Organization of Cancer Genetic Counselling in France

Various models of cancer genetic counselling, depending on national or regional expertise and resources, have been developed (Hopwood 2005).

In France, for example, the various professionals working in the field of cancer genetics, forming the "Genetics and cancer" group, have proposed guidelines for cancer genetic counselling, based on a multidisciplinary organization in which the various healthcare professionals meet with the counselee at various times.

The first meeting is a long consultation, for which the counselee is encouraged to attend with a certain amount of preparation (maximum of information about the family history of cancer). The counselee is invited to attend the visit with one or several members of the family. The coun-selee's family tree is constructed and a maximum of information is obtained about all cancers in the family; then, the geneticist describes the objectives of genetic counselling, the existence of genes and their possible alteration, the concept of risk, the implications of genetic testing, the various expected results and their consequences, the concept of specific surveillance and possible prophylactic surgical procedures aimed to decrease the risk of developing cancer. Finally, the geneticist provides information about the risk of the family members and advice concerning the transmission of this information. At the end of the visit, the geneticist provides the counselee with a fairly precise estimate of the probability that she carries the BRCA1 or BRCA2 genetic alteration. The counselee is given an information brochure, summarizing the information provided orally, which can be read at home and shared with other members of the family.

Usually, it is proposed not to take the blood sample for genetic testing immediately, as the counselee is given a period of reflection of about 2 months during which she is encouraged to attend a visit with a member of the psycho-oncology team. The psycho-oncology interview is an opportunity for the counselee to review her motivation to undergo genetic testing, to explain her expectations and to investigate the subject's representations of cancer, especially in the light of her family history, and to share her level of information and her integration of the information presented at the first meeting with the geneticist. The psycho-oncology interview investigates the counselee's perception of risk, her capacity to anticipate the results of genetic testing, her desire to transmit the information received to her family, and, more globally, the model of family communication. It also assesses the psychological impact of the genetic risk and the possible risk of psychiatric disturbance related to this situation. The interview sometimes leads to the decision not to perform the genetic test or at least to postpone it.

The second meeting with the geneticist, often shorter than the first, confirms the counselee's motivation and reinforces the main information. After understanding how the counselee and her family experience this period of reflection, the geneticist answers any of the patient's remaining questions. A letter summarizing the genetic information provided during the consultation is then handed to the counselee; this can be especially helpful for the counselee to recall this information and to transmit it to the family.

The psycho-oncologist may follow the coun-selee during this period, but is usually only consulted at the time of delivery of the genetic test results.

In every case, geneticists and psycho-oncologists meet regularly to pool their information in order to achieve a global understanding of the counselee's expectations, values, and choices and the possible psychological difficulties. Written summaries are included in the counselee's file, allowing sharing of information collected by the various professionals involved.

It should be underlined that the geneticist not only informs on the genetic situation but also takes part in the organization of the next steps of the process. After presenting the different possibilities to reduce the counselee's risks, surveillance or preventive surgery, he participates in the practical organization of the medical exams or further consultations with members of the mul-tidisciplinary medical team.

This cancer genetic counselling model is continually evolving, especially in view of the recent arrival, in France, of newly trained genetic counsellors, which will modify the distribution of roles between the various professionals involved.

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