Psychological side effects of breast cancer screening

Decision quality and regret with treatment decisions in women with breast cancer: Pre-operative breast MRI and breast density

PURPOSE

We evaluated self-report of decision quality and regret with breast cancer surgical treatment by pre-operative breast MRI use in women recently diagnosed with breast cancer.

METHODS

We conducted a survey with 957 women aged 18 + with stage 0-III breast cancer identified in the Breast Cancer Surveillance Consortium. Participants self-reported receipt of pre-operative breast MRI. Primary outcomes were process measures in the Breast Cancer Surgery Decision Quality Instrument (BCS-DQI) (continuous outcome) and Decision Regret Scale (dichotomized outcome as any/none). Generalized estimating equations with linear and logit link were used to estimate adjusted associations between breast MRI and primary outcomes. All analyses were also stratified by breast density.

RESULTS

Survey participation rate was 27.9% (957/3430). Study population was primarily > 60 years, White, college educated, and diagnosed with early-stage breast cancer. Pre-operative breast MRI was reported in 46% of women. A higher proportion of women who were younger age (< 50 years), commercially insured, and self-detected their breast cancer reported pre-operative breast MRI use. In adjusted analysis, pre-operative breast MRI use compared with no use was associated with a small but statistically significantly higher decision quality scores (69.5 vs 64.7, p-value = 0.043). Decision regret did not significantly differ in women who reported pre-operative breast MRI use compared with no use (54.2% v. 48.7%, respectively, p-value = 0.11). Study results did not vary when stratified by breast density for either primary outcome.

CONCLUSIONS AND RELEVANCE

Breast MRI use in the diagnostic work-up of breast cancer does not negatively alter women's perceptions of surgical treatment decisions in early survivorship.

CLINICAL TRIALS REGISTRATION NUMBER

NCT03029286.

Randomized trial of surveillance with abbreviated MRI in women with a personal history of breast cancer- impact on patient anxiety and cancer detection

BACKGROUND

Abbreviated breast MRI (A-MRI) substantially reduces the image acquisition and reading times and has been reported to have similar diagnostic accuracy as a full diagnostic protocol but has not been evaluated prospectively with respect to impact on psychological distress in women with a prior history of breast cancer (PHBC). This study aimed to determine if surveillance mammography (MG) plus A-MRI reduced psychological distress and if A-MRI improved cancer detection rates (CDR) as compared to MG alone.

METHODS

This prospective controlled trial of parallel design was performed at a tertiary cancer center on asymptomatic women with PHBC who were randomized into two groups: routine surveillance with MG or intervention of MG plus A-MRI in a 1:1 ratio. Primary outcome was anxiety measured by four validated questionnaires at three different time-points during the study. Other parameters including CDR and positive predictive value for biopsy (PPV3) were compared between imaging modalities of MG and A-MRI. Tissue diagnoses or 1 year of follow-up were used to establish the reference standard. Linear mixed models were used to analyze anxiety measures and Fisher's exact test to compare imaging outcomes.

RESULTS

One hundred ninety-eight patients were allocated to either MG alone (94) or MG plus A-MRI (104). No significant group difference emerged for improvement in trait anxiety, worry and perceived health status (all Time-by-surveillance group interaction ps > .05). There was some advantage of A-MRI in reducing state anxiety at Time 2 (p < .05). Anxiety scores in all questionnaires were similarly elevated in both groups (50.99 ± 4.6 with MG alone vs 51.73 ± 2.56 with MG plus A-MRI, p > 0.05) and did not change over time. A-MRI detected 5 invasive cancers and 1 ductal carcinoma in situ (DCIS), and MG detected 1 DCIS. A-MRI had higher incremental CDR (48/1000(5/104) vs MG 5/1000(1/198, p = 0.01)) and higher biopsy rates (19.2% (20/104) vs MG 2.1% (2/94), p < 0.00001) with no difference in PPV3 (A-MRI 28.6% (6/21) vs MG 16.7% (1/6, p > .05).

CONCLUSION

There was no significant impact of A-MRI to patient anxiety or perceived health status. Compared to MG alone, A-MRI had significantly higher incremental cancer detection in PHBC. Despite a higher rate of biopsies, A-MRI had no demonstrable impact on anxiety, worry, and perceived health status.

TRIAL REGISTRATION

ClinicalTrials.gov ( NCT02244593 ). Prospectively registered on Sept. 14, 2014.

Patient-reported experiences and views on the Cytosponge test: a mixed-methods analysis from the BEST3 trial

OBJECTIVES

The BEST3 trial demonstrated the efficacy and safety of the Cytosponge-trefoil factor 3, a cell collection device coupled with the biomarker trefoil factor 3, as a tool for detecting Barrett's oesophagus, a precursor of oesophageal adenocarcinoma (OAC), in primary care. In this nested study, our aim was to understand patient experiences.

DESIGN

Mixed-methods using questionnaires (including Inventory to Assess Patient Satisfaction, Spielberger State-Trait Anxiety Inventory-6 and two-item perceived risk) and interviews.

OUTCOME MEASURES

Participant satisfaction, anxiety and perceived risk of developing OAC.

SETTING

General practices in England.

PARTICIPANTS

Patients with acid reflux enrolled in the intervention arm of the BEST3 trial and attending the Cytosponge appointment (N=1750).

RESULTS

1488 patients successfully swallowing the Cytosponge completed the follow-up questionnaires, while 30 were interviewed, including some with an unsuccessful swallow.Overall, participants were satisfied with the Cytosponge test. Several items showed positive ratings, in particular convenience and accessibility, staff's interpersonal skills and perceived technical competence. The most discomfort was reported during the Cytosponge removal, with more than 60% of participants experiencing gagging. Nevertheless, about 80% were willing to have the procedure again or to recommend it to friends; this was true even for participants experiencing discomfort, as confirmed in the interviews.Median anxiety scores were below the predefined level of clinically significant anxiety and slightly decreased between baseline and follow-up (p < 0.001). Interviews revealed concerns around the ability to swallow, participating in a clinical trial, and waiting for test results.The perceived risk of OAC increased following the Cytosponge appointment (p<0.001). Moreover, interviews suggested that some participants had trouble conceptualising risk and did not understand the relationships between test results, gastro-oesophageal reflux and risk of Barrett's oesophagus and OAC.

CONCLUSIONS

When delivered during a trial in primary care, the Cytosponge is well accepted and causes little anxiety.

TRIAL REGISTRATION NUMBER

ISRCTN68382401.

Psychological distress and quality of life following provision of vascular imaging results of the coronary and carotid arteries to asymptomatic adults: a scoping review protocol

Background: Non-invasive screening for atherosclerosis or asymptomatic cardiovascular disease of the coronary and carotid arteries is commonly undertaken, and research has been focussed on how results from these screenings lead to behaviour change. However, no review has focused on the effects of these results on psychological distress and health-related quality of life (HRQoL). This protocol will outline how a scoping review will be conducted to map all available evidence on psychological distress and/or HRQoL outcomes following the provision of vascular imaging results of the coronary and carotid arteries.

Methods: Arksey and O’Malley’s (2005) framework subsequently enhanced by Levac et al. (2010)  and Peters et al (2015, 2017) will guide the scoping review. Databases such as MEDLINE (Clarivate), APA PsychINFO, EMBASE, Social Work Abstracts, Psychology and Behavioural Sciences Collection, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) will be searched using MeSH terms  such as "Coronary stenosis", "Carotid Stenosis", "Psychological Distress" and "Quality of Life" and related terms. Two investigators will screen title and abstract and all articles meeting inclusion criteria will be extracted.  Data on authors, publication year, country of origin, aims/purpose, methodology, intervention, outcome measures as well as key findings that relate to the scoping review questions will be extracted for each included study. The findings will be presented using tables and thematic narrative synthesis. The scoping review will not produce a pooled estimate of the impact of vascular imaging results on psychological distress and HRQoL but will present information from the included studies related to psychological distress and HRQoL.

Conclusion:  The review will highlight and address gaps in knowledge and provide direction for future investigations.

Home Radon Testing in Rural Appalachia

PURPOSE

This study compared differences in sociodemographic characteristics, personal risk perception of lung cancer, lung cancer worry, and synergistic risk perception among rural Appalachia residents who completed home radon testing with those who did not, after receiving a free long-term test kit at a rural primary care clinic. The study also examined the association between the Teachable Moment Model constructs and home radon testing.

METHODS

The study was an exploratory correlational design with a convenience sample of (N = 58) adult participants recruited from 2 rural primary care clinics in Appalachia Kentucky. Participants completed a brief survey and were given a free long-term home radon test kit. Multiple logistic regression was used to determine characteristics associated with home radon testing.

FINDINGS

Twenty-eight participants (48%) completed home radon testing. There were no differences in personal risk perception of lung cancer, lung cancer worry, or synergistic risk perception between those who completed home radon testing and those who did not. Age was the only significant factor associated with completion of radon testing (B = 0.077, P = .005). For every 5-year increase in age, participants were 47% more likely to test their home for radon.

CONCLUSION

Providing free home radon test kits in the primary care setting shows promise in prompting radon testing in rural Appalachia. As radon-induced lung cancer risk increases with exposure over time, health care providers in rural Appalachia need to encourage patients of all ages to test their home for radon, especially those who smoke or report smoking in the home.

