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Bossuyt PMM, McCaffery K. Additional patient outcomes and pathways in evaluations of testing. Med Decis Making 2009; 29:E30-8. [PMID: 19726782 DOI: 10.1177/0272989x09347013] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Before medical tests are introduced into practice, they should be properly evaluated. Randomized trials and other comprehensive evaluations of tests and test strategies can best be designed based on an understanding of how tests can benefit or harm patients. Tests primarily affect patients' health by guiding clinical decision making and downstream management, such as the decision to order more tests or to start, stop, or modify treatment. In this article, the authors demonstrate that tests can have additional effects on patient outcome, which may be cognitive, emotional, social, or behavioral. They present a framework to help researchers and policy makers consider the cognitive, emotional, social, and behavioral effects of testing. These additional effects may be important themselves and may also influence the clinical outcomes of testing through different pathways. The authors provide examples from test evaluations in the literature to illustrate how these additional effects can be important in the evaluation of testing or indeed any health intervention.
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Affiliation(s)
- Patrick M M Bossuyt
- Department of Clinical Epidemiology & Biostatistics, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
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2
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Rawl SM, Champion VL, Scott LL, Zhou H, Monahan P, Ding Y, Loehrer P, Skinner CS. A randomized trial of two print interventions to increase colon cancer screening among first-degree relatives. PATIENT EDUCATION AND COUNSELING 2008; 71:215-27. [PMID: 18308500 PMCID: PMC2492833 DOI: 10.1016/j.pec.2008.01.013] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2007] [Revised: 12/10/2007] [Accepted: 01/05/2008] [Indexed: 05/11/2023]
Abstract
OBJECTIVE First-degree relatives (FDRs) of people diagnosed with colorectal cancer (CRC) have a two- to threefold increased risk of developing the same disease. Tailored print interventions based on behavior change theories have demonstrated considerable promise in facilitating health-promoting behaviors. This study compared the impact of two mailed print interventions on CRC screening outcomes among FDRs. METHODS This randomized trial compared effects of two mailed print interventions--one tailored and one nontailored--on participation in CRC screening among FDRs of CRC survivors. Data collected via phone interviews from 140 FDRs at baseline, 1 week post-intervention, and 3 months post-intervention. RESULTS At 3 months, both the tailored and nontailored interventions yielded modest but statistically insignificant increases in adherence to any CRC screening test (14% vs. 21%, respectively; p=0.30). While there were no main effects for tailored versus nontailored interventions, there were significant interactions that showed that the tailored print intervention had significantly greater effects on forward stage movement for CRC screening depending on stage of adoption at baseline, race, and objective CRC risk. Receipt of the tailored intervention was 2.5 times more likely to move baseline precontemplators and contemplators forward in stage of adoption for colonoscopy (95% CI: 1.10-5.68) and was three times more likely to move Caucasians forward in stage of adoption for FOBT (95% CI: 1.00-9.07). In addition, the tailored intervention was 7.7 times more likely to move people at average risk forward in stage of adoption for colonoscopy (95% CI: 1.25-47.75). CONCLUSION The tailored print intervention was more effective at moving Caucasians, those in precontemplation and contemplation at baseline, and those at average risk forward in their stage of adoption for CRC screening. PRACTICE IMPLICATIONS Both tailored and nontailored print interventions showed moderate effects for increasing CRC screening participation. Tailored print interventions may be more effective for certain subgroups.
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Affiliation(s)
- Susan M Rawl
- School of Nursing, Indiana University, IN 46202, USA.
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Reifenstein K. Care-seeking behaviors of African American women with breast cancer symptoms. Res Nurs Health 2007; 30:542-57. [PMID: 17893935 DOI: 10.1002/nur.20246] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
In this descriptive correlational study, 48 African American women were assessed for delay in care-seeking for breast cancer symptoms by examining: (a) relationships between selected psychosocial variables (fear, denial, utility, and social norm) and delay, (b) relationships between delay and having an identified health provider, affordable health care services, and accessible health-care services, (c) whether denial would mediate the effect of fear on delay, (d) whether utility would moderate the effects of social norm and facilitating conditions on delay, and (e) whether denial was related to escape-avoidance coping. Participants completed mailed questionnaires. Pearson correlation and separate regression analyses showed that denial was associated with increased delay. Confrontive coping, social support, and problem-solving strategies had no relationship with delay. Interventions focusing on denial could help enhance early care seeking.
