Supportive care services in New Brunswick, Canada: An environmental scan.

Cancer diagnosis and treatment often have significant physical and psychological implications for both the survivor and their family/caregivers. Necessary services extend beyond medical treatment and include a variety of supportive care services (SCS) that address individuals' physical, social, educational, and emotional needs. This study seeks to map the SCS available in the province of New Brunswick (NB), Canada, for cancer survivors, their families, and their caregivers. An environmental scan was conducted to assess current SCS available in NB. While some SCS exist in NB, they are not always easily accessible or identifiable, and gaps in services were prevalent. In particular, a gap in services was found for individuals who are no longer actively receiving cancer treatment, as well as for family members and caregivers.

Virtual follow-up care among breast and prostate cancer patients during and beyond the COVID-19 pandemic: Association with distress.

BACKGROUND: The purpose of this study was to investigate associations between self-reported distress (anxiety/depression) and satisfaction with and desire for virtual follow-up (VFU) care among cancer patients during and beyond the COVID-19 pandemic. METHODS: Breast and prostate cancer patients receiving VFU at an urban cancer centre in Toronto, Canada completed an online survey on their sociodemographic, clinical, and technology, characteristics and experience with and views on VFU. EQ5D-5 L was used to assess distress. Statistical models adjusted for age, gender, education, income and Internet confidence. RESULTS: Of 352 participants, average age was 65 years, 48% were women,79% were within 5 years of treatment completion, 84% had college/university education and 74% were confident Internet users. Nearly, all (98%) had a virtual visit via phone and 22% had a virtual visit via video. The majority of patients (86%) were satisfied with VFU and 70% agreed that they would like VFU options after the COVID-19 pandemic. Participants who reported distress and who were not confident using the Internet for health purposes were significantly less likely to be satisfied with VFU (OR = 0.4; 95% CI: 0.2-0.8 and OR = 0.19; 95% CI: 0.09-0.38, respectively) and were less likely to desire VFU option after the COVID-19 pandemic (OR = 0.49; 95% CI: 0.30-0.82 and OR = 0.41; 95% CI: 0.23-0.70, respectively). CONCLUSIONS: The majority of respondents were satisfied with VFU and would like VFU options after the COVID-19 pandemic. Future research should determine how to optimize VFU options for cancer patients who are distressed and who are less confident using virtual care technology.

Understanding and addressing changing administrative workload in primary care in Canada: protocol for a mixed-method study.

INTRODUCTION: Many Canadians struggle to access the primary care they need while at the same time primary care providers report record levels of stress and overwork. There is an urgent need to understand factors contributing to the gap between a growing per-capita supply of primary care providers and declines in the availability of primary care services. The assumption of responsibility by primary care teams for services previously delivered on an in-patient basis, along with a rise in administrative responsibilities may be factors influencing reduced access to care. METHODS AND ANALYSIS: In this mixed-methods study, our first objective is to determine how the volume of services requiring primary care coordination has changed over time in the Canadian provinces of Nova Scotia and New Brunswick. We will collect quantitative administrative data to investigate how services have shifted in ways that may impact administrative workload in primary care. Our second objective is to use qualitative interviews with family physicians, nurse practitioners and administrative team members providing primary care to understand how administrative workload has changed over time. We will then identify priority issues and practical response strategies using two deliberative dialogue events convened with primary care providers, clinical and system leaders, and policy-makers.We will analyse changes in service use data between 2001/2002 and 2021/2022 using annual total counts, rates per capita, rates per primary care provider and per primary care service. We will conduct reflexive thematic analysis to develop themes and to compare and contrast participant responses reflecting differences across disciplines, payment and practice models, and practice settings. Areas of concern and potential solutions raised during interviews will inform deliberative dialogue events. ETHICS AND DISSEMINATION: We received research ethics approval from Nova Scotia Health (#1028815). Knowledge translation will occur through dialogue events, academic papers and presentations at national and international conferences.

Comparison of patients' perceptions of family physicians' patient-centeredness between virtual and in-person clinical encounters: A cross-sectional study.