Behavioral and Psychological Outcomes Associated with Skin Cancer Genetic Testing in Albuquerque Primary Care

Simple Summary

Genetic information is publicly available but research examining the best use of such information has not engaged diverse members of the public. We examined public reactions to melanoma genetic testing (using the melanocortin-1 receptor [MC1R] gene) in a study randomizing (like the flip of a coin) 600 diverse primary care patients to a MC1R test offer or usual care. We found that testing did not improve sun protection and skin cancer screening, nor did it lead worry to increase. However, groups less aware of their skin cancer risk, including those who thought their risk was “unlikely” at the start of the study, showed significant improvements in sun protection at three months. In conclusion, testing might be very helpful for certain people who have the most to learn about their risk, who may become motivated to protect themselves from the damaging effects of the sun as a result of skin cancer genetic testing.

Abstract

Public availability of genetic information is increasing; thus, efforts to improve diversity in basic and translational research in genomics is a top priority. Given the increasing U.S. incidence and mortality of melanoma, and the prevalence of common melanocortin-1 receptor (MC1R) gene melanoma risk variants in the general population, we examined genomic testing of MC1R for skin cancer risk in a randomized controlled trial in Albuquerque, New Mexico primary care. Participants were 48% Hispanic and were randomized 5:1 to a MC1R test invitation or usual care. We assessed 3 month sun protection, skin cancer screening, and skin cancer worry outcomes associated with testing, and key effect moderators (e.g., cancer risk perceptions, and skin cancer risk factors). Our findings indicate that the primary outcomes were unchanged by the MC1R test offer, test acceptance, and level of risk feedback. Moderator analyses showed that those with lower risk perception, and those with skin that readily tans, significantly increased their sun protection in response to higher than average risk feedback. Risk feedback did not prompt cancer worry, and average risk feedback did not erode existing sun protection. This study paves the way for the development of tailored strategies to address low skin cancer risk awareness in this understudied context of public health genomics.

Making Sense of a Health Threat: Illness Representations, Coping, and Psychological Distress among BRCA1/2 Mutation Carriers

Little is known about how women with a BRCA1/2 mutation develop an individual understanding of their breast and ovarian cancer risk and how this affects their psychological distress. In this study, we investigated associations between illness representations, coping strategies and psychological distress. N = 101 BRCA1/2 mutation carriers answered self-report questionnaires on illness representations, coping strategies, cancer worry and depressive symptoms. Women without cancer were compared to women with a previous cancer diagnosis. Illness representations explained 50% and 45% of the variability in cancer worry and depressive symptoms, respectively. Woman perceiving severe consequences (β = 0.29, p < 0.01) and having more concerns (β = 0.37, p < 0.01) were found to report more cancer worry. Perceiving information about the mutation as less coherent (β = −0.17, p < 0.05) and experiencing negative emotional responses (β = 0.60, p < 0.01) were both associated with more depressive symptoms. Women with a previous cancer diagnosis show patterns of illness representations that are potentially more distressing than women without a cancer diagnosis. Findings suggest that physicians involved in counseling should pay attention to illness representations of distressed women. Thereby, it would be possible to detect maladaptive thoughts associated with the mutation, address negative emotions and encourage adaptive coping strategies.

[Design and validation of a scale to measure worry for contagion of the COVID-19 (PRE-COVID-19)]

Objective

The increase in COVID-19 cases is generating fear and concern in society, which generates an emotional response that influences the adoption of health-related behaviors. The objective of the study is to design and validate the Scale of Worry for Contagion of COVID-19 (PRE-COVID-19).

Method

The study had a descriptive cross-sectional design. The population were young people and adults who resided in the cities of Lima and Callao (Perú) during the declaration of the national health emergency due to the COVID-19 pandemic, during the period from March 16 to 27, 2020, who were recruited through a non-probability sample. The PRE-COVID-19, the WHO-Five Well-Being Index, the Generalized Anxiety Disorder Scale-2 and a single item were applied to measure the general perception of health. The scales were shared using a Google form through social networks. An internal consistency reliability analysis and structural equation models were performed, specifically confirmatory factor analysis. The recommendations of the Declaration of Helsinki and the principles that guide the ethical practice of online studies were followed.

Results

Eight hundred and sixteen young people and adults from Lima and Callao (200 men and 616 women; mean age 28.40, SD 7.10) participated. The results show a one-dimensional model with satisfactory goodness-of-fit indices: χ2 (9) = 52.00; CFI = 0.99; RMSEA = 0.09 [0.07, 0.12]; WRMR = 0.85. The λ of the model were higher than 0.50 and the reliability had an excellent value (ω = 0.90). Likewise, the convergent and discriminant validity is evident between PRE-COVID-19 and measures of anxiety, well-being and self-reported health.

Conclusion

The results indicate that the PRE-COVID-19 is a valid and reliable instrument to measure concern about the spread of COVID-19 and the emotional impact on people.

The impact of information about different absolute benefits and harms on intention to participate in colorectal cancer screening: A think-aloud study and online randomised experiment

BACKGROUND

There is considerable heterogeneity in individuals' risk of disease and thus the absolute benefits and harms of population-wide screening programmes. Using colorectal cancer (CRC) screening as an exemplar, we explored how people make decisions about screening when presented with information about absolute benefits and harms, and how those preferences vary with baseline risk, between screening tests and between individuals.

METHOD

We conducted two linked studies with members of the public: a think-aloud study exploring decision making in-depth and an online randomised experiment quantifying preferences. In both, participants completed a web-based survey including information about three screening tests (colonoscopy, sigmoidoscopy, and faecal immunochemical testing) and then up to nine scenarios comparing screening to no screening for three levels of baseline risk (1%, 3% and 5% over 15 years) and the three screening tests. Participants reported, after each scenario, whether they would opt for screening (yes/no).

RESULTS

Of the 20 participants in the think-aloud study 13 did not consider absolute benefits or harms when making decisions concerning CRC screening. In the online experiment (n = 978), 60% expressed intention to attend at 1% risk of CRC, 70% at 3% and 77% at 5%, with no differences between screening tests. At an individual level, 535 (54.7%) would attend at all three risk levels and 178 (18.2%) at none. The 27% whose intention varied by baseline risk were more likely to be younger, without a family history of CRC, and without a prior history of screening.

CONCLUSIONS

Most people in our population were not influenced by the range of absolute benefits and harms associated with CRC screening presented. For an appreciable minority, however, magnitude of benefit was important.

Alleviating psychological distress associated with a positive cervical cancer screening result: a randomized control trial

Background

The method of communicating a positive cancer screening result should seek to alleviate psychological distress associated with a positive result. We evaluated whether the provision of information through a leaflet would help reduce psychological distress in a randomized controlled trial.

Methods

The participants were women aged 20–69 years who were about to undergo cervical cancer screening at health centers. Before the screening, they received hypothetical screening results, with a leaflet (intervention group, n = 493) or without it (control group, n = 479), randomly. Their psychological distress and intention to undergo further examination were then compared between the intervention and control groups.

Results

After the intervention (providing a leaflet with hypothetical screening results), psychological distress appeared to be higher in the control group than in the intervention group among those who received a hypothetical positive screening result (odds ratio: 2.57, 95% confidence interval: 1.87–3.54), while 95% and 97% of those in the intervention and control groups, respectively, reported that they would undergo further examination.

Conclusions

Information provision might help reduce psychological distress but not hinder further examination among women who screen positive for cervical cancer.

Trial registration: UMIN Clinical Trials Registry UMIN000029894. Date of Registration: November 2017.

Long-term positive psychological outcomes in an Australian pancreatic cancer screening program

Screening for pancreatic cancer (PC) in high-risk groups aimed to detect early cancers is currently done only in the research setting, and data on psychological outcomes of screening in these populations is scarce. To determine the psychological impact of a national Australian pancreatic screening program, a prospective study was conducted using validated psychological measures: impact of events scale (IES), psychological consequences questionnaire (PCQ) and the cancer worry scale. Measures were administered at baseline, 1-month and at 1-year post-enrolment and correlations with abnormal endoscopic ultrasound (EUS) results were calculated. Over a 6-year period, 102 participants were recruited to the screening program. Thirty-nine patients (38.2%) had an abnormal endoscopic ultrasound, and two patients (2.0%) were diagnosed with PC and two with other malignancies. Those with a personal history of cancer or a positive BRCA2 mutation demonstrated significantly increased worry about developing other types of cancer at baseline (p < 0.01). Irrespective of EUS result, there was a significant decrease of total IES score at 1 year (Z = - 2.0, p = 0.041). In patients with abnormal EUS results, there was a decrease in the total IES score at 1 year (Z = - 2.5, p = 0.011). In participants deemed to be most distressed at baseline based on their negative PCQ score, there was a significant decrease of the total PCQ (Z = - 3.2, p = 0.001), emotional (Z = - 3.0, p = 0.001), social (Z = 3.0, p = 0.001) and physical (Z = - 2.8, p = 0.002) subscale at 1-year post-intervention. This study provides evidence of the long-term psychological benefits of PC screening in high-risk patients. There was no negative impact of screening in the short-term and the positive benefits appeared at 1-year post-intervention irrespective of screening result.

