Counseling Appointment Research Articles

Rural Status, Suicide Ideation, and Telemental Health: Risk Assessment in a Clinical Sample.

Individuals living in rural areas die by suicide at higher rates than those living in metropolitan areas. Telemental health interventions provide rural residing individuals with access to needed care. Identifying telemental health clients at risk for suicide is an important task for clinicians and policymakers. This study evaluated to what degree rural status and other demographic variables predicted suicide ideation in clients seeking services at a telemental health clinic. Study participants included 457 low-income clients residing in the medically underserved, geographically diverse Brazos Valley region of Texas. Clients completed the patient health questionnaire during their initial counseling appointment, which assessed depression severity and suicide ideation in the 2 weeks prior to assessment. Suicide ideation was common among telemental health clients, with approximately 40% of clients in all demographic groups reporting some recent thoughts of suicide. Rates of suicide ideation did not significantly differ by geographic designation (ie, rural/metropolitan status), gender, or race/ethnicity. However, depression was a strong predictor of recent suicide ideation. Telemental health programs can effectively connect clinicians with rural residing clients who are otherwise isolated from health care services. However, clinicians working in high-need, historically underserved areas should be prepared to encounter a high prevalence of suicide ideation and depression. In these regions, clinical and diagnostic features may be better indicators of suicide ideation than demographic variables.

Logistics and Uptake of Genetic Testing for Patients Referred for Telegenetic Counselling for Cancer

Purpose: There is a dearth of information about the uptake of genetic testing after telegenetic (videoconference) counselling for hereditary cancer, which has been previously reported as a limitation of this service delivery model. Methods: We performed a review of the triage list for patients referred to The Ohio State University (OSU) from two community cancer centres for telegenetic counselling appointments from April 1, 2014 to May 31, 2016. Results: A total of 179 patients were referred for telegenetic counselling, and of these 62.6% (112/179) completed a 30-60 minute telegenetic counselling appointment. Of those counselled, 82.1% (92/112) completed genetic testing, 12.0% (11/92) of whom were found to have a pathogenic mutation. Of those with mutations, 45.5% (5/11) returned for a follow-up telegenetic counselling session to review results in more detail. In addition, 18.5% (17/92) of patients tested had at least one variant of uncertain significance (VUS). Conclusions: The presence of a nurse/nurse practitioner with the patient at the remote site during the telegenetic counselling session may have facilitated higher completion rates for genetic testing compared to previous reports in the literature, and appropriateness of genetic testing in this method of providing genetic counselling is reflected in the rates of results identifying deleterious mutations and variants of uncertain significance.

Creation and Implementation of an Environmental Scan to Assess Cancer Genetics Services at Three Oncology Care Settings.

An environmental scan (ES) is an efficient mixed-methods approach to collect and interpret relevant data for strategic planning and project design. To date, the ES has not been used nor evaluated in the clinical cancer genetics setting. We created and implemented an ES to inform the design of a quality improvement (QI) project to increase the rates of adherence to national guidelines for cancer genetic counseling and genetic testing at three unique oncology care settings (OCS). The ES collected qualitative and quantitative data from reviews of internal processes, past QI efforts, the literature, and each OCS. The ES used a data collection form and semi-structured interviews to aid in data collection. The ES was completed within 6months, and sufficient data were captured to identify opportunities and threats to the QI project's success, as well as potential barriers to, and facilitators of guideline-based cancer genetics services at each OCS. Previously unreported barriers were identified, including inefficient genetic counseling appointment scheduling processes and the inability to track referrals, genetics appointments, and genetic test results within electronic medical record systems. The ES was a valuable process for QI project planning at three OCS and may be used to evaluate genetics services in other settings.

Patient outcomes of genetic counseling: Assessing the impact of different approaches to family history collection.

