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Clinical Trial Details — Status: Completed

Administrative data

NCT number NCT03006913
Other study ID # UCSF-GC3-2021
Secondary ID R01CA197784-01A1
Status Completed
Phase N/A
First received
Last updated
Start date April 18, 2017
Est. completion date December 16, 2019

Study information

Verified date July 2021
Source University of California, San Francisco
Contact n/a
Is FDA regulated No
Health authority
Study type Interventional

Clinical Trial Summary

Using mixed methods, investigators will conduct a multicenter partially randomized preference noninferiority trial with high-risk English-, Spanish-, and Cantonese-speaking patients assigned by (1) patients´ preference or (2) randomization to three counseling modes: (a) in-person; (b) phone; or (c) video conference. A total of 600 patients will complete counseling and 540 will complete the final survey. Baseline and post-counseling surveys will use validated measures (adapted for literacy and language) of study outcomes. All counseling sessions will be audio-taped. A sample of 90 tapes will be analyzed for counseling content and to identify 30 participants for in-depth interviews and analysis triangulating all forms of data. Genetic counselors will be interviewed in depth to elicit their perceptions of the strengths and limitations of each counseling mode.


Description:

Specific Aims. The specific aims of this mixed methods study are: Aim 1. Compare the effectiveness of 3 modes of genetic counseling in a diverse sample of patients at high risk for HBOC in 3 public hospitals. Conduct a multicenter partially randomized preference noninferiority trial with high-risk patients assigned by (a) randomization to three counseling modes: in-person, phone, video conference; or (b) patients´ preference. Utilize validated measures of study outcomes adapted as needed for literacy and language. Recognizing that some potential participants may have a strong preference for one counseling mode, after explaining the study design and obtaining informed consent, participants will be asked if they have such a preference. Those who do will be offered that mode, and those who do not will be randomized. Randomization will be stratified according to hospital and personal history of breast cancer in order to ensure that there is no imbalance in important factors that may be associated with outcome. Aim 2. Explore inductively and qualitatively variation in patients' genetic counseling experiences and understandings, genetic counselor satisfaction and perceptions, counseling session similarities and differences, and implications of organizational context across three modes of genetic counseling. Aim 3 employs inductive, qualitative methods to explore in depth the cases of 30 patients using their pre- and post-counseling survey responses, audio tapes of their counseling session, and in-depth interviews to explore questions common to all respondents and those specific to what was learned about the individual from the other data sources. In-depth interviews will also be conducted with genetic counselors. Study Design: Using mixed methods, investigators will conduct a multicenter partially randomized preference noninferiority trial with high-risk English-, Spanish-, and Cantonese-speaking patients assigned by (1) patients´ preference or (2) randomization to three counseling modes: (a) in-person; (b) phone; or (c) video conference. A total of 600 patients will complete counseling and 540 will complete the final survey. Baseline and post-counseling surveys will use validated measures (adapted for literacy and language) of study outcomes. All counseling sessions will be audio-taped. A sample of 90 tapes will be analyzed for counseling content and to identify 30 participants for in-depth interviews and analysis triangulating all forms of data. Genetic counselors will be interviewed in depth to elicit their perceptions of the strengths and limitations of each counseling mode. Investigators' mixed methods combine a multicenter partially randomized preference noninferiority trial with inductive methods that embed this research in the real world of public health system patients. This is practice-based research, designed to emphasize external validity, (relevance and generalizability that enhance translation into actual use), as well as internal validity. The purpose of a non-inferiority trial is to compare an intervention to an active control or standard treatment when the intervention is not expected to have superior efficacy, but to have other benefits, e.g., greater convenience or fewer side effects. In the case of genetic counseling, in- person counseling is the standard of care, with well-documented efficacy.4 Since video and telephone counseling do not offer a more personalized approach or more pertinent content than in-person counseling, it seems unlikely that either mode would produce superior psychosocial outcomes or greater knowledge gains; similarly, investigators do not expect telephone counseling to be more efficacious than video counseling. The gold standard for assessing the effectiveness of interventions is the randomized clinical trial; yet patients who have a strong preference for one of the intervention conditions may decline to participate, which is a threat to external validity, or (if randomized) participate half-heartedly or drop out, threatening internal validity. Investigators will address this issue with a partially randomized preference trial in which patients with a strong preference are assigned to their preferred treatment (i.e., intervention condition) and those without a strong preference are randomized. This study design enables comparison of treatment outcomes among patients who receive their preferred treatment (the desired real world situation) and ascertainment of the effects of preference-as well as the evaluation of treatment outcomes in a randomized trial. However, comparisons involving preference participants are subject to confounding, since patients who prefer a particular treatment may differ in ways that affect outcome. In analyses involving preference participants it is possible to reduce confounding substantially using covariate adjustment. Nevertheless, because residual confounding may be present, preference participant outcomes should be considered observational data. Investigators will blend qualitative and quantitative, deductive and inductive methods using varied forms of data from in-depth interviews, surveys, and audio taped observations. This will allow us to address our central question from different perspectives triangulated in the analysis for a rich understanding of patient-counselor- institution relationships most of which are too complex to describe using one dimension alone (e.g., cognitive understanding captured in surveys). While the randomized trial is the gold standard for comparative effectiveness, it cannot answer questions such as what it is about the counseling interaction that was reassuring or anxiety-provoking to a patient? what techniques enabled a patient to recall important points? or what about the conversation precluded such recall? It is only by embedding the survey data in open-ended inductive exploration and audio observations that investigators can determine if a counselor provided too much information to a low-literacy patient, or alternatively used plain language to emphasize key points, checking frequently for patient comprehension. Importantly, was the counselor able to do this as well by phone or video? Thus, mixed methods illuminates important dynamics that informants may not be consciously aware of.