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Affiliation(s)
- Karen Reifenstein
- Wegmans School of Nursing, St. John Fisher College, 3690 East Avenue, Rochester, NY, USA
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Abstract
BACKGROUND Breast cancer is the most common cancer and the second most common cause of cancer-related death among North American and Western European women. Recent progress in understanding the genetic basis of breast cancer, along with rising incidence rates, have resulted in increased interest in prophylactic mastectomy as a method of preventing breast cancer, particularly in those with familial susceptibility. OBJECTIVES The primary objective was to determine whether prophylactic mastectomy reduces death from any cause in women who have never had breast cancer and in women who have a history of breast cancer in one breast. The secondary objective was to examine the effect of prophylactic mastectomy on other endpoints including breast cancer incidence, breast cancer mortality, disease-free survival, physical morbidity, and psychosocial outcomes. SEARCH STRATEGY Electronic searches were performed in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, Cancerlit, and the Science Citation Index. SELECTION CRITERIA Inclusion criteria were studies in English of any design type including randomized or nonrandomized controlled trials, cohort studies, case-control studies, and case series with at least ten participants. Participants included women at risk for breast cancer in at least one breast. Interventions included all types of mastectomy performed for the purpose of preventing breast cancer, including subcutaneous mastectomy, total or simple mastectomy, modified radical mastectomy, and radical mastectomy. DATA COLLECTION AND ANALYSIS Information on patients, interventions, methods, and results were extracted by at least two independent reviewers. Methodological quality was assessed based on how well each study minimized potential selection bias, performance bias, detection bias, and attrition bias. Data for each study were summarized descriptively; quantitative meta-analysis was not feasible due to heterogeneity of study designs and insufficient reporting. Data were analyzed separately for bilateral prophylactic mastectomy (BPM) and contralateral prophylactic mastectomy (CPM). MAIN RESULTS Twenty-three studies, including more than 4,000 patients, met inclusion criteria. No randomized or nonrandomized controlled trials were found. Most studies were either case series or cohort studies. All studies had methodological limitations, with the most common source of potential bias being systematic differences between the intervention and comparison groups that could potentially be associated with a particular outcome. Thirteen studies assessed the effectiveness of BPM. No study assessed all-cause mortality after BPM. All studies reporting on incidence of breast cancer and disease-specific mortality reported reductions after BPM. Nine studies assessed psychosocial measures; most reported high levels of satisfaction with the decision to have prophylactic mastectomy (PM) but more variable satisfaction with cosmetic results. Only one study assessed satisfaction with the psychological support provided by healthcare personnel during risk counseling and showed that more women were dissatisfied than satisfied with the support they received in the healthcare setting. Worry over breast cancer was significantly reduced after BPM when compared both to baseline worry levels and to the groups who opted for surveillance rather than BPM. Three studies reported body image/feelings of femininity outcomes, and all reported that a substantial minority (about 20%) reported BPM had adverse effects on those domains. Six studies assessed contralateral prophylactic mastectomy. Studies consistently reported reductions in contralateral incidence of breast cancer but were inconsistent about improvements in disease-specific survival. Only one study attempted to control for multiple differences between intervention groups, and this study showed no overall survival advantage for CPM at 15 years. Two case series were exclusively focused on adverse events from prophylactic mastectomy with reconstruction, and both reported rates of unanticipated re-operations from 30% to 49%. REVIEWERS' CONCLUSIONS While published observational studies demonstrated that BPM was effective in reducing both the incidence of, and death from, breast cancer, more rigorous prospective studies (ideally randomized trials) are needed. The studies need to be of sufficient duration and make better attempts to control for selection biases to arrive at better estimates of risk reduction. The state of the science is far from exact in predicting who will get or who will die from breast cancer. By one estimate, most of the women deemed high risk by family history (but not necessarily BRCA 1 or 2 mutation carriers) who underwent these procedures would not have died from breast cancer, even without prophylactic surgery. Therefore, women need to understand that this procedure should be considered only among those at very high risk of the disease. For women who had already been diagnosed with a primary tumor, the data were particularly lacking for indications for contralateral prophylactic mastectomy. While it appeared that contralateral mastectomy may reduce the incidence of cancer in the contralateral breast, there was insufficient evidence about whether, and for whom, CPM actually improved survival. Physical morbidity is not uncommon following PM, and many women underwent unanticipated re-operations (usually due to problems with reconstruction); however, these data need to be updated to reflect changes in surgical procedures and reconstruction. Regarding psychosocial outcomes, women generally reported satisfaction with their decisions to have PM but reported satisfaction less consistently for cosmetic outcomes, with diminished satisfaction often due to surgical complications. Therefore, physical morbidity and post-operative surgical complications were areas that should be considered when deciding about PM. With regard to emotional well-being, most women recovered well postoperatively, reporting reduced cancer worry and showing reduced psychological morbidity from their baseline measures; exceptions also have been noted. Of the psychosocial outcomes measured, body image and feelings of femininity were the most adversely affected.