No studies have yet evaluated whether different modalities for the collection of family history data influence patient outcomes of genetic counseling. We retrospectively compared outcomes of genetic counseling between patients whose family history (Fhx) was collected (1) via telephone prior to their appointment (FhxPrior) or (2) during the appointment (FhxDuring). We used a psychiatric genetic counseling clinic database, where information about demographics and Fhx timing is recorded, and patients complete the Genetic Counseling Outcomes Scale (GCOS, measuring empowerment) and Illness Management Self-Efficacy Scale (IMSES) immediately prior to (T1) and 1 month after their appointment (T2). We used ANCOVA to evaluate the effect of the Fhx method on patient outcomes at T2. Complete data were available for 240 patients and were used for analysis (FhxPrior, n = 206; FhxDuring, n = 34). GCOS and IMSES scores increased from T1 to T2 (P < .0005 and P = .004, respectively). Although there was no difference between groups for GCOS (P = .412), T2 IMSES scores were significantly higher for FhxPrior than FhxDuring after controlling for T1 scores (P = .011). Our data suggest that obtaining Fhx via telephone prior to genetic counseling may lead to greater increases in patients' self-efficacy as compared to obtaining Fhx during the genetic counseling appointment.

Abstract P4-10-11: An active approach to genetic counseling in Trinidadian women with breast cancer

Abstract Introduction Breast cancer (BC) is the leading cause of cancer death in Caribbean women. The prevalence of deleterious mutations in BRCA1/2, PALB2 and RAD51C among unselected BC patients in the Caribbean is 5-25%. We previously reported data on low usage of genetic counseling services by Bahamian women. In order to improve the dissemination of genetic testing results to Caribbean probands and their families we developed a structured approach to genetic test result dissemination and family counseling. Methods After approval by the University of Miami IRB and the Ethics Committee of the Ministry of Health of Trinidad &amp; Tobago, we prospectively evaluated the active approach to genetic counseling in 32 BC mutation carriers in Trinidad &amp; Tobago in 2015. The intervention consisted of: 1) initial appointment with referring oncologist for results discussion; 2) review of family tree with proband to identify all relatives at 25% or 50% risk (ARR) who should attend the genetic counseling session; 3) preschedule a counseling appointment for ARR within 2 weeks; 4) written invitation to genetic counseling session; 5) handouts of genetic information given to proband to distribute to family members; 6) offer assistance with contacting family members; 7) free genetic testing to ARR who attended the family counseling session. Results Twenty-five carriers (78%) consented to enroll in the study. At initial counseling, probands identified 158 ARR, however full family pedigree review at post-result counseling/consultation identified 225 ARR. 101 ARR (64%) attended the information sessions and 76 participants (75.2%) consented to be tested for BC gene mutations. Genetic sequencing revealed 35 ARR (46%) were carriers of at least one mutation. The most frequent reasons for ARR not attending the meetings were: living abroad (18%), unable to be contacted (17%), refusing to participate (17%), not showing up (17%), probands being estranged from ARR (12%) or being afraid to know the results (7%). Conclusions In Trinidad &amp; Tobago, a structured approach to the dissemination of genetic test results leads to a significant improvement in the rate of family participation compared to previous efforts (64% in Trinidad &amp; Tobago vs. 9% in the Bahamas). Citation Format: George SH, Bravo GL, Sandoval AC, Palacio S, Ali J, Donenberg TR, Akbari MR, Narod S, Hurley J. An active approach to genetic counseling in Trinidadian women with breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-10-11.

How Might the Genetics Profession Better Utilize Social Media.

Social media is a common method of communication in people's personal lives and professional settings. Gallagher et al. (2016) recommended, "it is time for genetic counselors to embrace social media as a means of communicating with patients or other healthcare professionals." Full members of the National Society of Genetic Counselors (NSGC) in the USA and Canada and genetics patients in Cleveland, OH, were surveyed to determine interest in using social media for patient-provider interactions. Both cohorts indicated that patient privacy and confidentiality would be a concern; however, survey results indicated patients would be interested in using social media to receive general information about genetic counseling and to learn about genetics services. Genetic counselors indicated privacy issues were not concerning if social media were to be used in this capacity. The majority of genetic counselor participants (88.7%) indicated they would welcome national guidelines for patient-provider social media use. Data from this study demonstrated that sharing what to expect at a genetic counseling appointment, defining genetic counseling, and announcing community outreach events are possible ways genetic counselors could utilize social media to communicate with and educate patients.

Impact of an embedded genetic counselor on breast cancer treatment.

