Impact of rapid genetic counselling and testing on the decision to undergo immediate or delayed prophylactic mastectomy in newly diagnosed breast cancer patients: findings from a randomised controlled trial.

BACKGROUND: Female breast cancer patients with a BRCA1/2 mutation have an increased risk of contralateral breast cancer. We investigated the effect of rapid genetic counselling and testing (RGCT) on choice of surgery. METHODS: Newly diagnosed breast cancer patients with at least a 10% risk of a BRCA1/2 mutation were randomised to an intervention group (offer of RGCT) or a control group (usual care; ratio 2 : 1). Primary study outcomes were uptake of direct bilateral mastectomy (BLM) and delayed contralateral prophylactic mastectomy (CPM). RESULTS: Between 2008 and 2010, we recruited 265 women. On the basis of intention-to-treat analyses, no significant group differences were observed in percentage of patients opting for a direct BLM (14.6% for the RGCT group vs 9.2% for the control group; odds ratio (OR) 2.31; confidence interval (CI) 0.92-5.81; P=0.08) or for a delayed CPM (4.5% for the RGCT group vs 5.7% for the control group; OR 0.89; CI 0.27-2.90; P=0.84). Per-protocol analysis indicated that patients who received DNA test results before surgery (59 out of 178 women in the RGCT group) opted for direct BLM significantly more often than patients who received usual care (22% vs 9.2%; OR 3.09, CI 1.15-8.31, P=0.03). INTERPRETATION: Although the large majority of patients in the intervention group underwent rapid genetic counselling, only a minority received DNA test results before surgery. This may explain why offering RGCT yielded only marginally significant differences in uptake of BLM. As patients who received DNA test results before surgery were more likely to undergo BLM, we hypothesise that when DNA test results are made routinely available pre-surgery, they will have a more significant role in surgical treatment decisions.

Ethnic, racial and cultural identity and perceived benefits and barriers related to genetic testing for breast cancer among at-risk women of African descent in New York City.

BACKGROUND: Due to disparities in the use of genetic services, there has been growing interest in examining beliefs and attitudes related to genetic testing for breast and/or ovarian cancer risk among women of African descent. However, to date, few studies have addressed critical cultural variations among this minority group and their influence on such beliefs and attitudes. METHODS: We assessed ethnic, racial and cultural identity and examined their relationships with perceived benefits and barriers related to genetic testing for cancer risk in a sample of 160 women of African descent (49% self-identified African American, 39% Black-West Indian/Caribbean, 12% Black-Other) who met genetic risk criteria and were participating in a larger longitudinal study including the opportunity for free genetic counseling and testing in New York City. All participants completed the following previously validated measures: (a) the multi-group ethnic identity measure (including ethnic search and affirmation subscales) and other-group orientation for ethnic identity, (b) centrality to assess racial identity, and (c) Africentrism to measure cultural identity. Perceived benefits and barriers related to genetic testing included: (1) pros/advantages (including family-related pros), (2) cons/disadvantages (including family-related cons, stigma and confidentiality concerns), and (3) concerns about abuses of genetic testing. RESULTS: In multivariate analyses, several ethnic identity elements showed significant, largely positive relationships to perceived benefits about genetic testing for breast and/or ovarian cancer risk, the exception being ethnic search, which was positively associated with cons/disadvantages, in general, and family-related cons/disadvantages. Racial identity (centrality) showed a significant association with confidentiality concerns. Cultural identity (Africentrism) was not related to perceived benefits and/or barriers. CONCLUSIONS: Ethnic and racial identity may influence perceived benefits and barriers related to genetic testing for breast and/or ovarian cancer risk among at-risk women of African descent. Genetic counseling services may want to take into account these factors in the creation of culturally-appropriate services which best meet the needs of this heterogenous population.

Stronger endocrine responses after brief psychological stress in women at familial risk of breast cancer.

