Long-term cohort study of women at intermediate risk of familial breast cancer: experiences of living at risk

How do women who are informed that they are at increased risk of breast cancer appraise their risk? A systematic review of qualitative research

This review aimed to synthesise qualitative research on how women notified that they are at increased risk of breast cancer view their risk. Five electronic databases were systematically reviewed for qualitative research investigating how women who have received an increased breast cancer risk estimate appraise their risk status. Fourteen records reporting 12 studies were included and critically appraised. Data were thematically synthesised. Four analytical themes were generated. Women appraise their risk of breast cancer through comparison with their risk of other familial diseases. Clinically derived risk estimates were understood in relation to pre-conceived risk appraisals, with incongruences met with surprise. Family history is relied upon strongly, with women exploring similarities and differences in attributes between themselves and affected relatives to gauge the likelihood of diagnosis. Women at increased risk reported living under a cloud of inevitability or uncertainty regarding diagnosis, resulting in concerns about risk management. Women hold stable appraisals of their breast cancer risk which appear to be mainly formed through their experiences of breast cancer in the family. Healthcare professionals should explore women's personal risk appraisals prior to providing clinically derived risk estimates in order to address misconceptions, reduce concerns about inevitability and increase perceived control over risk reduction.

Influence of lived experience on risk perception among women who received a breast cancer polygenic risk score: 'Another piece of the pie'

Polygenic risk scores (PRS) are personalized assessments of disease risk based on the cumulative effect of common low-risk genetic variants. PRS have been shown to accurately predict women's breast cancer risk and are likely to be incorporated into personalized breast cancer risk management programs. However, there are few studies investigating the individual impact of receiving a breast cancer PRS. Existing studies have not demonstrated significant changes in perceived risk or risk management behaviors after receipt of polygenic risk information. The aim of this qualitative study was to explore how women with a family history of breast cancer construct breast cancer risk perceptions after receipt of a breast cancer PRS. Unaffected women with a family history of breast cancer who had not previously received genetic counseling regarding their breast cancer risk were invited to participate in this study. In-depth, semi-structured interviews were conducted with 20 women who attended a familial cancer clinic in the Australian states of Victoria and Tasmania. Data were analyzed using an inductive thematic approach. Women's lived experience played a significant role in the construction and maintenance of their breast cancer risk perception. Women's pre-existing risk perceptions were informed by their family history and their knowledge that breast cancer is a multifactorial disease. Knowing that breast cancer is a multifactorial disease enabled most women to integrate genetic information with their pre-existing notions of risk. Women reported that the information they received was consistent with their existing notions of personal risk and screening advice. Therefore, the PRS did not lead to a change in perceived risk or risk management behaviors for most women. The results of this study provide insight into how polygenic risk information is integrated with pre-existing notions of risk, which will inform its implementation into clinical practice.

Theory-based training to promote breast cancer screening among women with breast cancer worries: randomized controlled trial

BACKGROUND

Breast cancer worries are important determinants in relation to behavior favoring breast cancer screening.

OBJECTIVE

To determine the effect of theory-based training to promote breast cancer screening among women with high and low levels of breast cancer worries.

DESIGN AND SETTING

Randomized controlled trial, conducted in two family health centers.

METHODS

In total, 285 women were recruited. Women with low levels of breast cancer worries were included in the first intervention group (112 women) and the first control group (112 women), while women with high levels of breast cancer worries were included in the second intervention group (37 women) and the second control group (43 women). Theory-based training to promote breast cancer screening was given to intervention groups. The women's willingness to undergo breast cancer screening and breast cancer worry scores were evaluated at 1, 3 and 6 months.

RESULTS

The women in the low cancer-worry intervention group performed breast self-examination more in months 1 and 6 following the training, and the women in the high cancer-worry control group performed breast self-examination more in month 3 (P < 0.05). No difference between the women who had low or high levels of breast cancer worries were observed in relation to breast self-examination, clinical breast examination or mammography (P > 0.05).

