Psychological distress and surveillance behaviors of women with a family history of breast cancer

Probability of carrying a mutation of breast-ovarian cancer gene BRCA1 based on family history

BACKGROUND

Heritable mutations of the breast cancer gene BRCA1 are rare, occurring in fewer than 1% of women in the general population, and therefore account for a small proportion of cases of breast and ovarian cancers. Nevertheless, the presence of such mutations is highly predictive of the development of these cancers.

PURPOSE

We developed and applied a mathematic model for calculating the probability that a woman with a family history of breast and/or ovarian cancer carries a mutation of BRCA1.

METHODS AND RESULTS

As a basis for the model, we use Mendelian genetics and apply Bayes' theorem to information on the family history of these diseases. Of importance are the exact relationships of all family members, including both affected and unaffected members, and ages at diagnosis of the affected members and current ages of the unaffected members. We used available estimates of BRCA1 mutation frequencies in the general population and age-specific incidence rates of breast and ovarian cancers in carriers and noncarriers of mutations to estimate the probability that a particular member of the family carries a mutation. This probability is based on cancer statuses of all first- and second-degree relatives. We first describe the model by considering single individuals: a woman diagnosed with breast and/or ovarian cancer and also a woman free of cancer. We next considered two artificial and two actual family histories and addressed the sensitivity of our calculations to various assumptions. Particular relationships of family members with and without cancer can have a substantial impact on the probability of carrying a susceptibility gene. Ages at diagnosis of affected family members and their types of cancer are also important. A woman with two primary cancers can have a probability of carrying a mutation in excess of 80%, even with no other information about family history. The number and relationships of unaffected members, along with their current ages or ages at death, are critical determinants of one's carrier probability. An affected woman with several cancers in her family can have a probability of carrying a mutation that ranges from close to 100% to less than 5%.

CONCLUSION

Our model gives informative and specific probabilities that a particular woman carries a mutation.

IMPLICATIONS

This model focuses on mutations in BRCA1 and assumes that all other breast cancer is sporadic. With the cloning of BRCA2, we now know that this assumption is incorrect. We have adjusted the model to include BRCA2, but the use of this version must await publication of penetrance data for BRCA2, including those for male breast cancer that are apparently associated with BRCA2 but not with BRCA1. The current model is, nevertheless, appropriate and useful. Of principal importance is its potential and that of improved versions for aiding women and their health care providers in assessing the need for genetic testing.

Cancer genetic susceptibility testing: ethical and policy implications for future research and clinical practice. Cancer Genetic Studies Consortium, National Institutes of Health

Authors examine the ethical and health policy implications in the Cancer Genetic Studies Consortium projects, which attempt to collect data on the clinical benefits and harms of cancer genetic testing. They suggest that more data are needed on the long-term physical and psychosocial effects of testing and that further examination is needed of the ethical issues raised by testing.

The influence of risk factors on breast carcinoma screening of Medicare-insured older women. National Cancer Institute Breast Cancer Screening Consortium

BACKGROUND

It is not certain whether older women with additional breast carcinoma risk factors are adequately screened or whether they are more likely to undergo screening than other older women. This study was conducted to determine whether selected risk factors influence the breast carcinoma screening rates of Medicare-insured older women (i.e., age 65 years or older).

METHODS

Self-reported rates of screening mammography and clinical breast examination in the previous year were compared for women with benign breast disease, women with a family history of breast carcinoma, and women lacking these risks, using samples of non-Hispanic white, Medicare-insured women surveyed at the 5 National Cancer Institute Breast Cancer Screening Consortium sites in 1991 (n = 5376, mean age = 69.7 years) and 1994 (n = 5086, mean age = 69.7 years).

RESULTS

In 1993, rates of screening mammography reported in the previous year at the 5 Consortium sites had a range of 46-61% for women with a family history of breast carcinoma, 49-66% for women with benign breast disease, and 31-43% for women lacking these risks. Women with a positive family history or a personal history of benign breast disease were also more likely to report having had a clinical breast examination in the previous year and having received a physician's mammography recommendation. A substantial proportion of older women with a positive family history remain inadequately screened, however. Between 25% and 35% of women in this group had not had a screening mammogram in the previous 2 years, while at some Consortium sites more than 20% reported never having had a mammogram in their lives.