We predicted that embedding a genetic counselor within our breast practice would improve identification of high-risk individuals, timeliness of care, and appropriateness of surgical decision making. The aim of this study is to compare cancer care between 2012 and 2014, prior to embedding a genetic counselor in the breast center and following the intervention, respectively. A retrospective review of patients diagnosed with breast cancer in 2012 (n=471) and 2014 (n=440) was performed to assess patterns of medical genetics referral, compliance with referral, genetic testing findings, and impact on treatment. Between 2012 and 2014, patients were 49% more likely to be referred to genetics, 66% more likely to follow through with their genetic counseling appointment, experienced a 73% reduction in wait times to genetic counseling visits and 69% more likely to have genetic testing results prior to surgery. Notably, while the number of genetic mutations identified was in the expected range over both time periods (9% of those tested in 2012 vs. 6.6% of those tested in 2014), there was a 31% reduction in time to treatment in 2014 vs. 2012. Awareness of germline genetic mutations is critical in surgical decision making for newly diagnosed breast cancer patients. Having an experienced genetics specialist on site in a busy surgical breast clinic allows for timely access to genetic counseling and testing, and may have influenced time to treatment in our institution.

College Students’ Likelihood of “no-showing” for an Initial Hypothetical Counseling Appointment

ABSTRACTUsing a vignette methodology, we examined college students’ likelihood of “no-showing” for a hypothetical initial appointment for counseling. Participants in a low level of distress condition were less likely to attend their appointment as compared to those in a high distress condition. Knowing they would see a male therapist and not knowing what counseling entails strongly influenced participants’ decision to not attend their appointment. We discuss the research and clinical implications of our findings.

Cancer genetic counseling communication with low-income Chinese immigrants.

As genetics and genomics become part of mainstream medicine, these advances have the potential to either reduce or exacerbate health disparities. Relatively, little research has explored the quality of genetic counseling communication experienced by limited English proficiency patients, especially Chinese Americans. We observed and audio recorded genetic counseling appointments (n= 40) of low-income, limited English-proficient Chinese patients (n= 25) and conducted post-visit interviews (n= 17) using stimulated recall to examine patient understanding of the communication. Standard techniques based in grounded theory, including iterative data review and multiple coders, were used to analyze observation fieldnotes and interview transcripts and to identify these themes: (1) strong beliefs in environmental causes of cancer and skepticism about genetic causes, (2) willingness to undergo genetic testing despite skepticism of hereditary cause of cancer, (3) misunderstanding of key information needed to make informed decisions about testing and screening/prevention options, (4) variable quality of medical interpretation, and (5) selective family communication about cancer and genetic counseling and testing. Together, these themes describe substantial gaps in communication and identify the need for genetic counseling techniques and skills that enable counselors to communicate more effectively across language, literacy, and culture. Understanding the mechanisms of inheritance and the implications of genetic test results can be challenging for anyone, and it is exceptionally daunting for those who have limited English proficiency and/or low literacy. For Chinese immigrant patients to reap the full benefits of genetic counseling and testing, effective communication is essential. Research on interventions to improve communication is needed to ensure that disparities do not widen as genomic medicine reaches a more diverse population.

Sociodemographic profile and predictors of outpatient clinic attendance among HIV-positive patients initiating antiretroviral therapy in Selangor, Malaysia.

BackgroundInconsistent literature evidence suggests that sociodemographic, economic, and system- and patient-related factors are associated with clinic attendance among the HIV-positive population receiving antiretroviral therapy (ART) around the world. We examined the factors that predict outpatient clinic attendance among a cohort of HIV-positive patients initiating ART in Selangor, Malaysia.Patients and methodsThis cross-sectional study analyzed secondary data on outpatient clinic attendance and sociodemographic, economic, psychosocial, and patient-related factors among 242 adult Malaysian patients initiating ART in Selangor, Malaysia. Study cohort was enrolled in a parent randomized controlled trial (RCT) in Hospital Sungai Buloh Malaysia between January and December 2014, during which peer counseling, medication, and clinic appointment reminders were provided to the intervention group through short message service (SMS) and telephone calls for 24 consecutive weeks. Data on outpatient clinic attendance were extracted from the hospital electronic medical records system, while other patient-level data were extracted from pre-validated Adult AIDS Clinical Trial Group (AACTG) adherence questionnaires in which primary data were collected. Outpatient clinic attendance was categorized into binary outcome – regular attendee and defaulter categories – based on the number of missed scheduled outpatient clinic appointments within a 6-month period. Multivariate regression models were fitted to examine predictors of outpatient clinic attendance using SPSS version 22 and R software.ResultsA total of 224 (93%) patients who completed 6-month assessment were included in the model. Out of those, 42 (18.7%) defaulted scheduled clinic attendance at least once. Missed appointments were significantly more prevalent among females (n=10, 37.0%), rural residents (n=10, 38.5%), and bisexual respondents (n=8, 47.1%). Multivariate binary logistic regression analysis showed that Indian ethnicity (adjusted odds ratio [AOR] =0.235; 95% CI [0.063–0.869]; P=0.030) and heterosexual orientation (AOR =4.199; 95% CI [1.040–16.957]; P=0.044) were significant predictors of outpatient clinic attendance among HIV-positive patients receiving ART in Malaysia.ConclusionEthnicity and sexual orientation of Malaysian patients may play a significant role in their level of adherence to scheduled clinic appointments. These factors should be considered during collaborative adherence strategy planning at ART initiation.

