Experience with breast cancer, pre-screening perceived susceptibility and the psychological impact of screening

"It Will Lead You to Make Better Decisions about Your Health"-A Focus Group and Survey Study on Women's Attitudes towards Risk-Based Breast Cancer Screening and Personalised Risk Assessments

Singapore launched a population-based organised mammography screening (MAM) programme in 2002. However, uptake is low. A better understanding of breast cancer (BC) risk factors has generated interest in shifting from a one-size-fits-all to a risk-based screening approach. However, public acceptability of the change is lacking. Focus group discussions (FGD) were conducted with 54 women (median age 37.5 years) with no BC history. Eight online sessions were transcribed, coded, and thematically analysed. Additionally, we surveyed 993 participants in a risk-based MAM study on how they felt in anticipation of receiving their risk profiles. Attitudes towards MAM (e.g., fear, low perceived risk) have remained unchanged for ~25 years. However, FGD participants reported that they would be more likely to attend routine mammography after having their BC risks assessed, despite uncertainty and concerns about risk-based screening. This insight was reinforced by the survey participants reporting more positive than negative feelings before receiving their risk reports. There is enthusiasm in knowing personal disease risk but concerns about the level of support for individuals learning they are at higher risk for breast cancer. Our results support the empowering of Singaporean women with personal health information to improve MAM uptake.

Patient-reported outcomes associated with cancer screening: a systematic review

Background

Multi-cancer early detection tests have been developed to enable earlier detection of multiple cancer types through screening. As reflected by patient-reported outcomes (PROs), the psychosocial impact of cancer screening is not yet clear. Our aim is to evaluate the impact of cancer screening through PRO assessment.

Methods

A systematic review was conducted using MEDLINE, EMBASE, and reference lists of articles from January 2000 to August 2020 for relevant publications assessing the psychosocial impact of cancer screening before and within 1 year after screening in the general asymptomatic population, including following receipt of results. Studies focused on diagnostic evaluation or involving patients previously diagnosed with cancer were excluded.

Results

In total, 31 studies (12 randomized controlled trials; 19 observational studies) were included, reflecting PRO assessments associated with lung, breast, colorectal, anal, ovarian, cervical, and prostate cancer screening procedures. The most commonly assessed construct was symptoms of anxiety, using the State-Trait Anxiety Inventory. Cancer-specific distress and worry were also assessed using a broad range of measures. Overall, individuals tolerated screening procedures well with no major psychosocial effects. Of note, increases in symptoms of anxiety and levels of distress and worry were generally found prior to communication of screening results and following communication of indeterminate or positive results that required further testing. These negative psychosocial effects were, however, not long-lasting and returned to baseline relatively soon after screening. Furthermore, individuals with higher cancer risk, such as current smokers and those with a family history of cancer, tended to have higher levels of anxiety and distress throughout the screening process, including following negative or indeterminate results.

Conclusions

The psychosocial impact of cancer screening is relatively low overall and short-lived, even following false-positive test results. Individuals with a higher risk of cancer tend to experience more symptoms of anxiety and distress during the screening process; thus, more attention to this group is recommended.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09261-5.

Prevalence and correlates of hopelessness in Tunisian women with benign breast disease and breast cancer

BACKGROUND

There is limited research suggesting that women with Benign Breast Disease (BBD) experience psychological distress similar to breast cancer (BC) women. We aimed to examine hopelessness and its related factors in BC and BBD women.

METHOD

This was a cross-sectional study. The Beck Hopelessness Scale and the Beck Depression Inventory were administered to 51 BBD and 52 BC women.

RESULTS

BC women had higher hopelessness scores as compared to those with BBD (6.9 ± 4.8 vs. 4.9 ± 3.6; p = .018). After controlling for confounding variables, depression and suicidal ideation/behavior were significantly associated with hopelessness in the BBD group, while only a lower socioeconomic status was associated with higher hopelessness scores in the BC group.

CONCLUSION

We found that not only BC but also BBD lead to a psychological burden. Early detection and handling of hopeless feelings and thoughts that may arise in this population are recommended.

Insights into the Slow Uptake of Residential Lead Paint Remediation Funds: A Lancaster, Pennsylvania, Case Study

Lead poisoning is a preventable condition that continues to affect thousands of children each year. Given that local governments and municipalities are eligible to apply for federal funds to perform lead remediation in low-income family homes, we sought to understand how lead poisoning knowledge levels may affect the uptake of these funds. We recruited and conducted 28 in-depth, semi-structured interviews with community members from Lancaster County in the state of Pennsylvania in the USA. We audio-recorded and transcribed each interview, and analyzed each transcript for salient themes. The interviewed participants displayed a varying degree of knowledge about lead and lead poisoning. Most of the participants were unaware of the lead paint remediation funds. Participants learned about lead from various sources, such as social media, and personal experiences with lead poisoning appeared to enhance knowledge. Some participants assumed lead poisoning prevention would be addressed by other stakeholders if necessary, including healthcare professionals and landlords. The results of this study suggest that in order to increase the timely uptake of the remediation funds, community-based organizations should design interventions that aim to increase awareness and knowledge about lead poisoning and lead poisoning prevention. These interventions should be tailored for different audiences including community members, healthcare professionals, and landlords.