CONCLUSIONS

Older women with additional risk factors are more likely to undergo screening mammography. This is due partly to more frequent physician recommendations for screening and partly to more frequent provision of clinical breast examinations. However, a substantial proportion of high risk older women remain inadequately screened, despite widespread clinical consensus that these women should be regularly screened. Interventions that target older women with risk factors and their physicians appear warranted. Understanding the mechanisms by which risk factors influence screening is an important area for future research.

Notification of a family history of breast cancer: issues of privacy and confidentiality

Little information is available about notifying individuals with a family history of cancer about their risk of cancer. With the recent identification of BRCA1, an important predisposition gene for breast and ovarian cancer, genetic testing is becoming available to high-risk women and their families. Some of these individuals, may not be aware of their family history and may be notified of their family history by medical personnel or biomedical investigators. This disclosure could be detrimental to the individual by changing their perception of risk, sense of privacy, or psychosocial well-being. Members of 544 breast cancer families are currently being contacted as part of an epidemiologic follow-up study at the University of Minnesota. Some family members were unaware of their relative's diagnosis and therefore, notification occurred when they were contacted by study personnel. To determine the impact of risk notification in this context, 376 male and female relatives of 160 breast cancer probands were surveyed to assess their prior knowledge of their family history of cancer, issues relating to study participation, and their concerns regarding the possibility of developing cancer. Following a telephone interview about family history, family members were administered a short, open-ended questionnaire. The majority of individuals (82%) were blood relatives of the proband and 71% were either first- or second-degree relatives. A proportion of blood relatives (24%) were not aware of their family history of breast cancer. More blood relatives (76%) than nonblood relatives (62%, P < 0.01) were aware of their family history. 43 respondents (12%) expressed specific concerns about participating in the large genetic follow-up study and 16 comments concerned privacy issues. Neither the reasons for participation nor an individual's concern about developing cancer was associated with gender of the respondent, relationship to the proband, or awareness of breast cancer in the family. Interestingly, individuals who were notified about their family history through the large follow-up study were no more likely than other family members to be more concerned about developing cancer. Understanding the privacy and psychosocial issues of family members who are informed about a family history of breast cancer may aid in developing appropriate guidelines for notification. Risk notification in this setting does not appear to have a significant impact on these family members.

Familial breast cancer: a controlled study of risk perception, psychological morbidity and health beliefs in women attending for genetic counselling

The present study set out to evaluate perceptions of risk, psychological morbidity and health behaviours in women with a family history of breast cancer who have attended genetic counselling and determine how these differ from general population risk women. Data were collected from 62 genetic counselees (cases) attending the Royal Marsden and Mayday University Hospital genetic counselling services and 62 matched GP attenders (controls). Levels of general psychological morbidity were found to be similar between cases and controls; however, cases reported significantly higher breast cancer-specific distress despite clinic attendance [mean (s.d.) total Impact of Event Scale score, 14.1 (14.3) cases; 2.4 (6.7) controls, P < 0.001]. Although cases perceived themselves to be more susceptible to breast cancer, many women failed correctly to recall risk figures provided by the clinic; 66% could not accurately recall their own lifetime chance. Clinics appeared to have a positive impact on preventive behaviours and cases tended to engage more regularly in breast self-examination (monthly, 66% of cases vs 47% of controls), although few differences were found between groups in terms of health beliefs. We conclude that counselees and GP controls showed considerable similarities on many of the outcome measures, and risk of breast cancer was not predictive of greater psychological morbidity; although cases were more vulnerable to cancer-specific distress. Despite genetic counselling, many cases continued to perceive their risk of breast cancer inaccurately.