Abstract DPOC-006: mAGIC – CREATION OF A MOBILE APPLICATION TO INCREASE GENETIC COUNSELING FOR WOMEN WITH OVARIAN CANCER

Abstract PURPOSE: Current guidelines published by the National Comprehensive Cancer Network and the Society of Gynecologic Oncology recommend that all women with invasive ovarian, fallopian tube, or primary peritoneal cancers receive genetic risk evaluation by a genetic counselor. Despite recommendations, physicians continue to under–refer and women under–use genetic services. This study developed the Mobile Application for Genetic Information on Cancer (mAGIC) intervention to motivate ovarian cancer survivors to undergo genetic counseling. The overall study objective was to develop and assess the feasibility and effectiveness of a theory–based intervention aimed to encourage ovarian cancer survivors to receive genetic counseling. METHODS: Based on the Precaution Adoption Process Model and the Fogg Behavior Model for Persuasive Design, a multi–step process was used to design a 7–day mobile application intervention delivering daily text and video messaging. Content and formatting was developed by a multi–disciplinary expert team in conjunction with a Community Advisory Board and was based on focus groups with ovarian cancer patients. The final content covered the following topics: genetic counseling, genetic testing, cancer genetics and personal health, cancer genetics and my family, taking care of yourself, and preparing for a genetic counseling appointment. Usability testing was conducted to ensure the intervention was relevant and easy to use. To test the effectiveness of the intervention, a randomized control trial of 104 women with ovarian cancer, who have not previously received genetic counseling, was initiated. Participants were randomized to the mobile app intervention or control (usual care). Regardless of randomization assignment, participants received a phone call from a patient health navigator two weeks following enrollment to determine their intentions, self–efficacy, and communication with family regarding seeking genetic counseling. A three month follow–up survey of all participants measured genetic counseling uptake, stage of readiness, self–efficacy, knowledge, and distress. RESULTS: To date, 45 of 104 women have been randomized; 39 have completed the telephone survey and 10 have completed the three month survey. No interim analyses of the primary outcomes were planned; however participant feedback has been positive. CONCLUSIONS: Despite consensus guidelines recommending the referral of all ovarian, fallopian tube and primary peritoneal cancer patients to genetic counseling, not all patients receive the recommended genetic counseling. This mobile application provides a new tool for disseminating needed information about genetic counseling directly to women with ovarian cancer. Citation Format: Melissa A. Geller, MD, Sue Petzel, PhD, Hee Lee, PhD, Heewon Lee, BA, Kristen Niendorf, MS, Rachel Isaksson Vogel, PhD. mAGIC – CREATION OF A MOBILE APPLICATION TO INCREASE GENETIC COUNSELING FOR WOMEN WITH OVARIAN CANCER [abstract]. In: Proceedings of the 11th Biennial Ovarian Cancer Research Symposium; Sep 12-13, 2016; Seattle, WA. Philadelphia (PA): AACR; Clin Cancer Res 2017;23(11 Suppl):Abstract nr DPOC-006.

High risk genetic screening program in a community hospital breast imaging center.