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Affiliation(s)
- L Lostumbo
- NBCC, 10615 Great Arbor Dr, Potomac, Maryland, USA, 20854.
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Cullen J, Schwartz MD, Lawrence WF, Selby JV, Mandelblatt JS. Short-term impact of cancer prevention and screening activities on quality of life. J Clin Oncol 2004; 22:943-52. [PMID: 14990651 DOI: 10.1200/jco.2004.05.191] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE There are few data on the short-term effects of participating in cancer prevention activities, undergoing genetic risk assessment, or having routine screening. The objective of this article is to systematically review existing research on short-term effects of prevention, genetic counseling and testing, and screening activities on quality of life. METHODS We conducted a MEDLINE search for original research studies that were published between January 1, 1985, and December 31, 2002, and conducted in North America or Western Europe. Data were abstracted and summarized using a standardized format. RESULTS We reviewed 210 publications. Most studies focused on psychological states (anxiety, depression), symptoms, or general health status. One hundred thirty-one studies used 51 previously validated noncancer instruments. Many researchers (12.6%) also added cancer-specific measures, such as perceived cancer risk or symptom indices. Only one study measured satisfaction or quality of provider-client communication. While one report examined lost workdays, no other economic consequences of short-term outcomes were evaluated. Among seven studies that assessed short-term outcomes preferences, only four specifically used time trade-off or linear rating scale methods. No study used standard gamble or willingness-to-pay methods. The overwhelming majority of research indicated that short-term effects were transient. Only two studies linked short-term effects to long-term cancer-related health behaviors such as repeat screening. CONCLUSION There is considerable heterogeneity in short-term outcome measurement. Clinicians need to be aware of potential for short-term, transient adverse effects. The impact of short-term experiences should to be linked to long-term health status and use of services.
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Affiliation(s)
- Jennifer Cullen
- Department of Oncology, Georgetown University, 2233 Wisconsin Ave NW, Suite 440, Washington, DC, USA.
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Abstract
Epidemiological studies over the past several decades have consistently supported the concept that a proportion of breast cancers develop as the result of an inherited familial predisposition. However, until recently our understanding and knowledge of the underlying genetic processes involved have been limited. Current advances in molecular biology have shown that hereditary breast cancer may arise as the result of mutations of several specific gene loci including BRCA1, BRCA2, ATM gene, PTEN and p53. Several other less frequently occurring predisposition genes such as the androgen receptor gene (AR), the HNPCC genes and the oestrogen receptor gene may also be involved, but to a lesser extent. It is estimated that approximately 5-10% of all breast cancers involve one of these inherited predisposition genes, with BRCA1 and BRCA2 accounting for up to 90% of this group. Mutation analysis is complex in nature and is presently in a developmental and evolving phase, for which reason genetic testing should be offered on a selective basis and through genetic counselling clinics. This report reviews the current knowledge and roles of the various predisposition genes and discusses the management implications for both affected and nonaffected members of breast cancer families. Comprehensive and informative counselling is critical for women with an inherited predisposition to breast cancer and this has led to the evolution of familial cancer clinics involving a multi-disciplinary specialist team approach. Familial cancer clinics can provide individuals with information about their risk of developing breast cancer and offer advice regarding the various management options presently available.