Information, support, and communication needs of women with a family history of breast cancer

In this article, the role of information, support, and communication in promoting adaptation to the risk of breast cancer is reported. These variables emerged from an in-depth study of women at risk for breast cancer because of breast cancer in one or more of their primary (first degree) relatives. Fifty-five women with mothers, sisters, mother and sister, or mother and another primary relative were interviewed using in-depth semi-structured, tape-recorded interviews. After transcription, data were analyzed using qualitative analysis procedures. A three-phase process of adaptation to the risk of breast cancer was uncovered, which was subsequently validated with two study participants. Information, support, and communication emerged as important factors in facilitating the adjustment of women throughout the three phases of the process: as women "lived" the breast cancer experience of their relative; as they developed a perception of their personal risk for breast cancer; and finally as they put the risk of breast cancer "in its place." Despite the importance of information and support, most women had difficulty meeting these needs. Also, communication patterns both within the family and with health professionals were generally not helpful for these women. Issues related to the ill relative as "manager" of cancer-related information, the "ownership style" of the woman at risk, and the accessibility and availability of resources influenced women's adaptation to feelings of risk. Women's needs for information, support, and communication and facilitating factors are described in detail, and recommendations for clinical practice and research offered.

Participation in a women's breast cancer risk counseling trial. Who participates? Who declines? High Risk Breast Cancer Consortium

BACKGROUND

Little is known about what factors influence women to participate its trials designed for women at high risk for breast cancer. Yet the recruitment phase is of utmost importance in determining whether the trial can achieve its goals. The purpose of this study was to examine predictors of participation in a risk counseling trial for first-degree relatives of breast cancer patients.

METHODS

Subjects were identified by their relatives who had received a diagnosis of breast cancer at one of six institutions. Letters of introduction were sent to potentially eligible, unaffected relatives. They were informed about the risk counseling study and given the opportunity to decline. Letters were sent to 1392 first-degree relatives; of these, 1149 women were contacted for an interview and 14% refused. Of the 987 respondents, 47% accepted and 53% declined to participate. Bivariate and multivariate statistics were used to examine predictors of participation.

RESULTS

In the total sample, there were five significant multivariable predictors of participation: level of education, recent clinical breast examination (CBE), objective and perceived breast cancer risk, and any current use of alcohol. Participation was moderated by time since the relative's diagnosis. There was a statistically significant relationship to education such that women with a higher level of education were significantly more likely to participate if they were approached within 2 months of their relative's diagnosis of breast cancer.

CONCLUSIONS

Like many other kinds of trials, participants in this risk counseling trial were significantly more likely to have more than a high school education and more likely to be nonsmokers than the nonparticipants. They also were significantly more likely to drink alcohol (dichotomous measure), have had a recent CBE, and have higher subjective and objective breast cancer risks. Different types of recruitment strategies may be needed depending on the characteristics of the people being recruited and the timing of the invitation.

Hereditary breast cancer

An overview is provided of the genetics of hereditary breast cancer, as well as the clinical aspects and the management of this disease. In September 1994 a new breast cancer gene, BRCA 2, was located and BRCA 1, discovered in 1990, was sequenced (Miki et al., 1994; Wooster et al., 1994). The implications of these discoveries are immense. Tests are now available to women who have a family history of breast cancer that can determine if they carry one of these defective genes. The genetic nurse specialist can play a huge role in counselling women who wish to have predictive testing and in advising them about screening and risk.

Cancer genetics clinics: target population and consultees' expectations

The aim of this study was to determine in healthy consultees attending cancer genetics clinics their risk status, their pathways leading to the clinics, their expectations and perception of cancer risk. In 1994, the consultees at six French centres completed a questionnaire before their first oncogenetic consultation. The oncogeneticists subsequently filled in a standardised form giving their risk assessment. Among the 206 healthy consultees, 91.3% were women, 92.2% had at least one cancer-affected first-degree relative and 73% had a "cancer family risk" as assessed by the oncogeneticist. Sixty-nine per cent of the consultees were referred to the clinics by a physician, 10.4% by their family and 18.8% on their own initiative: 83.5% of the sample perceived their family risk of cancer as being high and this belief was confirmed in 74.3% of the cases studied by the oncogeneticist. The families of self-referred consultees were less often at risk than those of consultees referred by a physician or by their family (P = 0.012). The majority (78%) expected to be informed about cancer prevention and screening, and this expectation depended on the consultee's level of education (P = 0.001). This study shows that medical pathways are more effective than the media as a means of reaching the members of the general population who are genuinely at risk, and shows that fuller information about prevention needs to be provided at cancer genetic consultations.