1507 Background: The NCCN has published guidelines for screening and testing of Hereditary Breast and Ovarian Cancer (HBOC) that is typically used by the primary physician or oncologist. Little data exists on the value of genetic screening at a major health care access point: the breast imaging center (BIC). Using BICs as potential clinics to identify high risk women could increase the number of appropriate referrals for genetic risk assessment. Therefore, at our hospital-based BIC serving mostly low to middle income patients in a major metropolitan center, we developed a practical screening tool based on the HBOC guidelines and prospectively screened women receiving screening and diagnostic mammography. Methods: A questionnaire based on the NCCN HBOC genetic referral guidelines was added to the intake forms of all patients (pts) obtaining breast imaging at our BIC from 2012 to 2015. Forms were reviewed by the radiologists and flagged if the patient met the guidelines of the tool. Identified pts were contacted by letter and/or telephone and a nurse navigator or genetic counselor verified data, and provided information about genetic counseling to the patient prior to scheduling genetic counseling appointments. Results: Almost 35, 000 pts were seen during the study period. 1214 pts (3.5%) were flagged as possibly high risk, of which 189 pts. had received prior genetic testing. Of the 1025 remaining pts identified as candidates for genetic counseling, 258 (25%) made a genetic counseling appointment and 163 (16%) received genetic counseling. 106 pts. were tested for BRCA1/2. 9 pts (8.5%) tested positive for a BRCA1/2 pathogenic mutation and 8 pts (7.5%) had a Variant of Unknown Significance. Conclusions: Screening for HBOC syndromes at the time of annual breast imaging in a community-based middle to low income metropolitan breast imaging center is practical. Our screening tool identified women with BRCA mutations who would have been otherwise missed. This will have immediate implications for the patient and their family members in regards to increased surveillance and risk reductive surgery discussions.

The Feasibility of a Patient-Centered Medical Home to Treat Pregnant Women With Opioid Use Disorder: A Pilot Study [19Q

INTRODUCTION: The patient-centered medical home (PCMH) is a healthcare model intended to improve healthcare quality while reducing costs. Pregnant women with opioid use disorder (OUD) require intensive healthcare resources. Therefore, a pilot study was conducted to establish the feasibility of a buprenorphine PCMH for pregnant women with OUD. METHODS: The Pregnancy Recovery Center (PRC) was created by five buprenorphine-licensed obstetricians and one addiction certified nurse in 2014. The PRC provides co-located buprenorphine, prenatal care, counseling, and social services support through a PCMH approach. Feasibility was measured by the ability to enroll, treat and retain patients. Successful completion (retention) was defined by negative drug screens, compliance with prenatal care, buprenorphine and counseling appointments. Additional outcomes were also compared between PRC vs non-PRC buprenorphine patients. RESULTS: Of 50 pregnant women enrolled from July 2014 to July 2015, 32 (64%) women successfully completed the program. The mean age was 28.1 years and 95.5% of women were white. Among 32 PRC and 78 non-PRC patients, buprenorphine dose at delivery was significantly higher for PRC vs non-PRC patients (18.4 vs 14.7 mg; P &lt; .01), but neonatal abstinence syndrome (NAS) treatment rates were similar between the groups (46.2% vs 43.8%, P=.82). Fewer hospital charges for antepartum and delivery hospitalizations ($23,554.00 vs $183,703.00) were found for PRC vs non-PRC patients. CONCLUSION: A buprenorphine PCMH is feasible and may improve maternal and neonatal outcomes for pregnant women with OUD. Future large-scale clinical trials are needed to compare outcomes associated with alternative healthcare delivery models such as PCMHs for this population.

The Rate of Elevated Antenatal Edinburgh Depression Score in Pregnancies Complicated by Gestational Diabetes [12Q

INTRODUCTION: The US Preventative Task Force recommends depression screening in pregnancy. The Edinburgh Depression Scale (EDS) is a self-administered screening tool for the diagnosis of depression. An EDS of greater than or equal to 10 is considered elevated and correlated with depression. Despite correlation with depression, maternal and neonatal outcome in high risk populations is unclear. METHODS: This is a retrospective study of singleton pregnancies with gestational diabetes at UC San Diego between 2010-2014 with an antepartum EDS. The primary outcome was the rate of elevated EDS and referral for treatment. The secondary outcomes included maternal characteristics, perinatal outcome, and postpartum follow-up. RESULTS: 210 women met inclusion criteria. 53.2% (107/210) had an elevated EDS score and 71% (76/107) were referred for counseling. Of these, 24.5% (26/76) attended their counseling appointments. 18.7% (20/107) received pharmacologic treatment. Patients with a positive EDS score had a higher rate of PTD (19.6% vs 9.7% (p=0.05)), higher rate of obesity, and less weight gain. No statistical differences were noted in SGA, however, a trend toward a higher rate of these outcomes were noted in the group with elevated EDS (SGA 9.4% vs 2.9% (p=0.08). There were no differences in delivery method, rates of macrosomia, and diabetic control. CONCLUSION: 53% of women with gestational diabetes had an elevated antenatal EDS and approximately 44.9% received treatment. Despite these interventions, a higher rate of PTD and lower weight gain was noted in those with an elevated EDS. Further studies are needed to determine the best intervention and its effect on perinatal outcomes.

