Biopsychological stress factors in BRCA mutation carriers

Stress, anxiety, and health-related quality of life in BRCA1/2-positive women with and without cancer: A comparison of four US female samples

•

Anxiety and stress were significantly worse in BRCA1/2-positive women compared to comparable US female samples.

•

All health-related quality of life domains were better in BRCA1/2-positive women except energy/vitality, which was lower.

•

Patient-provider training and mental health referrals are needed to lessen psychosocial consequences of genetic testing.

Introduction

Women with BRCA1/2 mutations have a 11–72% increased risk of breast/ovarian cancers throughout their lifetime. The current study examines psychosocial differences between the current sample of BRCA1/2-positive women with and without cancer histories and three comparable United States (US) female samples without BRCA1/2 mutations.

Methods

Sixty BRCA1/2-positive women (with and without cancer histories) were recruited through multiple private online support groups in the US. Participants completed an online survey outlining sociodemographic and genetic counseling information, and anxiety, stress, and health-related quality of life (HRQoL) outcomes. Outcomes were compared to three similar US female normative samples via independent samples t-test analyses.

Results

State and trait anxiety (p = 0.00) and stress (p = 0.001) were significantly worse in the current sample of BRCA1/2-positive women compared comparable US female samples. All HRQoL domains were significantly better in the current sample except energy/vitality, which was significantly lower (p = 0.02) in the current sample. Results were stratified by cancer and recurrence status.

Conclusions

This study provides insight into how a sample of BRCA1/2-positive women both with and without cancer fare post-genetic counseling as compared to three normative female populations. Results infer the need for additional education, patient-provider training, and mental health referrals to support this population in order to circumvent unintended consequences and to improve psychosocial health in those being tested for, and those who test positive for, BRCA1/2 genetic mutations.

Cost-Effectiveness of BRCA 1/2 Genetic Test and Preventive Strategies: Using Real-World Data From an Upper-Middle Income Country

Although BRCA1/2 genetic testing in developed countries is part of the reality for high-risk patients for hereditary breast and ovarian cancer (HBOC), the same is not true for upper-middle-income countries. For that reason, this study aimed to evaluate whether the BRCA1/2 genetic test and preventive strategies for women at high risk for HBOC are cost-effective compared to not performing these strategies in an upper-middle-income country. Adopting a payer perspective, a Markov model with a time horizon of 70 years was built to delineate the health states for a cohort of healthy women aged 30 years that fulfilled the BRCA1/2 testing criteria according to the guidelines. Transition probabilities were calculated based on real-world data of women tested for BRCA1/2 germline mutations in a cancer reference hospital from 2011 to 2020. We analyzed 275 BRCA mutated index cases and 356 BRCA mutation carriers that were first- or second-degree relatives of the patients. Costs were based on the Brazilian public health system reimbursement values. Health state utilities were retrieved from literature. The BRCA1/2 genetic test and preventive strategies result in more quality-adjusted life years (QALYs) and costs with an incremental cost-effectiveness ratio of R$ 11,900.31 (U$ 5,504.31)/QALY. This result can represent a strong argument in favor of implementing genetic testing strategies for high-risk women even in countries with upper-middle income, considering not only the cancer prevention possibilities associated with the genetic testing but also its cost-effectiveness to the health system. These strategies are cost-effective, considering a willingness-to-pay threshold of R$ 25,000 (U$ 11,563.37)/QALY, indicating that the government should consider offering them for women at high risk for HBOC. The results were robust in deterministic and probabilistic sensitivity analyses.

Perceptions and care Recommendations from Previvors: Qualitative analysis of female BRCA1/2 mutation Carriers' experience with genetic testing and counseling

Introduction

It is estimated that 12.5% of women will be diagnosed with breast cancer and 1.10% with ovarian cancer during their lifetime. Although less common, women with these mutations have a 11-72% increased risk of breast/ovarian cancers and are hereditary. Genetic testing/counseling presents the opportunity to identify carriers of BRCA1/2 genetic mutations before a cancer diagnosis.