Overview of natural history, pathology, molecular genetics and management of HNPCC (Lynch Syndrome)

Hereditary non-polyposis colorectal cancer (HNPCC) predisposes to cancers of the colon, endometrium and several other extra-colonic sites in the absence of premonitory physical stigmata (Muir-Torre syndrome excepted). Discovery of the several DNA mismatch repair genes (hMSH2, hMLH1, hPMS1, hPMS2) holds the potential for determining the cancer destiny of patients, theoretically in utero. Pre-symptomatic DNA testing is now possible in patients from HNPCC families and will be clinically available once inexpensive and simple tests for these germ-line mutations have been effected. Genetic counseling will be mandatory, given the myriad socio-psychological, insurance, and potentially other personal issues which may impact this knowledge. New findings in the pathology of HNPCC, particularly an increased frequency of interval cancers and the likely accelerated rate of the adenoma to cancer sequence, indicate the need for more frequent colonoscopic surveillance with an option for prophylactic subtotal colectomy in germ-line-positive individuals.

The effect of an educational intervention on the perceived risk of breast cancer

OBJECTIVE

To appraise women's perceived risk of developing breast cancer and the effects of a physician's educational intervention on this perception.

DESIGN

Longitudinal before-and-after study involving four measures of participants risk of developing breast cancer. Eligible women provided the data needed to calculate an objective estimate of their individual risk of developing breast cancer before age 80 using the Gail formula. They also provided a subjective estimate of their individual perceived risk. Then, each participant met with a general internal medicine physician who provided personalized information and education. Immediately after education, and again several months later, we reassessed each woman's perceived risk.

SETTING

Physicians office.

PARTICIPANTS

A convenience sample of 59 women participating in the Tamoxifen Breast Cancer Prevention Trial. Twenty-nine women returned for the follow-up risk assessment.

MEASUREMENTS AND MAIN RESULTS

The median calculated risk of breast cancer before age 80 (by the Gail formula) was 15%, but the median perceived risk before educational intervention was 50%. The perceived risk after educational intervention fell to 25%. At late follow-up, the median perceived risk remained at 25%. The difference between the preeducational perceptions and the calculated estimates was significant (1) < .0001). After educational intervention, perceived risk measures shifted closer to the calculated value, but still remained significantly higher (p <.0001).

CONCLUSIONS

Women often substantially overestimate their chances of getting breast cancer. Educational intervention by a physician, including explanation of an individual's calculated risk, can reduce this error. The effect of education appears to persist at least for several months.

Ethnic differences in risk perception among women at increased risk for breast cancer

There has been increasing interest in the role of cultural and ethnic factors in breast cancer risk perceptions and screening practices. This study examined ethnic differences in breast cancer risk perception in 112 African American and 224 white women ages 35 and older who had at least one first-degree relative diagnosed with breast cancer. These samples were matched for education and age. Data on breast cancer risk factors, risk perceptions, breast cancer worries, and breast cancer screening practices were collected through structured telephone interviews. The results show that African American women were significantly less likely than white women to report heightened perceptions of personal risk after their relative was diagnosed with breast cancer (61% vs 82%; p < .001). Despite this, African American women had significantly greater concerns about their personal risk of breast cancer and worries about their affected relative. African American women also scored significantly higher than white women on a measure of avoidance of breast cancer-related thoughts and feelings. These psychological variables were associated independently with breast cancer risk perception in multivariate models, taking precedence over demographic and risk factor predictors. Observed ethnic differences in breast cancer risk perceptions and psychological distress may be attributable to the influence of cultural factors particular to people of African descent, such as the importance of interpersonal relationships, spirituality, and time orientation. An Africentric perspective is used to interpret these findings and to provide suggestions for delivering effective breast cancer risk counseling to African American women.