Public attitudes towards screening for kidney cancer: an online survey

BACKGROUND

Kidney cancer is often asymptomatic, leading to proposals for a screening programme. The views of the public towards introducing a new screening programme for kidney cancer are unknown. The aim of this study was to explore attitudes towards kidney cancer screening and factors influencing intention to attend a future screening programme.

METHODS

We conducted an online population-based survey of 1021 adults aged 45-77 years. The main outcome measure was intention to attend four possible screening tests (urine, blood, ultrasound scan, low-dose CT) as well as extended low-dose CT scans within lung cancer screening programmes. We used multivariable regression to examine the association between intention and each screening test.

RESULTS

Most participants stated that they would be 'very likely' or 'likely' to undergo each of the screening tests [urine test: n = 961 (94.1%); blood test: n = 922 (90.3%); ultrasound: n = 914 (89.5%); low-dose CT: n = 804 (78.8%); lung CT: n = 962 (95.2%)]. Greater intention to attend was associated with higher general cancer worry and less perceived burden/inconvenience about the screening tests. Less worry about the screening test was also associated with higher intention to attend, but only in those with low general cancer worry (cancer worry scale ≤ 5). Compared with intention to take up screening with a urine test, participants were half as likely to report that they intended to undergo blood [OR 0.56 (0.43-0.73)] or ultrasound [OR 0.50 (0.38-0.67)] testing, and half as likely again to report that they intended to take part in a screening programme featuring a low dose CT scan for kidney cancer screening alone [OR 0.19 (0.14-0.27)].

CONCLUSION

Participants in this study expressed high levels of intention to accept an invitation to screening for kidney cancer, both within a kidney cancer specific screening programme and in conjunction with lung cancer screening. The choice of screening test is likely to influence uptake. Together these findings support on-going research into kidney cancer screening tests and the potential for combining kidney cancer screening with existing or new screening programmes.

Development and use of health outcome descriptors: a guideline development case study

BACKGROUND

During healthcare guideline development, panel members often have implicit, different definitions of health outcomes that can lead to misunderstandings about how important these outcomes are and how to balance benefits and harms. McMaster GRADE Centre researchers developed 'health outcome descriptors' for standardizing descriptions of health outcomes and overcoming these problems to support the European Commission Initiative on Breast Cancer (ECIBC) Guideline Development Group (GDG). We aimed to determine which aspects of the development, content, and use of health outcome descriptors were valuable to guideline developers.

METHODS

We developed 24 health outcome descriptors related to breast cancer screening and diagnosis for the European Commission Breast Guideline Development Group (GDG). Eighteen GDG members provided feedback in written format or in interviews. We then evaluated the process and conducted two health utility rating surveys.

RESULTS

Feedback from GDG members revealed that health outcome descriptors are probably useful for developing recommendations and improving transparency of guideline methods. Time commitment, methodology training, and need for multidisciplinary expertise throughout development were considered important determinants of the process. Comparison of the two health utility surveys showed a decrease in standard deviation in the second survey across 21 (88%) of the outcomes.

CONCLUSIONS

Health outcome descriptors are feasible and should be developed prior to the outcome prioritization step in the guideline development process. Guideline developers should involve a subgroup of multidisciplinary experts in all stages of development and ensure all guideline panel members are trained in guideline methodology that includes understanding the importance of defining and understanding the outcomes of interest.

Risk estimation, anxiety, and breast cancer worry in women at risk for breast cancer: A single-arm trial of personalized risk communication

OBJECTIVE

Elevated anxiety and breast cancer worry can impede mammographic screening and early breast cancer detection. Genetic advances and risk models make personalized breast cancer risk assessment and communication feasible, but it is unknown whether such communication of risk affects anxiety and disease-specific worry. We studied the effect of a personalized breast cancer screening intervention on risk perception, anxiety, and breast cancer worry.

METHODS

Women with a normal mammogram but elevated risk for breast cancer (N = 122) enrolled in the Athena Breast Health risk communication program were surveyed before and after receiving a letter conveying their breast cancer risk and a breast health genetic counselor consultation. We compared breast cancer risk estimation, anxiety, and breast cancer worry before and after risk communication and evaluated the relationship of anxiety and breast cancer worry to risk estimation accuracy.

RESULTS

Women substantially overestimated their lifetime breast cancer risk, and risk communication somewhat mitigated this overestimation (49% pre-intervention, 42% post-intervention, 13% Gail model risk estimate, P < .001). Both general anxiety and breast cancer worry declined significantly after risk communication in women with high baseline anxiety. Baseline anxiety and breast cancer worry were essentially unrelated to risk estimation accuracy, but risk communication increased alignment of worry with accuracy of risk assessment.

CONCLUSIONS

Personalized communication about breast cancer risk was associated with modestly improved risk estimation accuracy in women with relatively low anxiety and less anxiety and breast cancer worry in women with higher anxiety. We detected no negative consequences of informing women about elevated breast cancer risk.

Willingness to decrease mammogram frequency among women at low risk for hereditary breast cancer

This study aimed to assess women's willingness to alter mammogram frequency based on their low risk for HBOC, and to examine if cognitive and emotional factors are associated with women's inclination to decrease mammogram frequency. We conducted an online survey with women (N = 124) who were unlikely to have a BRCA mutation and at average population risk for breast cancer based on family history. Most women were either white (50%) or African American (38%) and were 50 years or older (74%). One-third of women (32%) were willing to decrease mammogram frequency (as consistent with the USPSTF guideline), 42% reported being unwilling and 26% were unsure. Multivariate logistic regression showed that feeling worried about breast cancer (Adjust OR = 0.33, p = 0.01), greater genetic risk knowledge (Adjust OR = 0.74, p = 0.047), and more frequent past mammogram screening (Adjust OR = 0.13, p = 0.001) were associated with being less willing to decrease screening frequency. Findings suggest that emerging genomics-informed medical guidelines may not be accepted by many patients when the recommendations go against what is considered standard practice. Further study of the interplay between emotion- and cognition-based processing of the HBOC screen result will be important for strategizing communication interventions aimed at realizing the potential of precision public health.

Reminders of cancer risk and pain catastrophizing: relationships with cancer worry and perceived risk in women with a first-degree relative with breast cancer

First-degree relatives of women with breast cancer may experience increased worry or perceived risk when faced with reminders of their own cancer risk. Worry and risk reminders may include physical symptoms (e.g., persistent breast pain) and caregiving experiences. Women who engage in pain catastrophizing may be particularly likely to experience increased distress when risk reminders are present. We examined the degree to which persistent breast pain and experience as a cancer caregiver were related to cancer worry and perceived risk in first-degree relatives of women with breast cancer (N = 85) and how catastrophic thoughts about breast pain could impact these relationships. There was a significant interaction between persistent breast pain and pain catastrophizing in predicting cancer worry (p = .03); among women who engaged in pain catastrophizing, cancer worry remained high even in the absence of breast pain. Pain catastrophizing also moderated the relationships between caregiving involvement and cancer worry (p = .003) and perceived risk (p = .03). As the degree of caregiving responsibility increased, cancer worry and perceived risk increased for women who engaged in pain catastrophizing; levels of cancer worry and perceived risk remained low and stable for women who did not engage in pain catastrophizing regardless of caregiving experience. The results suggest that first-degree relatives of breast cancer survivors who engage in pain catastrophizing may experience greater cancer worry and perceived risk and may benefit from interventions aimed at reducing catastrophic thoughts about pain.

False-positive screening events and worry influence decisions about surgery among high-risk women

OBJECTIVE

Studies of cancer screening have found that false positive screening events (FPSE) can affect worry about cancer risk and screening program use, we sought to further explore this.

METHOD

In a study of 1,100 women at high risk for ovarian cancer who participated in a previously published randomized controlled trial (RCT), we sought to explore whether worry might also influence the use of risk-reducing surgical procedures by women. Participants included 234 women with BRCA1/2 mutations and 866 women with high-risk pedigrees. We followed the women for up to 6 years.

RESULTS

Worry predicted risk reducing prophylactic bilateral salpingo-oophorectomy (pBSO) for both mutation carriers (HR = 1.74; p = .02), and women with high-risk pedigree (HR = 3.41; p < .001). FPSE also predicted subsequent pBSO among women with a high-risk pedigree (HR 2.31; p < .01). While screening may reduce worry among those who never receive a positive result, FPSE increase worry at least temporarily. Worry about ovarian cancer risk predicted use of preventative pBSO among high-risk women including those with BRCA1/2 mutations enrolled in an ovarian cancer-screening program. FPSE also predicted risk-reducing ovarian surgery among high-risk women without a known mutation at the time of screening program enrollment.

CONCLUSIONS

Physicians who offer screening should know that false positive results may increase use of pBSO, how this should effect clinical practice is unclear. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Psychosocial consequences of false-positive results in screening mammography

Introduction:

To evaluate the psychosocial impact of benign breast biopsies on Lebanese women after a screening mammography and the effect of these biopsies on patients’ attitudes toward subsequent screening.