The emotional impact of surveillance programs for pancreatic cancer on high-risk individuals: A prospective analysis

OBJECTIVE

Literature shows that emotional status can influence participation in screening/surveillance programs, and that screening/surveillance programs may alter the psychological well-being of subjects examined. This study aims to assess if participating in a surveillance program for pancreatic cancer early detection is associated with abnormal levels of psychological distress in high-risk individuals (HRIs), compared to the general population.

METHODS

Fifty-four HRIs participating in a magnetic resonance cholangiopancreatography (MRCP)-based surveillance program completed several psychological assessment questionnaires, investigating global functioning, self-efficacy, perceived stress, coping abilities, and social support. The questionnaires were administered by a clinical psychologist after the MRCP but before the subjects were informed about the results of the scans. The HRIs were subjects with strong familiarity of pancreatic cancer and/or carriers of known genetic mutations related to cancer susceptibility. The psychological assessment was made at the time of the first examination.

RESULTS

The population was characterized by an overall good psychological status. Scoring of our sample was comparable to the general population norms. The HRIs showed decent global functioning, high self-efficacy levels, low perceived stress in the last month prior to examination, efficient emotion-focused coping strategies, and an adequate social support system. The younger subjects' subpopulation only revealed higher levels of stress.

CONCLUSIONS

From a psychological point of view, an MRCP-based pancreatic cancer annual surveillance seemed not to influence the HRIs' psychological well-being, unless in young people. Further studies are needed to better establish if there are any changes in distress levels over time and how emotional status influences participation in surveillance programs.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Educational Intervention for Women Undergoing Image-Guided Breast Biopsy: Results of a Randomized Clinical Trial

Background

The process of informed consent has been examined for patients undergoing various procedures but not breast biopsy. Our study was a randomized trial that examined the effect of an educational flip chart as part of the informed consent.

Methods

A total of 122 patients referred for stereotactic or ultrasound-guided core breast biopsy were randomly assigned to receive an informed consent discussion with or without an illustrated flip chart. The chart included information about breast anatomy, pathology, and diagnostic procedures. Outcome measures included objective knowledge, subjective knowledge, anxiety, and satisfaction.

Results

Analysis showed few significant main effects of the intervention. However, results showed interactions between experimental condition and race/ethnicity, indicating that the intervention was effective in enhancing objective and subjective knowledge for African American but not Caucasian patients. Anxiety after consultation was higher among patients assigned to the flip chart condition, possibly because they were better informed about the risks of the procedure. Patients who underwent biopsy sooner after learning they needed one were more satisfied with their care.

Conclusions

The usual care consent process is effective for many but not all patients. Informed consent that employs visual aids may help overcome characteristics of the consent process that are ineffective for some patients.

How Many of the Biopsy Decisions Taken at Inexperienced Breast Radiology Units Were Correct?

OBJECTIVE

In this study, we aimed to determine the need for biopsy in patients referred from other clinics for the performance of biopsy with the suspicion of breast cancer.

MATERIALS AND METHODS

112 patients were included in the study. It was decided that their biopsies be performed following examinations in other clinics and they presented to the breast radiology unit of our hospital for a second opinion. The demographic characteristics, diagnostic studies completed in the other centers, properties of lesions, decision made as a result of examinations and BI-RADS (Breast Imaging Reporting and Data Systems) categorizations were recorded on the registration forms of the study patients. In addition, the quality of examinations, reasons of repeat tests, additional tests features and the last decision of our clinic were documented. The obtained data were analyzed in terms of re-examination, additional tests and change in the biopsy decision. Changes in the biopsy decisions for patients were specifically inquired.

RESULTS

The biopsy decisions were cancelled in our breast radiology unit for 63 out of 112 patients (56.3%) whose biopsy decisions were made at an external institute. For 42 patients, examinations made by the other clinics were deemed adequate, yet there was no need for biopsy in 22 of them. The biopsy decisions were cancelled for 27 out of 47 patients (57.4%) with repeat examination and 18 out of 28 patients (64.3%) with additional tests because of the insufficient test quality.

CONCLUSION

Incorrect, inadequate breast screening and false positivity were higher at inexperienced institutes.

Cues to Cervical Cancer Screening Among U.S. Hispanic Women

Introduction:

Hispanic women’s cervical cancer rates are disproportionately high. Cues to cervical cancer screening (Cues to Action) are strategies to activate the decision-making process to get screened for cervical cancer. This study used the health belief model to examine which cues prompt Hispanic women to undergo cervical cancer screening and how perceptions could be potentiated by cues to cervical cancer screening.

Method:

A cross-sectional survey was conducted among Hispanic women 18 to 65 years old ( n = 220). Generalized linear modeling was used.

Results:

Spanish media and reminders by mother and doctors were relevant cues. Generalized linear modeling showed cues to action modified significantly the predictive effect of Perceived Threats (i.e., Susceptibility, Severity), benefits, barriers, and self-efficacy on Hispanic women’s cervical cancer screening behavior. “Mother told me” and Spanish media messages were significant covariates.