CONCLUSION

The level of worry did not affect the success of theory-based training, and the training was partially effective with regard to willingness to undergo breast cancer screening.

How do women at increased breast cancer risk perceive and decide between risks of cancer and risk-reducing treatments? A synthesis of qualitative research

Objective

Risk‐reducing procedures can be offered to people at increased cancer risk, but many procedures can have iatrogenic effects. People therefore need to weigh risks associated with both cancer and the risk‐reduction procedure in their decisions. By reviewing relevant literature on breast cancer (BC) risk reduction, we aimed to understand how women at relatively high risk of BC perceive their risk and how their risk perceptions influence their decisions about risk reduction.

Methods

Synthesis of 15 qualitative studies obtained from systematic searches of SCOPUS, Web of Knowledge, PsychINFO, and Medline electronic databases (inception‐June 2015).

Results

Women did not think about risk probabilistically. Instead, they allocated themselves to broad risk categories, typically influenced by their own or familial experiences of BC. In deciding about risk‐reduction procedures, some women reported weighing the risks and benefits, but papers did not describe how they did so. For many women, however, an overriding wish to reduce intense worry about BC led them to choose aggressive risk‐reducing procedures without such deliberation.

Conclusions

Reasoning that categorisation is a fundamental aspect of risk perception, we argue that patients can be encouraged to develop more nuanced and accurate categorisations of their own risk through their interactions with clinicians. Empirically‐based ethical reflection is required to determine whether and when it is appropriate to provide risk‐reduction procedures to alleviate worry.

Primary care management of women with breast cancer-related concerns-a dynamic cohort study using a network database

The aim of this study was to determine the incidence, management and diagnostic outcomes of breast cancer-related concerns presented in primary care. A dynamic cohort study was performed in the anonymised routine electronic medical records (EMRs) extracted from 49 General Practices in the Netherlands (163,471 person-years, women aged 18-75). Main Outcome Measures were: (1) incidence rates for breast cancer-related concerns in Primary Care, (2) proportions of these women with and without symptoms of the breast referred for further investigation, (3) proportions of referrals (not) according to the guideline and (4) proportions of women with breast cancer-related concerns diagnosed with breast cancer during follow-up. Breast cancer-related concerns are presented frequently in Primary Care (incidence rate 25.9 per 1,000 women annually). About half these women are referred for further investigation. There is room to improve General Practitioner management, mainly for women with an increased lifetime risk of developing breast cancer. Information concerning family history of cancer is often missing in the EMR. Since cancer is rarely diagnosed during follow-up, particularly when symptoms are absent, reduction of unnecessary concerns is plausible if identification of those without an increased risk is improved.

Cognitive Behavioral Stress Management for Healthy Women at Risk for Breast Cancer: a Novel Application of a Proven Intervention

BACKGROUND

Women at risk for breast cancer report elevated psychological distress, which has been adversely associated with cancer-relevant behaviors and biology.

PURPOSE

The present study sought to examine the effects of a 10-week cognitive behavioral stress management (CBSM) group intervention on distress among women with a family history of breast cancer.

METHODS

Participants were randomly assigned to CBSM (N = 82) or a wait-list comparison group (N = 76). Baseline to postintervention effects of CBSM on depressive symptoms and perceived stress were examined using hierarchical regression.

RESULTS

CBSM participants reported significantly lower posttreatment depressive symptoms (β = -0.17, p < 0.05) and perceived stress (β = -0.23, p < 0.05) than wait-list comparison participants. Additionally, greater relaxation practice predicted lower distress.

CONCLUSIONS

Group-based CBSM intervention is feasible and can reduce psychological distress among women with a family history of breast cancer. The present findings represent an encouraging avenue for the future application of CBSM. ( Clinicaltrials.gov number NCT00121160).

