Anxiety and specific distress in women at intermediate and high risk of breast cancer before and after surveillance by magnetic resonance imaging and mammography versus standard mammography

Psychosocial outcomes after varying risk management strategies in women at increased familial breast cancer risk: a mixed methods study of patient and partner outcomes

INTRODUCTION

Female carriers of BRCA1/2 genes have an increased lifetime risk of breast cancer. Options for managing risk include imaging surveillance or risk-reducing surgery (RRS). This mixed methods study aimed to identify factors affecting risk-management decisions and the psychosocial outcomes of these decisions for high-risk women and their partners.

METHODS

Semi-structured qualitative interviews were performed with women at high breast cancer risk who had faced these choices. Partners were also interviewed. Analysis used a framework approach. A bespoke questionnaire was developed to quantify and explore associations.

RESULTS

A total of 32 women were interviewed. Of these, 27 had partners of whom 7 (26%) agreed to be interviewed. Four main themes arose: perception of risk and impact of increased risk; risk-management strategy decision-making; impact of risk-management strategy; support needs and partner relationship issues. The questionnaire response rate was 36/157 (23%). Decision satisfaction was high in both surveillance and RRS groups. Relationship changes were common but not universal. Common causes of distress following RRS included adverse body image changes. Both groups experienced generalised and cancer-specific anxiety. Drivers for surgery included having children, deaths of close family from breast cancer and higher levels of cancer anxiety.

CONCLUSIONS

Levels of psychosocial and decision satisfaction were high for women choosing both RRS and surveillance but, for a minority, risk-reducing measures result in long-term psychosocial morbidity. Efforts to recognise women at increased risk of psychological morbidity may allow targeted support.

Effects of a 360° virtual counselling environment on patient anxiety and CCTA process time: A randomised controlled trial

INTRODUCTION

This study investigated whether a 360° virtual counselling environment (360°VCE) was more effective at decreasing patients' anxiety than routine standard of care counselling for patients undergoing coronary computed tomography angiography (CCTA), and if there was any difference in the process times for both of these groups.

METHODS

A total of 86 patients underwent CCTA in this randomised controlled trial. Patients were randomly assigned to intervention and control groups. The 360°VCE was developed using spherical panoramic images and non-immersive 360° technology. The primary outcome, anxiety, was measured using the State-Trait Anxiety Inventory (STAI). The secondary outcome, CCTA process time, was measured from the time of arrival in the department until end of examination.

RESULTS

Pre-scan anxiety was lower among patients in the 360°VCE group immediately before CCTA in comparison to patients in the control group (p = 0.015). Women demonstrated higher levels of anxiety than men in both groups. No between-group differences were discerned in CCTA process time.

CONCLUSION

Access to 360°VCE can reduce patients' pre-CCTA anxiety levels.

IMPLICATIONS FOR PRACTICE

The presented results can be used to improve patient counselling and care, reduce anxiety among patients undergoing CCTA, and optimise the CCTA examination procedure.

High Risk Breast Cancer Screening is a Double Edged Sword: A Qualitative Study of Patient Perspectives on the Ontario High Risk Breast Cancer Screening Program

BACKGROUND

MRI-based breast cancer screening for high-risk women has been associated with false positives. This study explored the benefits and drawbacks of MRI-based screening using in-depth patient interviews.

METHODS

This was a qualitative study of interviews with women participating in the High Risk Ontario Breast Screening Program. Women enrolled at two centers who had completed at least one round of screening were invited to participate. Recruitment was suspended when thematic saturation was reached. Semi-structured telephone interviews were conducted and transcribed verbatim. Emergent themes were identified and a coding framework established.