Introduction: A clinician's patient-centeredness is a core construct of quality healthcare and is associated with several positive patient outcomes. This study aimed to compare patient-perceived patient centeredness between in-person and virtual clinical encounters during the coronavirus pandemic. Materials and Methods: Participants completed an online anonymous questionnaire pertaining to a recent clinical encounter. Patients of an academic family medicine teaching clinic scheduled for either an in-person or a virtual clinical encounter were recruited by phone over a two-month period. Using the patient-centered clinical method as a conceptual framework, patient-perceived patient centeredness was measured by the Patient-Perceived Patient-Centeredness Questionnaire-Revised (PPPC-R), consisting of 18 items that reflect three factors (healthcare process, context and relationship, and roles). Results: The sample consisted of 72 participants. There was no difference in the PPPC-R scores between participants who received in-person and those who received virtual care. However, the mean ranks for the PPPC-R total score and for all three factors were higher for participants who saw a family physician compared to participants who saw a family medicine learner. Conclusion: Family physicians provided similar quality healthcare, measured through a patient-perceived patient-centeredness lens, via both virtual and in-person appointments. These results support sustaining virtual care when deemed appropriate by both patient and clinician.

Patient Engagement in Health Research: Perspectives from Patient Participants.

BACKGROUND AND PURPOSE: Over the past decade, patient engagement (PE) has emerged as an important way to help improve the relevance, quality, and impact of health research. However, there is limited consensus on how best to meaningfully engage patients in the research process. The goal of this article is to share our experiences and insights as members of a Patient Advisory Committee (PAC) on a large, multidisciplinary cancer research study that has spanned six years. We hope by sharing our reflections of the PAC experiences, we can highlight successes, challenges, and lessons learned to help guide PE in future health research. To the best of our knowledge, few publications describing PE experiences in health research teams have been written by patients, survivors, or family caregivers themselves. METHODS: A qualitative approach was used to gather reflections from members of the Patient Advisory Committee regarding their experiences in participating in a research study over six years. Each member completed an online survey and engaged in a group discussion based on the emergent themes from the survey responses. RESULTS: Our reflections about experiences as a PAC on a large, pan-Canadian research study include three overarching topics (1) what worked well; (2) areas for improvement; and (3) reflections on our overall contribution and impact. Overall, we found the experience positive and experienced personal satisfaction but there were areas where future improvements could be made. These areas include earlier engagement and training in the research process, more frequent communication between the patient committee and the research team, and on-going monitoring regarding the nature of the patient engagement. CONCLUSIONS: Engaging individuals who have experienced the types of events which are the focus of a research study can contribute to the overall relevance of the project. However, intentional efforts are necessary to ensure satisfactory involvement.

Every Story Is Different: Experiences With Body Changes Related to Cancer.

One of the important aspects of stakeholder engagement in cancer care and system planning is hearing from individuals who have been diagnosed with cancer about the impact of the diagnosis and treatment on their lives. Hearing stories from the perspectives of cancer survivors offers opportunity to gain new insight and understanding about experiences of being diagnosed and treated for cancer. This article presents ten short narratives about survivors' perspectives on body image and cancer. Each story is unique but, taken together, the picture they create is one of facing challenges, discovering personal resilience, and moving forward to engage in living. The stories emphasize the importance of communication and support from healthcare providers and understanding needs for a person-centered cancer care system.

Risk Stratification and Cancer Follow-Up: Towards More Personalized Post-Treatment Care in Canada.

After treatment, cancer survivors require ongoing, comprehensive care to improve quality of life, reduce disability, limit complications, and restore function. In Canada and internationally, follow-up care continues to be delivered most often by oncologists in institution-based settings. There is extensive evidence to demonstrate that this model of care does not work well for many survivors or our cancer systems. Randomized controlled trials have clearly demonstrated that alternate approaches to follow-up care are equivalent to oncologist-led follow-up in terms of patient outcomes, such as recurrence, survival, and quality of life in a number of common cancers. In this paper, we discuss the state of follow-up care for survivors of prevalent cancers and the need for more personalized models of follow-up. Indeed, there is no one-size-fits-all solution to post-treatment follow-up care, and more personalized approaches to follow-up that are based on individual risks and needs after cancer treatment are warranted. Canada lags behind when it comes to personalizing follow-up care for cancer survivors. There are many reasons for this, including difficulty in determining who is best served by different follow-up pathways, a paucity of evidence-informed self-management education and supports for most survivors, poorly developed IT solutions and systems, and uneven coordination of care. Using implementation science theories, approaches, and methods may help in addressing these challenges and delineating what might work best in particular settings and circumstances.