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Affiliation(s)
- I C Bennett
- Department of Surgery, Princess Alexandra Hospital, Brisbane and University of Queensland, Herston, Brisbane, Australia
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Cohen M. First-degree relatives of breast-cancer patients: cognitive perceptions, coping, and adherence to breast self-examination. Behav Med 2003; 28:15-22. [PMID: 12244641 DOI: 10.1080/08964280209596394] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The author assessed patterns of breast self-examination (BSE) related to cognitive appraisal, coping, and emotional distress in 80 women with first-degree relatives who were breast-cancer patients and 47 matched controls. Participants with first-degree relatives adhered to BSE better than did women with no family history of breast cancer, and women whose relatives had recurrent or metastatic disease performed more BSE than those whose relatives were currently disease free. Greater adherence to BSE was associated with lower levels of depression, more problem-focused coping, older age, and more education. In the women with first-degree relatives, BSE was also associated with higher perceptions of (a) control over prevention, (b) risk for breast cancer, and (c) higher levels of state anxiety. Perception of control, problem-focused coping, depression, and anxiety predicted 35% of the variance in adherence to BSE. The findings suggest that cognitive appraisal, coping strategies, and levels of emotional distress should be considered in designing programs for enhancing adherence to early detection procedures.
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Affiliation(s)
- Miri Cohen
- School of Social Work, Faculty of Social Welfare and Health Studies, Haifa University, Mount Carmel, Israel.
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Facione NC, Miaskowski C, Dodd MJ, Paul SM. The self-reported likelihood of patient delay in breast cancer: new thoughts for early detection. Prev Med 2002; 34:397-407. [PMID: 11914045 DOI: 10.1006/pmed.2001.0998] [Citation(s) in RCA: 123] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Delayed presentation of self-discovered breast symptoms influences stage of cancer at diagnosis and decreases breast cancer survival. METHODS A total of 699 asymptomatic women (black, white, and Latino), recruited in community settings and stratified by age, income, and educational level, were surveyed for their likelihood to delay (J-Delay scale) in the event of a breast symptom discovery. Models of likelihood were tested with logistic regression analyses. RESULTS A total of 166 women (23.7%) reported likelihood to delay. Lower income, lower educational level, self identification as Latino or black, experienced prejudice in care delivery, perceived lack of access to health care, fatalism about breast cancer, poor health care utilization habits, self-care behavior, spouse/partner and employer perceived constraints, problem-solving style, and a lack of knowledge of breast cancer's presenting symptoms were associated with likelihood to delay. A combined sample multiple logistic regression model correctly predicted 40.6% of women reporting a likelihood to delay, 94.9% of those not likely to delay, and 82.4% (551 of 669) of cases overall. CONCLUSIONS Self-reported likelihood of patient delay is measurable in advance of symptom occurrence, and this measure is consistent with behavioral and knowledge variables previously linked with advanced breast cancer at diagnosis.
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Freyer G, Ligneau B, Schlumberger M, Blandy C, Contedevolx B, Trillet-Lenoir V, Lenoir GM, Chau N, Dazord A. Quality of life in patients at risk of medullary thyroid carcinoma and followed by a comprehensive medical network: trends for future evaluations. Ann Oncol 2001; 12:1461-5. [PMID: 11762820 DOI: 10.1023/a:1012593410510] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND As shown in a previous study, the knowledge of the genetic risk in individuals belonging to families at risk of medullary-thyroid carcinoma (MTC) could be associated with impaired quality of life (QoL). PATIENTS AND METHODS In the present study, we compared the QoL scores obtained in the same period with the subjective quality of life profile (SQLP): in 82 individuals at risk of MTC who had been tested for Ret-mutations; in 200 women at risk of familial breast/ovarian cancer syndrome (BOC); and in a control population of 3,501 healthy volunteers. RESULTS Significant differences were observed in favour of healthy volunteers as well as individuals at risk of MTC, over women at risk of BOC (mean scores: 0.89, 0.85, and 0.64, respectively, P < or = 0.001), but QoL scores were not statistically different between individuals at risk of MTC and the control population (P = 0.2). However, they were significantly inferior in the subgroup of germline Ret-mutation carriers, as compared to the control population (mean scores: 0.73 and 0.89, P = 0.04). In the latter, the relationships with the children and the family were the most important facets of their QoL. CONCLUSION Our results confirm the potentially negative impact of the knowledge of the genetic risk of cancer and its consequences in terms of morbidity and follow-up, on the QoL in people followed at oncogenetic visits.