Identification of women at high genetic risk of breast cancer through the National Health Service Breast Screening Programme (NHSBSP)

Breast cancer is a multifactorial disease with an inherited predisposition being implicated in around 5% of all cases. Using previous epidemiological data assessing risks for the relatives of women with breast cancer, we have identified 154 women (from a screened population of 35,505) and 289 of their relatives between 50 and 64 years who have more than twice the age related risk of developing breast cancer. This constitutes 1.24% of the breast screening population attending the North East Scotland NHSBSP. For each woman identified to be at high risk, we have found 1.87 female relatives between 50 and 64 years and 1.85 relatives under 50 years also to be at high risk. Around 78% of the women identified with a significant family history of breast or other cancer have attended for counselling about their risks. The breast screening programme can be used to identify women at high risk of breast cancer in order to offer them (and their relatives) access to genetic counselling and appropriate screening.

Psychosocial and ethical implications of defining genetic risk for cancers

In summary, we need to provide fully informed consent regarding the hazards and the benefits of genetic testing and defining risk. This reflects the first ethical principle of autonomy. It is the responsibility of the counseling team to make sure that the individual is psychologically equipped to deal with the emotional distress that may result from testing. An undue burden must not be placed on someone and harm must not be inflicted. This is the second ethical principle of beneficence. Third, awareness of the potential problems of testing is extremely important. These issues are those of disclosure, insurance problems, and employment problems--the third ethical principle of confidentiality. Recommendations for screening guidelines, regardless of testing results, should be provided. It is important for women who are not gene carriers to know that they still need to go for screening. Lastly, we need to find ways to help individuals cope with their risk status, whether it is actual high risk or perceived high risk. Helping women to develop positive coping strategies and to adhere to screening is extremely important. As the Huntington's data indicated, over time, regardless of their risk levels, individuals do learn how to cope and adapt with the outcome of testing. Women and men need to learn how to live with their risk status so that the negative psychological sequelae will be minimized.

Interest in genetic testing among first-degree relatives of breast cancer patients

The recent cloning of a breast-ovarian cancer susceptibility gene (BRCA1), and determination of the locus of a related gene (BRCA2), offers potential for clinical genetic testing for breast cancer susceptibility. This study examined interest in and expectations about an impending genetic test among first-degree relatives (FDRs) of breast cancer patients. One hundred five females completed two structured telephone interviews to assess demographics, breast cancer risk factors, psychological factors, and attitudes about genetic testing for breast cancer susceptibility. Overall, 91% of FDRs said that they would want to be tested, 4% said they would not, and 5% were uncertain. The most commonly cited reasons for wanting genetic testing were to learn about one's children's risk, to increase use of cancer screening tests, and to take better care of oneself. Women with less formal education were motivated by childbearing decisions and future planning to a greater degree than were women with education beyond high school. Most women anticipated a negative psychological impact of positive test results, involving increased anxiety (83%), depression (80%), and impaired quality of life (46%). In addition, 72% of women indicated that they would still worry if they tested negative. In multivariate regression analysis, level of baseline depression was the strongest predictor of an anticipated negative impact of genetic testing (Beta = .15; P, .0001). These results suggest that the demand for genetic testing for breast cancer susceptibility may be great, even among women who are not likely to have predisposing mutations.(ABSTRACT TRUNCATED AT 250 WORDS)

Update on the differential diagnosis, surveillance and management of hereditary non-polyposis colorectal cancer

Hereditary non-polyposis colorectal cancer (HNPCC) is the most common hereditary form of colorectal cancer (CRC), accounting for approximately 10% of the total CRC burden. HNPCC lacks premonitory physical stigmata, thereby making the family history crucial for diagnosis. Advances in molecular genetics during the past 2 years have led to the cloning of four HNPCC genes (MHS2, MLH1, PMS1 and PMS2). It is now possible to provide presymptomatic DNA testing followed by genetic counselling for gene carriers. Some studies have shown that adenomas in HNPCC are larger, more villous, and have more high grade dysplasia than sporadic cases, suggesting an accelerated adenoma-carcinoma sequence. Given the early age of onset and proximal predominance of CRC, we initiate colonoscopy at age 20-25 years and we recommend that it be performed every 1-2 years. The wealth of clinical and molecular genetic knowledge currently available to physicians about HNPCC can be used effectively for cancer control.

