Kaitlynn Wright and Wendy C. Birmingham, Department of Psychology

Introduction

Colorectal cancer (CRC) is one of the most common cancer types in the United States. Having CRC in one’s family history is one of the strongest risk factors for this cancer, suggesting a genetic influence in developing CRC. While this cancer can be deadly, many steps can be taken to reduce one’s risk of getting CRC by making healthy lifestyle choices such as improving one’s diet, maintaining a healthy BMI, and engaging in an exercise regimen. Receiving CRC screening is a highly effective method for reducing one’s risk for the disease, however many with CRC in their family histories do not obtain a screening nor make healthy lifestyle choices to reduce their risk. Factors that increase the use of CRC screening methods in high-risk individuals include positive social influence, marital support, and family support for obtaining CRC screening and lessening levels of social isolation in individuals. Having a good support system also increases the chances that at-risk individuals will also participate in making better lifestyle choices to prevent the disease. One’s spouse can be an important source of influence and support for someone with high CRC risk, encouraging their partner to obtain CRC screenings and improve their lifestyle choices. However, the quality of the marital relationship may differ between married couples, and this could affect the outcome of an at-risk individual’s decision to obtain CRC screening and make healthier life choices to reduce risk. For example, a more supportive spouse’s encouragement could be thought of as “being supportive” while encouragement from a spouse who is perceived as more ambivalent may elicit a response that is perceived as “he is trying to be controlling!” Considering the lack of research in regards to the differences in influence and encouragement for lifestyle choices and screening adherence in supportive and ambivalent couples, our study aims to fill this gap in the literature by showing that perceptions of spousal relationship quality (e.g., supportive or ambivalent) may influence at-risk individuals in obtaining screening and making better lifestyle choices. This study particularly looks at relationship quality in a sample of at-risk individuals in increasing healthier lifestyle choices and screening adherence. Additionally, this project examined attitudes in regards to direct-to-consumer (DTC) genetic screenings for CRC and individuals’ rationale for obtaining or not obtaining this screening.

Methods

CRC patients were requested to provide information on their first-degree relatives and those relatives were contacted to determine interest in the study. Patients were recruited from Huntsman Cancer Center Gastroenterology clinic, through newspaper ads and community flyers. Sixteen heterosexual married couples agreed to participate. In each couple, one spouse had an increased-risk for developing CRC where at least one first-degree relative (FDR) in that individual’s family history had developed CRC. Each couple met with a genetic counselor for a semi-personalized genetic counseling session where CRC risk was analyzed as well as methods for preventing the development of CRC through lifestyle choices and screening adherence. Couples were informed about genetic testing that could determine risk such as DTC testing. After attending this counseling session, each married couple met privately and discussed what they had learned about CRC risk, how they felt about it, and their plans for decreasing risk. All sessions were recorded and then transcribed verbatim. All transcripts were coded individually by at least two research assistants who had frequent communication to ensure coding agreement.

Analysis

Qualitative data were analyzed using NVivo 11 and quantitative data were analyzed in Microsoft Excel 2010 and SPSS version 23. The married couples’ discussions were transcribed verbatim by one research assistant and then verified by another to ensure accuracy before being coded in NVivo. Basic statistical tests were run to determine whether each spousal relationship was supportive or ambivalent and to discover to what extent each couple felt that receiving DTC genetic testing would be a viable prevention method for the at-risk individual in the couple.

Results

We found that seven increased-risk individuals rated their spouse as being ambivalent (44%), eight rated their spouse as supportive (50%), and one did not answer. All sixteen couples (100%) worked together to create plans to improve lifestyle choices. Only three (19%) of the increased-risk individuals said they were likely to get DTC genetic testing, even after hearing about its effectiveness during the genetic counseling session. In additional post hoc analysis we found that of the sixteen married couples (n=32), only eight individuals (25%) stated that valuable information could be learned from such testing while sixteen individuals (50%) felt little worry or concern about genetic risk being a factor in developing CRC and four of these individuals explicitly expressed a belief that cancer was caused more due to environmental factors than genetic ones (Figure 1).

Discussion and Conclusion

No associations were found between couples’ relationship quality (i.e. supportive or ambivalent) and intention to make healthier lifestyle decisions. In fact, each couple, regardless of relationship quality, discussed and agreed upon patterns of behavior that would lead to healthier lifestyles such as exercising together and including more vegetables in their diets. Relationship quality did not appear to influence couples to decide on and work toward better lifestyle choices. Due to this finding, a greater emphasis was placed on analyzing the data surrounding beliefs about DTC testing than originally planned for this project. Surprisingly, results indicated very few increased-risk individuals indicated they would get DTC testing. To discover why this was so, we examined participants’ beliefs on the cause of cancer and how this might influence their perception on the usefulness of the testing. Few individuals expressed a belief in genetic determinism (e.g., the belief that genes determine one’s risk for disease) in regards to developing cancer, while more individuals thought that environmental causes played a more important role in the etiology of cancer. These participants indicated they wanted to focus on healthy lifestyle choices rather than genetic probability. This finding suggests that an individual’s belief in the cause of cancer could be an influential factor in making the choice to receive DTC testing, possibly even more so than the influence and encouragement via relationship quality from their spouse. This belief in environmental factors over genetic factors also helps explain why spousal relationship quality did not predict FDRs’ intention to improve lifestyle choices. If one believes environment influences cancer risk and plans to increase risk-reducing behaviors while reducing risk-increasing behaviors, then the quality of their marital relationship will likely not factor into those decisions. However, our sample was small and further examination in a larger sample may reveal more influence from supportive spouses than ambivalent spouses. For further research we suggest following-up with participants to see which parts of their plans they put into practice and how spousal support helped or hindered them in accomplishing this. We would also like to record the incidence of CRC in the increased-risk individuals and see how developing or not developing the disease influenced their beliefs on the cause of cancer and the importance of obtaining DTC testing.