Methods

Thirty-four BRCA1/2-positive women (with and without histories of breast/ovarian cancers) were recruited through online national support groups to gain a better understanding of their genetic testing/counseling perceptions and experiences. After confirming eligibility, they were invited to participate in either a telephone or webcam interview. Interview transcripts were analyzed using qualitative thematic text analysis and descriptive coding techniques.

Results

Six major themes emerged, capturing the perceptions and experiences of genetic testing/counseling for these women: 1) Emotional Reactions to Results and Genetic Counseling, 2) Future Recommendations, 3) Family Solidarity and Support, 4) Experiences with the Healthcare System, 5) Preventive Concerns and Decisions, and 6) Sources Affecting Perceived Risk. Two subthemes also emerged within the first theme, which are termed "Pre-vivor," and "Testing Intuition."

Conclusions

Participants indicated that genetic testing/counseling improvements would be helpful for women in this population surrounding quality care, including sensitivity training for healthcare professionals involved in testing/counseling, additional educational resources, and increased emotional and financial support. Although these recommendations may be beneficial, more widespread research with greater generalizability to disparate groups may be necessary prior to implementation.

Self-concept and health anxiety relate to psychological outcomes for BRCA1/2 carriers

OBJECTIVE

Leventhal's common sense model of self-regulation highlights how specific beliefs about illness influence psychological outcomes. Little is known on how such beliefs relate to BRCA1/2 adjustment. Furthermore, beliefs about one's self-concept may be relevant to genetic conditions and may relate to psychological wellbeing.

METHODS

One-hundred and eighteen female BRCA1/2 carriers from an Irish University Hospital completed questionnaires for this cross-sectional study. Outcomes measured were state anxiety and physical and mental health-related quality of life (HRQOL). Explanatory variables included sociodemographics, health anxiety, illness perceptions, coping and self-concept. Hierarchical multiple regression analyses were conducted.

RESULTS

Then, 44% of participants had clinically significant state anxiety and 12% had clinically significant health anxiety. Vulnerability, stigma, mastery and health anxiety explained 42% of the variance in state anxiety. Previous mental health difficulty, vulnerability, stigma, mastery and health anxiety explained 40% of the variance in mental HRQOL. Dysfunctional coping strategies were strongly related to the physical functioning aspect of quality of life.

CONCLUSION

BRCA-specific beliefs related to self and health anxiety are important factors to consider in the adjustment to BRCA1/2 confirmation.

A Cross-Sectional Exploration of Cytokine-Symptom Networks in Breast Cancer Survivors Using Network Analysis

PURPOSE

The purpose of this study is to (a) visualize the symptom-cytokine networks (perceived stress, fatigue, loneliness, perceived cognitive impairment, daytime sleepiness, sleep quality, and 13 cytokines) and (b) explore centrality metrics of symptom-cytokine networks in breast cancer survivors who completed chemotherapy treatment.

METHODS

Cross-sectional analysis of data collected from 66 breast cancer survivors who were on average three years post chemotherapy completion. Perceived stress, fatigue, loneliness, perceived cognitive impairment, daytime sleepiness, and sleep quality were measured with self-report instruments, and a panel of 13 cytokines was measured from serum using multiplex assays. Symptoms and cytokines were simultaneously evaluated with correlations, network analysis, and community analysis.

RESULTS

Network analysis revealed the nodes with the greatest degree and closeness were interleukin-2, granulocyte-macrophage colony-stimulating factor, interleukin-13, and perceived cognitive impairment. Node betweenness was highest for perceived cognitive impairment and interleukin-2. Community analysis revealed two separate communities of nodes within the network (symptoms and the cytokines). Several edges connected the two communities including perceived cognitive impairment, stress, fatigue, depression, interleukin-2, granulocyte-macrophage colony-stimulating factor, interleukin-8, interleukin-13, and interleukin-10. Partial correlation analyses revealed significant negative relationships between interleukin-2 and fatigue, loneliness, stress, and perceived cognitive impairment (rs = -.27 to -.37, ps < .05) and a significant negative relationship between perceived cognitive impairment and granulocyte-macrophage colony-stimulating factor (r = -.34, p < .01).