Methods:

In this retrospective study (January 2005 till April 2011), 109 consecutive patients with a history of breast biopsy without cancer were asked to answer a phone questionnaire. The response rate was 91.7% (100 women accepted to participate). A questionnaire about sociodemographic characteristics, biopsy characteristics, and patients’ attitudes as measured by the negative Psychosocial Consequences Questionnaire (PCQ) and other independent questions was filled by phone call by one interviewer.

Results:

The negative PCQ score was low for most women (only 9% have a negative PCQ score ≥18/36) and is statistically dependent on the result of the last mammography (P = 0.01) and the number of previous benign breast biopsies (P = 0.01). A total of 10% of women increased their medical visits after this biopsy, 8% were treated for psychiatric problems after this biopsy, and 19% self-examine their breasts more than once per week. The benign breast biopsy experience increases the willingness to adhere to the screening mammography in 71% of the patients, this reported adherence depends positively on the score of the negative PCQ (P = 0.043).

Conclusions:

The negative psychosocial effect of the biopsy is minimal in general and is positively correlated to the adherence to future mammographies. Interventions are necessary to decrease the anxiety in most susceptible women and to raise the awareness of women at risk of nonadherence to the screening mammography.

The iPrevent Online Breast Cancer Risk Assessment and Risk Management Tool: Usability and Acceptability Testing

BACKGROUND

iPrevent estimates breast cancer (BC) risk and provides tailored risk management information.

OBJECTIVE

The objective of this study was to assess the usability and acceptability of the iPrevent prototype.

METHODS

Clinicians were eligible for participation in the study if they worked in primary care, breast surgery, or genetics clinics. Female patients aged 18-70 years with no personal cancer history were eligible. Clinicians were first familiarized with iPrevent using hypothetical paper-based cases and then actor scenarios; subsequently, they used iPrevent with their patients. Clinicians and patients completed the System Usability Scale (SUS) and an Acceptability questionnaire 2 weeks after using iPrevent; patients also completed measures of BC worry, anxiety, risk perception, and knowledge pre- and 2 weeks post-iPrevent. Data were summarized using descriptive statistics.

RESULTS

The SUS and Acceptability questionnaires were completed by 19 of 20 clinicians and 37 of 43 patients. Usability was above average (SUS score >68) for 68% (13/19) clinicians and 76% (28/37) patients. The amount of information provided by iPrevent was reported as "about right" by 89% (17/19) clinicians and 89% (33/37) patients and 95% (18/19) and 97% (36/37), respectively, would recommend iPrevent to others, although 53% (10/19) clinicians and 27% (10/37) patients found it too long. Exploratory analyses suggested that iPrevent could improve risk perception, decrease frequency of BC worry, and enhance BC prevention knowledge without changing state anxiety.

CONCLUSIONS

The iPrevent prototype demonstrated good usability and acceptability. Because concerns about length could be an implementation barrier, data entry has been abbreviated in the publicly available version of iPrevent.

Correlates of Dominicans' Identification of Cancer as a Worrisome Health Problem

There is a paucity of studies centering on the correlates of cancer worry among Hispanics from the Dominican Republic and the potential informatics strategies to address such worries. Data were analyzed using descriptive and correlational statistics, and logistic regression with the dependent variable of cancer worry. Independent variables for the regression were: age, gender, marital status, education, socioeconomic status, previous diagnosis of cancer, anxiety, depression, sleep disturbance, and chronic burden. Four variables significantly increased cancer worry: married marital status (OR = 1.19 [95% CI 1.01, 1.41]), younger age (OR = .992 [95% CI 0.987, 0.997]), less depression (OR = .96 [95% CI 0.94, 0.98]), and cancer diagnosis (OR = 2.12 [95% CI 1.24, 3.65]). New knowledge was generated on the contextual factors that influence these health concerns in a major Hispanic sub-group. Implications for practice, research and education are discussed.

Barrett's oESophagus trial 3 (BEST3): study protocol for a randomised controlled trial comparing the Cytosponge-TFF3 test with usual care to facilitate the diagnosis of oesophageal pre-cancer in primary care patients with chronic acid reflux

BACKGROUND

Early detection of oesophageal cancer improves outcomes; however, the optimal strategy for identifying patients at increased risk from the pre-cancerous lesion Barrett's oesophagus (BE) is not clear. The Cytosponge, a novel non-endoscopic sponge device, combined with the biomarker Trefoil Factor 3 (TFF3) has been tested in four clinical studies. It was found to be safe, accurate and acceptable to patients. The aim of the BEST3 trial is to evaluate if the offer of a Cytosponge-TFF3 test in primary care for patients on long term acid suppressants leads to an increase in the number of patients diagnosed with BE.

METHODS

The BEST3 trial is a pragmatic multi-site cluster-randomised controlled trial set in primary care in England. Approximately 120 practices will be randomised 1:1 to either the intervention arm, invitation to a Cytosponge-TFF3 test, or the control arm usual care. Inclusion criteria are men and women aged 50 or over with records of at least 6 months of prescriptions for acid-suppressants in the last year. Patients in the intervention arm will receive an invitation to have a Cytosponge-TFF3 test in their general practice. Patients with a positive TFF3 test will receive an invitation for an upper gastro-intestinal endoscopy at their local hospital-based endoscopy clinic to test for BE. The primary objective is to compare histologically confirmed BE diagnosis between the intervention and control arms to determine whether the offer of the Cytosponge-TFF3 test in primary care results in an increase in BE diagnosis within 12 months of study entry.

DISCUSSION

The BEST3 trial is a well-powered pragmatic trial testing the use of the Cytosponge-TFF3 test in the same population that we envisage it being used in clinical practice. The data generated from this trial will enable NICE and other clinical bodies to decide whether this test is suitable for routine clinical use.

TRIAL REGISTRATION

This trial was prospectively registered with the ISRCTN Registry on 19/01/2017, trial number ISRCTN68382401 .

Psychosocial morbidity in TP53 mutation carriers: is whole-body cancer screening beneficial?

Germline TP53 mutation carriers are at high risk of developing a range of cancers. Effective cancer risk management is an important issue for these individuals. We assessed the psychosocial impact in TP53 mutation carriers of WB-MRI screening as part of the Surveillance in Multi-Organ Cancer (SMOC+) protocol, measuring their unmet needs, anxiety and depression levels as well as cancer worry using psychological questionnaires and in-depth interviews about their experiences of screening. We present preliminary psychosocial findings from 17 participants during their first 12 months on the trial. We found a significant reduction in participants' mean anxiety from baseline to two weeks post WB-MRI (1.2, 95% CI 0.17 to 2.23 p = 0.025), indicative of some benefit. Emerging qualitative themes show most participants are emotionally supported and contained by the screening program and are motivated by their immediate concern about staying alive, despite being informed about the current lack of evidence around efficacy of screening for people with TP53 mutations in terms of cancer morbidity or mortality. For those that do gain emotional reassurance from participating in the screening study, feelings of abandonment by the research team are a risk when the study ends. For others, screening was seen as a burden, consistent with the relentless nature of cancer risk associated with Li-Fraumeni syndrome, though these patients still declared they wished to participate due to their concern with staying alive. Families with TP53 mutations need ongoing support due to the impact on the whole family system. These findings suggest a comprehensive multi-organ screening program for people with TP53 mutations provides psychological benefit independent of an impact on cancer morbidity and mortality associated with the syndrome. The benefits of a multi-organ screening program will be greater still if the screening tests additionally reduce the cancer morbidity and mortality associated with the syndrome. These findings may also inform the care of individuals and families with other multi-organ cancer predisposition syndromes.

Association of Smoking in the Home With Lung Cancer Worry, Perceived Risk, and Synergistic Risk

PURPOSE/OBJECTIVES

To examine the association of smoking in the home with lung cancer worry, perceived risk, and synergistic risk, controlling for sociodemographics, family history of lung cancer, and health-related self-concept. The hypothesis is that participants with smoking in the home would have higher scores for lung cancer worry, perceived risk, and synergistic risk.
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DESIGN

Cross-sectional baseline survey. 
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SETTING

Participants recruited from an outpatient clinic and pharmacy at University of Kentucky HealthCare, an academic medical center.
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SAMPLE

515 homeowners from a larger randomized, controlled trial aimed at reducing exposure to radon and secondhand smoke (SHS).
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METHODS

Homeowners were selected via quota sampling so that about half would have a smoker or smokers in the home.
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MAIN RESEARCH VARIABLES

Lung cancer worry and perceived risk; perception of synergistic risk of radon and SHS exposure; demographics.
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FINDINGS

Participants with smoking in the home had higher rates of lung cancer worry and perceived risk. In addition, those with less education and a family history of lung cancer and who were current smokers had higher lung cancer worry and perceived lung cancer risk scores. Predictors of perception of synergistic risk were marital status and health-related self-concept.
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CONCLUSIONS

Homeowners with smoking in the home, less education, and a family history of lung cancer had greater lung cancer worry and perceived lung cancer risk. Lung cancer risk reduction interventions with vulnerable populations are needed. 
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IMPLICATIONS FOR NURSING

Nurses are in a unique position to target high-risk populations and identify opportunities to create teachable moments to reduce environmental risks of radon and tobacco smoke exposure.

