

A patient with a family history of a hereditary cancer is interested in predictive genetic testing and convinces an affected family member, who initially expresses unwillingness, to be tested in order to establish the familial mutation. In this scenario, the surviving family member admits to feeling pressured into consenting for genetic testing. Both the patient and the affected family member are patients. What takes precedence — the patient’s right to know or the family member’s autonomy? The following issues are important to consider in resolving this case.

1. Explore, with the patient, alternatives to testing that do not involve the participation of the unwilling family member, such as testing stored tissue of a deceased relative. (Refer to the Value of Testing an Affected Family Member First section of this summary for more information).
2. If the patient does not want to consider other options and the family member has agreed to be tested without coercion or interference, inform the family member of the implications of the test results, including risks and benefits, and assess her emotional well-being prior to testing.[19] (Refer to the Informed Consent section of this summary for more information.)

A hereditary cancer syndrome has been identified in a family. Within that family, an adult child wants a cancer susceptibility test that her parent declined, and one identical twin wants testing but the other does not. Even though the noninterested parties have declined testing and do not want to know the results, it is possible that testing one relative can disclose results for the other family members. Do the rights of the family members interested in predictive testing take precedence over the rights of the relatives who do not want to know? The following issues are important to consider in resolving this case.

1. In hereditary cancer syndromes, an individual’s right to know takes precedence over an individual’s right not to know especially if there are early detection and prevention strategies to reduce the likelihood of morbidity and mortality.
2. Since the family has a documented deleterious mutation, standard of care recommendations include guidelines for screening and monitoring. In the event that testing is not done, it is important to take “reasonable steps” to guarantee immediate family members are warned of the hereditary cancer risk. (Refer to the Privacy and Confidentiality: Disclosure of Patient’s Genetic Information section of this summary for more information.)
3. Pretest and posttest discussions can include the possibility of medical, psychological, and social impact on family members and strategies on how to lessen any negative impact. The patient should honor the wishes of relatives who request not to know and attempt to keep the results secret.[19]

A psychological assessment of a patient interested in predictive testing for an autosomal dominant cancer reveals a history of depression and suicidal attempts. The health care provider is considering denying or deferring testing because of concerns for the patient’s emotional well-being even though the patient refuses a referral to a psychologist because he reports feeling emotionally stable. Is deferring or denying predictive genetic testing a beneficent gesture or an act of paternalism? The following issues are important to consider in resolving this case.

1. Despite the patient’s refusal to speak with a psychologist, the health care provider can discuss the details of the case with a mental health professional to determine suicidal risk. (Refer to the Psychological Impact of Genetic Information/Test Results on the Individual section of this summary for more information.)
2. If there is risk of psychosocial disturbances because of test results, it is possible to defer testing. Conditions under which testing can resume are explained to the patient. For example, the NSGC Code of Ethics recommends that clients be referred to other qualified professionals when the patient requires additional services.[19]
3. Denying a test does not seem justifiable under any circumstances because it implies that the client will never be able to undergo testing.

Refer to the PDQ summary on Cancer Genetics Overview Genetics Resource section for more information about the ELSI of genetic testing and counseling.

References

1. Burke W, Press N: Genetics as a tool to improve cancer outcomes: ethics and policy. Nat Rev Cancer 6 (6): 476-82, 2006.  [PUBMED Abstract]
   
   
2. Schneider K: The ethical issues. In: Schneider KA: Counseling About Cancer: Strategies for Genetic Counseling. 2nd ed. New York, NY: Wiley-Liss, 2002, pp 291-312. 
   
   
3. Offit K: Clinical Cancer Genetics: Risk Counseling and Management. New York, NY: John Wiley and Sons, 1998. 
   
   
4. Godard B, Hurlimann T, Letendre M, et al.: Guidelines for disclosing genetic information to family members: from development to use. Fam Cancer 5 (1): 103-16, 2006.  [PUBMED Abstract]
   
   
5. Offit K: Psychological, ethical, and legal issues in cancer risk counseling. In: Offit K: Clinical Cancer Genetics: Risk Counseling and Management. New York, NY: John Wiley and Sons, 1998, pp 287-315. 
   