Motivations for cancer history disclosure among young adult cancer survivors.

PURPOSE: To gain an in-depth understanding of the motivations for cancer history disclosure and/or non-disclosure among young adult cancer survivors. METHODS: Using a constructivist grounded theory approach, semi-structured telephone interviews were conducted with breast and testicular cancer survivors diagnosed between the ages of 18 and 39 from across Canada. FINDINGS: Twenty-eight young adult cancer survivors (16 female; 12 male) participated in this study. Analysis of the interviews revealed two basic motivational systems for disclosure at play: approach-focused motivations geared towards a positive outcome (desire for understanding, acceptance, support and to promote cancer awareness) and avoidance-focused motivations which are geared towards avoiding a negative outcome (fear of discrimination/stigmatization, unwanted attention, pity, loss of privacy, and rejection). Those exhibiting approach-focused motivations were more likely to disclose than those expressing avoidance-focused motivations. Participants also described a series of situational/contextual factors (social/cultural context, relevance, situation/timing, person disclosing, audience/confidant, and time passed since cancer diagnosis) which had the potential to change or influence the disclosure decision despite overarching motivations to disclose or not. IMPLICATIONS FOR CANCER SURVIVORS: Gaining a better understanding of the cancer history disclosure decision processes of young adult cancer survivors can help them to better adapt and socially reintegrate back into their pre-cancer lives after the completion of treatment. Acknowledging and understanding the disclosure decision process and communication challenges faced by young cancer survivors can also be beneficial to healthcare professionals in the development and provision of better support interventions and informational resources to help improve psychosocial well-being after cancer.

Patients' experiences with continuity of cancer care in Canada: Results from the CanIMPACT study.

OBJECTIVE: To explore patient perspectives on and experiences with the coordination and continuity of cancer care. DESIGN: Qualitative study using semistructured telephone interviews. SETTING: Canada. PARTICIPANTS: Thirty-eight breast and colorectal cancer survivors 1 to 4 years after diagnosis. METHODS: Using a constructivist grounded theory approach, semistructured telephone interviews were conducted with the participants. The interviews were digitally recorded, transcribed verbatim, and proofread. Transcripts were reviewed to create a focused coding scheme that was used to develop categories for participants' experiences. MAIN FINDINGS: Although this study focused on the continuity of cancer care, patients described their experiences with cancer care in general, concentrating predominantly on their relationships with individual health care providers (HCPs). Based on patients' experiences, several themes were identified as the core components of providing good continuity and well coordinated care. The most important overarching theme was communication, which overlapped with 4 other themes: patient-HCP relationships, the role of HCPs, lack of access to care, and timely and tailored information. CONCLUSION: Patients believed that good communication between HCPs and patients was key to improving the overall continuity of cancer care. Continuity of care is an important theoretical concept in cancer care, but it is not easily recognized by patients. They perceive the cancer care continuum and continuity of care as cancer care in general, which is typically framed by the individual relationships with their HCPs. Future research and interventions need to focus on finding and testing ways to improve communication to enhance continuity of cancer care.

Coordination of cancer care between family physicians and cancer specialists: Importance of communication.

OBJECTIVE: To explore health care provider (HCP) perspectives on the coordination of cancer care between FPs and cancer specialists. DESIGN: Qualitative study using semistructured telephone interviews. SETTING: Canada. PARTICIPANTS: A total of 58 HCPs, comprising 21 FPs, 15 surgeons, 12 medical oncologists, 6 radiation oncologists, and 4 GPs in oncology. METHODS: This qualitative study is nested within a larger mixed-methods program of research, CanIMPACT (Canadian Team to Improve Community-Based Cancer Care along the Continuum), focused on improving the coordination of cancer care between FPs and cancer specialists. Using a constructivist grounded theory approach, telephone interviews were conducted with HCPs involved in cancer care. Invitations to participate were sent to a purposive sample of HCPs based on medical specialty, sex, province or territory, and geographic location (urban or rural). A coding schema was developed by 4 team members; subsequently, 1 team member coded the remaining transcripts. The resulting themes were reviewed by the entire team and a summary of results was mailed to participants for review. MAIN FINDINGS: Communication challenges emerged as the most prominent theme. Five key related subthemes were identified around this core concept that occurred at both system and individual levels. System-level issues included delays in medical transcription, difficulties accessing patient information, and physicians not being copied on all reports. Individual-level issues included the lack of rapport between FPs and cancer specialists, and the lack of clearly defined and broadly communicated roles. CONCLUSION: Effective and timely communication of medical information, as well as clearly defined roles for each provider, are essential to good coordination of care along the cancer care trajectory, particularly during transitions of care between cancer specialist and FP care. Despite advances in technology, substantial communication challenges still exist. This can lead to serious consequences that affect clinical decision making.