How do patients with uveal melanoma experience and manage uncertainty? A qualitative study

OBJECTIVES

Cancer survivors experience uncertainty about the future, which can be distressing. A prognostication tool is available for uveal melanoma survivors, which can provide accurate estimates of life expectancy - a key source of uncertainty. Accurate prognostic information has not previously been available for healthy cancer survivors. The aims of this study were to identify how patients experience prognostic information and how it affects their experience of uncertainty.

METHODS

Semi-structured interviews were conducted with 25 healthy survivors of uveal melanoma 6-60 months after treatment (approximately 8-62 months after receiving prognostic information). Data were analysed qualitatively.

RESULTS

Patients did not feel that the prognostic information relieved uncertainty, which still overshadowed their lives. Different prognoses engendered different experiences of uncertainty. Those receiving poor life expectancy estimates reported uncertainties regarding the timing and form of metastases that they were likely to experience, but they also used uncertainty to justify feeling hopeful. Those receiving good prognoses were often unable wholly to accept these. Patients whose test results failed or were intermediate retained their original uncertainties. Patients managed their uncertainties by suppressing thoughts about them and by trusting in the care of clinicians and the health-care system.

CONCLUSIONS

Uncertainty in the context of uveal melanoma is a complex and multifaceted experience that is not easily resolved by prognostication. Additional approaches are needed to help patients with the uncertainty that persists despite prognostication.

Can risk and illness perceptions predict breast cancer worry in healthy women?

Predictors of breast cancer worry in healthy women remain unclear. Healthy women less than 50 years (N = 857) completed measures of family history, anxiety, absolute and comparative risk perceptions, illness perceptions, and breast cancer worry. Regression analyses revealed that having a family history of breast cancer, greater anxiety, higher absolute risk perceptions and negative illness perceptions predicted 45 per cent of the variance in breast cancer worry. Risk perceptions also partially mediated the relationship between illness perceptions and worry. This study provides novel evidence that both illness and risk perceptions are predictors of breast cancer worry in younger women from the community.

Routine assessment of psychosocial problems after cancer genetic counseling: results from a randomized controlled trial

Approximately 70% of counselees undergoing cancer genetic counseling and testing (CGCT) experience some degree of CGCT-related psychosocial problems. We evaluated the efficacy of an intervention designed to increase detection and management of problems 4 weeks after completion of CGCT. In this randomized, controlled trial, 118 participants completed a CGCT-related problem questionnaire prior to an - audiotaped - telephone session with their counselor 1 month after DNA-test disclosure. For those randomized to the intervention group (n = 63), a summary of the questionnaire results was provided to the counselor prior to the telephone session. Primary outcomes were discussion of the problems, counselors' awareness of problems, and problem management. Secondary outcomes included self-reported distress, cancer worries, CGCT-related problems, and satisfaction. Counselors who received a summary of the questionnaire were more aware of counselees' problems in only one psychosocial domain (practical issues). No significant differences in the number of problems discussed, in problem management, or on any of the secondary outcomes were observed. The prevalence of problems was generally low. The telephone session, combined with feedback on psychosocial problems, has minimal impact. The low prevalence of psychosocial problems 1 month post-CGCT recommends against its use as a routine extension of the CGCT procedure.

Predicting post-traumatic stress and health anxiety following a venous thrombotic embolism

This research identified psychosocial factors associated with post-traumatic stress and health anxiety following a venous thrombotic embolism. In all, 158 participants, largely registered with a venous thrombotic embolism information website (Lifeblood: The Thrombosis Charity), completed an online survey. Post-traumatic symptom scores were linked to health threat, and not moderated by perceived control over risk for further venous thrombotic embolism. Health anxiety was associated with continuing symptoms and a negative emotional response to the venous thrombotic embolism. There is a need to intervene to reduce both short- and long-term distress in this population, ideally using a stepped-care model.