RESULTS

21 women (median age 41 years) participated in telephone interviews. Women had been in the program a median of 4 years (IQR 1-5), and 71% had experienced at least one abnormal screen. Eight participants (38%) had undergone biopsies. Six women (29%) were BRCA mutation carriers. MRIs were described as intimidating, uncomfortable, and claustrophobic. Participants were concerned about long-term exposure to gadolinium contrast. Compared to MRI, mammography alone was viewed as painful, less sensitive, and a "useless…waste of time." MRI provided a "psychological safety net" that outweighed the distress associated with abnormal screens. Many women accepted this trade-off as a "two-edged sword" that was "worth it" and provided a sense of control. Suggestions for improvement included more information regarding the risks of MRI, and access to counselling.

CONCLUSIONS

Women participating in MRI-based screening strongly value reassurance from a highly sensitive screening test. This outweighed the distress of abnormal screens. There are areas for improvement around patient communication and psychosocial support.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

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

Influence of Depression and Anxiety on Non-Surgical Periodontal Treatment Outcomes: A 6-Month Prospective Study

Periodontal treatment could be worsened by risk factors. Depression and anxiety have been suggested as potentially influencing periodontal treatment outcomes. The aim of this study was to determine their association with non-surgical periodontal treatment outcomes in patients with generalized severe periodontitis (stage III/IV generalized periodontitis) at 6 months. A total of 68 patients diagnosed with generalized severe periodontitis were treated with scaling and root planing (SRP) and were followed at 3 and 6 months. The data of the 54 patients that followed the entire protocol were considered for analysis. Depression and anxiety levels were determined at baseline by the Beck Depression Inventory (BDI) and State-Trait Inventory (STAI) questionnaires. The association between psychological scores and periodontal parameters was evaluated by multivariate analysis. At 3 and 6 months, SRP induced an improvement for all periodontal parameters (plaque index (PI), bleeding on probing (BOP), periodontal probing depth (PPD) and clinical attachment loss (CAL)). BDI and STAI scores were associated with the evolution of PI, BOP, mean PPD and number of sites with PPD > 3 mm and with CAL > 3 mm. Depression and anxiety should be considered as risk factors for SRP and the identification of at-risk patients should be performed using well-established tools.

Psychological consequences of MRI-based screening among women with strong family histories of breast cancer

PURPOSE

MRI-based screening in women with a ≥ 25% lifetime risk of breast cancer , but no identifiable genetic mutations may be associated with false positives. This study examined the psychological impact of abnormal screens and biopsies in non-mutation carriers participating in high-risk screening with no personal history of breast cancer.

METHODS

Non-mutation carriers participating in the High-Risk Ontario Breast Screening Program at two sites were mailed demographic surveys, psychological scales, and chart review consent. Scales included the Consequences of Screening in Breast Cancer questionnaire, Lerman Breast Cancer Worry Scale, and Worry Interference Scale. Missing data were managed with multiple imputation. Multivariable regression was used to assess whether abnormal screens or biopsies were associated with adverse psychological effects.

RESULTS

After contacting 465 participants, 169 non-mutation carriers were included. Median age was 46 years (range 30-65). Over a median 3 years of screening, 63.9% of women experienced at least one abnormal screen, and 24.9% underwent biopsies. Statements relating to cancer worry/anxiety scored highest, with 19.5% indicating they worried "a lot". Higher scores among anxiety-related statements were strongly associated with higher dejection scores. Overall, coping and daily functioning were preserved. Women indicated some positive reactions to screening, including improved existential values and reassurance they do not have breast cancer. Abnormal screens and biopsies were not significantly associated with any psychological scale, even after adjustment for patient characteristics.

CONCLUSION

Non-mutation carriers undergoing MRI-based screening had considerable baseline anxiety and cancer worry, although daily functioning was not impaired. Abnormal screens and biopsies did not appear to have adverse psychological effects.

Scanxiety: a scoping review about scan-associated anxiety

OBJECTIVES

To identify available literature on prevalence, severity and contributing factors of scan-associated anxiety ('scanxiety') and interventions to reduce it.

DESIGN

Systematic scoping review.

DATA SOURCES

Ovid MEDLINE, Ovid EMBASE, Ovid PsycINFO, Ovid Cochrane Central Register of Controlled Trials, Scopus, EBSCO CINAHL and PubMed up to July 2020.