Primary care providers' experiences with and perceptions of personalized genomic medicine.

OBJECTIVE: To assess primary care providers' (PCPs') experiences with, perceptions of, and desired role in personalized medicine, with a focus on cancer. DESIGN: Qualitative study involving focus groups. SETTING: Urban and rural interprofessional primary care team practices in Alberta and Ontario. PARTICIPANTS: Fifty-one PCPs. METHODS: Semistructured focus groups were conducted and audiorecorded. Recordings were transcribed and analyzed using techniques informed by grounded theory including coding, interpretations of patterns in the data, and constant comparison. MAIN FINDINGS: Five focus groups with the 51 participants were conducted; 2 took place in Alberta and 3 in Ontario. Primary care providers described limited experience with personalized medicine, citing breast cancer and prenatal care as main areas of involvement. They expressed concern over their lack of knowledge, in some circumstances relying on personal experiences to inform their attitudes and practice. Participants anticipated an inevitable role in personalized medicine primarily because patients seek and trust their advice; however, there was underlying concern about the magnitude of information and pace of discovery in this area, particularly in direct-to-consumer personal genomic testing. Increased knowledge, closer ties to genetics specialists, and relevant, reliable personalized medicine resources accessible at the point of care were reported as important for successful implementation of personalized medicine. CONCLUSION: Primary care providers are prepared to discuss personalized medicine, but they require better resources. Models of care that support a more meaningful relationship between PCPs and genetics specialists should be pursued. Continuing education strategies need to address knowledge gaps including direct-to-consumer genetic testing, a relatively new area provoking PCP concern. Primary care providers should be mindful of using personal experiences to guide care.

Do new and traditional models of primary care differ with regard to access?: Canadian QUALICOPC study.

OBJECTIVE: To examine access to primary care in new and traditional models using 2 dimensions of the concept of patient-centred access. DESIGN: An international survey examining the quality and costs of primary health care (the QUALICOPC study) was conducted in 2013 in Canada. This study adopted a descriptive cross-sectional survey method using data from practices across Canada. Each participating practice filled out the Family Physician Survey and the Practice Survey, and patients in each participating practice were asked to complete the Patient Experiences Survey. SETTING: All 10 Canadian provinces. PARTICIPANTS: A total of 759 practices and 7172 patients. MAIN OUTCOME MEASURES: Independent t tests were conducted to examine differences between new and traditional models of care in terms of availability and accommodation, and affordability of care. RESULTS: Of the 759 practices, 407 were identified as having new models of care and 352 were identified as traditional. New models of care were distinct with respect to payment structure, opening hours, and having an interdisciplinary work force. Most participating practices were from large cities or suburban areas. There were few differences between new and traditional models of care regarding accessibility and accommodation in primary care. Patients under new models of care reported easier access to other physicians in the same practice, while patients from traditional models reported seeing their regular family physicians more frequently. There was no difference between the new and traditional models of care with regard to affordability of primary care. Patients attending clinics with new models of care reported that their physicians were more involved with them as a whole person than patients attending clinics based on traditional models did. CONCLUSION: Primary care access issues do not differ strongly between traditional and new models of care; however, patients in the new models of care believed that their physicians were more involved with them as people.

Young adult cancer survivors and the challenges of intimacy.

The purpose of this study was to explore intimate relationships after a cancer diagnosis, applying constructivist grounded theory to interviews with 55 Canadian young adult cancer survivors. The core category found was the dynamic interplay between participants' experiences of cancer and their intimate relationships. The authors found four themes within this core category: the mental experience of cancer, challenged sexual intimacy, the relationship response to strain (supportive or nonsupportive), and adapted intimacy. This research demonstrates the importance of intimate relationships for young adults along their cancer trajectory, revealing that those relationships are severely strained by a cancer diagnosis and treatment yet help to limit negative consequences.