Conclusion:

Cues to Action influenced Hispanic’s women participation in cervical cancer screening. Cues to Action increased the strength of the health belief model as an explanatory model, and must be considered in designing culturally appropriate cervical cancer screening interventions.

Psychological effects of colorectal cancer screening: Participants vs individuals not invited

AIM

To investigate the possible long-term psychological harm of participating in colorectal cancer (CRC) screening in Norway.

METHODS

In a prospective, randomized trial, 14294 participants (aged 50-74 years) were invited to either flexible sigmoidoscopy (FS) screening, or a faecal immunochemical test (FIT) (1:1). In total, 4422 screening participants (32%) completed the questionnaire, which consisted of the Hospital Anxiety and Depression Scale and the SF-12, a generic health-related quality of life (HRQOL) measurement, when invited to screening and one year after the invitation. A control group of 7650 individuals was invited to complete the questionnaire only, at baseline and one year after, and 1911 (25%) completed the questionnaires.

RESULTS

Receiving a positive or negative screening result and participating in the two different screening modalities did not cause clinically relevant mean changes in anxiety, depression or HRQOL after one year. FS screening, but not FIT, was associated with an increased probability of being an anxiety case (score ≥ 8) at the one-year follow-up (5.6% of FS participants transitioned from being not anxious to anxious, while 3.0% experienced the reverse). This increase was moderately significantly different from the changes in the control group (in which the corresponding numbers were 4.8% and 4.5%, respectively), P = 0.06.

CONCLUSION

Most individuals do not experience psychological effects of CRC screening participation after one year, while FS participation is associated with increased anxiety for a smaller group.

Pre-Feedback Risk Expectancies and Reception of Low-Risk Health Feedback: Absolute and Comparative Lack of Reassurance

BACKGROUND

Personalised health-risk assessment is one of the most common components of health promotion programs. Previous research on responses to health risk feedback has commonly focused on the reception of bad news (high-risk feedback). The reception of low-risk feedback has been comparably neglected since it is assumed that good news is reassuring and readily received. However, field studies suggest mixed responses to low-risk health feedback. Accordingly, we examine whether pre-feedback risk expectancies can mitigate the reassuring effects of good news.

METHODS

In two studies (N = 187, N = 565), after assessing pre-feedback risk expectancies, participants received low-risk personalised feedback about their own risk of developing (the fictitious) Tucson Chronic Fatigue Syndrome (TCFS). Study 2 also included peer TCFS risk status feedback. Afterwards, self- and peer-related risk perception for TCFS was assessed.

RESULTS

In both studies, participants who expected to be at high risk but received good news (unexpected low-risk feedback) showed absolute lack of reassurance. Specifically, they felt at significantly greater TCFS risk than participants who received expected good news. Moreover, the unexpected low-risk group even believed that their risk was as high as (Study 1) or higher (Study 2) than that of their peers (comparative lack of reassurance).

CONCLUSION

Results support the notion that high pre-feedback risk expectancies can mitigate absolute and comparative reassuring effects of good news.

Diagnostic invasiveness and psychosocial consequences of false-positive mammography

PURPOSE

We undertook a study to assess whether women with false-positive mammography have worse psychosocial consequences if managed with a workup that involves a biopsy (invasive group) than if managed with only additional imaging (noninvasive group).

METHODS

We performed subgroup analysis of a cohort study of 454 women with abnormal screening mammography and 908 matched control women with normal results. Using a condition-specific questionnaire (Consequences of Screening in Breast Cancer), we assessed 12 psychosocial consequences at 5 time points (0, 1, 6, 18, and 36 months after final diagnosis) and compared the 2 groups of women with false-positives (invasive and noninvasive management groups).

RESULTS

Among the 252 women with false-positive mammography eligible for this study, psychosocial consequences were similar for those managed invasively and those managed noninvasively during the 36 months of follow-up. In 60 comparisons (12 scales and 5 time points), differences between the groups were never statistically significant (P <.01) and the point estimates for the differences were always close to zero. The psychosocial consequences of women with false-positive results, regardless of management, fell between those of women with normal mammography and those of women determined to have breast cancer.

CONCLUSIONS

We found no evidence that use of more invasive diagnostics was associated with worse psychosocial consequences. It is therefore reasonable to pool subgroups of women with false-positives in a single analysis. The invasiveness of subsequent diagnostic procedures does not help to identify women at higher risk for adverse psychosocial consequences of false-positive mammography.

A review of the evidence of harm from self-tests

Although HIV self-testing may overcome some barriers to HIV testing, various stakeholders have expressed concerns that HIV self-testing may lead to unintended harm, including psychological, social and medical harm. Recognizing that similar concerns were raised in the past for some other self-tests, we conduct a review of the literature on a set of self-tests that share some characteristics with HIV self-tests to determine whether there is any evidence of harm. We find that although the potential for harm is discussed in the literature on self-tests, there is very little evidence that such harm occurs.