Put focus on mental health issues to keep campus safe

Richard Beary, chief of police at the University of Central Florida, believes in keeping his campus safe by addressing the core problems that lead to crime and create safety challenges. And the biggest problem campus police units face is mental health issues. About 30 percent of people who are shot by law enforcement officers have mental health problems, Beary said. And on a large campus like UCF, many students struggle with mental health challenges. “The majority of our cases have young people who know they need help and are trying to get it,” Beary said. Campus officials can't just say, “See you in nine weeks [for a counseling appointment],” he added.

Abstract P3-08-05: The yield of germline genetic testing in breast cancer patients diagnosed prior to age 50

Abstract Young breast cancer (BC) patients are more likely to carry a mutation in a cancer predisposition gene than women diagnosed later in life. Historically young BC patients were eligible for BRCA1/2 genetic testing, but now with the advent of larger panels, more extensive germline genetic testing is available. Little is known about the yield of panel testing in young BC patients. The goal of this study is to report on the testing outcomes of referrals to a single institution cancer genetics program for women who had a diagnosis of BC at or prior to age 50. METHODS: Cases were identified from the cancer registry of a single institution. Women with invasive breast cancer or DCIS were included if their diagnosis was at or before age 50. Charts were reviewed to abstract data on age of diagnosis, type of testing offered, and results of genetic testing, as well as insurance status and family history of cancer. RESULTS: A total of 386 young BC patients were referred for genetic counseling in 2011-2015. Of those, 287 (74%) attended a genetic counseling appointment. Many of the women not attending had previously had genetic testing with an outside provider; their test results were included in the table below. Of the 287 attending a genetics consultation, most were offered genetic testing (87.1%); most of those not offered testing had either already been tested but without genetic counseling, or did not meet current NCCN or their insurer's criteria for testing. Eighteen women were offered a panel but elected to have only BRCA testing due to concerns about variants of unknown significance (VUS). Of those tested, 15.4% had a pathogenic or likely pathogenic mutation identified. Of women who had only BRCA testing, 11.7% were positive and 4.4% had a VUS. Of those who had panel testing, 16.9% were positive and 19.3% had a VUS. Percentage of women with positive tests by age at diagnosisAge at Dx30 or less31-3536-4041-4546-50Total (n=18)(n=39)(n=78)(n=109)(n=108)(n=352)BRCA1/227.8%18.0%16.7%6.4%6.5%11.1%Other genes11.1%5.1%3.8%4.6%2.8%4.3%Total yield38.9%23.1%20.5%11.0%9.3%15.4% Other genes with positive panel results included 4 x TP53 mutations, 4 x CHEK2, 2 x PALB2 and 1x each of RAD51C, RAD51D, STK11, NF1, and PTEN. The three patients who tested positive for a hereditary cancer predisposition syndrome (STK11, NF1, and PTEN positive) had clinical features of their respective syndromes. The STK11 patient was previously known to have Peutz-Jeghers syndrome, while the NF1 and PTEN patients had subtler features of Neurofibromatosis type 1 and PTEN-Hamartoma Tumor Syndrome (Cowden Syndrome) respectively. CONCLUSIONS: The yield of germline genetic testing in BC patients increases with younger age of diagnosis. Panel testing increases the yield of testing above that of BRCA1/2 alone, and enabled the formal diagnosis of a few individuals with hereditary cancer syndromes who did not have classic features of their syndromes. The VUS rate for panel testing remains significant, and some women elect to have BRCA1/2 testing only due to personal preference because of VUS rates. These data describing the yield of testing in BC patients diagnosed at a young age may be useful for genetic counseling of this patient population. Citation Format: Madlensky L, De Rosa D, Forbes K. The yield of germline genetic testing in breast cancer patients diagnosed prior to age 50 [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-08-05.

