Survey of genetic counselors and clinical geneticists' use and attitudes toward pharmacogenetic testing.

Pharmacogenetic (PGx) testing aims to improve therapeutic outcomes through tailoring treatment based on a patient's genetic risk for non-response and/or an adverse event. Given their expertise, geneticists could facilitate the use of PGx testing; however, the preparedness and perceived role of the clinical genetics community is unclear. To assess the attitudes, preparedness, and perceived roles of geneticists in the delivery of PGx testing, we conducted a survey of 1500 randomly selected board-certified genetic counselors and clinical geneticists in the United States [response rate: 37.8% (n = 516)]. Twelve percent of genetic counselors and 41% of clinical geneticists indicated that they had ordered or coordinated patient care for PGx testing, a seemingly high proportion at this early stage of adoption. Almost all respondents had some education on pharmacogenetics, although only 28% of counselors and 58% of clinical geneticists indicated they felt well-informed about PGx testing. About half of counselors (52%) and clinical geneticists (46%) felt they would play 'some' role in the delivery of PGx testing; 17 and 19%, respectively, felt that they would play 'no' or 'a little' role. At this early stage of PGx testing, the role of geneticists and genetic counselors is unclear. However, their experience may aid in readying PGx testing and informing delivery strategies into clinical practice.

Understanding the potential of teachable moments: the case of smoking cessation.

The label 'teachable moment' (TM) has been used to describe naturally occurring health events thought to motivate individuals to spontaneously adopt risk-reducing health behaviors. This manuscript summarizes the evidence of TMs for smoking cessation, and makes recommendations for conceptual and methodological refinements to improve the next generation of related research. TM studies were identified for the following event categories: office visits, notification of abnormal test results, pregnancy, hospitalization and disease diagnosis. Cessation rates associated with pregnancy, hospitalization and disease diagnosis were high (10-60 and 15-78%, respectively), whereas rates for clinic visits and abnormal test results were consistently lower (2-10 and 7-21%, respectively). Drawing from accepted conceptual models, a TM heuristic is outlined that suggests three domains underlie whether a cueing event is significant enough to be a TM for smoking cessation: the extent to which the event (1) increases perceptions of personal risk and outcome expectancies, (2) prompts strong affective or emotional responses, and (3) redefines self-concept or social role. Research in TMs could be improved by giving greater attention to assessment of conceptually grounded cognitive and emotional variables, appropriately timed assessment and intervention, and inclusion of appropriate target and comparison samples.

Reasons for quitting smoking among low-income African American smokers.

The psychometric characteristics of the Reasons For Quitting scale (RFQ) were assessed among a sample of African American smokers with low income (N=487). The intrinsic and extrinsic scales and their respective subscales were replicated. As hypothesized, higher levels of motivation were associated significantly, in patterns that supported the measure's construct validity, with advanced stage of readiness to quit smoking, greater perceived vulnerability to health effects of smoking, and greater social support for cessation. On the basis of the present study, the RFQ might best predict short-term cessation among older and female smokers. Refinement of the RFQ is needed to assess intrinsic motivators other than health concerns and to identify salient motivators for young and male smokers.

Communicating breast cancer risks to women using different formats.

Using a pre-post test design with a baseline, laboratory, and a 6-month follow-up, we communicated women's objective breast cancer risks, based on the Gail Model, using two formats: (a) range of risks (e.g., risk of breast cancer can be as low as 1% and as high as 5%); and (b) as a point estimate (e.g., your risk of breast cancer is 3%). We examined how these presentations individually and jointly affected women's perceived lifetime breast cancer risks. Overall, providing risk estimates either as a range of risks or as a point estimate lowered women's perceived lifetime risks compared with women who did not get information presented this way shortly after receipt of this information relative to baseline. At the 6-month follow-up, perceptions of lifetime risks generally returned to their baseline values. Overall, women viewed their risk feedback, whether presented as a point estimate or as a range of risks, as equally credible, trustworthy, accurate, and personally relevant. These results suggest that women evaluate risk feedback containing either point estimates or range of risks as equally acceptable. Both formats lead to short-term reductions in perceived risk (i.e., greater accuracy).

Women's interest in chemoprevention for breast cancer.