Influences on anticipated time to ovarian cancer symptom presentation in women at increased risk compared to population risk of ovarian cancer

Background

In the absence of routine ovarian cancer screening, promoting help-seeking in response to ovarian symptoms is a potential route to early diagnosis. The factors influencing women’s anticipated time to presentation with potential ovarian cancer symptoms were examined.

Methods

Cross-sectional questionnaires were completed by a sample of women at increased familial risk (n = 283) and population risk (n = 1043) for ovarian cancer. Measures included demographic characteristics, symptom knowledge, anticipated time to symptom presentation, and health beliefs (perceived susceptibility, worry, perceived threat, confidence in symptom detection, benefits and barriers to presentation). Structural equation modelling was used to identify determinants of anticipated time to symptomatic presentation in both groups.

Results

Associations between health beliefs and anticipated symptom presentation differed according to risk group. In increased risk women, high perceived susceptibility (r = .35***), ovarian cancer worry (r = .98**), perceived threat (r = −.18**), confidence (r = .16**) and perceiving more benefits than barriers to presentation (r = −.34**), were statistically significant in determining earlier anticipated presentation. The pattern was the same for population risk women, except ovarian cancer worry (r = .36) and perceived threat (r = −.03) were not statistically significant determinants.

Conclusions

Associations between underlying health beliefs and anticipated presentation differed according to risk group. Women at population risk had higher symptom knowledge and anticipated presenting in shorter time frames than the increased risk sample. The cancer worry component of perceived threat was a unique predictor in the increased risk group. In increased risk women, the worry component of perceived threat may be more influential than susceptibility aspects in influencing early presentation behaviour, highlighting the need for ovarian symptom awareness interventions with tailored content to minimise cancer-related worry in this population.

Electronic supplementary material

The online version of this article (10.1186/s12885-017-3835-y) contains supplementary material, which is available to authorized users.

Protocol for the melatools skin self-monitoring trial: a phase II randomised controlled trial of an intervention for primary care patients at higher risk of melanoma

INTRODUCTION

Melanoma is the fifth most common cancer in the UK. Incidence rates have quadrupled over the last 30 years and continue to rise, especially among younger people. As routine screening of the general population is not currently recommended in the UK, a focus on secondary prevention through early detection and prompt treatment in individuals at increased risk of melanoma could make an important contribution to improve melanoma outcomes. This paper describes the protocol for a phase II, multisite, randomised controlled trial, in the primary care setting, for patients at increased risk of melanoma. A skin self-monitoring (SSM) smartphone 'App' was used to improve symptom appraisal and encourage help seeking in primary care, thereby promoting early presentation with skin changes suspicious of melanoma.

METHODS AND ANALYSIS

We aim to recruit 200 participants from general practice waiting rooms in the East of England. Eligible patients are those identified at higher melanoma risk (using a real-time risk assessment tool), without a personal history of melanoma, aged 18 to 75 years. Participants will be invited to a primary care nurse consultation, and randomised to the intervention group (standard written advice on skin cancer detection and sun protection, loading of an SSM 'App' onto the participant's smartphone and instructions on use including self-monitoring reminders) or control group (standard written advice alone). The primary outcomes are consultation rates for changes to a pigmented skin lesion, and the patient interval (time from first noticing a skin change to consultation). Secondary outcomes include patient sun protection behaviours, psychosocial outcomes, and measures of trial feasibility and acceptability.

ETHICS AND DISSEMINATION

NHS ethical approval has been obtained from Cambridgeshire and Hertfordshire research ethics committee (REC reference 16/EE/0248). The findings from the MelaTools SSM Trial will be disseminated widely through peer-reviewed publications and scientific conferences.

TRIAL REGISTRATION NUMBER

ISCTRN16061621.

Primary care visit use after positive fecal immunochemical test for colorectal cancer screening

BACKGROUND

For some patients, positive cancer screening test results can be a stressful experience that can affect future screening compliance and increase the use of health care services unrelated to medically indicated follow-up.

METHODS

Among 483,216 individuals aged 50 to 75 years who completed a fecal immunochemical test to screen for colorectal cancer at a large integrated health care setting between 2007 and 2011, the authors evaluated whether a positive test was associated with a net change in outpatient primary care visit use within the year after screening. Multivariable regression models were used to evaluate the relationship between test result group and net changes in primary care visits after fecal immunochemical testing.

RESULTS

In the year after the fecal immunochemical test, use increased by 0.60 clinic visits for patients with true-positive results. The absolute change in visits was largest (3.00) among individuals with positive test results who were diagnosed with colorectal cancer, but significant small increases also were found for patients treated with polypectomy and who had no neoplasia (0.36) and those with a normal examination and no polypectomy performed (0.17). Groups of patients who demonstrated an increase in net visit use compared with the true-negative group included patients with true-positive results (odds ratio [OR], 1.60; 95% confidence interval [95% CI], 1.54-1.66), and positive groups with a colorectal cancer diagnosis (OR, 7.19; 95% CI, 6.12-8.44), polypectomy/no neoplasia (OR, 1.37; 95% CI, 1.27-1.48), and normal examination/no polypectomy (OR, 1.24; 95% CI, 1.18-1.30).

CONCLUSIONS

Given the large size of outreach programs, these small changes can cumulatively generate thousands of excess visits and have a substantial impact on total health care use. Therefore, these changes should be included in colorectal cancer screening cost models and their causes investigated further. Cancer 2017;123:3744-3753. © 2017 American Cancer Society.

Health-related quality of life in Black breast cancer survivors with and without triple-negative breast cancer (TNBC)

PURPOSE

Black women are more likely to develop early-onset (≤50 years) breast cancer (BC) and have the lowest five-year, cause-specific survival rate of any United States (U.S.) racial or ethnic group. These disparities can be attributed partially to the higher rate of triple-negative BC (TNBC) in Blacks. Yet, little is known about health-related quality of life (HRQOL) among Black women with TNBC.

METHODS

Black women with invasive BC ≤ 50 years were recruited via the Florida Cancer Data System as part of a population-based case-only study of etiology and outcomes of early-onset invasive BC. Of 460 consented participants, a subset of 355 self-reported sociodemographic, clinical, and psychosocial variables. Descriptive analyses included participants with known TNBC (n = 85) or non-TNBC (n = 245) disease. Univariable and multivariable analyses were conducted to examine differences in factors associated with HRQOL.

RESULTS

In unadjusted analyses, TNBC participants had significantly lower FACT-B total scores (90.1 ± 27.9) compared to non-TNBC (98.5 ± 27.6) participants (p < 0.05). For the TNBC group, multivariable analyses indicated five individual-level, and three systemic-level factors explain 80% of the response variation in HRQOL. For the non-TNBC group, seven individual-level factors and three systemic-level factors account for 76% of the variation in HRQOL scores.

CONCLUSIONS

Compared to Black women with non-TNBC, TNBC women have worse HRQOL. There are key individual and systemic-level factors that are unique to both groups. Findings can inform future HRQOL interventions to support young Black BC survivors.

Effects of a web-based intervention on women's breast health behaviors

Helping women make choices to reduce cancer risk and to improve breast health behaviors is important, but the best ways to reach more people with intervention assistance is not known. To test the efficacy of a web-based intervention designed to help women make better breast health choices, we adapted our previously tested, successful breast health intervention package to be delivered on the Internet, and then we tested it in a randomized trial. We recruited women from the general public to be randomized to either an active intervention group or a delayed intervention control group. The intervention consisted of a specialized website providing tailored and personalized risk information to all participants, followed by offers of additional support if needed. Follow-up at one-year post randomization revealed significant improvements in mammography screening in intervention women compared with control women (improvement of 13 percentage points). The intervention effects were more powerful in women who increased breast health knowledge and decreased cancer worry during intervention. These data indicate that increases in mammography can be accomplished in population-based mostly insured samples by implementing this simple, low resource intensive intervention.

Implementing an Internet-Delivered Skin Cancer Genetic Testing Intervention to Improve Sun Protection Behavior in a Diverse Population: Protocol for a Randomized Controlled Trial

Background

Limited translational genomic research currently exists to guide the availability, comprehension, and appropriate use of personalized genomics in diverse general population subgroups. Melanoma skin cancers are preventable, curable, common in the general population, and disproportionately increasing in Hispanics.

Objective

Variants in the melanocortin-1 receptor (MC1R) gene are present in approximately 50% of the population, are major factors in determining sun sensitivity, and confer a 2-to-3-fold increase in melanoma risk in the general population, even in populations with darker skin. Therefore, feedback regarding MC1R risk status may raise risk awareness and protective behavior in the general population.

Methods

We are conducting a randomized controlled trial examining Internet presentation of the risks and benefits of personalized genomic testing for MC1R gene variants that are associated with increased melanoma risk. We will enroll a total of 885 participants (462 participants are currently enrolled), who will be randomized 6:1 to personalized genomic testing for melanoma risk versus waiting list control. Control participants will be offered testing after outcome assessments. Participants will be balanced across self-reported Hispanic versus non-Hispanic ethnicity (n=750 in personalized genomic testing for melanoma risk arm; n=135 in control arm), and will be recruited from a general population cohort in Albuquerque, New Mexico, which is subject to year-round sun exposure. Baseline surveys will be completed in-person with study staff and follow-up measures will be completed via telephone.