Abstract B84: Practical risk assessment: Identifying women at risk for hereditary cancer in a low-income cancer clinic

Abstract Introduction: The identification of breast and ovarian patients for genetic counseling and genetic testing is of paramount importance in order to offer tailored treatments to patients and their family members at high risk. Current guidelines for genetic counseling referrals require physicians to devote an inordinate amount of time to investigate patient family histories and risk factors. We devised a hereditary risk assessment strategy utilizing a previously described 10-item Family Cancer Risk Assessment (RISK) tool1 to accurately and quickly identify appropriate patients for genetic counseling referrals in an unobtrusive manner in a busy low-income oncology clinic. Methods: All women with a history of breast or ovarian cancer at the Robert Hardy Cancer Clinic at Nashville General Hospital at Meharry Medical College were approached for inclusion in this study. Exclusions included severe illness and previous genetic testing. Survey questions included family history of breast or ovarian cancer, ethnic background, and age at diagnosis, among others. Points were conferred as described previously1 and a score greater than or equal to six entailed an automatic referral to the Vanderbilt Hereditary Cancer Program (VHCP). Referred patients had an initial telephone appointment to construct a pedigree then followed by a face to face genetic counseling appointment and genetic testing if advised by the counselor. Sociodemographic data, cancer stage and cancer treatment data were collected using a RedCap database2 sponsored by Vanderbilt. The study was approved by the IRB of each institution. Results: 79 women were approached over a ten-month period. 73 (92%) of the women agreed to take the RISK survey. One patient had ovarian cancer and the others had a personal history of breast cancer. The average age of the women in the study was 56 (range 34-75). 48% of patients were African-American, 37% Caucasian, and 8% Hispanic. 83% of patients had Tennessee Medicaid as their sole insurance coverage. 79% of the 38 patients who completed questions regarding finances indicated their annual household income was less than $15,000. 14% of patients were diagnosed with triple negative breast cancer (TNBC) before the age of 60 and 35% were diagnosed with non-TNBC before age 50. 41 (56%) women scored six or greater on the RISK tool, and all of these women were referred to the VHCP. To date, 18 women have completed the genetics telephone interview with pedigree construction and 23 are awaiting telephone appointments. Of these 18 women, 17 (94%) met current NCCN guidelines3 for hereditary cancer screening based on pedigree analysis, age of diagnosis, and histology of the malignancy. 10 of the 18 patients were offered genetic testing, one patient declined the test after counseling. The other 8 women either failed (n=4) or are awaiting an appointment (n=4). No deleterious mutations were found in those tested and 4 variants of unknown significance (VUS) were found in 3 individual patients. Conclusions: A hereditary risk assessment strategy utilizing a 10-item RISK tool is an effective means for physicians practicing in a low-income, predominantly African-American clinic to easily identify appropriate patients with history of breast cancer for genetic counseling referral. Further, the extremely high participation rate of this patient population may indicate a high level of interest in genetic screening. Importantly, a number of patients did not follow through and attend the genetic counseling appointments; we are studying the reasons behind this lack of follow-through. Overall, this strategy could be easily implemented in other busy low-income clinics to screen patients for risk of hereditary cancer. 1 Joseph G. et al. 2012 Public Health Genomics. 2 Harris et al. 2009. J Biomed Inform. 3 National Comprehensive Cancer Network: Genetic/High-risk Breast_Ovarian (Version 2.2016). This study was funded by GreaterGood.org and by the Robert Wood Johnson Foundation. Citation Format: Eden Biltibo, Philip E. Lammers, Kimberley Thomas, Smita Rao, Renee Ashworth, Georgia L. Wiesner. Practical risk assessment: Identifying women at risk for hereditary cancer in a low-income cancer clinic. [abstract]. In: Proceedings of the Ninth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2016 Sep 25-28; Fort Lauderdale, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2017;26(2 Suppl):Abstract nr B84.

