Objective Genetic testing is increasingly part of routine clinical care for women with a family history of breast cancer. Given their substantially elevated risk for breast cancer, BRCA1/BRCA2 mutation carriers must make the difficult decision whether or not to opt for risk reducing mastectomy. To help BRCA1/2 carriers make this decision, we developed a computer-based interactive decision aid which we tested against usual care in a randomized controlled trial. Design Following the completion of genetic counseling, 214 female (aged 21–75) BRCA1/BRCA2 mutation carriers were randomized to Usual Care (UC; N=114) or Usual Care plus Decision Aid (DA; N=100) arms. UC participants received no additional intervention. DA participants were sent the CD-ROM decision aid to view at home. Main Outcome Measures We measured final management decision, decisional conflict, decisional satisfaction and receipt of risk reducing mastectomy at 1-, 6-, and 12-months post-randomization. Results Longitudinal analyses revealed that the DA was effective among carriers who were initially undecided about how to manage their breast cancer risk. Within this group, the DA led to an increased likelihood of reaching a management decision (OR=3.09, 95% CI=1.62, 5.90; p<.001), decreased decisional conflict (B=−.46, z=−3.1, p<.002), and increased satisfaction (B=.27, z=3.1, p=0.002) compared to UC. Among carriers who had already made a management decision by the time of randomization, the DA had no benefit relative to UC. Conclusion These results demonstrate that BRCA1/BRCA2 mutation carriers who are having difficulty making a breast cancer risk management decision can benefit from adjunct decision support.

Women who receive uninformative BRCA1/2 genetic test results face ongoing uncertainty about their future cancer risks. This article prospectively examined the influence of intolerance for uncertainty and perceived breast cancer risk on psychological distress following the receipt of uninformative BRCA1/2 test results. Sixty-four women who received uninformative BRCA1/2 mutation test results completed measures of Intolerance for Uncertainty, perceived breast cancer risk, and measures of cancer-related, genetic testing, and general distress. Cancer-related (DeltaR(2) = 0.18, P < or = 0.001), general (DeltaR(2) = 0.04, P < or = 0.05), and genetic testing distress (DeltaR(2) = 0.12, P < or = 0.01) were associated with intolerance for uncertainty at 1 month post-disclosure. The interaction of intolerance for uncertainty and breast cancer perceived risk predicted cancer-related (DeltaR(2) = 0.10, P < or = 0.001) and genetic testing distress (DeltaR(2) = 0.09, P < or = 0.01) at 6 months post-disclosure. Distress was highest among patients with highest perceived risk and intolerance for uncertainty, suggesting that those who have difficulty coping with their ambiguous risk are at risk for long-term distress. The clinical and research implications of these results are discussed.

The present study prospectively examined change in diet and physical activity behaviors in 115 women undergoing BRCA1/2 gene testing (46 mutation positive, 46 uninformative and 23 definitive negative). Participants completed measures of diet and physical activity at three time points: prior to genetic testing and 1-and 6-months after receipt of genetic test results. Repeated measures analyses examined between-and within-group differences among participants who received BRCA1/2 positive, uninformative, or definitive negative results. There were no within-group differences across time points or between-group differences at any time point for diet or physical activity. Most participants, overall and within each group, did not meet recommended guidelines for fruit and vegetable and dietary fat consumption. These findings suggest that women do not make spontaneous changes in diet and physical activity following the genetic testing and counseling process. A brief intervention may be necessary for patients who are interested in making changes in modifiable risk factors to complement more definitive risk-reduction strategies.

Shared decision making between patients and providers is becoming increasingly common, particularly when there is no clear preferred course of action. As a result, decision aids are being adopted with growing frequency and have been applied to many medical decision-making issues. One such issue where there is uncertainty is breast cancer risk management among BRCA1/BRCA2 carriers. We present the development of a CD-ROM decision aid to facilitate risk management decision making in this population. Our decision aid was developed with the intention of providing it through a randomized clinical trial. The CD-ROM is a multimedia, interactive intervention which provides information about breast cancer, risks associated with BRCA1 and BRCA2 mutations, risk management options for hereditary breast cancer, and a breast cancer risk management decision aid. The goal of this CD-ROM, offered as an adjunctive intervention, is to reduce decisional conflict and psychological distress and improve comprehension of risk information, decisional satisfaction, medical adherence, and quality of life for this population of women at increased risk for breast cancer.

The diabetic foot assessment is a key component in the care of a patient with diabetes. The assessment includes risk factor identification in both the diabetic patient's history and physical examination, foot care education, treatment, and referrals as needed. The foot complications related to diabetes such as peripheral neuropathy, foot ulceration, and amputation can be life altering. The American Diabetes Association recommends a diabetic foot examination annually for patients with diabetes with foot care education. Diabetic foot assessment may be recommended more frequently for individuals with risk factors contributing to ulceration, peripheral arterial disease, and peripheral neuropathy. This article reviews the diabetic foot assessment that nurses in healthcare settings and other healthcare professionals should use when caring for a diabetic patient.