CONCLUSIONS

Our analyses support that perceived cognitive impairment, stress, loneliness, depressive symptoms, and fatigue co-occur and extend the literature by suggesting that interleukin-2 may contribute to the underlying mechanistic pathway of these co-occurring symptoms. Our findings add to a growing body of literature that is shifting to study symptoms as they co-occur, or cluster, rather than individual symptoms.

Exploring Relationships Among Peripheral Amyloid Beta, Tau, Cytokines, Cognitive Function, and Psychosomatic Symptoms in Breast Cancer Survivors

OBJECTIVE

Accelerated brain aging has been proposed to explain cancer-related cognitive impairment, but empirical evidence for this relationship is lacking. The purpose of this study was to evaluate amyloid beta (Aβ) and tau, biomarkers of neurodegeneration, in relation to cognition in breast cancer survivors (BCSs). We explored relationships among peripheral concentrations of Aβ42, Aβ-40, tau, and cytokines; cognitive function; and psychosomatic symptoms in a cohort of BCSs post-chemotherapy.

METHODS

This secondary analysis of a cross-sectional study was conducted with 65 BCSs. Serum total Aβ-42, Aβ-40, and tau levels were measured with single molecule array technology. Cytokines (interleukin [IL]-6, tumor necrosis factor [TNF]-α, granulocyte-macrophage colony-stimulating factor [GM-CSF], interferon [IFN]-g, IL-10, IL-12, IL-13, IL1-b, IL-2, IL-4, IL-5, IL-7, and IL-8) were simultaneously measured in serum using multiplex assays. Cognitive function was measured with five standardized neuropsychological tests and psychosomatic symptoms (stress, loneliness, anxiety, depressive symptoms, fatigue, sleep quality, and daytime sleepiness) with self-report questionnaires. Data analyses included correlations and random forest regression (RFR).

RESULTS

Significant correlations were identified among hip-to-waste ratio, number of treatment modalities, Aβ-42, Aβ-40, and tau levels (rs = .27-.35, ps < .05). RFR modeling including Aβ-42, Aβ-40, tau, and cytokines as features explained significant variance in cognitive function (R2 = .71, F = 9.01, p < .0001) and psychosomatic symptoms (R2 = .74, F = 10.22, p < .0001).

CONCLUSIONS

This study suggests that neurodegenerative biomarkers interact with cytokines to influence cognitive functioning and psychosomatic symptoms in BCSs following chemotherapy, but additional research is needed.

Rethinking ovarian cancer II: reducing mortality from high-grade serous ovarian cancer

High-grade serous ovarian cancer (HGSOC) accounts for 70-80% of ovarian cancer deaths, and overall survival has not changed significantly for several decades. In this Opinion article, we outline a set of research priorities that we believe will reduce incidence and improve outcomes for women with this disease. This 'roadmap' for HGSOC was determined after extensive discussions at an Ovarian Cancer Action meeting in January 2015.

Rethinking ovarian cancer II: reducing mortality from high-grade serous ovarian cancer

High-grade serous ovarian cancer (HGSOC) accounts for 70-80% of ovarian cancer deaths, and overall survival has not changed significantly for several decades. In this Opinion article, we outline a set of research priorities that we believe will reduce incidence and improve outcomes for women with this disease. This 'roadmap' for HGSOC was determined after extensive discussions at an Ovarian Cancer Action meeting in January 2015.

Rethinking ovarian cancer II: reducing mortality from high-grade serous ovarian cancer

High-grade serous ovarian cancer (HGSOC) accounts for 70-80% of ovarian cancer deaths, and overall survival has not changed significantly for several decades. In this Opinion article, we outline a set of research priorities that we believe will reduce incidence and improve outcomes for women with this disease. This 'roadmap' for HGSOC was determined after extensive discussions at an Ovarian Cancer Action meeting in January 2015.