Recent research has linked exposure to chronic stress to altered acute stress responses and suggests a sensitizing effect of chronic stress leading to a stronger endocrine and cardiovascular response to acute stressors. Substantial evidence indicates that familial breast cancer risk is a chronic life stressor with higher levels of self reported distress. In this study, we investigated whether the endocrine response to a brief psychological stressor was stronger for women at familial risk for breast cancer. Thirty-six women at normal risk of breast cancer (FR- Stress Group) and 17 women at familial risk (FR+ Stress Group) underwent a brief psychological laboratory stress test (speech task and mental arithmetic) over a 15 min period. Thirty women at normal risk not subjected to the stressful task served as controls (FR- Control Group). Plasma epinephrine, norepinephrine and cortisol were measured at baseline, directly after the stress test (15 min) and at 30 min and 45 min post baseline. Heart rate data confirmed the effectiveness of the stress regimen. While there were no significant baseline group differences in the endocrine parameters, the response curves for the familial risk group revealed stronger epinephrine and cortisol reactivity to the stress test, as confirmed by significant group by time interactions. Norepinephrine levels showed a similar pattern, but results did not reach significance. These findings are in line with previous research documenting the facilitating effects of chronic stressors on acute stress response in animals and humans and provide the first evidence in the literature of a heightened endocrine reactivity to acute psychological stress in women at familial risk of breast cancer. The heightened endocrine reactivity to the experimental tasks seen here suggests that these women may experience stronger responses to stressors in their daily lives. According to the recently proposed concept of allostatic load, repeated overly strong stress responses may cumulatively have negative health implications.

Emotional expressivity and intrusive cognitions in women with family histories of breast cancer: application of a cognitive processing model.

OBJECTIVES: Women with family histories of breast cancer exhibit significant distress and intrusive cognitions about cancer. The role of intrusive cognitions in adjustment to chronic stressors is unclear. While they may be a source of distress in themselves, they may also be part of a cognitive processing strategy that aids in the adaptation process, particularly if they are accompanied by more deliberate processing such as emotional expression. Applying cognitive processing models of stress, the present study examined the role of dispositional emotional expressivity in intrusive cognitions about breast cancer and distress in women dealing with the stressful experience of having a family history of breast cancer. Two competing hypotheses were tested: (1) emotional expressivity is associated with reduced intrusive cognitions and thus lower distress; (2) emotional expressivity buffers the relations between intrusive cognitions and distress. DESIGN: Using a cross-sectional design, hypotheses were addressed with multiple regression analyses according to established methods. METHOD: Healthy women (N = 104) who had one or more first-degree relatives with breast cancer were recruited from cancer screening programs. They completed questionnaires regarding family history of cancer, emotional expressivity, distress, and intrusive cognitions. RESULTS: Emotional expressivity was not associated with reduced intrusive cognitions (Hypothesis 1) but moderated the relations between intrusive cognitions and distress (Hypothesis 2). CONCLUSIONS: The data further our understanding of cognitive processing theories of stress and underline the importance of including emotional expression in interventions, helping women to process the stressful experiences associated with having family histories of breast cancer.

Looking forward and back: distress among women at familial risk for breast cancer.

Healthy women with family histories of breast cancer in a first-degree relative (FH+) have been reported to exhibit higher levels of breast cancer-related distress than women without family histories of breast cancer (FH-). Recent data suggest that this may be particularly true for women who had a parent die of cancer. In line with theories emphasizing the psychological impacts of past stressors and concerns for the future, the present study examined the hypotheses that past cancer stressors (i.e. maternal breast cancer caregiving and death, "Looking Back") and perceptions of one's own heightened future risk for developing the disease ("Looking Forward") would predict current levels of distress. One hundred forty-eight healthy women (57 FH+, 91 FH-) recruited from large medical centers in the New York City area completed measures of breast cancer-related distress, general psychological distress, and items assessing whether or not they had taken care of their mother with breast cancer or had had their mother die from the disease. Consistent with previous research, results indicated that FH+ women whose mothers had died of breast cancer had significantly higher breast cancer-related distress than either FH+ women whose mothers had not died of breast cancer or FH- women (p < .05). Further analyses revealed that FH+ women who had cared for their mothers with breast cancer had higher cancer-related distress than women who did not (p < .01), and that FH+ women whose experience included both caregiving and the death of their mother from breast cancer had the highest levels of cancer-related distress (p < .01) and depressive symptoms (p < .05). Findings also indicated that FH+ women with heightened perceptions of risk for breast cancer had higher levels of distress, independent of past stressors. These findings suggest that psychosocial interventions for women with family histories of breast cancer might be appropriately focused on these issues.