BACKGROUND: Chemoprevention is the use of pharmacologic or natural agents to inhibit the development of cancer. Tamoxifen citrate is the only approved chemopreventive agent for breast cancer. We sought to determine whether women are interested in taking a drug to prevent breast cancer and to assess the relationship between objective and subjective breast cancer risk and interest in chemoprevention. METHODS: We conducted telephone interviews (November 3, 1997, to May 6, 1998) among a community sample of women aged 40 to 45 and 50 to 55 years enrolled in a randomized controlled trial to evaluate the efficacy of a tailored mammography decision aid. Objective breast cancer risk was measured using the 5-year Gail score. Subjective breast cancer risk was measured using perceptions of absolute risk, perceptions of comparative risk, and worry about getting breast cancer. At 12-month follow-up (November 2, 1998, to July 20, 1999), we measured interest in taking a drug to prevent breast cancer. RESULTS: Among the 1273 women surveyed, 23% were interested in taking a drug to prevent breast cancer; 8% were potentially eligible for tamoxifen therapy (5-year Gail score > or = 1.66%). Eligibility for chemoprevention, based on the 5-year Gail score, was not associated with interest in taking a drug to prevent breast cancer. Women who were worried about breast cancer were 3 times more likely to be interested in taking a drug to prevent breast cancer than those who were not worried. CONCLUSION: Women's interest in chemoprevention might arise more from worries about getting breast cancer than from their objective risk factors.

Informing women about their breast cancer risks: truth and consequences.

We assessed the extent to which informing women about their risk for breast cancer affected their perceived 10-year and lifetime risks for getting breast cancer, their emotional reactions toward getting breast cancer, and their intentions to get mammograms. In a pre- to posttest design, 121 women were given their 10-year risk of getting breast cancer with or without being compared with women their age and race at lowest risk. Women's perceptions of their 10-year risks became more congruent (i.e., more accurate) with their actual risk. Participants were more accurate when they received their own risk without being compared with women at lowest risk. Women who received only their own risk estimate reported being at lower risk than other women. Overall, women reported that obtaining their 10-year risk estimate either did not affect or increased their intentions to get mammograms. These results suggest that giving women their individual risk of getting breast cancer improves accuracy while also enhancing their feelings that they are at lower risk than other women. Counter to many theories of health behavior, reducing women's perceived risk of breast cancer did not lower their intentions to get mammograms. Implications for the communication of breast cancer risk are discussed.

The short-term impact of tailored mammography decision-making interventions.

BACKGROUND: We assessed the short-term impact of decision-making interventions on knowledge about mammography, accuracy of women's breast cancer risk perceptions, attitudes toward mammography, satisfaction with decisions, and mammography use since the intervention. METHODS: The study was conducted among women who were members of Blue Cross Blue Shield of North Carolina and were in their 40s or 50s at the time the study began in 1997. Women were randomly assigned to usual care (UC), tailored print booklets (TP) alone, or TP plus telephone counseling (TP+TC ). RESULTS: 12-month interviews were completed by 1127 women to assess short-term intervention effects. Generally, women who received TP+TC were significantly more knowledgeable about mammography and breast cancer risk and were more accurate in their breast cancer risk perceptions than women in the TP and UC groups. They also were more likely to have had a mammogram since the baseline interview. In multivariable analyses, we found significant benefits of the combination of TP+TC compared to TP and to UC for knowledge, accuracy of risk perceptions, and mammography use. DISCUSSION: For complex decision-making tasks, such as women's decisions about mammography in the face of controversy, the combination of TP and TC may be more effective than TP alone, and certainly more effective than UC. It is critical that investigators determine the topics for which TP is appropriate and the situations that require additional supportive interventions.

General performance on a numeracy scale among highly educated samples.

BACKGROUND: Numeracy, how facile people are with basic probability and mathematical concepts, is associated with how people perceive health risks. Performance on simple numeracy problems has been poor among populations with little as well as more formal education. Here, we examine how highly educated participants performed on a general and an expanded numeracy scale. The latter was designed within the context of health risks. METHOD: A total of 463 men and women aged 40 and older completed a 3-item general and an expanded 7-item numeracy scale. The expanded scale assessed how well people 1) differentiate and perform simple mathematical operations on risk magnitudes using percentages and proportions, 2) convert percentages to proportions, 3) convert proportions to percentages, and 4) convert probabilities to proportions. RESULTS: On average, 18% and 32% of participants correctly answered all of the general and expanded numeracy scale items, respectively. Approximately 16% to 20% incorrectly answered the most straightforward questions pertaining to risk magnitudes (e.g., Which represents the larger risk: 1%, 5%, or 10%?). A factor analysis revealed that the general and expanded risk numeracy items tapped the construct of global numeracy. CONCLUSIONS: These results suggest that even highly educated participants have difficulty with relatively simple numeracy questions, thus replicating in part earlier studies. The implication is that usual strategies for communicating numerical risk may be flawed. Methods and consequences of communicating health risk information tailored to a person's level of numeracy should be explored further.