STUDY SELECTION

Eligible studies recruited people having cancer-related non-invasive scans (including screening) and contained a quantitative assessment of scanxiety.

DATA EXTRACTION

Demographics and scanxiety outcomes were recorded, and data were summarised by descriptive statistics.

RESULTS

Of 26 693 citations, 57 studies were included across a range of scan types (mammogram: 26/57, 46%; positron-emission tomography: 14/57, 25%; CT: 14/57, 25%) and designs (observation: 47/57, 82%; intervention: 10/57, 18%). Eighty-one measurement tools were used to quantify prevalence and/or severity of scanxiety, including purpose-designed Likert scales (17/81, 21%); the State Trait Anxiety Inventory (14/81, 17%) and the Hospital Anxiety and Depression Scale (9/81, 11%). Scanxiety prevalence ranged from 0% to 64% (above prespecified thresholds) or from 13% to 83% ('any' anxiety, if no threshold). Mean severity scores appeared low in almost all measures that quantitatively measured scanxiety (54/62, 87%), regardless of whether anxiety thresholds were prespecified. Moderate to severe scanxiety occurred in 4%-28% of people in studies using descriptive measures. Nine of 20 studies assessing scanxiety prescan and postscan reported significant postscan reduction in scanxiety. Lower education, smoking, higher levels of pain, higher perceived risk of cancer and diagnostic scans (vs screening scans) consistently correlated with higher scanxiety severity but not age, gender, ethnicity or marital status. Interventions included relaxation, distraction, education and psychological support. Six of 10 interventions showed a reduction in scanxiety.

CONCLUSIONS

Prevalence and severity of scanxiety varied widely likely due to heterogeneous methods of measurement. A uniform approach to evaluating scanxiety will improve understanding of the phenomenon and help guide interventions.

[New surgical strategy in breast reconstruction with implants for bilateral prophylactic mastectomies with BRCA gene mutation]

BACKGROUND

For the past decades, number of prophylactic bilateral mastectomies using reconstruction with implants increases. We describe a new surgical strategy and analyse its safety and feasability.

METHOD

It is a retrospective, descriptive and monocentric study. The first step of surgery consisted in obteining a peri-prosthetic capsule with implants and if there was a mammary hypertrophy and/or ptosis, it was corrected at the same time. The second step of surgery was the nipple-sparing mastectomy with change of implants for bigger ones. Third step consisted in a lipofilling.

RESULTS

Seven patients were included. 6 women had a BRCA1 gene mutation. Mean age was 35.6 year-old [29.6; 41.6], mean BMI was 23.8kg/m² [20.6; 27], mean chest circumference was 93.7cm [87.4; 100], mean cup was C- [B-; D-]. 4 women had mammary hypertrophy and/or ptosis. Mean number of procedure per woman was 3.6 [2.5; 4.7]. Mean volume of implants used at the first step was 248.6ml [211.3; 285.9]. The second step was performed mean 33.9 weeks [22.3; 45.5] later. Mean increase of implants volume was 120ml [80.4; 159.6]. 4 patients had complications including 1 who had implant exposure. Six patients had lipofilling of mean volume per breast of 175ml [116; 234].

CONCLUSION

This new strategy could decrease complication rate, improve aesthetic outcome and decrease psychological impact of surgery.

Integration of Health Questionnaire Systems to Facilitate Supportive Care Services for Patients at an Academic Breast Care Center

PURPOSE

This study evaluated the use of an electronic Health Questionnaire System (HQS) within the University of California San Francisco Breast Care Center as a screening and triage tool to proactively recognize patients' supportive care needs during new patient consultations and identify demographic characteristics associated with referrals to three supportive care services.

PATIENTS AND METHODS

A total of 428 patients with and without breast cancer between the ages of 18 and 84 years completed HQS intake forms before appointments at the University of California San Francisco Breast Care Center between November 2014 and May 2015 and agreed to participate in this study. Patient HQS responses triggered referrals to supportive care services, and a review of electronic health records was conducted to determine the outcomes of these referrals.