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Affiliation(s)
- G Freyer
- Medical Oncology Unit, Centre Hospitalier Lyon-Sud, and EA 643, Université Lyon I, France.
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10
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Wood ME, Mullineaux L, Rahm AK, Fairclough D, Wenzel L. Impact of BRCA1 testing on women with cancer: a pilot study. GENETIC TESTING 2001; 4:265-72. [PMID: 11142757 DOI: 10.1089/10906570050501489] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
We sought to understand better the impact of genetic testing and counseling in a group of women who had early breast cancer (age <50) or ovarian cancer and a family history of cancer. Thirty-five women underwent genetic counseling and genetic testing for BRCA1/2 at the University of Colorado Cancer Center, Hereditary Cancer Clinic. Psychological assessment (IES and Hopkins Symptom Checklist) was made before counseling, and 1 month after genetic test results were reported to women. A statistically significant decrease in anxiety was evidenced 1 month after results were given (p = 0.024). Decreased intrusive thoughts related to genetic testing were seen only for those testing negative (p = 0.0003). Women diagnosed with cancer less than 1 year prior to genetic testing experienced the greatest cancer-specific distress (p = 0.01) and distress related to genetic testing (p = not significant). Satisfaction with the counseling and testing process was high. In conclusion, genetic testing and counseling can occur with little anxiety and stress. However, women less than 1 year from a cancer diagnosis will experience the greatest distress associated with genetic testing and counseling. Women who are considering genetic testing and counseling close to a diagnosis of cancer may require greater psychological support.
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Affiliation(s)
- M E Wood
- University of Vermont, Department of Medicine, Burlington 05401, USA.
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Hatcher MB, Fallowfield L, A'Hern R. The psychosocial impact of bilateral prophylactic mastectomy: prospective study using questionnaires and semistructured interviews. BMJ (CLINICAL RESEARCH ED.) 2001; 322:76. [PMID: 11154619 PMCID: PMC26594 DOI: 10.1136/bmj.322.7278.76] [Citation(s) in RCA: 111] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To investigate the psychosocial impact of bilateral prophylactic mastectomy for women with increased risk of breast cancer and to identify, preoperatively, risk factors for postoperative distress. DESIGN Prospective study using interviews and questionnaire assessments. SETTING Participants' homes throughout the United Kingdom. PARTICIPANTS 143 women with increased risk of developing breast cancer who were offered bilateral prophylactic mastectomy and who accepted or declined the surgery; a further 11 were offered surgery but deferred making a decision. MAIN OUTCOME MEASURES Psychological and sexual morbidity. RESULTS Psychological morbidity decreased significantly over time for the 79 women who chose to have surgery (accepters): 58% (41/71) preoperatively v 41% (29/71) 6 months postoperatively (difference in percentages 17%, 95% confidence interval 2% to 32%; P=0.04) and 60% (39/65) preoperatively v 29% (19/65) 18 months postoperatively (31%, 15% to 47%; P<0.001). Psychological morbidity in the 64 women who declined surgery (decliners) did not decrease significantly: 57% (31/54) at baseline v 43% (23/54) at 6 months (14%, 0% to 29%; P=0.08) and 57% (29/52) at baseline v 41% (21/52) at 18 months (16%; -2% to 33%; P=0.11). Greater than normal proneness to anxiety was more common in the decliners than in the accepters: 78% (45/58) v 56% (41/73) (22%, 6% to 38%; P=0.006). Accepters were more likely than decliners to believe it inevitable that they would develop breast cancer (32% (24/74) v 10% (6/58) (difference in percentages 22%, 9% to 35%; P=0.003)), and decliners were more likely to believe that screening could help (92% (55/60) v 74% (55/74) (18%, 5% to 31%; P=0.007)). Level of sexual discomfort and degree of sexual pleasure did not change significantly over time in either of the two groups. CONCLUSIONS Bilateral prophylactic mastectomy may provide psychological benefits in women with a high risk of developing breast cancer.