Specific psychosocial issues of individuals undergoing genetic counseling for cancer - a literature review

Approximately 25% of individuals undergoing genetic counseling for cancer experiences clinically relevant levels of distress, anxiety and/or depression. However, these general psychological outcomes that are used in many studies do not provide detailed information on the specific psychosocial problems experienced by counselees. The aim of this review was to investigate the specific psychosocial issues encountered by individuals undergoing genetic counseling for cancer, and to identify overarching themes across these issues. A literature search was performed, using four electronic databases (PubMed, PsychInfo, CINAHL and Embase). Papers published between January 2000 and January 2013 were selected using combinations, and related indexing terms of the keywords: 'genetic counseling', 'psychology' and 'cancer'. In total, 25 articles met our inclusion criteria. We identified the specific issues addressed by these papers, and used meta-ethnography to identify the following six overarching themes: coping with cancer risk, practical issues, family issues, children-related issues, living with cancer, and emotions. A large overlap in the specific issues and themes was found between these studies, suggesting that research on specific psychosocial problems within genetic counseling has reached a point of saturation. As a next step, efforts should be made to detect and monitor these problems of counselees at an early stage within the genetic counseling process.

Risk factors for psychological distress in women at risk for hereditary/familial breast cancer: a systematic review

SUMMARY Some women at risk for hereditary breast cancer are at increased risk of psychological distress. In order to correctly identify vulnerable women at an early stage for whom referral to a specialized psychologist or social worker may be considered, it is important that healthcare workers involved in the care of high-risk women have knowledge about risk factors that should be addressed during counseling. The aim of the current review is to investigate current knowledge on personal and social risk factors associated with psychological maladjustment in women at risk for hereditary breast cancer. The risk factors described in the current review may be used to develop appropriate interventions with respect to, for example, self-concept, risk appraisal, coping, family communication, social support and the partner relationship.

How do women at increased, but unexplained, familial risk of breast cancer perceive and manage their risk? A qualitative interview study

Background

The perception of breast cancer risk held by women who have not had breast cancer, and who are at increased, but unexplained, familial risk of breast cancer is poorly described. This study aims to describe risk perception and how it is related to screening behaviour for these women.

Methods

Participants were recruited from a population-based sample (the Australian Breast Cancer Family Study - ABCFS). The ABCFS includes women diagnosed with breast cancer and their relatives. For this study, women without breast cancer with at least one first- or second-degree relative diagnosed with breast cancer before age 50 were eligible unless a BRCA1 or BRCA2 mutation had been identified in their family. Data collection consisted of an audio recorded, semi-structured interview on the topic of breast cancer risk and screening decision-making. Data was analysed thematically.

Results

A total of 24 interviews were conducted, and saturation of the main themes was achieved. Women were classified into one of five groups: don't worry about cancer risk, but do screening; concerned about cancer risk, so do something; concerned about cancer risk, so why don't I do anything?; cancer inevitable; cancer unlikely.

Conclusions

The language and framework women use to describe their risk of breast cancer must be the starting point in attempts to enhance women's understanding of risk and their prevention behaviour.

A UK collaborative 1-day pilot information and support forum facilitated by a national breast cancer charity and NHS cancer genetic counsellors, for women at high risk, BRCA 1/2 gene carriers and hereditary breast cancer

Since the identification of the breast cancer susceptibility genes BRCA 1/2, genetic assessments of individuals and their families has greatly increased. The assessment of an individual as being at high risk, a gene carrier or an inheritor of cancer changes that individual's life. There is then a great need for ongoing information and support, not only from healthcare professionals but from peers - other women in the same situation. Breast Cancer Care is aware of this need; for a number of years, we have been providing published information, online-based information and support and telephone support to women who are BRCA 1/2 gene carriers and women with hereditary breast cancer. As part of our continuing commitment to improve on and develop other information and support services to this target group, we collaborated with a number of Genetic Counsellors from London, Oxford, Cambridge and Southampton to develop and pilot a 1-day support forum. This article discusses the factors that led to the pilot information and support forum, its development and how it was evaluated, and suggests a potential way forward.