RESULTS

A total of 242 patients (56.5%) met criteria for at least one supportive care referral. Women with invasive breast cancer or ductal carcinoma in situ met criteria for supportive services more frequently than women without breast cancer diagnoses (76.9% v 23.8%; P < .001) and were most likely to receive referrals for genetic counseling (67.0%), psychological services (32.2%), and social services (12.1%). Multivariable logistic regression analysis showed that being married was associated with fewer referrals to social work (OR, 0.42; 95% CI, 0.21 to 0.81) and that those between 45 and 54 years of age were less likely to receive referrals to genetic counseling than those ≥ 55 years of age (OR, 0.41; 95% CI, 0.23 to 0.73). Among all referrals (n = 369), 26.8% resulted in completed appointments.

CONCLUSION

Using an automated intake form is an efficient way to identify and triage individuals in need of supportive care services and can provide insight into the populations with supportive care needs for targeted outreach.

Imaging surveillance programs for women at high breast cancer risk in Europe: Are women from ethnic minority groups adequately included? (Review)

Women from ethnic minority groups, including immigrants and refugees are reported to have low breast cancer (BC) screening rates. Active, culturally-sensitive outreach is vital for increasing participation of these women in BC screening programs. Women at high BC risk and who belong to an ethnic minority group are of special concern. Such women could benefit from ongoing trials aimed at optimizing screening strategies for early BC detection among those at increased BC risk. Considering the marked disparities in BC survival in Europe and its enormous and dynamic ethnic diversity, these issues are extremely timely for Europe. We systematically reviewed the literature concerning European surveillance studies that had imaging in the protocol and that targeted women at high BC risk. The aim of the present review was thereby to assess the likelihood that women at high BC risk from minority ethnic groups were adequately included in these surveillance programs. Twenty-seven research groups in Europe reported on their imaging surveillance programs for women at increased BC risk. The benefit of strategies such as inclusion of magnetic resonance imaging and/or more intensive screening was clearly documented for the participating women at increased BC risk. However, none of the reports indicated that sufficient outreach was performed to ensure that women at increased BC risk from minority ethnic groups were adequately included in these surveillance programs. On the basis of this systematic review, we conclude that the specific screening needs of ethnic minority women at increased BC risk have not yet been met in Europe. Active, culturally-sensitive outreach is needed to identify minority women at increased BC risk and to facilitate their inclusion in on-going surveillance programs. It is anticipated that these efforts would be most effective if coordinated with the development of European-wide, population-based approaches to BC screening.

Contrast-enhanced spectral mammography (CESM) and contrast enhanced MRI (CEMRI): Patient preferences and tolerance

INTRODUCTION

Contrast-enhanced spectral mammography (CESM) may have similar diagnostic performance to Contrast-enhanced MRI (CEMRI) in the diagnosis and staging of breast cancer. To date, research has focused exclusively on diagnostic performance when comparing these two techniques. Patient experience is also an important factor when comparing and deciding on which of these modalities is preferable. The aim of this study is to compare patient experience of CESM against CEMRI during preoperative breast cancer staging.

METHODS

Forty-nine participants who underwent both CESM and CEMRI, as part of a larger trial, completed a Likert questionnaire about their preference for each modality according to the following criteria: comfort of breast compression, comfort of intravenous (IV) contrast injection, anxiety and overall preference. Participants also reported reasons for preferring one modality to the other. Quantitative data were analysed using a Wilcoxon sign-rank test and chi-squared test. Qualitative data are reported descriptively.

RESULTS

A significantly higher overall preference towards CESM was demonstrated (n = 49, P < 0.001), with faster procedure time, greater comfort and lower noise level cited as the commonest reasons. Participants also reported significantly lower rates of anxiety during CESM compared with CEMRI (n = 36, P = 0.009). A significantly higher rate of comfort was reported during CEMRI for measures of breast compression (n = 49, P = 0.001) and the sensation of IV contrast injection (n = 49, P = 0.003).