Negative affect differentiation and adherence during treatment for thalassemia

BACKGROUND

Although research has demonstrated the detrimental effects of excessive negative affect on treatment adherence and morbidity in chronic illness, rarely have researchers investigated the benefits of awareness of negative emotional experiences during treatment.

PURPOSE

In this investigation, we examined the association of negative affect differentiation (the ability to report negative emotional experiences as separate and distinct from each other,) to treatment adherence in adult patients with the congenital blood disorder thalassemia.

METHOD

Negative affect differentiation was assessed during a 12-16-week treatment-based diary and adherence was operationalized as attendance at routine screenings over 12 months. Participants were adult patients (n = 32; age M = 31.63, SD = 7.72; 72 % female) with transfusion-dependent thalassemia in treatment in a large metropolitan hospital in the Northeastern USA.

RESULTS

The results indicate that negative affect differentiation is significantly associated with greater adherence to treatment, even when controlling for disease burden and level of psychological distress.

CONCLUSION

Although preliminary, this investigation suggests that differentiated processing of negative emotional experiences during illness can lead to adaptive treatment-related behavior. As such, it may present a new avenue for research and intervention targeting the improvement of adherence during treatment for chronic illness.

Predictive factors for psychological distress related to diagnosis of breast cancer

OBJECTIVE

The aims of the present study were as follows: (i) to clarify the proportion of women who experience psychological distress during breast cancer diagnosis and (ii) to identify the predictors of psychological distress related to the diagnostic process.

METHODS

This was a longitudinal prospective study of women who required further breast examination. Questionnaires were administered at pre-medical consultations (Time 1), after describing radiological examination (Time 2), and after explaining pathological findings (Time 3). All participants completed Hospital Anxiety and Depression Scale (HADS), Functional Assessment of Cancer Therapy--Breast, and Functional Assessment of Chronic Illness Therapy--Spiritual subscale at Time 1 to identify predictors. Participants also completed HADS at Times 2 and 3 to identify the presence or absence of psychological distress.

RESULTS

Of the 222 eligible patients, at Time 2, 31 (22.6%) participants with no clinical abnormalities and 39 (45.9%) participants with abnormal findings had HADS scores of ≥ 11 points (χ2 test, 13.14; p < 0.001). At Time 3, 14 (28.0%) participants with benign breast changes and 24 (68.6%) participants with breast cancer had scores of ≥ 11 (χ2 test, 13.71; p < 0.001). Higher HADS scores at Time 1 were associated with the presence of psychological distress at all stages of breast cancer diagnosis. Advanced tumor stage was a predictor of psychological distress for participants with breast cancer (odds ratios = 3.314, 95% confidence interval = 1.033-9.509; p = 0.044).

CONCLUSION

These results suggest that intensive psychological intervention is necessary for breast cancer patients with large tumors, as well as for women with suspected breast cancer with high HADS scores at pre-consultation.

Levels of state and trait anxiety in patients referred to ophthalmology by primary care clinicians: a cross sectional study

Purpose

There is a high level of over-referral from primary eye care leading to significant numbers of people without ocular pathology (false positives) being referred to secondary eye care. The present study used a psychometric instrument to determine whether there is a psychological burden on patients due to referral to secondary eye care, and used Rasch analysis to convert the data from an ordinal to an interval scale.

Design

Cross sectional study.

Participants and Controls

322 participants and 80 control participants.

Methods

State (i.e. current) and trait (i.e. propensity to) anxiety were measured in a group of patients referred to a hospital eye department in the UK and in a control group who have had a sight test but were not referred. Response category analysis plus infit and outfit Rasch statistics and person separation indices were used to determine the usefulness of individual items and the response categories. Principal components analysis was used to determine dimensionality.

Main Outcome Measure

Levels of state and trait anxiety measured using the State-Trait Anxiety Inventory.

Results

State anxiety scores were significantly higher in the patients referred to secondary eye care than the controls (p<0.04), but similar for trait anxiety (p>0.1). Rasch analysis highlighted that the questionnaire results needed to be split into “anxiety-absent” and “anxiety-present” items for both state and trait anxiety, but both subscales showed the same profile of results between patients and controls.

Conclusions

State anxiety was shown to be higher in patients referred to secondary eye care than the controls, and at similar levels to people with moderate to high perceived susceptibility to breast cancer. This suggests that referral from primary to secondary eye care can result in a significant psychological burden on some patients.

Breast cancer worry in further examination of mammography screening--a systematic review

AIMS

In this systematic review, we explored which factors are associated with breast cancer (BC) worry in further examination (FE) of mammography screening and for how long women experience BC worry associated with FE.

METHODS

Medline, Cochrane, Cinahl and the International Network of Agencies for Health Technology Assessment databases were used in the search. In addition to this, reference lists of the selected articles were inspected. The subject headings and keywords searched included breast screening, mammography screening, BC worry, distress or anxiety, additional test, further examination and recall. These were used separately and in combination. The databases gave 598 references. From the selected titles, 83 abstracts were read; from these, 23 publications were selected for full-text review. On the basis of full texts, 15 articles were chosen.