It's the "good" cancer, so who cares? Perceived lack of support among young thyroid cancer survivors.

PURPOSE/OBJECTIVES: To describe the survivorship experience of young adult patients with thyroid cancer. RESEARCH APPROACH: A qualitative, descriptive study. SETTING: Four Canadian provinces, with most participants from Ontario. PARTICIPANTS: 12 young adult thyroid cancer survivors who participated in a larger study on follow-up care needs consisting of 55 young adult cancer survivors. METHODOLOGIC APPROACH: Telephone interviews were conducted with cancer survivors who were diagnosed from age 18-39 years and were 1-5 years post-treatment. FINDINGS: All 12 thyroid cancer survivors discussed the feeling that their cancer experiences often were downplayed because thyroid cancer is labeled as the "good" cancer. Many said that they were not considered real patients with cancer by healthcare providers and other patients with cancer, and they were unable or unwilling to access support programs or assistance from healthcare providers. CONCLUSIONS: Cancer can have an impact on a person's life regardless of the prognosis. Being diagnosed with thyroid cancer at a young age can pose additional challenges because of the lack of available support to address needs specific to young adults. INTERPRETATION: Healthcare providers must recognize the needs of thyroid cancer survivors and encourage them to access supportive services. KNOWLEDGE TRANSLATION: Patients with thyroid cancer believe that their needs often are overlooked because of high survival rates, and they have difficulty accessing support resources and finding help. Young adults with cancer often have unique support needs. Support needs may not be the same for all young adult patients with cancer, and those needs should be recognized and addressed.

Comparing urban and rural young adult cancer survivors' experiences: a qualitative study.

INTRODUCTION: Large administrative data set analyses demonstrate that geography has a significant impact on access to health care and subsequent health outcomes. In general, rural populations have poorer access to healthcare services. This article explores the reality of this issue for young adult cancer survivors. METHODS: Data was of a subset of 30 participants from a larger qualitative study that examined cancer survivorship issues for young adult cancer patients in Canada. The subset of participants are from New Brunswick, a predominantly rural province in Eastern Canada with a population of 750,000 spread out over a large geographical area, and from Canada's largest metropolis center, Greater Toronto Area, with a population of around 6 million. RESULTS: Analysis of the qualitative data using constructivist grounded theory revealed several expected and unexpected differences between the two geographically distinct groups. The rural group of young adult cancer survivors reported more frequent episodes of delayed diagnosis and lower levels of community support compared to the urban participants. The urban young adult cancer survivors discussed out-of-pocket expenses for cancer treatment more often than the rural participants. Many rural participants made it clear that they were keenly aware that not all cancer care services were readily available where they lived, and yet they reported considerably higher levels of satisfaction with the cancer care that they received than the urban participants. CONCLUSION: Despite the lack of important cancer services in rural areas, rural young adult cancer survivors expressed higher levels of satisfaction with their care than did urban cancer survivors. It appears that levels of satisfaction are related to expectations. Rural participants were aware of the more limited services available and felt that their cancer care practitioners provided the best care possible given the limited resources. Urban participants may have higher expectations of cancer care and felt that the cancer care they received fell below expectations. In the future, researchers may want to focus on cancer care expectations, satisfaction levels and psychosocial outcomes in greater detail.

Rehabilitation after breast cancer: recommendations from young survivors.

PURPOSE: Studies show that younger women have a greater physical, psychological, and social morbidity, and poorer quality of life after a breast cancer diagnosis than older women. With improving survival rates, cancer rehabilitation has an increasing role in the cancer care continuum, particularly for younger women who potentially have many productive years ahead of them. The purpose of this study was to assess the cancer rehabilitation needs of young women after breast cancer treatment. METHODS: In this qualitative, descriptive study, we purposefully sampled 35 breast cancer survivors diagnosed under the age of 50 in Atlantic Canada to participate in two telephone interviews. RESULTS/DISCUSSION: Recommendations included: improved communication between the various healthcare professionals; healthcare professionals taking on a more proactive approach in recommending rehabilitation after treatment; better insurance coverage or financial assistance for rehabilitation services; and more rehabilitation support for rural populations. CONCLUSION: Rehabilitation nurses can play an important role in educating patients, recognizing long-term sequelae, and directing patients to various medical and allied health care professionals to provide proper support and care post-breast cancer treatment.