CONCLUSION

Our data suggest that overall, patients prefer the experience of CESM to CEMRI, adding support for the role of CESM as a possible alternative to CEMRI for breast cancer staging.

A survivorship care plan for breast cancer survivors: extended results of a randomized clinical trial

PURPOSE

Prevailing wisdom suggests that implementation of a survivorship care plan (SCP) will address deficits in survivorship care planning and delivery for cancer patients. Here, we present 24-month results of a randomized clinical trial on health service and patient-reported outcomes among breast cancer patients transferred to their primary care physician for follow-up care. The 24-month assessments represent the long-term benefit and sustainability of the implantation of a SCP.

METHODS

In all, 408 patients with early-stage breast cancer were randomized to the SCP or control group. Patient self-completed questionnaires, supplemented with telephone interviews, during the 24-month study period assessed health service and patient-reported outcomes. The primary outcome was cancer-specific distress. Secondary outcomes included health-related quality of life, patient satisfaction, continuity and coordination of care, and health service outcomes such as adherence to guidelines.

RESULTS

Over the course of 24 months, there were no differences between both groups in health service and patient-reported outcomes. Women from Quebec compared to those from Western Canada (p < 0.001), women within 2 years of completion of primary treatment compared to a longer period (p = 0.013), and those with a higher SF-36 mental component score compared to a lower score (p = 0.044) were positively associated with adherence to guidelines.

CONCLUSION

The implementation of a SCP in the transition of survivorship care from cancer center to primary care did not contribute to improved health service or patient-reported outcomes in this study population. Therefore, additional research is needed before widespread implementation of a SCP in clinical practice.

IMPLICATIONS OF CANCER SURVIVORS

The transition of survivorship care from cancer center to the primary care setting showed no negative effect on health service and patient-reported outcomes.

Frequency and intensity of pain related to thyroid nodule fine-needle aspiration cytology

BACKGROUND

Quality of life is an important issue in endocrine tumors because of the high prevalence of benign tumors and the indolent course of most malignant tumors.

OBJECTIVE

To evaluate the frequency and the intensity of pain and anxiety in patients undergoing thyroid nodule fine-needle aspiration cytology (FNAC) and to identify factors associated with pain.

METHODS

Single center prospective study in the setting of a one-stop outpatient diagnostic clinic for thyroid nodules. Pain was evaluated using a 100-mm visual analogue scale (VAS) immediately following (VAS1) and 30 minutes after (VAS2) FNAC and was considered significant if ≥ 30. Anxiety symptoms were assessed prior to FNAC using a self-report measure questionnaire: the state form of Spielberger State-Trait Anxiety Inventory (STAI, form Y-A). FNAC was performed with a 25-gauge needle and a moderate aspiration and two passes for each nodule.

RESULTS

Two hundred eighteen consecutive patients (163 females, 55 males; mean age 53 years, range 12-84 years) undergoing FNAC of one to three nodules were included. VAS1 was ≥ 30 in 24% of the patients and VAS(2) was ≥ 30 in 13% of the patients. Independent significant factors correlated to a VAS1 of ≥ 30 were age under 25 years and the number of nodules being biopsied. Independent significant factors correlated to a VAS2 of ≥ 30 were VAS1 ≥ 30 and female sex. No correlation was found between pain and nodule size or nodule depth, nor the duration of application of the eutectic mixture of local anesthetics (EMLA) patch prior to FNAC. The mean STAI score for anxiety was 37 ± 12. The average STAI score was significantly higher in women (39) than in men (33; p = 0.01). There was no significant correlation between STAI score and age under 25 years, previous FNAC, number of nodules biopsied, or acetaminophen administration, but the STAI score was significantly correlated to VAS1 and VAS2.

CONCLUSIONS

FNAC-related pain is frequent and correlates with the number of nodules biopsied, age under 25 years, female sex, and anxiety.