FINDINGS

There were very few studies about the associations between FE and BC worry. In those found, the amount of measured variables was limited. BC worry in FE of breast screening was associated with several sociodemographic and psychosocial factors of recalled women, as well as those related to the FE process. About half of the recalled women were quite or very anxious in the prediagnostic phase.

CONCLUSIONS

The review gave implications for interventions in the FE process of mammography screening. These interventions should predominantly be made in the preclinical phase and should differ according to the type of recall visit and characteristics of recalled women. In communicating the diagnosis to the women, the time from the examination process to diagnosis should be as short as possible, and in addition to physicians being present, other health care professionals should also be there to ensure the necessary emotional and practical support a woman needs in such a situation.

Moderators of cancer-related distress and worry after a pancreatic cancer genetic counseling and screening intervention

OBJECTIVES

Although the hereditary breast and ovarian cancer literature has demonstrated short-term gains in psychological adjustment following genetic counseling, there has been limited research examining long-term outcomes and moderators. Moreover, there has been minimal research into the psychological effects of this intervention in populations at high risk for pancreatic cancer. This study examines the long-term effects of pancreatic cancer screening and genetic counseling on cancer-related distress and cancer worry in a high-risk population at 1-year follow-up. Additionally, this study explores potential moderators of the effectiveness of this intervention.

METHODS

One hundred twenty-nine participants with familial pancreatic cancer or with the BRCA2 gene mutation completed a baseline questionnaire prior to their first pancreatic cancer screening and genetic counseling session. Participants also completed questionnaires at 3- and 12-month follow-up.

RESULTS

Cancer-related intrusive thoughts decreased significantly over time, whereas cancer-related worry decreased at 3 months and showed a small but significant increase at 1 year. Age and baseline distress exhibited moderator effects. Younger individuals showed a significant decrease in cancer-related intrusive thoughts, cancer-related avoidant thoughts, and cancer worry. Additionally, individuals with greater baseline distress showed a significant decrease in cancer-related intrusive thoughts over time.

CONCLUSIONS

Analysis of the long-term effects of pancreatic cancer screening and genetic testing reveal psychological gains that are maintained at 1-year follow-up. This intervention is particularly effective for younger participants and individuals with greater baseline distress.

Psychosocial factors influencing breast cancer risk appraisal among older women

Although the incidence of breast cancer increases with age, many older women are uninformed about the increased risk and have lower mammography screening rates than younger women. Understanding older women's perceptions of risk might assist health care providers in offering appropriate resources that result in screening. In this study, we explored psychosocial components influencing older women's breast cancer risk appraisal. To identify key psychosocial components of breast cancer risk appraisal, we conducted focus group interviews. Data saturation occurred with four groups (N = 36) of older Black (58%) and White (42%) women with no prior history of breast cancer. On analysis of the data, we found three themes representing psychosocial factors influencing breast cancer risk appraisal with this cohort. Our findings revealed that worry/fear/anxiety, self-regulating empowerment, and realistic optimism were psychosocial mechanisms older Black and White women in this sample used in appraising breast cancer risk.

Clinical, demographic, and situational factors linked to distress associated with benign breast biopsy

Benign breast biopsy (BBB) can be distressing for many women. Few studies have examined specific aspects of the BBB more or less distressing or risk factors for distress. Women (N = 51) who had a recent BBB reported the magnitude of distress associated with specific aspects of their experience. Clinical and demographic variables were also examined as risk factors for distress. All women reported some distress associated with the BBB with one third reporting their experience was "very stressful." Generally, biopsy-specific events were more distressing than follow-up mammography. Distress risk factors included younger age, less education, nonsurgical biopsy, and no family history of breast cancer. Clinical efforts to better manage biopsy-related distress are warranted. The authors identified clinical and demographic risk factors that furnish a simple, efficient, and potentially cost-effective means of stratifying risk for distress in the breast biopsy setting.

Pancreatic cancer risk counselling and screening: impact on perceived risk and psychological functioning

Individuals at increased risk for pancreatic cancer who undergo screening can experience psychological and emotional distress. The objective of this study is to determine whether individuals participating in a pancreatic cancer screening program experience disruptions in risk perception, cancer-related anxiety or emotional distress. A pretestposttest design was used to examine perceived risk and psychological functioning of individuals participating in a pancreatic cancer screening protocol. The screening protocol includes genetic counselling, transcutaneous abdominal ultrasound, magnetic resonance imaging, and blood collection and eligible participants included individuals with a family history of pancreatic cancer or BRCA2 mutation carriers. At baseline, participants (n = 198) showed low to moderate levels of risk perception, pancreatic cancer-related anxiety, and general distress. Participants with familial pancreatic cancer (FPC) (n = 131) endorsed higher risk perception of pancreatic cancer than the BRCA2 carriers (n = 67) (perceived lifetime risk 42 vs. 15%), but did not differ on cancer worry or general distress prior to the first study appointment. From baseline to 3 months follow-up, no significant time or time by group interactions emerged on risk perception or general distress, but cancer worry decreased over time for the FPC group regardless of the number of affected relatives. Our findings indicate that participation in a pancreatic cancer screening program does not lead to a significant increase in risk perception, cancer worry, or general distress and that participants with high baseline levels of risk perception and distress may benefit from a more comprehensive risk assessment and psychological support.