Colorectal cancer risk perceptions and screening intentions in a minority population.

This is a 2-year follow-up to a previously reported baseline paper. We focused on a predominantly low-income African-American population from a community health center and investigated the relationships among perceptions of perceived risks for colorectal cancer (CRC), concerns about getting CRC, screening intentions, and whether participants had a fecal occult blood test (FOBT) on schedule at follow-up. Baseline absolute risk did not predict screening intentions or being on schedule (15% of sample), nor did it predict follow-up perceived absolute risk, comparative risk, or CRC concerns. Participants who expressed greater perceived absolute risk, comparative risk, and concerns at follow-up were more likely to report thinking about or definitely planning to get an FOBT within the next 2 years (49% of the sample). In addition, baseline absolute risk and whether or not a person had an FOBT on schedule at baseline did not predict being on schedule at follow-up. A significant percentage of the population (20%) were not able to state whether their CRC risk was below average, average, or above average. In addition, 44% of the population viewed their risks as lower than their peers, and 58% reported being not at all or slightly concerned about getting CRC. These results suggest that educational efforts are needed especially for low-income minority populations to enhance knowledge and accuracy of risk perceptions for CRC and interventions that explicitly manipulate risk are needed to assess to what extent risk perceptions can be modified and subsequently affect screening.

The impact of abnormal mammograms on psychosocial outcomes and subsequent screening.

Few studies have examined the impact of abnormal mammograms on subsequent mammography screening and psychosocial outcomes specifically as a function of the length of time that has passed since the abnormal test result. This cross-sectional report compared breast cancer screening practices and psychosocial outcomes among three groups of women. These groups were women who (1) never had an abnormal mammogram, (2) had an abnormal mammogram 2 or more years prior to the study's baseline interview, and (3) had an abnormal mammogram within 2 years prior to the study's baseline interview. Women who had an abnormal mammogram at least 2 years prior to the baseline interview expressed greater 10-year and lifetime risks of getting breast cancer than women who never had an abnormal mammogram. Women who had abnormal mammograms, independent of when they occurred, were substantially more worried about getting breast cancer than were women who never had abnormal mammograms. Women who had an abnormal mammogram within 2 years prior to the baseline interview were more likely to be on schedule for mammography, compared with women who never had an abnormal mammogram.

Psychological impact of diagnosis and risk reduction among cancer survivors.

Life-threatening health events prompt psychological distress that may motivate individuals to reduce health risks. If so, interventions timed to take advantage of these 'teachable moments' could be particularly effective. To explore this association, early stage prostate and breast cancer patients were identified from a hospital-based tumor registry within 6 years of diagnosis. These patients (n=920) completed a mailed survey assessing the Horowitz impact of events scale, risk behaviors and readiness to change the behaviors. Breast cancer patients, younger patients and those reporting poor health status reported the greatest impact of the cancer diagnosis. Impact was inversely associated with time from diagnosis for prostate, but not breast cancer patients. Prostate patients who reported exercising regularly had lower impact scores than those who were not exercising (medians: 0.13 vs 0.56, respectively; p=0.02). Breast patients who were eating five or more fruits and vegetables reported lower impact scores than those who were not eating the recommended servings (0.75 vs 1.06, respectively; p=0.03). Breast patients who were non-smokers reported lower impact scores than smokers (0.88 vs 1.31, respectively; p=0. 02). Prospective studies are needed to understand the psychological impact of cancer diagnosis and how it might facilitate or impede the adoption of health promoting behaviors.

Relationships among breast cancer perceived absolute risk, comparative risk, and worries.

When trying to predict breast cancer screening, it may be important to understand the relationships between perceived breast cancer risks and worries about getting breast cancer. This study examines the extent to which women's worries about breast cancer correlate with perceptions of both absolute (assessment of own) and comparative (self versus other) 10-year and lifetime risks. As part of a larger randomized intervention trial concerning hormone replacement therapy, 581 women participated in a telephone baseline survey to assess their perceptions of breast cancer risks and worries. Worries about getting breast cancer in the next 10 years and in one's lifetime were related positively to both absolute and comparative 10-year and lifetime risks. The magnitude of these relationships did not differ by time frame. Worry about breast cancer is a function of both how a woman views her own risk and how she compares her risk with that of other women. Some practitioners may encourage women to get screened for breast cancer by using emotional appeals, such as heightening women's worries about breast cancer by using risk information. Our data suggest that they should give careful consideration how best to combine, if at all, information about absolute and comparative risks. For example, if the motivation to screen is based on a sequential assessment of risk beginning with comparative and then absolute risk, creating communications that heighten perceived risk on both of these risk dimensions may be needed to evoke sufficient worry to initiate breast cancer screening.