An evaluation of mammography beliefs using a decision model

The purpose of this study was to identify factors that contribute to a group of working women's decision related to mammography. The study was guided by a decision model called the Multiattribute Utility Model. Exploratory interviews were conducted among 36 women to identify positive and negative factors associated with the mammography decision. Eighteen factors emerged and were categorized into three broad areas: Knowledge and Attitudes (Confidence in Efficacy, Personal Risk, Other Means of Knowing, Fear of Cancer/Treatment, Belief in Fate, Embarrassment), Issues Related to Participation (Accessibility and Convenience, Difficulty Arranging, Time, Cost, Pain, Radiation), and Social Concerns (Role Model, Responsibility to Self, Responsibility to Others, Family/Friends' Influence, Societal Influences, Health Care Providers' Influence). This information served as the basis of a survey among 87 women to determine the importance of these factors. Seven factors emerged as significantly different between compliers and noncompliers. In order of significance, they were Difficulty Arranging, Fear of Cancer/Treatment, Cost, Accessibility and Convenience, Time, Other Means of Knowing, and Influence of Health Care Provider. The predictive validity of this analysis was 85%. Implications of findings are discussed.

Psychological aspects of monitoring high risk women for breast cancer

BACKGROUND

There is a paucity of knowledge pertaining to the attitudes, feelings, and emotions of women who are at increased familial risk for breast cancer and how these concerns will affect their surveillance behavior. A review of the literature shows an unevenness in the conclusions about these matters, with some reports indicating that anxiety aroused in the familial cancer setting may abet surveillance behavior, whereas other data indicates a negative effect.

METHODS

The authors reported anecdotal accounts of such behavior in women from hereditary breast and hereditary breast-ovarian cancer prone families.

RESULTS

Although these responses of fear, anxiety, and apprehension about cancer risk are not unique to this hereditary cohort, they nevertheless must have been tempered by often life-long exposure of cancer occurrences that may have decimated their families.

CONCLUSIONS

All accounts agree with the need to devote more research to the special needs--psychological, social, insurance, and general public health measures--of these high risk women.

The effect of risk on changes in breast cancer screening rates in Los Angeles, 1988-1990

BACKGROUND

Although there have been clear secular trends of increased use of some breast cancer screening modalities, such as mammography, it is less certain that similar trends have occurred among high risk women.

METHODS

Population-based surveys were conducted in three socioeconomically diverse Los Angeles communities in 1988 and 1990. Trends in breast cancer screening behavior and key determinants of screening were compared separately for women with a family history of breast cancer, a personal history of benign breast disease, and for women without these risks.

RESULTS

In two independent samples drawn in 1988 and 1990, women at a higher risk of breast cancer (positive family history) showed smaller increases in the prevalence of self-reported breast cancer screening than a comparison group of women without a family history of breast cancer or a history of benign breast disease. This was especially true for family-history-positive minority women and women aged 65 years and older, for whom screening actually decreased. In 1990, mammograms for the prior year were reported by only 39% of women with a positive family history, 54% of women with benign breast disease, and 35% of women without these risks. Trends in physicians' office visit discussions of breast cancer screening paralleled trends observed in screening behavior.

CONCLUSIONS

Although breast cancer screening increased substantially among lower risk women, rates were unchanged for women at increased risk because of a family history of breast cancer. By identifying and counseling higher risk women, physicians can play an important role in promoting appropriate screening to this group.

Hereditary breast cancer and family cancer syndromes

Hereditary breast cancer (HBC) shows extant clinical and genetic heterogeneity. Clinically one finds the onset of breast cancer at an early age, an excess of bilaterality, and patterns of multiple primary cancer such as combinations of breast and ovarian carcinoma in the hereditary breast-ovarian cancer (HBOC) syndrome. In addition to HBOC, one sees a variety of putative breast cancer-prone genotypes inclusive of hereditary site-specific breast cancer, and the Li-Fraumeni (SBLA) syndrome that is characterized by cancers involving all three germinal layers including sarcomas, brain tumors, leukemia, lymphoma, and adrenal cortical carcinoma in addition to often markedly early-onset breast cancer. Breast cancer is also associated with autosomal dominantly inherited Cowden's disease and autosomal recessively inherited ataxia-telangiectasia. Examples of pedigrees depicting clinical examples of these several HBC syndromes are presented in order to describe HBC's heterogeneity. The recent identification of the BRCA1 gene in early-onset hereditary site-specific breast cancer and the HBOC syndrome has led to new challenges for the genetic counselor. We review genetic counseling, which embraces surveillance and management recommendations that are responsive to the natural history of HBC and address the concept for future development of centers of expertise for HBC in the interest of improving cancer control.