Barriers to rehabilitative care for young breast cancer survivors: a qualitative understanding.

PURPOSE: The goal of this study was to assess the rehabilitation needs of young women breast cancer survivors under the age of 50 and to identify factors that may impact or prevent cancer rehabilitation utilization. METHODS: Utilizing a grounded theory methodology, 35 young breast cancer survivors were interviewed twice in four Atlantic Canadian provinces. RESULTS: A considerable number of barriers exist to receiving rehabilitative care post-treatment for young breast cancer survivors. The systemic barriers include the lack of availability of services, travel issues, cost of services, and the lack of support to address the unique needs for this age group. However, the most complicated barriers to accessing rehabilitative care were personal barriers which related more to choice and circumstances, such as the lack of time due to family responsibilities and appointment fatigue. Many of these personal barriers were rooted in the complex set of gender roles of young women as patients, mothers, workers, and caregivers. CONCLUSIONS: The contexts of young women's lives can have a substantial impact on their decisions to seek and receive rehabilitative care after breast cancer treatment. The systemic barriers can be reduced by introducing more services or financial assistance; however, the personal barriers to rehabilitation services are difficult to ameliorate due to the complex set of roles within and outside the family for this group of young breast cancer survivors. Health care providers need to take into consideration the multiple contexts of women's lives when developing and promoting breast cancer rehabilitation services and programs.

"You can only take so much, and it took everything out of me": coping strategies used by parents of children with cancer.

OBJECTIVE: This study qualitatively assesses the coping strategies of parents who care for a child with cancer. METHOD: Semi-structured interviews were conducted with 28 French and English families who had had a child diagnosed with cancer in the last ten years in two Eastern Canadian provinces. Interviews were transcribed verbatim and coded with a focus on parental coping strategies. RESULTS: Using coping behaviors as described and categorized in the Family Adjustment and Adaptation Response (FAAR) model as a foundation, we found that families used a variety of appraisal-, emotion-, and problem-focused coping. Appraisal-focused coping strategies involved trying to stay "positive" and "making positive comparisons." Problem-focused coping involved behaviors such as being an advocate for the child and seeking information. The majority of parents, however, described using emotion-focused coping behaviors such as trying to avoid "feeling too much" by hiding difficult emotions and "escaping" from problems. Others used more positive emotion-focused coping behaviors such as humor, seeking support (informal or formal), or writing diaries. A small group of parents used ineffective coping strategies (alcohol abuse, misdirected anger) that added to family stress. These ineffective strategies have led to a modification of the FAAR model indicating that not all coping behaviors are beneficial to family adjustment in crisis. Overall, many parents felt that their coping strategies were effective; however, a few described having a complete "coping breakdown". SIGNIFICANCE OF RESULTS: Parents used a range of coping strategies of which emotion-focused coping was the most prominent. We have enhanced the FAAR model by including additional coping behaviors as well as a description of how some coping behaviors add to the daily stressors for parents dealing with a child's illness. Professional health care providers need to understand the variability of the coping behaviors in order to appropriately assist parents to avoid coping breakdowns.

Young women's responses to smoking and breast cancer risk information.

Current evidence confirms that young women who smoke or who have regular long-term exposure to secondhand smoke (SHS) have an increased risk of developing premenopausal breast cancer. The aim of this research was to examine the responses of young women to health information about the links between active smoking and SHS exposure and breast cancer and obtain their advice about messaging approaches. Data were collected in focus groups with 46 women, divided in three age cohorts: 15-17, 18-19 and 20-24 and organized according to smoking status (smoking, non-smoking and mixed smoking status groups). The discussion questions were preceded by information about passive and active smoking and its associated breast cancer risk. The study findings show young women's interest in this risk factor for breast cancer. Three themes were drawn from the analysis: making sense of the information on smoking and breast cancer, personal susceptibility and tobacco exposure and suggestions for increasing awareness about tobacco exposure and breast cancer. There was general consensus on framing public awareness messages about this risk factor on 'protecting others' from breast cancer to catch smokers' attention, providing young women with the facts and personal stories of breast cancer to help establish a personal connection with this information and overcome desensitization related to tobacco messages, and targeting all smokers who may place young women at risk. Cautions were also raised about the potential for stigmatization. Implications for raising awareness about this modifiable risk factor for breast cancer are discussed.