Psychological distress, health beliefs, and frequency of breast self-examination.

Although monthly breast self-examination (BSE) is recommended for early breast cancer detection, most women do not comply. Few studies have examined the impact of psychological distress on BSE frequency. Recent research suggests that it may be particularly important to examine the role of distress in the recently identified phenomenon of BSE overperformance (> 1/month). One hundred thirty-five healthy women with and without family histories of breast cancer completed sociodemographic, health belief, general and cancer-specific psychological distress, and BSE frequency questionnaires. The central finding of the study was that BSE underperformance and overperformance had two distinct sets of predictors: health beliefs, specifically barriers against BSE and low confidence in BSE performance, were related to BSE underperformance, while higher levels of psychological distress, particularly cancer-specific intrusive thoughts, were related to BSE overperformance. Findings underscore the need to evaluate BSE under- and overperformance separately and to develop problem-specific interventions to increase compliance with monthly BSE.

It won't happen to me: lower perception of heart disease risk among women with family histories of breast cancer.

BACKGROUND: The threat that breast cancer poses to American women, particularly to women with family histories of the disease, has received widespread attention in both medical and popular literatures. While this emphasis may have laudable consequences on breast cancer screening, it may also have a negative consequence, obscuring women's recognition of their risks for other health threats, such as heart disease. This study examined the possibility that women with family histories of breast cancer may be particularly susceptible to overestimating their risks of breast cancer while minimizing their risks of cardiovascular disease. METHODS: Healthy women with (n = 73) and without n = 104) family histories of breast cancer (64% African American, 26% Caucasian, 10% other ethnicities, mean age 41.7 years) were recruited from medical centers in New York City, and completed questionnaires concerning their family histories and perceptions of risk. RESULTS: Consistent with the study hypothesis, women with family histories of breast cancer had significantly higher perceived lifetime risk of breast cancer (P<0.0002) but lower perceived lifetime risk of heart disease (P<0.002) than women without family histories. Additionally, women with family histories of breast cancer had lower perceived colon cancer risk (P<0.02), suggesting that women with family histories of breast cancer may be underestimating their risks for a variety of diseases. CONCLUSION: The emphasis on breast cancer risk, especially for women with family histories of the disease, may need to be balanced by educational efforts concerning women's risk of other diseases, particularly cardiovascular disease.

[Predictors of mammography adherence among Icelandic women.].

OBJECTIVE: In Iceland, breast cancer is a second only to lung cancer as a cause of women s cancer related deaths. Despite the widely-recognized utility of mammography for detecting breast cancer at early stages when it is most curable, many Icelandic women do not adhere to mammography screening recommendations. The aim of the present population-based study was to identify factors that facilitate and hinder women s adherence to mammography screening in Iceland. MATERIAL AND METHODS: A randomly selected sample of Icelandic women between the ages of 40-69 years, not previously diagnosed with breast cancer (n=1000), were recruited to the study by mail. Participants (n=619) completed questionnaires assessing: demopgraphic variables, knowledge of screening guidelines, possible facilitators (e.g., physician recommendation) and barriers (e.g. concern about radiation) to adherence, as well as stages of mammography screening adoption (precontemplation, contemplation, action and maintenance). RESULTS: Women in the precontemplation stage were more afraid of radiation than women on other stages. They as well as women on contemplation stage were more afraid that mammography would be painful, and less satisfied with previous service at the mammography screening center. Doctors recommendations, as well as women s knowledge about mammography screening guidelines, were positively related to mammography adherence. CONCLUSIONS: These findings suggest that physicians may have an important role in motivating women to follow mammography screening recommendations. Educating women about mammography screening guidelines and addressing their concern about radiation and pain may increase mammography adherence further. Service at the mammography screening center may also improve adherence.