Recruitment information / eligibility

Status Completed
Enrollment 1273
Est. completion date December 16, 2019
Est. primary completion date December 16, 2019
Accepts healthy volunteers Accepts Healthy Volunteers
Gender All
Age group 18 Years to 70 Years
Eligibility Inclusion Criteria:Eligible participants include patients who - visit the mammography, high risk or oncology clinics at Contra Costa County, Highland or SFGH hospitals, - are referred to genetic counseling services at SFGH by a community clinic through the E-Referral system or are considered to be high risk based on their breast/ovarian cancer genetics Referral Screening Tool (RST) score (= 2 checks) - speak English, Spanish, or Cantonese Investigators will also include two genetic counselors who provide services at SFGH and UCSF. Exclusion Criteria: - do not speak English, Spanish, or Cantonese; - are age 17 and under; and - don't have a family history of cancer.

Study Design


Related Conditions & MeSH terms


Intervention

Behavioral:
In-person
At all sites, patients randomized to/preferring in-person counseling will meet with a counselor.
By phone
Patients in the phone arm will receive a scheduled call at their home.
By video
Because low income patients are not likely to have video conference capability at home, this service will be offered at all three hospitals, and patients will have scheduled appointments to come to the hospital to receive counseling delivered through a computer.

Locations

Country Name City State
United States Contra Costa Regional Medical Center Health Services Martinez California
United States Highland General Hospital Oakland California
United States San Francisco General Hospital San Francisco California

Sponsors (4)

Lead Sponsor Collaborator
University of California, San Francisco National Cancer Institute (NCI), National Institutes of Health (NIH), University of California, Davis

Country where clinical trial is conducted

United States, 

References & Publications (21)

Armstrong K, Micco E, Carney A, Stopfer J, Putt M. Racial differences in the use of BRCA1/2 testing among women with a family history of breast or ovarian cancer. JAMA. 2005 Apr 13;293(14):1729-36. — View Citation

Cohen SA, Marvin ML, Riley BD, Vig HS, Rousseau JA, Gustafson SL. Identification of genetic counseling service delivery models in practice: a report from the NSGC Service Delivery Model Task Force. J Genet Couns. 2013 Aug;22(4):411-21. doi: 10.1007/s10897-013-9588-0. Epub 2013 Apr 25. — View Citation

D'Agostino RB Sr, Massaro JM, Sullivan LM. Non-inferiority trials: design concepts and issues - the encounters of academic consultants in statistics. Stat Med. 2003 Jan 30;22(2):169-86. — View Citation

Forman AD, Hall MJ. Influence of race/ethnicity on genetic counseling and testing for hereditary breast and ovarian cancer. Breast J. 2009 Sep-Oct;15 Suppl 1:S56-62. doi: 10.1111/j.1524-4741.2009.00798.x. Review. — View Citation

Green LW, Glasgow RE. Evaluating the relevance, generalization, and applicability of research: issues in external validation and translation methodology. Eval Health Prof. 2006 Mar;29(1):126-53. Review. — View Citation

Halbert CH, Kessler L, Stopfer JE, Domchek S, Wileyto EP. Low rates of acceptance of BRCA1 and BRCA2 test results among African American women at increased risk for hereditary breast-ovarian cancer. Genet Med. 2006 Sep;8(9):576-82. — View Citation

Hall MJ, Olopade OI. Disparities in genetic testing: thinking outside the BRCA box. J Clin Oncol. 2006 May 10;24(14):2197-203. Review. — View Citation

Joseph G, Guerra C. To worry or not to worry: breast cancer genetic counseling communication with low-income Latina immigrants. J Community Genet. 2015 Jan;6(1):63-76. doi: 10.1007/s12687-014-0202-4. Epub 2014 Aug 23. — View Citation

Karliner LS, Napoles-Springer A, Kerlikowske K, Haas JS, Gregorich SE, Kaplan CP. Missed opportunities: family history and behavioral risk factors in breast cancer risk assessment among a multiethnic group of women. J Gen Intern Med. 2007 Mar;22(3):308-14. — View Citation

King MC, Marks JH, Mandell JB; New York Breast Cancer Study Group. Breast and ovarian cancer risks due to inherited mutations in BRCA1 and BRCA2. Science. 2003 Oct 24;302(5645):643-6. — View Citation