Results

Aim 1 of the trial will examine the personal utility of personalized genomic testing for melanoma risk in terms of short-term (3-month) sun protection and skin screening behaviors, family and physician communication, and melanoma threat and control beliefs (ie, putative mediators of behavior change). We will also examine potential unintended consequences of testing among those who receive average-risk personalized genomic testing for melanoma risk findings, and examine predictors of sun protection at 3 months as the outcome. These findings will be used to develop messages for groups that receive average-risk feedback. Aim 2 will compare rates of test consideration in Hispanics versus non-Hispanics, including consideration of testing pros and cons and registration of a decision to either accept or decline testing. Aim 3 will examine personalized genomic testing for melanoma risk feedback comprehension, recall, satisfaction, and cancer-related distress in those who undergo testing, and whether these outcomes differ by ethnicity (Hispanic vs non-Hispanic), or sociocultural or demographic factors. Final outcome data collection is anticipated to be complete by October 2017, at which point data analysis will commence.

Conclusions

This study has important implications for personalized genomics in the context of melanoma risk, and may be broadly applicable as a model for delivery of personalized genomic feedback for other health conditions.

Predictors of Breast Cancer Worry in a Hispanic and Predominantly Immigrant Mammography Screening Population

OBJECTIVE

Worry about developing breast cancer (BC) has been associated with participation in screening and genetic testing and with follow-up of abnormal screening results. Little is known about the scope and predictors of BC worry in Hispanic and immigrant populations.

METHODS

We collected in-person interview data from 250 self-identified Hispanic women recruited from an urban mammography facility (average age 50.4 years; 82% foreign-born). Women reported whether they worried about developing breast cancer rarely/never (low worry), sometimes (moderate worry), or often/all the time (high worry). We examined whether sociocultural and psychological factors (e.g., acculturation, education, perceived risk), and risk factors and objective risk for BC (e.g., family history, Gail model 5-year risk estimates, parity) predicted BC worry using multinomial and logistic regression.

RESULTS

In multivariable models, women who perceived higher absolute BC risk (odds ratio, 1.66 [95% confidence interval, 1.28-2.14] for a one-unit increase in perceived lifetime risk) and comparative BC risk (e.g., odds ratio, 2.73, 95% confidence interval, 1.23-6.06) were more likely to report high BC worry than moderate or low BC worry. There were no associations between BC worry and indicators of objective risk or acculturation.

CONCLUSIONS

In Hispanic women undergoing screening mammography, higher perceptions of BC risk, in both absolute and comparative terms, were associated independently with high BC worry, and were stronger predictors of BC worry than indicators of objective BC risk, including family history, mammographic density, and personal BC risk estimates.

Internet-based physical activity intervention for women with a family history of breast cancer

OBJECTIVE

Physical inactivity is a modifiable risk factor for breast cancer. Physical activity interventions that can be delivered through the Internet have the potential to increase participant reach. The efficacy of an Internet-based physical activity intervention was tested in a sample of women at an elevated risk for breast cancer.

METHOD

A total of 55 women with at least 1 first-degree relative with breast cancer (but no personal history of breast cancer) were randomized to a 3-month theoretically grounded Internet-based physical activity intervention or an active control arm. Minutes of moderate to vigorous physical activity, psychosocial mediators of physical activity adoption and maintenance, as well as worry and perceived risk of developing breast cancer were assessed at baseline, 3-month, and 5-month follow up.

RESULTS

Participants were on average 46.2 (SD = 11.4) years old with a body mass index of 27.3 (SD = 4.8) kg/m2. The intervention arm significantly increased minutes of moderate to vigorous physical activity compared to the active control arm at 3 months (213 vs. 129 min/week) and 5 months (208 vs. 119 min/week; both ps < .001). Regression models indicated that participants in the intervention had significantly higher self-efficacy for physical activity at 3 months (p < .01) and borderline significantly higher self-efficacy at 5 months (p = .05). Baseline breast cancer worry and perceived risk were not associated with physical activity.

CONCLUSION

Findings from this study suggest that an Internet-based physical activity intervention may substantially increase physical activity in women with a family history of breast cancer.

Prospective Study of Surgical Decision-making Processes for Contralateral Prophylactic Mastectomy in Women With Breast Cancer

OBJECTIVE

We prospectively examined the psychosocial predictors and the decision-making process regarding contralateral prophylactic mastectomy (CPM) among women with sporadic breast cancer.

BACKGROUND

Increasing numbers of women with breast cancer are seeking CPM. Data are limited about the surgical decision-making process and the psychosocial factors that influence interest in CPM.

METHODS

Women with early-stage unilateral breast cancer (n = 117) were recruited before their first surgical visit at MD Anderson and completed questionnaires assessing knowledge of and interest in CPM and associated psychosocial factors. After the appointment, women and their surgeons completed questions about the extent that various surgical options (including CPM) were discussed; also, the women rated their perceived likelihood of having CPM and the surgeons rated the appropriateness of CPM.

RESULTS

Before their first visit, 50% of women were moderately to extremely interested in CPM and 12 (10%) of women had CPM at the time of their primary breast cancer surgery. Less knowledge about breast cancer (P = 0.02) and greater cancer worry (P = 0.03) predicted interest in CPM. Greater cancer worry predicted who had CPM (P = 0.02). Interest in CPM before surgical visit and the likelihood of having CPM after the visit differed (P ≤ 0.001). Surgeons' rating of the appropriateness of CPM and the patient's reported likelihood of having CPM were not significantly different (P = 0.49).

CONCLUSIONS

Interest in CPM is common among women with sporadic breast cancer. The informational and emotional aspects of CPM may affect the decision to have CPM and should be addressed when discussing surgical options.

Deliberative and intuitive risk perceptions as predictors of colorectal cancer screening over time

Cancer risk perceptions may involve intuitions-including both affect as well as gut-level thoughts about risk-and deliberative risk magnitudes. Yet, little research has examined the potentially diverse relations between risk perceptions and behavior across time. A highly diverse primary care sample (N = 544, aged ≥50) was utilized to compare how deliberative and intuitive perceptions of risk relate to chart-confirmed colorectal cancer screening at cross-sectional and prospective time points. At baseline, deliberative and intuitive risk perceptions were negatively associated with chart-confirmed colorectal cancer screening adherence in bivariable but not multivariable analyses. Among those who were non-adherent with colorectal cancer screening at baseline, deliberative and intuitive risk perceptions were positively associated with prospective uptake of chart-confirmed colorectal cancer screening adherence at 12-months in bivariable analyses; only deliberative risk perceptions remained significant in the multivariable model. This study indicates that diverse risk perceptions are differentially important for screening at different time points.

The impact of risk-reducing gynaecological surgery in premenopausal women at high risk of endometrial and ovarian cancer due to Lynch syndrome

Women with Lynch syndrome (LS) have a significantly increased lifetime risk of endometrial cancer (40-60 %) and ovarian cancer (7-12 %). Currently there is little evidence to support the efficacy of screening for the early detection of these cancers. Another option is risk-reducing hysterectomy and/or bilateral salpingo-oophorectomy (BSO). Research on the impact of BSO in premenopausal women with a non-LS associated family history cancer has generally shown that women have a high level of satisfaction about their decision to undergo surgery. However, debilitating menopausal symptoms and sexual dysfunction are common post-surgical problems. We used a mixed methods study to explore the impact of risk-reducing gynaecological surgery in women with LS: 24 women were invited to take part; 15 (62.5 %) completed validated questionnaires and 12 (50 %) participated in semi-structured interviews. Our results suggest that risk reducing surgery does not lead to significant psychological distress and the women tend not to think or worry much about developing cancer. However, they tend to be distressed about the physical and somatic symptoms associated with menopause; their social well-being is somewhat affected, but sexual difficulties are minimal. The women reported being overwhelmingly satisfied with their decision to have surgery and with the quality of information they received prior to the operation. However, they felt underprepared for menopausal symptoms and received conflicting advice about whether or not to use HRT. Recommendations from the study include that professionals discuss the menopause, its side effects and HRT in detail prior to surgery.

Cervical cancer worry and screening among appalachian women

Although many have sought to understand cervical cancer screening (CCS) behavior, little research has examined worry about cervical cancer and its relationship to CCS, particularly in the underserved, predominantly rural Appalachian region. Our mixed method investigation aimed to obtain a more complete and theoretically-informed understanding of the role of cancer worry in CCS among Appalachian women, using the Self-Regulation Model (SRM). Our quantitative analysis indicated that the perception of being at higher risk of cervical cancer and having greater distress about cancer were both associated with greater worry about cancer. In our qualitative analysis, we found that, consistent with the SRM, negative affect had a largely concrete-experiential component, with many women having first-hand experience of the physical consequences of cervical cancer. Based on the results of this manuscript, we describe a number of approaches to lessen the fear associated with CCS. Intervention in this elevated risk community is merited and may focus on decreasing feelings of worry about cervical cancer and increasing communication of objective risk and need for screening. From a policy perspective, increasing the quantity and quality of care may also improve CCS rates and decrease the burden of cancer in Appalachia.