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Affiliation(s)
- M B Hatcher
- Cancer Research Campaign Psychosocial Oncology Group, Bland Sutton Institute, Royal Free and University College Medical School, London W1P 7PL
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Abstract
This issue of Cancer Biology is focused on inherited cancer. In this short introduction to the topic we give a brief overview and list genes and the corresponding inherited cancer syndromes. We discuss the basic mechanisms of inherited cancer and the clinical implication of predictive genetic testing for cancer.
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Affiliation(s)
- A Lindblom
- Department of Molecular Medicine, Karolinska Institutet, Stockholm, SE-171 76, Sweden
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13
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Facione NC, Giancarlo C, Chan L. Perceived risk and help-seeking behavior for breast cancer. A Chinese-American perspective. Cancer Nurs 2000; 23:258-67. [PMID: 10939173 DOI: 10.1097/00002820-200008000-00002] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Delay in the diagnosis and treatment of breast cancer diminishes a woman's chance of survival. How do women decide whether and when to seek an evaluation of breast symptoms that may signal breast cancer? Prior studies of African-American, white, and Latino women have described a number of critical factors associated with making the judgment to delay, but at this writing, there have been no studies factors influencing Chinese-American women. By means of focus group methods in English, Mandarin, and Cantonese, a sample of 45, predominantly first-generation Chinese-American women explained their understanding of breast cancer risk and their likelihood of delaying versus seeking evaluation of self-discovered breast symptoms. There was much congruence with the ideas of other American women despite the differing cultural heritage. Unique to these Chinese Americans was a sense of invulnerability to breast cancer, a linking of cancer to tragic luck, and the predominant likelihood of delay. To preserve modesty and to conserve wealth and time, many study participants favored using Chinese medicine and delaying Western therapies. This study suggests ways by which health care providers must approach guidelines for breast cancer early detection in this population.
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Affiliation(s)
- N C Facione
- University of California, San Francisco 94143-0610, USA
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Fasouliotis SJ, Schenker JG. BRCA1 and BRCA2 gene mutations: decision-making dilemmas concerning testing and management. Obstet Gynecol Surv 2000; 55:373-84. [PMID: 10841315 DOI: 10.1097/00006254-200006000-00023] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The identification of the BRCA genes, and their possible etiologic relationship with various forms of inherited cancer, has been recognized universally as a cornerstone in the search of cancer's genetic susceptibility. Female BRCA gene mutation carriers are found to carry an increased risk of developing breast or ovarian cancer and to a lesser degree, colon cancer, and male BRCA mutation carriers are also related to an increased risk of breast, colon, or prostate cancer. Although genetic testing promises a possible future presymptomatic determination and treatment of women who are genetically susceptible to cancer, current data reveal certain dilemmas and uncertainties regarding our ability to interpret the results from testing and offer effective management options. In addition, several complex ethical, legal, and social issues have been revealed with the advent of this new information, which also confirm the need for additional research regarding the most effective use of this genetic information and for the establishment of appropriate clinical management strategies.