Risk perceptions among participants undergoing lung cancer screening: baseline results from the National Lung Screening Trial

BACKGROUND

Lung cancer screening could present a "teachable moment" for promoting smoking cessation and relapse prevention. Understanding the risk perceptions of older individuals who undergo screening will guide these efforts.

PURPOSE

This paper examines National Lung Screening Trial (NLST) participants' perceptions of risk for lung cancer and other smoking-related diseases. We investigated (1) whether risk perceptions of lung cancer screening participants differed between current and former smokers and (2) which factors (sociodemographic, smoking and medical history, cognitive, emotional, and knowledge) were associated with these risk perceptions.

METHODS

We analyzed baseline data collected from 630 NLST participants prior to their initial screen. Participants were older (55-74 years), heavy (minimum 30 pack years) current or former smokers. A ten-item risk perception measure was developed to assess perceived lifetime risk of lung cancer and other smoking-related diseases.

RESULTS

The risk perception measure had excellent internal consistency (alpha = 0.93). Former smokers had lower risk perceptions compared to current smokers. Factors independently associated with high risk perceptions among current smokers included having a personal history of a smoking-related disease, higher lifetime maximum number of cigarettes smoked daily, having lived with a smoker, high worry, high perceived severity of lung cancer and smoking-related diseases, and accurate knowledge of tenfold increased risk of lung cancer for a one pack per day smoker. Factors independently associated with high risk perceptions among former smokers included being White, past history of smoking within 30 min of waking, high worry, and accurate knowledge of tenfold increased risk of lung cancer for a one pack per day smoker.

CONCLUSIONS

Using a comprehensive risk perception measurement, we found that current and former smokers held different risk perceptions. Former and current smokers' smoking and medical history, race, emotional concerns, behavior change cognitions, and knowledge should be considered during a prescreening risk communication session. We highlight the theoretical and risk communication implications for former and current smokers undergoing lung cancer screening.

What Is the Psychological Impact of Mammographic Screening on Younger Women With a Family History of Breast Cancer? Findings From a Prospective Cohort Study by the PIMMS Management Group

Purpose

Studies are underway to establish the clinical effectiveness of annual mammographic screening in women younger than 50 years with a family history of breast cancer. This study investigated both the positive and negative psychological effects of screening on these women.

Patients and Methods

Women who received an immediate all-clear result after mammography (n = 1,174) and women who were recalled for additional tests before receiving an all-clear result (false positive; n = 112) completed questionnaires: 1 month before mammography, and 1 and 6 months after receiving final results. The questionnaires included measures of cancer worry, psychological consequences, and perceived benefits of breast screening.

Results

Women who received an immediate all-clear result experienced a decrease in cancer worry and negative psychological consequences immediately after the result, whereas women who were recalled for additional tests did not. By 6 months this cancer-specific distress had reduced significantly in both groups. Changes in levels of distress were significantly different between the two groups, but in absolute terms the differences were not large. Recalled women reported significantly greater positive psychological consequences of screening immediately after the result, and were also more positive about the benefits of screening compared with women who received an immediate all-clear result.

Conclusion

For women receiving an immediate all-clear result, participating in annual mammographic screening is psychologically beneficial. Furthermore, women who are recalled for additional tests do not appear to be harmed by screening: these women's positive views about mammography suggest that they view any distress caused by recall as an acceptable part of screening.

Tolerance for uncertainty and perceived risk among women receiving uninformative BRCA1/2 test results

Women who receive uninformative BRCA1/2 genetic test results face ongoing uncertainty about their future cancer risks. This article prospectively examined the influence of intolerance for uncertainty and perceived breast cancer risk on psychological distress following the receipt of uninformative BRCA1/2 test results. Sixty-four women who received uninformative BRCA1/2 mutation test results completed measures of Intolerance for Uncertainty, perceived breast cancer risk, and measures of cancer-related, genetic testing, and general distress. Cancer-related (DeltaR(2) = 0.18, P < or = 0.001), general (DeltaR(2) = 0.04, P < or = 0.05), and genetic testing distress (DeltaR(2) = 0.12, P < or = 0.01) were associated with intolerance for uncertainty at 1 month post-disclosure. The interaction of intolerance for uncertainty and breast cancer perceived risk predicted cancer-related (DeltaR(2) = 0.10, P < or = 0.001) and genetic testing distress (DeltaR(2) = 0.09, P < or = 0.01) at 6 months post-disclosure. Distress was highest among patients with highest perceived risk and intolerance for uncertainty, suggesting that those who have difficulty coping with their ambiguous risk are at risk for long-term distress. The clinical and research implications of these results are discussed.

Psychological Distress in U.S. Women Who Have Experienced False-Positive Mammograms

BACKGROUND

In the United States, approximately 10.7% of all screening mammograms lead to a false-positive result, but the overall impact of false-positives on psychological well-being is poorly understood.