Impact of Genetic Counseling and Testing on Altruistic Motivations to Test for BRCA1/2: a Longitudinal Study

Despite the importance of altruism in an individual's participation in genetic counseling and testing, little research has explored the change in altruistic motivations to test over time. This study analyzed altruistic motivations to test and change in altruistic motivations after genetic counseling and testing among individuals (N = 120) at elevated risk for BRCA1/2 mutations. The perceived benefits of genetic testing were assessed and utilized in a mixed-methods, repeated measures design at three time points: pre-counseling, counseling and post-genetic testing, along with transcripts of genetic counseling sessions. Qualitative analysis using an immersion/crystallization method resulted in six common perceived benefits of testing: cancer prevention, awareness, family's survival, relief from anxiety, for science, and future planning. Perceived benefits were then coded into three categories according to Hamilton's kin selection theory: altruistic motivation, personal motivation, and motivation for mutual benefit. At pre-counseling, those with a personal cancer history (p = 0.003) and those with one or more children (p = 0.013), were significantly more likely to cite altruistic motivations to test. Altruistic motivations significantly increased post-counseling (p = 0.01) but declined post-testing (p < 0.001). Labov's narrative analysis further elucidated the context of altruistic and personal motivations. The possibility of a positive test result might have led those with personal history of cancer to have altruistic motivations for testing. Genetic counseling may have increased altruistic motivations to help family and may be a prime opportunity to discuss other forms of altruism.

Relationship between Cancer Worry and Stages of Adoption for Breast Cancer Screening among Korean Women

Background

The possibility of developing breast cancer is a concern for all women; however, few studies have examined the relationship between cancer worry and the stages of adoption for breast cancer screening in Korea. Here, we investigated the associations between cancer worry, the stages of adopting breast cancer screening, and socio-demographic factors known to influence screening behaviors.

Methods

This study was based on the 2013 Korean National Cancer Screening Survey, an annual cross-sectional survey that utilized nationally representative random sampling to investigate cancer screening rates. Data were analyzed from 1,773 randomly selected women aged 40–74 years. Chi-squared tests and multinomial logistic analyses were conducted to determine the associations between cancer worry and the stages of adoption for breast cancer screening and to outline the factors associated with each stage.

Results

Korean women were classified into the following stages of adoption for breast cancer screening: pre-contemplation (24.7%), contemplation (13.0%), action/maintenance (50.8%), relapse risk (8.9%), and relapse (2.6%). Women in the action/maintenance stages reported more moderate to higher levels of worry about getting cancer than those in the pre-contemplation stage. Further, age of 40–49 years and having private cancer insurance were associated with women in the action/maintenance stages.

Conclusion

Interventions to address breast cancer worry may play an important role in increasing participation and equity in breast cancer screening.

Incorporating a Psychological Counselor in a Cancer Risk Assessment Program: Necessity, Acceptability, and Potential Roles

Evidence suggests that cancer risk assessment may be associated with increased psychological distress. This exploratory study assessed the necessity and acceptability of incorporating psychological counseling into routine clinic procedures at a cancer risk program. Following a visit to a university-based cancer risk clinic, patients (N = 102) completed an anonymous self-report instrument. Participants reported experiencing current stress and anxiety (41%), depression (29%), and suicidal ideation (2%). Patients with a history of cancer were more likely to be experiencing current emotional difficulties. Sixty-nine percent of the participants found the visit with the psychological counselor to be helpful, while 41% of the participants reported interest in follow-up psychological services. Interest in receiving future psychological services was positively correlated with levels of anxiety, depression, and cancer worry. This pilot study demonstrates the acceptability and potential role for psychological counselors in increasing adjustment in high-risk patients undergoing genetic counseling for inherited cancers.

Breast cancer screening: an evidence-based update

Routine screening mammography is recommended by most groups issuing breast cancer screening guidelines, especially for women 50 years of age and older. However, both the potential benefits and risks of screening should be discussed with individual patients to allow for shared decision making regarding their participation in screening, age of commencement and conclusion, and interval of mammography screening.

Optimism and depression: a new look at social support as a mediator among women at risk for breast cancer

OBJECTIVE

Breast cancer risk is a chronic stressor associated with depression. Optimism is associated with lower levels of depression among breast cancer survivors. However, to our knowledge, no studies have explored the relationship between optimism and depression among women at risk for breast cancer. We hypothesized that women at risk for breast cancer who have higher levels of optimism would report lower levels of depression and that social support would mediate this relationship.

METHOD

Participants (N = 199) with elevated distress were recruited from the community and completed self-report measures of depression, optimism, and social support. Participants were grouped based on their family history of breast cancer. Path analysis was used to examine the cross-sectional relationship between optimism, social support, and depressive symptoms in each group.

RESULTS

Results indicated that the variance in depressive symptoms was partially explained through direct paths from optimism and social support among women with a family history of breast cancer. The indirect path from optimism to depressive symptoms via social support was significant (β = -.053; 90% CI = -.099 to -.011, p = .037) in this group. However, among individuals without a family history of breast cancer, the indirect path from optimism to depressive symptoms via social support was not significant.

CONCLUSIONS

These results suggest that social support partially mediates the relationship between optimism and depression among women at risk for breast cancer. Social support may be an important intervention target to reduce depression among women at risk for breast cancer.

Expected survival with and without second-line palliative chemotherapy: who wants to know?

BACKGROUND

According to surveys, many patients with advanced cancer wish to receive survival information.

OBJECTIVE

This study investigated information preferences by offering patients a decision aid (DA) with information on expected survival for two treatment options: supportive care with or without second-line palliative chemotherapy. Predictors of accepting survival information were explored.

DESIGN

Eligible patients in this multicentre prospective study were offered second-line chemotherapy for advanced breast or colorectal cancer. A nurse presented a DA on second-line treatment and asked patients whether they desired information on (i) adverse events, (ii) tumour response and (iii) survival. Data on 50 clinical and psychosocial patient characteristics were collected from inclusion forms and patient questionnaires.

RESULTS

Seventy-seven patients received a DA; median age 62 years (range 32-80), 61% female, 77% colorectal cancer. Fifty-seven patients (74%; 95% CI 64-84) desired survival information. Four psychosocial characteristics (e.g. deliberative decision style) independently predicted information desire. However, the use of these characteristics to predict information desire hardly outperformed a simple prediction rule.

CONCLUSIONS

Many patients desired information on expected survival when deciding about second-line treatment. However, our exploratory analysis indicated that patients desiring this information could not be identified based on their clinical or psychosocial characteristics. These findings can help encourage candid discussions about expected survival. Health professionals should be careful not to make implicit assumptions of information desire based on patient characteristics, but to explicitly ask patients if survival information is desired, and act accordingly.

Online support: Impact on anxiety in women who experience an abnormal screening mammogram

OBJECTIVES

To determine whether an online support tool can impact anxiety in women experiencing an abnormal mammogram.

MATERIALS AND METHODS

We developed an online support system using the Comprehensive Health Enhancement Support System (CHESS) designed for women experiencing an abnormal mammogram as a model. Our trial randomized 130 of these women to online support (the intervention group) or to a list of five commonly used Internet sites (the comparison group). Surveys assessed anxiety and breast cancer worry, and patient satisfaction at three important clinical time points: when women were notified of their abnormal mammogram, at the time of diagnostic imaging, and at the time of biopsy (if biopsy was recommended).

RESULTS

Study participants in the intervention group showed a significant decrease in anxiety at the time of biopsy compared to the comparison group (p = 0.017). However, there was no significant difference in anxiety between the intervention group and the comparison group at the time of diagnostic work-up. We discontinued assessment of patient satisfaction after finding that many women had substantial difficulty answering the questions that referenced their physician, because they did not understand who their physician was for this process of care.

CONCLUSION

The combination of the inability to identify the physician providing care during the mammography work-up and anxiety effects seen only after an interaction with the breast imaging team may indicate that online support only decreases the anxiety of women in concert with direct interpersonal support from the healthcare team.

Patient-reported hereditary breast and ovarian cancer in a primary care practice

Identifying women appropriate for cancer genetic counseling referral depends on patient-reported family history. Understanding predictors of reporting a high-risk family is critical in ensuring compliance with current referral guidelines. Our objectives were to (1) assess prevalence of candidates for BRCA1 and BRCA2 counseling referral in a primary care setting, (2) explore associations with high-risk status and various patient (e.g., race) and family structure (e.g., number of relatives) characteristics, and (3) determine whether high-risk patients had genetic counseling and/or testing. Survey and pedigree data were collected between 2010 and 2012 for 486 Women's Health Clinic patients. Analyses in 2013 investigated perceived cancer risk and worry, family structure, and receipt of genetic counseling. We explored whether these were associated with meeting USPSTF guidelines for genetic counseling referral. Twenty-two (4.5 %) women met the criteria for BRCA referral. Only one of these women had previous genetic counseling, and one reported prior genetic testing. Older women were more likely to meet BRCA referral criteria (P < 0.001). Although perceived risk was higher among high-risk women, 27 % of high-risk women felt their breast cancer risk was "low", and 32 % felt their risk was lower than average. About one in 22 women in primary care may require genetics services for hereditary breast and ovarian cancer, but alarmingly, few actually receive these services. Also, a significant proportion do not perceive that they are at increased risk. Educational interventions may be needed for both providers and patients to increase awareness of familial risk and appropriate genetic counseling services.