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Affiliation(s)
- S J Fasouliotis
- Department of Obstetrics and Gynecology, Hebrew University, Hadassah Medical Center, Jerusalem, Israel
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15
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Hartmann LC, Sellers TA, Schaid DJ, Nayfield S, Grant CS, Bjoraker JA, Woods J, Couch F. Clinical options for women at high risk for breast cancer. Surg Clin North Am 1999; 79:1189-206. [PMID: 10572558 DOI: 10.1016/s0039-6109(05)70068-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Women at hereditary risk of breast cancer face a difficult clinical decision. Each of the options available to them has unique advantages and disadvantages that are summarized in Table 9. Many components enter a high-risk woman's decision: her objective risk of breast cancer; clinical features, such as the consistency of breast tissue and resultant ease of examination; breast density on mammography; personal characteristics, including her experience with cancer within her family; her role and [table: see text] responsibilities within her own nuclear family; her values and goals; her experiences with the medical system; and her subjective assessment of risk. It is generally believed that women significantly overestimate their risk of breast cancer. Thus, it is vital that a woman at risk have access to a genetic counselor who can provide accurate assessment of her risk. Women should be encouraged to take time to understand their risk level and the advantages and disadvantages of the options before them.
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Freyer G, Dazord A, Schlumberger M, Conte-Devolx B, Ligneau B, Trillet-Lenoir V, Lenoir GM. Psychosocial impact of genetic testing in familial medullary-thyroid carcinoma: a multicentric pilot-evaluation. Ann Oncol 1999; 10:87-95. [PMID: 10076727 DOI: 10.1023/a:1008349318728] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Many crucial problems are associated with the diagnosis of inherited cancer susceptibility. One of the most important is related to the psychosocial consequences of the knowledge by the patients and their relatives of their own genetical status. Little data are available in the literature, mainly from studies including small numbers of selected and motivated patients. PATIENTS AND METHODS From January till December 1997, we studied the psychometric and quality of life parameters of 77 subjects followed in two French specialized centers. These subjects had been treated for either sporadic or familial or were at risk for medullary thyroid carcinoma. All patients had previously attended genetic counselling with detection of germline Ret-mutations, were informed on their own genetic risk, had good short-term prognosis and performance status and did not receive recent cancer treatment. Each patient was invited to answer two questionnaires, the hospital anxiety and depression scale (HADS) and the subjective quality of life profile (SQLP). RESULTS We report herein the descriptive results of this study (HADS and SQLP scores and distributions) and describe the individual clinical covariates that might explain the observed differences between subgroups of individuals. Although psychometric scores appeared similar in these subgroups, quality of life scores were lower in Ret-mutation carriers. Genetically-predisposed patients were less satisfied and expressed more expectations for favourable change in their quality of life. CONCLUSION This finding suggests a high level of frustration and latent unsatisfaction related either to the management of the genetic information given by the clinicians and its psychosocial consequences or simply to the knowledge of the genetic risk of cancer. Further studies on the individual consequences of genetic testing, information delivery and when necessary psychotherapeutic interventions, are needed to insure the quality of presymptomatic genetic testing in this field of oncology.
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Affiliation(s)
- G Freyer
- Unité d'Oncologie Médicale, Centre Hospitalier Lyon-Sud, France.
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Hallowell N. 'You don't want to lose your ovaries because you think 'I might become a man". Women's perceptions of prophylactic surgery as a cancer risk management option. Psychooncology 1998; 7:263-75. [PMID: 9638787 DOI: 10.1002/(sici)1099-1611(199805/06)7:3<263::aid-pon307>3.0.co;2-q] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
This preliminary study provides insight into the meaning of prophylactic surgery as a risk management strategy for women who have a familial risk of breast or ovarian cancer. Data were collected during observations of genetic consultations and in semi-structured interviews with 41 women following their attendance at genetic counselling. The option of prophylactic surgery was raised in 29 consultations and discussed in 35 of the post-clinic interviews. Fifteen women said they would consider having an oophorectomy in the future and nine said they would consider having a mastectomy. The implications of undergoing oophorectomy and mastectomy were discussed during the post-clinic interviews. Prophylactic surgery was described by the counsellees as providing individuals with a means to (a) fulfil their obligations to other family members and (b) reduce risk and contain their fear of cancer. The costs of this form of risk management, were described as: (a) compromising social obligations; (b) upsetting the natural balance of the body; (c) not offering protection from cancer; (d) operative and post-operative complications; (e) the onset of menopause (f) the effects on body image, gender and personal identity and (g) potential effects on sexual relationships.