   
6. Beskow LM, Botkin JR, Daly M, et al.: Ethical issues in identifying and recruiting participants for familial genetic research. Am J Med Genet A 130A (4): 424-31, 2004.  [PUBMED Abstract]
   
   
7. Tantravahi U, Wheeler P: Molecular genetic testing for prenatal diagnosis. Clin Lab Med 23 (2): 481-502, 2003.  [PUBMED Abstract]
   
   
8. Offit K, Groeger E, Turner S, et al.: The "duty to warn" a patient's family members about hereditary disease risks. JAMA 292 (12): 1469-73, 2004.  [PUBMED Abstract]
   
   
9. Tarasoff v. the Regents of the University of California, 551 P 2d 334 (Cal 1976). 1976 Also available online. Last accessed July 17, 2008. 
   
   
10. Harris M, Winship I, Spriggs M: Controversies and ethical issues in cancer-genetics clinics. Lancet Oncol 6 (5): 301-10, 2005.  [PUBMED Abstract]
    
    
11. Pate v. Threlkel, 661 So. 2d 278 ( Florida 1995). 1995 Also available online. Last accessed July 18, 2008. 
    
    
12. Sankar P: Genetic privacy. Annu Rev Med 54: 393-407, 2003.  [PUBMED Abstract]
    
    
13. Safer v. Estate of Pack, 677 A2d 1188 (NJ App), appeal denied, 683 A2d 1163 (NJ 1996). 1996 Also available online. Last accessed July 18, 2008. 
    
    
14. Molloy v. Meier, Nos. C9-02-1821, C2-02-1837 (Minn 2004). 2004 Also available online. Last accessed July 18, 2008. 
    
    
15. Health Insurance Portability and Accountability Act of 1996 Public Law 104-191, 104th Congress. Washington, DC: 1996 Also available online. Last accessed July 28, 2008. 
    
    
16. US Department of Health and Human Services.: OCR Privacy Brief: Summary of the HIPAA Privacy Rule. Washington, DC: US Department of Health and Human Services, 2002 Also available online. Last accessed July 28, 2008. 
    
    
17. Gordijn B: Genetic diagnosis, confidentiality and counseling: an ethics committee's potential deliberations about the do's and don'ts. HEC Forum 19 (4): 303-12, 2007.  [PUBMED Abstract]
    
    
18. American Society of Clinical Oncology.: American Society of Clinical Oncology policy statement update: genetic testing for cancer susceptibility. J Clin Oncol 21 (12): 2397-406, 2003.  [PUBMED Abstract]
    
    
19. National Society of Genetic Counselors.: National Society of Genetic Counselors Code of Ethics. Chicago, Il: National Society of Genetic Counselors, 2006. Available online. Last accessed July 29, 2008. 
    
    
20. International Society of Nurses in Genetics.: Position Statements: Privacy and Confidentiality of Genetic Information: The Role of the Nurse. Pittsburgh, Pa: International Society of Nurses in Genetics, 2008. Available online. Last accessed July 29, 2008. 
    
    
21. US President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research.: Screening and Counseling for Genetic Conditions: A Report on the Ethical, Social, and Legal Implications of Genetic Screening, Counseling, and Education Programs. Washington, DC: Government Printing Office, 1983. Also available online. Last accessed July 28, 2008. 
    
    
22. ASHG statement. Professional disclosure of familial genetic information. The American Society of Human Genetics Social Issues Subcommittee on Familial Disclosure. Am J Hum Genet 62 (2): 474-83, 1998.  [PUBMED Abstract]
    
    
23. Lowrey KM: Legal and ethical issues in cancer genetics nursing. Semin Oncol Nurs 20 (3): 203-8, 2004.  [PUBMED Abstract]
    
    
24. Lapham EV, Kozma C, Weiss JO: Genetic discrimination: perspectives of consumers. Science 274 (5287): 621-4, 1996.  [PUBMED Abstract]
    
    
25. National Conference of State Legislatures.: Summary: Selected Health Legislation 110th Congress. Washington, DC: National Conference of State Legislatures, 2008. Available online. Last accessed July 29, 2008. 
    