MATERIALS AND METHODS

Data were analyzed from the 2000 U.S. National Health Interview Survey (NHIS), the most recent national survey that included a cancer control module. Study subjects were 9,755 women who ever had a mammogram, of which 1,450 had experienced a false-positive result. Psychological distress was assessed using the validated K6 questionnaire and logistic regression was used to discern any association with previous false-positive mammograms.

RESULTS

In a multivariate analysis, women who had indicated a previous false-positive mammogram were more likely to report feeling sad (OR = 1.18, 95% CI, 1.03-1.35), restless (OR = 1.23, 95% CI, 1.08-1.40), worthless (OR = 1.27, 95% CI, 1.04-1.54), and finding that everything was an effort (OR = 1.27, 95% CI, 1.10-1.47). These women were also more likely to have seen a mental health professional in the 12 months preceding the survey (OR = 1.28, 95% CI, 1.03-1.58) and had a higher composite score on all items of the K6 scale (P < 0.0001), a reflection of increased psychological distress. Analyses by age and race revealed that, among women who had experienced false-positives, younger women were more likely to feel that everything was an effort, and blacks were more likely to feel restless.

CONCLUSION

In a random sampling of the U.S. population, women who had previously experienced false-positive mammograms were more likely to report symptoms of anxiety and depression.

The psychological impact of mammographic screening. A systematic review

Concerns have been raised regarding the possible negative psychological impact of the cancer screening programmes offered in the UK. This review aims to assess the extent of and factors associated with the adverse psychological consequences of mammographic screening. Fifty-four papers from 13 countries were identified, a majority of which were published after 1990, coinciding more or less with the onset of routine mammographic screening. The results report that mammographic screening does not appear to create anxiety in women who are given a clear result after a mammogram and are subsequently placed on routine recall. However, women who have further investigations following their routine mammogram experience significant anxiety in the short term, and possibly in the long term. The nature and extent of the further investigation that women are exposed to during mammographic screening determines the intensity of the psychological impact. Factors associated with the adverse psychological impact of mammographic screening included: social demographic factors of younger age, lower education, living in urban areas, manual occupation, and one or no children; cancer screening factors of dissatisfaction with information and communication during screening process, waiting time between recall letter and recall appointment, pain experienced during the mammographic screening procedures, and previous false positive result; and cancer worry factors including fear of cancer and greater perceived risk of breast cancer. Difficulties in measuring the psychological impact of screening are discussed, and methods of alleviating the negative psychological outcomes are suggested.

Depressive symptoms, eating psychopathology, and physical activity in obese breast cancer survivors

Psychosocial problems such as depression are present as long-term sequelae of breast cancer and its treatment in a substantial minority of patients. In general and patient populations, lifestyle factors such as obesity and physical activity have been associated with depression, and these and related characteristics may be associated with depression in breast cancer survivors. The purpose of this cross-sectional study was to examine factors associated with depression in overweight or obese women (n=85) who had been diagnosed and treated for early stage breast cancer. Depressive symptoms were measured with the Beck depression inventory (BDI), eating psychopathology was assessed with the eating disorder examination--questionnaire (EDE-Q), and physical activity was estimated with the seven-day physical activity recall. BDI was directly correlated with global EDE-Q score (r=0.56, P<0.01) and inversely associated with age (r=-0.22, P<0.05) in bivariate analysis. Controlling for body mass index, age, education and other factors, BDI was directly associated with global EDE-Q score (P<0.001) and inversely associated with level of physical activity (P<0.05) in a model that explained 61% of the variance. Eating attitudes and behaviors, and physical activity level, are independently associated with depressive symptoms in overweight or obese breast cancer survivors.

Adverse psychological outcomes in colorectal cancer screening: does health anxiety play a role?

People who are anxious about their health are more likely to misinterpret health information as personally threatening and less likely to be reassured by medical investigations that show they are free from disease. Consequently, health anxious people would be expected to react more adversely to cancer screening, but this possibility has rarely been explored. The moderating role of health anxiety on the psychological impact of participating in colorectal cancer screening was examined among a sub-sample of 3535 participants in a large, community-based trial of colorectal cancer screening in the UK. The screening modality was flexible sigmoidoscopy, which examines the bowel for pre-cancerous polyps. It was predicted that health anxiety would be associated with more worry about cancer before screening, a greater increase in worry if polyps were detected, and less reassurance after a clear result. As expected, health anxious participants were more anxious and more worried about bowel cancer both before and after screening. However, they experienced greater reductions in anxiety and worry about cancer following the examination. They reported lower levels of reassurance following screening, but also expressed more positive reactions to the experience. The positive psychological benefits of attending medical investigations should be examined in future work, because this may go some way towards explaining why health anxious people repeatedly seek medical interventions.

Morbidity After Sentinel Lymph Node Biopsy in Primary Breast Cancer: Results From a Randomized Controlled Trial

Purpose

Axillary lymph node dissection (ALND) as part of surgical treatment for patients with breast cancer is associated with significant morbidity. Sentinel lymph node biopsy (SLNB) is a newly developed method of staging the axilla and has the potential to avoid an ALND in lymph node–negative patients, thereby minimizing morbidity. The aim of this study was to investigate physical and psychological morbidity after SLNB in the treatment of early breast cancer in a randomized controlled trial.