Can tailored interventions increase mammography use among HMO women?

BACKGROUND: Telephone counseling and tailored print communications have emerged as promising methods for promoting mammography screening. However, there has been little research testing, within the same randomized field trial, of the efficacy of these two methods compared to a high-quality usual care system for enhancing screening. This study addressed the question: Compared to usual care, is tailored telephone counseling more effective than tailored print materials for promoting mammography screening? DESIGN: Three-year randomized field trial. PARTICIPANTS: One thousand ninety-nine women aged 50 and older recruited from a health maintenance organization in North Carolina. INTERVENTION: Women were randomized to 1 of 3 groups: (1) usual care, (2) tailored print communications, and (3) tailored telephone counseling. MAIN OUTCOME: Adherence to mammography screening based on self-reports obtained during 1995, 1996, and 1997. RESULTS: Compared to usual care alone, telephone counseling promoted a significantly higher proportion of women having mammograms on schedule (71% vs 61%) than did tailored print (67% vs 61%) but only after the first year of intervention (during 1996). Furthermore, compared to usual care, telephone counseling was more effective than tailored print materials at promoting being on schedule with screening during 1996 and 1997 among women who were off-schedule during the previous year. CONCLUSIONS: The effects of the intervention were most pronounced after the first intervention. Compared to usual care, telephone counseling seemed particularly effective at promoting change among nonadherent women, the group for whom the intervention was developed. These results suggest that telephone counseling, rather than tailored print, might be the preferred first-line intervention for getting nonadherent women on schedule for mammography screening. Many questions would have to be answered about why the tailored print intervention was not more powerful. Nevertheless, it is clear that additional interventions will be needed to maintain women's adherence to mammography. Medical Subject Headings (MeSH): mammography screening, telephone counseling, tailored print communications, barriers.

Relationships among breast cancer concern, risk perceptions, and interest in genetic testing for breast cancer susceptibility among African-American women with and without a family history of breast cancer.

There has been very little research exploring the relationships among perceptions of, and concern about, getting breast cancer and interest in genetic testing for breast cancer among African-American women with and without a family history of breast cancer. This study explored these issues among 130 and 136 African-American women with and without a family history of breast cancer, respectively. Women with a family history reported having greater perceived breast cancer risks and concerns than women without a family history of breast cancer. Knowledge of breast cancer risk factors was very poor and correlated weakly with perceptions of risk and concern. In attributional analyses, acknowledging one's family history status was the strongest predictor of perceived risk only among women with a family history. Women with a family history of breast cancer expressed greater interest in genetic testing for breast cancer susceptibility than women without a family history, although interest in testing was high overall. Increasing perceptions of breast cancer risks and concerns were related to a greater interest in genetic testing, and this relationship was not moderated by family history status. Attributions of risk and knowledge of breast cancer risk factors generally were not related to interest in testing. Overall, these results suggest that: (a) African-American women with a family history are more concerned about and do recognize their greater risk of breast cancer; (b) knowledge of risk factors and attributions of risk are not directly related to interest in genetic testing; and (c) concerns, rather than beliefs about one's risk, are more powerfully related to interest in genetic testing, independent of family history status.

Confusion about mammography: prevalence and consequences.

Over the last decade, there has been significant controversy about the schedule on which women, particularly women in their 40s, should have mammograms. The purpose of the analysis reported here was to assess whether women in their 40s and 50s were confused as a result of the controversy following the January 1997 National Institutes of Health Consensus Development Conference on Breast Cancer Screening For Women Ages 40-49. We also examined if confusion was related to being off schedule for mammography. The study sample included 1287 women recruited from a random sample of 2165 Blue Cross/Blue Shield of North Carolina members. The data described in this analysis were derived from a baseline telephone interview conducted as part of a larger intervention trial. Study measures included a variety of sociodemographic, medical, belief, and behavioral variables. Overall, 28% of women were confused, and 35% were off schedule. Although a higher proportion of women in their 40s than 50s were confused, more women in their 50s were off schedule. Confusion was a significant predictor for the outcome being off schedule. Predictors of confusion included several belief variables, risk perceptions, age (40s), whether the woman had a regular physician, and whether she had enough information about mammography. Healthcare providers should ask some simple questions to determine if women are confused and then seek to meet their information needs.

The visual communication of risk.