    
26. National Human Genome Research Institute.: National Human Genome Research Institute Policy and Legislation Database. Bethesda, Md: National Human Genome Research Institute, 2008. Available online. Last accessed July 29, 2008. 
    
    
27. Leib JR, Hoodfar E, Haidle JL, et al.: The new genetic privacy law: how GINA will affect patients seeking counseling and testing for inherited cancer risk. Community Oncology 5 (6): 351-4, 2008. 
    
    
28. American Society of Human Genetics.: Genetic Scientists Applaud U.S. Senate Passage of the Genetic Information Nondiscrimination Act: American Society of Human Genetics Supports Important New Legislation [Press Release - April 25, 2008]. Bethesda, Md: American Society of Human Genetics, 2008. Also available online. Last accessed July 28, 2008. 
    
    
29. Genetics and Public Policy Center.: Information on the Genetic Information Nondiscrimination Act (GINA). Washington, DC: Genetics and Public Policy Center, 2008. Also available online. Last accessed July 28, 2008. 
    
    
30. National Conference of State Legislatures.: Genetics Laws and Legislative Activity. Washington, DC: National Conference of State Legislatures, 2008. Available online. Last accessed July 29, 2008. 
    
    
31. Hudson KL, Holohan MK, Collins FS: Keeping pace with the times--the Genetic Information Nondiscrimination Act of 2008. N Engl J Med 358 (25): 2661-3, 2008.  [PUBMED Abstract]
    
    
32. Genetics Perspectives on Policy Seminar - Genes in Uniform: Don't Test, Don't Tell. Washington DC, The Genetics and Public Policy Center, 2006 Available online. Last accessed September 5, 2007. 
    
    

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Changes to This Summary (04/15/2009)

The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.

Components of the Risk Assessment Process

Added text that complementary and alternative medicine practics may be included in the consultand's health history .

Education and Counseling About Risk/Risk Communication

Added text about a systematic review of studies that evaluated communication interventions and showed that risk communication benefits users cognitively by increasing their knowledge and understanding of risk perception (cited 2008 Edwards et al. as reference 5 and 2003 Edwards et al. as reference 6).

The Option of Genetic Testing

Added Direct-to-Consumer Marketing of Genetic Tests as a new subsection.

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More Information

About PDQ

• PDQ® - NCI's Comprehensive Cancer Database.

  Full description of the NCI PDQ database.

Additional PDQ Summaries

• PDQ® Cancer Information Summaries: Adult Treatment

  Treatment options for adult cancers.

• PDQ® Cancer Information Summaries: Pediatric Treatment

  Treatment options for childhood cancers.

• PDQ® Cancer Information Summaries: Supportive and Palliative Care

  Side effects of cancer treatment, management of cancer-related complications and pain, and psychosocial concerns.

• PDQ® Cancer Information Summaries: Screening/Detection (Testing for Cancer)

  Tests or procedures that detect specific types of cancer.

• PDQ® Cancer Information Summaries: Prevention

  Risk factors and methods to increase chances of preventing specific types of cancer.

• PDQ® Cancer Information Summaries: Genetics

  Genetics of specific cancers and inherited cancer syndromes, and ethical, legal, and social concerns.

• PDQ® Cancer Information Summaries: Complementary and Alternative Medicine

  Information about complementary and alternative forms of treatment for patients with cancer.

Important:

This information is intended mainly for use by doctors and other health care professionals. If you have questions about this topic, you can ask your doctor, or call the Cancer Information Service at 1-800-4-CANCER (1-800-422-6237).

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