[Interest in breast cancer genetic testing among Icelandic women.].

OBJECTIVE: It is estimated that 6-10% of all breast cancers in Iceland can be attributed to inherited mutations in newly identified breast cancer susceptibility genes (BRCA1 and BRCA2). Before genetic testing becomes widely available in Iceland it is important to understand what motivates women s interest in undergoing testing as that will provide the data necessary for designing effective counseling interventions. Therefore, the aim of this population-based study was to examine interest in and predictors of interest in genetic testing among Icelandic women. MATERIAL AND METHODS: A randomly selected sample of 534 Icelandic women, who had not been previously diagnosed with breast cancer, completed questionnaires assessing, demographic/medical variables, interest in genetic testing, perceived risk of carrying mutations in BRCA1/2 genes, cancer-specific distress and perceived benefits and barriers of genetic testing. The mean age was 53.8 years and 197 of the women had at least one first degree-relative that had been diagnosed with breast cancer. RESULTS: Interest in testing was high with 74% of the women indicating that they were interested in testing. Family history of breast cancer was unrelated to interest in testing whereas perceived risk of being a mutation carrier was significantly and positively related to interest in testing. Interest in testing was also significantly higher among younger women and among women with higher levels of cancer-specific distress. The most commonly cited reasons for wanting to be tested were to increase use of mammography screening and to learn if one s children were at risk for developing cancer. The most commonly citied reasons against being tested were fear of being mutation carrier and worry that test results would not stay confidential. CONCLUSIONS: These results suggest that demand for genetic testing, once it becomes commercially available, among Icelandic women may be high even among women without family history of breast cancer. The results also suggest that genetic counseling needs to address women s breast cancer worries as that may increase the probability that the decision to undergo testing is based on knowledge rather than driven by breast cancer fear and distress.

Psychosocial factors and secretory immunoglobulin A.

This review focuses on studies that have examined the relation between psychosocial factors and secretory immunoglobulin A (s-IgA). Several studies have examined the relation between s-IgA and stressful circumstances ranging from major life events to minor daily events. The findings from these studies were often contradictory, since different experimenters reported different stress-related changes in s-IgA. The effects of stress reduction interventions, such as relaxation and imagery, on s-IgA levels have also been examined. Although these studies indicate that various interventions are associated with increases in s-IgA levels, methodological refinements are needed before more definitive conclusions can be made. The possibility that the relation between stress and s-IgA may be moderated by personality characteristics or mediated by psychological distress was supported in some studies. The review concludes with suggestions for future research.

Predictors of intrusive thoughts and avoidance in women with family histories of breast cancer.

Having a family history of cancer is an important predictor of lifetime cancer risk. Individuals with family histories of cancer have been reported to experience symptoms of general distress and to have frequent intrusive thoughts and avoidance regarding cancer. To date, little is known about predictors of such distress. A relation between perception of cancer risk and distress has been suggested, but the possibility that prior cancer-related events may contribute to distress in these women has received little attention. The major aim of the study was to examine the contribution of the past experience of the death of a parent from cancer to distress in women at familiar risk for breast cancer. Women with family histories of breast cancer (Risk Group, N = 46) were assessed on the day of their yearly mammography screening and four to eight weeks after normal result notification in order to confirm the generalizability of their distress. Their levels of intrusive thoughts, avoidance, and perceived lifetime risk for breast cancer were significantly higher than those of women with no family histories of cancer who were not undergoing mammography (Comparison Group, N = 43), and this was true on both assessment days. Among the women in the Risk Group, those whose parent(s) had died of cancer had the highest levels of intrusive thoughts, avoidance, and perceived risk. Results suggested that perceived risk mediated the effect of this event on intrusive thoughts and avoidance regarding breast cancer. The findings are discussed in terms of theories of cognitive responses to traumatic and stressful life events. Implications for future research and interventions are discussed.