The Embedded Counseling Model: An Application to Dental Students

Prior research has suggested that dental students experience high rates of stress, anxiety, and mood concerns, which have been linked to poor academic performance, health concerns, and substance abuse. The aim of this study was to evaluate the impact of an embedded counseling office at the University of Iowa College of Dentistry & Dental Clinics in its first three academic semesters. Data were gathered from students attending appointments, and two inventories were used to monitor students' counseling progress and gather psychological outcomes data: the Counseling Center Assessment of Psychological Symptoms-34 (CCAPS-34) and the Outcome Rating Scale (ORS). In the three semesters, 55 students attended 251 counseling appointments, with an average of 4.5 appointments per student. Their presenting psychological concerns included academic concerns, time management, test anxiety, study skills, low self-esteem, self-care, interpersonal conflicts, anxiety, depression, stress management, sexual concerns, substance abuse, eating/body image concerns, work-life balance, and financial issues. The CCAPS-34 data showed that, at initial clinical assessment, students experienced moderate levels of depression, generalized anxiety, social anxiety, academic distress, and overall psychological distress; 45 (82%) showed clinically significant symptoms on at least one CCAPS-34 subscale. The ORS data further showed that the students entered counseling experiencing high levels of psychological distress. A positive relationship was found between number of counseling appointments and increased overall functioning. These results suggest that an embedded counseling office can help dental schools meet the needs of their students.

M6 - Presymptomatic Genetic Counseling In Frontotemporal Dementia/Amyotrophic Lateral Sclerosis: A Potential Model For Genetic Testing In Neurodegenerative Disorders

Recent advances in disease gene-identification and genetic testing utilization have led to a dramatic increase in genetic testing for neuropsychiatric disorders. There is in particular a growing interest in the C9orf72 gene, implicated in a sizable portion of familial and sporadic frontotemporal dementia (FTD) and amyotrophic lateral sclerosis (ALS) cases. As more FTD/ALS patients are genotyped, the necessity for accurate and ethically informed genetic counseling grows. While presymptomatic testing protocols in Huntington disease and familial Alzheimer disease have been well-studied and implemented, there emerges a need to shorten this protocol to make it less prohibitive, to generalize it to other neurodegenerative disorders, and to address complex diagnostic and counseling issues such that apply to FTD/ALS. To that end, we developed a presymptomatic genetic counseling algorithm for the FTD/ALS population, generalizable to other neurodegenerative genetic disorders. This multidisciplinary, multi-step, and psychosocially-oriented approach may be of interest to the field of psychiatric genetics as a whole. Experts in genetics, neurology, psychiatry, neuropsychology, and nursing were consulted to assess the need for genetic counseling services in the FTD/ALS population. Based on perceived need and interest, an ALS genetic counseling clinic was established. In addition, a genetic counseling and testing protocol was developed based on the Huntington disease presymptomatic testing protocol, modified for specific needs of the FTD/ALS population. From 2014 to 2016, 42 cases were referred for clinical neuropsychiatric genetic counseling, to which this protocol was applied. To date, our protocol has been applied to 42 referrals received for neuropsychiatric genetic counseling, the majority involving FTD/ALS probands. Of these, 30 patients were scheduled for and completed at least an initial genetic counseling appointment; 17 were symptomatic individuals referred to establish genetic etiology, and 13 were presymptomatic cases with a known family history of neurodegenerative disease. Based on our protocol, 4 of these cases were advised against genetic testing as they did not meet testing criteria, 5 were offered but either did not return for follow-up or declined genetic testing for psychosocial reasons, and 4 completed presymptomatic genetic counseling and testing. Furthermore, our approach integrated multiple genetic counseling sessions to address several challenges and psychosocial needs pertinent to this clinical population. These included diagnostic uncertainty, variable expressivity, oligogenic inheritance, variants of unknown significance, confidentiality concerns regarding electronic health records, and lack of disease-specific support resources. The proposed genetic testing and counseling framework for FTD/ALS is unique in its aims to address the psychosocial challenges of this population, to provide accurate anticipatory guidance in light of genetic diagnostic limitations and complex inheritance patterns, and to refer for psychological and psychiatric assessment as needed. This shortened, streamlined protocol is potentially applicable to neuropsychiatric genetic disorders in general. Further research will aim at assessing long-term genetic counseling outcomes, with the goals of providing the most targeted and comprehensive clinical care to this growing at-risk population.

Lawyering in the Hague: An Introduction to the Roles of Counsel Practising at the icc

This article identifies and describes the roles that counsel in independent practice may play at the International Criminal Court (icc), as well as the rules governing the criteria to be met by counsel to be included in the List of Counsel and the appointment of counsel. It also seeks to identify legal issues concerning the roles, qualifications, and appointment of counsel that may deserve further consideration and study. In the light of the law and practice of the icc, the article concludes that counsel may play at least four different roles in icc proceedings, and that the meaning of the term counsel in the law and practice of the icc lacks precision, which in turn may create problems as regards the applicability of certain legal instruments to certain categories of counsel practising at the icc.