Psycho-oncology and breast cancer: a paradigm for research and intervention

The recent award to the Lombardi Cancer Research Center of a National Cancer Institute funded Specialized Program of Research Excellence (or SPORE) grant in Breast Cancer has created a unique opportunity to develop and apply a comprehensive psycho-oncology research model that can serve as a paradigm for studies in this area across disease sites. In the following article, the rationale for and design of the psycho-oncology research program at Georgetown is presented. Areas of research are outlined, specific topics of concern within these are delineated and progress towards addressing these is briefly reviewed.

Adherence and psychological adjustment among women at high risk for breast cancer

Increasingly, women with a positive family history of breast cancer are being targeted for cancer prevention and control efforts. Two findings have been demonstrated consistently across studies of this high risk population. First, these women often have high levels of psychological distress, as well as persistent and intrusive worries about developing breast cancer. Second, despite their increased risk for developing breast cancer, a substantial proportion of these women do not adhere to recommended breast cancer screening guidelines. There is growing evidence that psychological distress is an important barrier to adherence among high risk women. Despite this, little is known about how to intervene to improve psychological adjustment and adherence in this population. In the present paper, we review the literature on adherence and psychological adjustment in women who are at increased risk for breast cancer because of a positive family history of disease. This review provides the basis for a discussion of potential intervention strategies designed to increase adherence and reduce psychological distress in this population. Finally, we present some of the psychological implications of recent developments in genetic testing for breast cancer susceptibility.

Familial cancer, emotional distress, and low natural cytotoxic activity in healthy women

BACKGROUND

We investigated the possibility that healthy individuals with a family history of cancer may have lower levels of natural cytotoxic activity and examined the possible contribution of distress-induced immune suppression.

MATERIALS AND METHODS

Forty-three healthy women, recruited without regard to their family histories of cancer, came to the laboratory on two consecutive days. On each day, subjects completed questionnaires and provided blood samples for assessment of natural cytotoxic activity.

RESULTS

1) Women with a history of cancer in one or more first degree relatives had lower levels of natural cytotoxic activity than women without cancer in first degree relatives. 2) There were no differences in demographic, health, or behavioral variables, but we could not rule out differences in emotional distress. 3) Independent of family history, women with higher levels of distress had lower natural cytotoxic activity. 4) When the contribution of this distress-induced immune suppression was statistically removed, natural cytotoxic activity remained lower in women with cancer in first degree relatives.

CONCLUSIONS

These findings raise the possibility that reductions in systemic natural cytotoxic activity, in conjunction with heritable defects in the preneoplastic cell, may contribute to increased cancer risk in individuals with a family history of cancer.

Psychologic adaptation of survivors of childhood cancer

When adult survivors of childhood cancer were compared with their peers, survivors were found to be at least as well adjusted. Indeed, some evidence was suggestive of survivors having adaptive advantages in everyday life. The survivors reported significantly more positive affect, less negative affect, higher intimacy motivation, more perceived personal control, and greater satisfaction with control in life situations. Despite these apparent strengths associated with surviving childhood cancer, several specific problems were documented. Survivors were more likely than peers to have repeated school grades, to be worried about issues of fertility, and to express dissatisfaction with important relationships. The latter finding was interpreted as reflecting the high expectations of survivors for relationships, based on their difficult yet interpersonally rewarding experiences during times of illness.

Informational needs of individuals and families with hereditary cancers

Individuals and families with hereditary cancers have informational needs that differ, depending on the availability of testing for increased hereditary risk and major focus of concern (reproductive decision-making or risk to self). Cancer risk counseling helps individuals understand risk information so they can make decisions appropriate to their lives and value systems.