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Affiliation(s)
- N Hallowell
- Centre for Family Research, Faculty of Social and Political Sciences, University of Cambridge, UK
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18
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Abstract
Two genes, called BRCA-1 and BRCA-2, have been identified that appear to be responsible for the majority of familial breast cancer syndromes. These genes now play a prominent role in the practice of the surgeon treating breast cancer. Additional genes, PTEN (Cowden disease), MSH1 or MLH2 (HNPCC), and p53 (Li-Fraumeni syndrome) are responsible for other breast cancer syndromes but have not yet entered the clinical arena on a large scale. The risk of breast and ovarian cancer by age 70 in a BRCA-1 mutation carrier is estimated at 55-75% and 16-26 %, respectively, overall, and as high as 87% and 44% in those with a strong family history. The cancer risks associated with BRCA-2 mutations appear to be somewhat lower than those of BRCA-1. BRCA mutations show a strong founder effect. This is best recognized in the Ashkenazi Jewish community, in which the incidence of one of three characteristic mutations is about 2%. In other ethnic groups the pattern of mutations is different, with over 100 distinct mutations throughout the genes having been described. Most mutations so far have been frame-shift or mis-sense mutations, although large deletions have also been described. Thus, in most situations, assessment of the whole coding sequence is required to confirm or exclude a mutation. Guidelines to suggest who is likely to be a mutation carrier are being clarified, but the appropriate management of someone who tests positive remains difficult. Prophylactic mastectomy and oophorectomy are likely to offer substantial gains in life expectancy to mutation carriers, especially for young women with a strong family history. Unfortunately, there are no currently available strategies to eliminate the risk of breast or ovarian cancer. The psychological impact of testing also remains poorly understood, and the danger of various forms of discrimination remain. These factors must be clearly understood by all parties prior to testing. The process of a dynamic, interactive informed consent--much more than a simple printed document--and also counseling are central to the testing process.
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Affiliation(s)
- G B Mann
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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19
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Bottorff JL, Ratner PA, Johnson JL, Lovato CY, Joab SA. Communicating cancer risk information: the challenges of uncertainty. PATIENT EDUCATION AND COUNSELING 1998; 33:67-81. [PMID: 9481350 DOI: 10.1016/s0738-3991(97)00047-5] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
Developments in predictive testing for inherited cancers have focused attention on the accurate and sensitive communication of risk information. Although sharing risk information is often equated with genetic testing, it is important to acknowledge that the need for risk information related to familial cancer is also relevant to those not eligible for, or interested in, testing. Communicating cancer risk information is germane to a number of health professions including physicians, geneticists, genetic counsellors, psychologists, nurses, health educators and social workers. Based on a literature review of 75 research reports, expert opinion papers and clinical protocols, we provide a synthesis of what is known about the communication of cancer risk information and make recommendations for the enhancement of knowledge and practice in the field.
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Affiliation(s)
- J L Bottorff
- School of Nursing, University of British Columbia, Vancouver, Canada.
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20
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Walker LG, Eremin O. Psychological assessment and intervention: future prospects for women with breast cancer. SEMINARS IN SURGICAL ONCOLOGY 1996; 12:76-83. [PMID: 8821413 DOI: 10.1002/(sici)1098-2388(199601/02)12:1<76::aid-ssu11>3.0.co;2-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
During the last decade, there has been a growing interest in the psychosocial aspects of breast cancer. Studies have addressed multifarious aspects, including the possible importance of personality factors and stress in the onset and progression of malignancy, the psychological impact of diagnosis and treatment, the incidence and nature of psychological and psychiatric problems, the development and evaluation of psychological interventions to ameliorate treatment side effects and to enhance quality of life, the psychological effects of screening for breast cancer and of counselling women at high risk, the organization of services, training, and psychoneuroimmunology. These and other studies are reviewed and possible directions for future research are indicated. It is clear that psychosocial factors are becoming increasingly important components of the assessment and management of patients with breast cancer.
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Affiliation(s)
- L G Walker
- Department of Mental Health, Aberdeen University Medical School, Scotland
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