Patients and Methods

Between November 1999 and February 2003, 298 patients with early breast cancer (tumors 3 cm or less on ultrasound examination) who were clinically node negative were randomly allocated to undergo ALND (control group) or SLNB followed by ALND if subsequently found to be lymph node positive (study group). A detailed assessment of physical and psychological morbidity was performed during a 1-year period postoperatively.

Results

A significant reduction in postoperative arm swelling, rate of seroma formation, numbness, loss of sensitivity to light touch and pinprick was observed in the study group. Although shoulder mobility was less impaired on average in the study group, this was significant only for abduction at 1 month and flexion at 3 months. Scores reflecting quality of life and psychological morbidity were significantly better in the study group in the immediate postoperative period, with fewer long-term differences.

Conclusion

SLNB in patients undergoing surgery for breast cancer results in a significant reduction in physical and psychological morbidity.

The psychological impact of mammographic screening on women with a family history of breast cancer—a systematic review

This systematic review aims to assess the psychological impact of mammographic screening on women with a family history of breast cancer. Women with a family history, and hence increased risk, of breast cancer are known to experience higher levels of anxiety about cancer. They are also often offered screening from an earlier age. The psychological consequences of screening are therefore of particular importance for this group of women. A comprehensive search of 4 electronic databases was conducted from 1982 to 2003, combining sets of terms relating to (1) breast screening or mammography (breast screen*; mammogra*), (2) psychological impact (adverse effects; anxi*; distress; nervous; psych*, psychological consequences; stress; worry) and (3) family history. Reference lists from relevant papers were examined for additional papers. The review identified seven papers from four countries. Overall, the findings indicate that, similar to women in the general population, most women with a family history do not appear to experience high levels of anxiety associated with mammographic screening. Although women who are recalled for further tests do experience increased anxiety the levels appear to be no greater than for women without a family history. We conclude that further research on this topic is required--this should include studies designed specifically to consider both the negative and positive impact of mammographic screening on women with a family history, using validated measures of anxiety and worry in combination with qualitative research.

Who is not reassured following benign diagnosis of breast symptoms?

Many women fail to be reassured about their breast symptom following benign diagnosis. Identification of the factors contributing to this continued anxiety is important in order that appropriate intervention can be incorporated into the care of women undergoing diagnosis. In this study, we measured levels of anxiety, depression, stress, perceived personal risk of breast cancer, fear of breast cancer treatment and general health anxiety along with clinical and demographic variables in women undergoing investigation of breast symptoms. We then assessed if these factors were associated with reassurance about the breast symptom immediately following benign diagnosis.

METHODS

Women attending a specialist 'one-stop' breast clinic completed a questionnaire in the clinic prior to diagnosis and a reassurance measure post-benign breast symptom diagnosis.

RESULTS

Post-diagnosis, 67% of women were reassured however, 33% were not reassured about their breast symptom despite a benign diagnosis. Women who were not reassured were more likely to be educated only to high school level and have presenting symptoms of a change in breast shape/dimpling of the breast. There was a trend for women who were not reassured to have breast pain and be diagnosed with a benign breast cyst. Examination of the psychological variables showed that women who were not reassured compared to reassured women had higher levels of health anxiety, perceived stress, fear of breast cancer treatment and general anxiety. Logistic regression analysis entering all the predictors suggests that level of education was the strongest predictor of lack of reassurance following benign diagnosis.

CONCLUSION

This study found that a significant proportion of women who undergo investigation and receive a benign diagnosis of their breast symptom experience uncertainty. Our finding that women who were not reassured were more likely to be educated only to high school level suggests that this group may benefit from additional information about breast symptoms and benign diagnosis. Additionally, our results indicate that women with high levels of anxiety, perceived stress and general worry about their health may need further reassurance in the immediate diagnosis phase. Further research focussing on how reassurance is interpreted in the context of women's perceptions about breast symptoms and breast disease is important so that appropriate support can be offered for women undergoing diagnosis of breast symptoms.

Increasing mammography screening through inpatient education

BACKGROUND

The reasons why women do not undergo regular screening mammograms have not been clearly defined. In this study, we addressed an educational intervention based on Health Belief Model constructs for 3 of the most common reasons why women do not participate in mammography screening: cost, fear, and lack of knowledge. The purpose of the project was to study whether an educational intervention addressing these factors could increase mammography screening among age-appropriate women who had not had a recommended mammogram within the previous 12 months.

METHODS

The educational intervention consisted of providing a tailored brochure addressing either the barrier of (1) cost, (2) fear, or (3) lack of information. Participants were hospital inpatients admitted for noncancer diagnoses. They were followed up approximately 3 months after hospital discharge to ascertain subsequent mammography utilization either before or after leaving the hospital.

RESULTS

Of the 272 women originally interviewed, 147 (54%) were reached for follow-up. Although there were no differences related to which mammography barrier was addressed, 42 (28.6%) reported that they had obtained a mammogram after the intervention.

CONCLUSIONS

These data suggest that a fairly simple, low-cost patient education intervention of brochure distribution can produce substantially increased patient awareness and consequent mammography utilization.