This paper 1) provides reasons why graphics should be effective aids to communicate risk; 2) reviews the use of visuals, especially graphical displays, to communicate risk; 3) discusses issues to consider when designing graphs to communicate risk; and 4) provides suggestions for future research. Key articles and materials were obtained from MEDLINE(R) and PsychInfo(R) databases, from reference article citations, and from discussion with experts in risk communication. Research has been devoted primarily to communicating risk magnitudes. Among the various graphical displays, the risk ladder appears to be a promising tool for communicating absolute and relative risks. Preliminary evidence suggests that people understand risk information presented in histograms and pie charts. Areas that need further attention include 1) applying theoretical models to the visual communication of risk, 2) testing which graphical displays can be applied best to different risk communication tasks (e.g., which graphs best convey absolute or relative risks), 3) communicating risk uncertainty, and 4) testing whether the lay public's perceptions and understanding of risk varies by graphical format and whether the addition of graphical displays improves comprehension substantially beyond numerical or narrative translations of risk and, if so, by how much. There is a need to ascertain the extent to which graphics and other visuals enhance the public's understanding of disease risk to facilitate decision-making and behavioral change processes. Nine suggestions are provided to help achieve these ends.

Testing different formats for communicating colorectal cancer risk.

This study assessed the extent to which different formats of informing men and women age 50 and over of the risks of colorectal cancer (CRC) affected their perceptions of their absolute and comparative (self versus other) 10-year and lifetime risks; emotional reactions about getting CRC; and screening intentions. Forty-four men and 78 women received information about the absolute lifetime risk of getting CRC. In addition, participants either did or did not receive information about (1) lifetime risk of getting CRC compared with other cancers, and (2) risk factors for CRC (age and polyps). Participants who received risk factors information were more likely to increase their perceived absolute 10-year and lifetime risks of getting CRC compared with participants who did not receive risk factors information. In addition, participants who received risk factors information were more likely to believe age was related to getting CRC and felt at greater risk for having polyps compared with participants who did not receive this information. None of the experimental conditions affected how worried, anxious, and fearful participants felt about getting CRC, nor did they affect screening intentions. Independent of experimental condition, participants tended to increase their intentions to get screened for CRC in the next year or two. Intention to be screened was more pronounced among participants who had been screened via a fecal occult blood test (FOBT) or sigmoidoscopy (SIG). Implications for the design of interventions involving the communication of CRC risks are discussed.

Using tailored interventions to enhance smoking cessation among African-Americans at a community health center.

This prospective randomized study examined the impact of three tailored intervention approaches to increase quitting rates among African-American smokers who were clients of a community health center that serves primarily low-income and indigent persons. Smokers were randomized to one of three groups: (1) health care provider prompting intervention alone, (2) health care provider prompting intervention with tailored print communications, and (3) health care provider prompting intervention with tailored print communications and tailored telephone counseling. Among the 160 smokers who completed the study, 35 (21.8%) had quit smoking at follow-up. Smokers who received the provider prompting intervention with tailored print materials were more likely to report having quit than smokers who received the provider intervention alone (32.7% vs. 13.2%, p < 0.05). Smokers who received all three intervention components were not more likely to report having quit at follow-up than those who only received the provider intervention (19.2% vs. 13.2%). Smokers who at baseline were less educated, smoked less than half a pack of cigarettes per day, had a stronger desire to quit, felt more efficacious, and had thought about quitting were more likely to report having quit at follow-up. These results provide support for continued refinement of tailored communications to aid smoking cessation among African-American smokers.

Colorectal screening patterns and perceptions of risk among African-American users of a community health center.

This study investigated risk perceptions and screening patterns for colorectal cancer among predominately low-income African-Americans age 50 and older who used a community health center. The majority of respondents either rated their risk as below average (36%) or did not know their risk (37%) for colorectal cancer. Individuals who provided a risk estimate versus those who did not know their risk were younger and held more accurate beliefs about colorectal cancer. Attributions of perceived risk best distinguished respondents who evaluated their risk to be below average versus average and above average. Compared to respondents who could not explain their risk, those who provided psychological, personal action, and heredity causes were more likely to view their risk as below average than average or above average. In comparison to national norms, these subjects reported higher frequencies of ever having had a digital rectal exam (DRE, 90%), fecal occult blood test (FOBT, 75%) and sigmoidoscopy (SIG, 33%). Moreover, 63%, 53%, and 81% reported their most recent screening for DRE, FOBT, and SIG, respectively, in accordance with ACS and NCI recommended guidelines. However, a subsequent medical audit failed to confirm these self-reports. These results suggest that: 1) educational efforts are needed to enhance knowledge and accuracy of risk perceptions for colorectal cancer; 2) further studies on attributions of risk are needed that may prove useful for developing intervention programs, and 3) studies need to interpret self-report data for colorectal cancer with caution.