Predictors of colonoscopy use one year after colonoscopy: prospective study of surveillance behavior for colorectal cancer

We hypothesized that perceived risk of colorectal cancer (CRC) and CRC worry would be the main predictors of surveillance behavior in patients undergoing colonoscopy. We therefore assessed factors predicting colonoscopy use for re-examination one year after colonoscopy. Patients who had undergone colonoscopy and were scheduled for re-examination one year later were recruited. Patients were administered questionnaires after baseline colonoscopy assessing demographic factors, perceived risk, CRC worry, cancer preventability, knowledge of CRC and results of colonoscopy. We confirmed whether participants underwent colonoscopy re-examinations one year later (follow-up). Finally, 56 participants completed the research and were used in the final analysis (response rate = 65.1%). We found that 37.5% of the participants who underwent baseline colonoscopy underwent follow-up colonoscopy one year later. Follow-up colonoscopy was not significantly associated with any psychological variables, but was significantly associated with educational status (postsecondary) (odds ratio [OR] = 7.10, 95% confidence interval [CI] = 1.83-27.56) and the results of baseline colonoscopy in patients who did not undergo polypectomy but had remaining polyps (OR = 4.26, 95% CI = 1.02-17.84). Additionally, significant differences in cancer threat-related variables were observed among groups of patients who, during baseline colonoscopy, underwent polypectomy but had no remaining polyps, had polyps removed with some polyps remaining, or did not undergo polypectomy but had remaining polyps (p < .05), with the latter group having a significant relationship with repeat colonoscopy. Cancer threat-related variables were not predictive of repeat colonoscopy after one year. In contrast, patient educational status and the colonoscopy results were predictors. We also found a non-linear relationship between high CRC threat and inhibition of the screening behavior in that the CRC threat functions as motivation for the surveillance behavior of colonoscopy.

Risk perception, worry, and test acceptance in average-risk women who undergo ovarian cancer screening

OBJECTIVE

We evaluated baseline knowledge of ovarian cancer risk and perceptions toward ovarian cancer screening (OCS) by initiating the normal risk ovarian screening study.

STUDY DESIGN

Average-risk, postmenopausal women were enrolled between 2001 and 2011 as they entered the normal risk ovarian screening study. Participants completed baseline surveys of risk perception, cancer worry (Cancer Worry Scale), anxiety (State-Trait Anxiety Inventory), health and well-being survey (SF-36 HEALTH SURVEY), and acceptability of OCS.

RESULTS

Of the 1242 women who were enrolled, 925 women (74.5%) completed surveys. The respondents estimated a mean lifetime risk of ovarian cancer of 29.9%, which is much higher than the actual risk of 1.4% for women in the United States. Only 2.8% of participants correctly estimated their risk; 35.4% of the participants reported their lifetime risk to be ≥50%. Cancer worry was low, with a median Cancer Worry Scale score of 7 of 24. Anxiety was comparable with published norms for women in this age group, with median STAI-State and STAI-Trait scores of 30 and 29 of 80, respectively. Overall, women reported good physical and mental well-being. In terms of OCS acceptability, 97.2% of respondents agreed or strongly agreed that "the benefits of screening outweigh the difficulties." Very few women were reluctant to undergo OCS because of time constraints (1.1%), pain (2.0%), or embarrassment (1.9%).

CONCLUSION

Average-risk women who underwent OCS highly overestimated their risk of ovarian cancer. Despite this, participants reported low cancer worry and anxiety. The discrepancy between knowledge of and attitudes toward ovarian cancer risk highlights the need for educational efforts in this area.

Associations between cancer-related information seeking and receiving PET imaging for routine cancer surveillance--an analysis of longitudinal survey data

BACKGROUND

Routine cancer surveillance with positron emission tomography (PET) is not recommended for most patients who have completed curative treatment for cancer. Yet, recent trends suggest that PET is increasingly used for follow-up among patients with cancer. This study investigates whether information-seeking behaviors predicted self-reported utilization of PET for routine surveillance in patients with colorectal, breast, and prostate cancer.

METHODS

We conducted annual surveys for 3 years in a cohort of Pennsylvania cancer survivors diagnosed with colorectal, breast, or prostate cancer in 2005. The outcome was self-reported PET receipt for routine surveillance among 944 patients diagnosed with nonmetastatic disease (stages 0-III). Predictors included cancer-related information seeking from nonmedical sources and providers. Weighted multiple logistic regression analyses were performed.

RESULTS

In this population, 11% of patients reported receiving at least one PET scan for routine follow-up in a 12-month period several years after diagnosis. Seeking cancer-related information from nonmedical sources was associated with higher odds of subsequent reported PET use [OR, 3.7; 95% confidence interval (CI), 1.1-12.1; P = 0.032], after adjusting for potential confounders. Patient engagement with physicians about cancer-related information was not a significant predictor.

CONCLUSIONS

Overall reported PET utilization for routine surveillance of colorectal, breast, and prostate cancer is low. However, we found a significant association with information seeking from nonmedical sources but not from providers.

IMPACT

Exposure to cancer-related information through mass media and lay interpersonal sources may be driving inappropriate utilization of high-cost advanced imaging procedures. These findings have important implications for cancer survivors, healthcare providers, and health policy.

Addressing women's breast cancer risk and perceptions of control in medical settings

Many women with family histories of breast cancer deal with two distinct but related issues: their objective physical risk and the emotions this risk engenders. Studies indicate that approximately 70% of African American and white women are concerned about their chances of developing breast cancer someday and perceive themselves to be at risk. Health care providers, including psychologists, need to be aware of the special needs and psychosocial concerns of high-risk women with family histories of breast cancer, since perceptions of breast cancer risk influence screening practices. Providers need training in understanding the significance of specific family patterns of breast cancer, screening guidelines appropriate for women at risk, and the benefits and risks of available prevention options, including genetic screening. Delivering accurate information about both established risk factors known to elevate personal risk, such as age and family history, and factors which women associate with breast cancer, such as bumping and bruising a breast, smoking, and oral contraceptive use, is essential for promoting accurate risk perceptions and appropriate screening schedules.

The effectiveness of a graphical presentation in addition to a frequency format in the context of familial breast cancer risk communication: a multicenter controlled trial

Background

Inadequate understanding of risk among counselees is a common problem in familial cancer clinics. It has been suggested that graphical displays can help counselees understand cancer risks and subsequent decision-making. We evaluated the effects of a graphical presentation in addition to a frequency format on counselees’ understanding, psychological well-being, and preventive intentions.

Design: Multicenter controlled trial.

Setting: Three familial cancer clinics in the Netherlands.

Methods

Participants: Unaffected women with a breast cancer family history (first-time attendees).

Intervention: Immediately after standard genetic counseling, an additional consultation by a trained risk counselor took place where women were presented with their lifetime breast cancer risk in frequency format (X out of 100) (n = 63) or frequency format plus graphical display (10 × 10 human icons) (n = 91).

Main outcome measures: understanding of risk (risk accuracy, risk perception), psychological well-being, and intentions regarding cancer prevention. Measurements were assessed using questionnaires at baseline, 2-week and 6-month follow-up.

Results

Baseline participant characteristics did not differ between the two groups. In both groups there was an increase in women’s risk accuracy from baseline to follow-up. No significant differences were found between women who received the frequency format and those who received an additional graphical display in terms of understanding, psychological well-being and intentions regarding cancer prevention. The groups did not differ in their evaluation of the process of counseling.

Conclusion

Women’s personal risk estimation accuracy was generally high at baseline and the results suggest that an additional graphical display does not lead to a significant benefit in terms of increasing understanding of risk, psychological well-being and preventive intentions.

Trial registration

Current Controlled Trials http://ISRCTN14566836

Engaging in health behaviors to lower risk for breast cancer recurrence

PURPOSE

While post-treatment breast cancer survivors face up to twice the cancer risk of the general population, modifiable health behaviors may somewhat reduce this risk. We sought to better understand health behaviors that early stage breast cancer survivors engage in to reduce recurrence risk.

METHODS

Data came from a cross-sectional multi-site survey of 186 early-stage breast cancer survivors who received genomic testing for breast cancer recurrence risk (Oncotype DX) during their clinical care. Study outcomes were meeting health behavior recommendations (daily fruit and vegetable intake, regular physical activity, and having a healthy body mass index (BMI)).

RESULTS

Approximately three-quarters of survivors we surveyed believed the 3 behaviors might reduce their cancer risk but many did not engage in these behaviors for this purpose: 62% for BMI, 36% for fruit and vegetable consumption, and 37% for physical activity. Survivors with higher recurrence risk, as indicated by their genomic test results, were no more likely to meet any of the three health behavior recommendations. Adherence to health behavior recommendations was higher for women who were white, college-educated, and had higher incomes.

CONCLUSIONS

Many nonadherent breast cancer survivors wish to use these behavioral strategies to reduce their risk for recurrence, suggesting an important opportunity for intervention. Improving BMI, which has the largest association with cancer risk, is an especially promising target.