Kinney AY, Butler KM, Schwartz MD, Mandelblatt JS, Boucher KM, Pappas LM, Gammon A, Kohlmann W, Edwards SL, Stroup AM, Buys SS, Flores KG, Campo RA. Expanding access to BRCA1/2 genetic counseling with telephone delivery: a cluster randomized trial. J Natl Cancer Inst. 2014 Nov 5;106(12). pii: dju328. doi: 10.1093/jnci/dju328. Print 2014 Dec. — View Citation

Lea DH, Kaphingst KA, Bowen D, Lipkus I, Hadley DW. Communicating genetic and genomic information: health literacy and numeracy considerations. Public Health Genomics. 2011;14(4-5):279-89. doi: 10.1159/000294191. Epub 2010 Apr 20. — View Citation

Madlensky L. Is it time to embrace telephone genetic counseling in the oncology setting? J Clin Oncol. 2014 Mar 1;32(7):611-2. doi: 10.1200/JCO.2013.53.8975. Epub 2014 Jan 21. — View Citation

Narod SA, Foulkes WD. BRCA1 and BRCA2: 1994 and beyond. Nat Rev Cancer. 2004 Sep;4(9):665-76. Review. — View Citation

Nelson HD, Pappas M, Zakher B, Mitchell JP, Okinaka-Hu L, Fu R. Risk assessment, genetic counseling, and genetic testing for BRCA-related cancer in women: a systematic review to update the U.S. Preventive Services Task Force recommendation. Ann Intern Med. 2014 Feb 18;160(4):255-66. Review. — View Citation

Prevalence and penetrance of BRCA1 and BRCA2 mutations in a population-based series of breast cancer cases. Anglian Breast Cancer Study Group. Br J Cancer. 2000 Nov;83(10):1301-8. — View Citation

Schwartz MD, Valdimarsdottir HB, Peshkin BN, Mandelblatt J, Nusbaum R, Huang AT, Chang Y, Graves K, Isaacs C, Wood M, McKinnon W, Garber J, McCormick S, Kinney AY, Luta G, Kelleher S, Leventhal KG, Vegella P, Tong A, King L. Randomized noninferiority trial of telephone versus in-person genetic counseling for hereditary breast and ovarian cancer. J Clin Oncol. 2014 Mar 1;32(7):618-26. doi: 10.1200/JCO.2013.51.3226. Epub 2014 Jan 21. — View Citation

Squiers L, Peinado S, Berkman N, Boudewyns V, McCormack L. The health literacy skills framework. J Health Commun. 2012;17 Suppl 3:30-54. doi: 10.1080/10810730.2012.713442. — View Citation

Sussner KM, Jandorf L, Thompson HS, Valdimarsdottir HB. Interest and beliefs about BRCA genetic counseling among at-risk Latinas in New York City. J Genet Couns. 2010 Jun;19(3):255-68. doi: 10.1007/s10897-010-9282-4. Epub 2010 Feb 12. — View Citation

Vig HS, Wang C. The evolution of personalized cancer genetic counseling in the era of personalized medicine. Fam Cancer. 2012 Sep;11(3):539-44. doi: 10.1007/s10689-012-9524-8. — View Citation

Whittemore AS, Gong G, John EM, McGuire V, Li FP, Ostrow KL, Dicioccio R, Felberg A, West DW. Prevalence of BRCA1 mutation carriers among U.S. non-Hispanic Whites. Cancer Epidemiol Biomarkers Prev. 2004 Dec;13(12):2078-83. — View Citation

* Note: There are 21 references in allClick here to view all references

Outcome

Type Measure Description Time frame Safety issue
Primary Differences in change scores among three counseling modes: Breast Cancer Knowledge Scale Will measure knowledge of hereditary breast cancer information before and after delivery of counseling modes. One week post counseling
Primary Differences in change scores among three counseling modes: Impact of Events Scale Will measure cancer-specific distress before and after delivery of counseling modes. One week post counseling
Secondary Differences in change scores among three counseling modes: Decisional Conflict Scale Will measure decisional conflict before and after implementation of counseling modes. One week post counseling
Secondary Differences in change scores among three counseling modes: Perceived Stress Scale Will measure general perceptions of stress before and after implementation of counseling modes. One week post counseling
Secondary Differences in change scores among three counseling modes: Breast/Ovarian Cancer Risk Perception and Worry Scale Will measure breast cancer and ovarian cancer risk perception and worry before and after implementation of counseling modes. One week post counseling
Secondary Differences in change scores among three counseling modes: Perceptions of Risks and Benefits of Genetic Counseling Scale Will measure perceptions of risks and benefits of genetic counseling before and after implementation of counseling modes. One week post counseling
Secondary Differences in change scores among three counseling modes: Genetic Counseling Satisfaction Scale Will measure genetic counseling satisfaction before and after implementation of counseling modes. One week post counseling
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