How medical choices influence quality of life of women carrying a BRCA mutation

Germline mutations in BRCA1 and BRCA2 genes were discovered twenty years ago. Female BRCA mutation carriers have an increased risk of breast and ovarian cancer at a relatively young age. Several choices have to be made with respect to cancer risk management, and consequences of these choices may affect quality of life. A review of the literature was performed to evaluate quality of life in unaffected BRCA mutation carriers and the influence of these medical choices. Overall, general quality of life appears not to be permanently affected in BRCA mutation carriers or by their choices. Risk-reducing salpingo-oophorectomy and its subsequent premature menopause affect (menopause specific) quality of life most. Hormone replacement therapy does not fully alleviate climacteric symptoms and therefore, there is a strong need for alternative strategies to reduce ovarian cancer risk and/or for improvements in postoperative care. Future research should focus on these needs.

Overestimation of mortality risk and preoperative anxiety in patients undergoing elective general surgery procedures: a propensity matched analysis

BACKGROUND

Deficiencies in risk communication have been identified in perioperative medicine. Objective measurement of risk overestimation by general surgery patients has not been performed. In addition, it is unknown if surgical risk overestimation is associated with the development of preoperative anxiety. The main objective of the current investigation was to examine the association between overestimation of surgical mortality risk and the development of preoperative anxiety.

METHODS

Patients estimation of surgical morality risk was compared to the actual mortality risk obtained by the American College of Surgeons national database. Preoperative anxiety was evaluated using a validated instrument. Propensity matched analysis was performed to examine an independent association between mortality risk overestimation and preoperative anxiety.

RESULTS

138 patients completed the study. 40 out of 138 (29%) patients overestimated their surgical mortality risk by at least 5%. 31 out of 138 (22%) patients estimated their surgical mortality risk by at least 10%. Patients who overestimated mortality risk (≥5%) were more likely to have postponed the surgery voluntarily, 9 out of 40 (23%) compared to patients who did not overestimate risk, 1 out of 98 (1%), P < 0.001. After propensity matching to control for covariate imbalances, overestimation of mortality risk was associated with the development of preoperative anxiety, OR (95%CI) of 9.5 (2.7-32.9).

CONCLUSIONS

Overestimation of perioperative mortality risk is common in patients undergoing general surgery and it is associated with preoperative anxiety and voluntarily delays of surgical treatment. Improved communication strategies are needed to minimize misleading risk perception in surgical patients.

BRCA1 germline mutations may be associated with reduced ovarian reserve

OBJECTIVE

To determine whether BRCA carriers have a decreased ovarian reserve compared with women without BRCA mutations, because BRCA mutations may lead to accelerated oocyte apoptosis due to accumulation of damaged DNA.

DESIGN

Cross-sectional study.

SETTING

Academic tertiary care center.

PATIENT(S)

A total of 143 women, aged 18-45 years, who underwent clinical genetic testing for BRCA deleterious mutations because of a family history of cancer, were included. The cohort was classified into three groups: BRCA1 carriers, BRCA2 carriers, and women without BRCA mutations (controls). None had a personal history of breast or ovarian cancer.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

The main outcome was serum antimüllerian hormone (AMH) level. Linear and logistic regression models adjusting for age and body mass index (BMI) were performed to determine the association between BRCA mutations and AMH.

RESULT(S)

BRCA1 mutation carriers had a significant decrease in AMH levels compared with controls after adjusting for age and BMI (0.53 ng/mL [95% confidence interval (CI) 0.33-0.77 ng/mL] vs. 1.05 ng/mL [95% CI 0.76-1.40 ng/mL]). Logistic regression confirmed that BRCA1 carriers had a fourfold greater odds of having AMH <1 ng/mL compared with controls (odds ratio 4.22, 95% CI 1.48-12.0). There was no difference in AMH levels between BRCA2 carriers and controls.

CONCLUSION(S)

BRCA1 carriers have lower age- and BMI-adjusted serum AMH levels compared with women without BRCA mutations. Our results contribute to the current body of literature regarding BRCA carriers and their reproductive outcomes. Larger prospective studies with clinical outcomes such as infertility and age at menopause in this population are needed to further substantiate our findings.

Impact of family history on choosing risk-reducing surgery among BRCA mutation carriers

OBJECTIVE

Despite substantial survival benefits of risk-reducing mastectomy (RRM) and risk-reducing bilateral salpingo-oophorectomy (RRBSO) among BRCA mutation carriers, only a minority elect to undergo these procedures. This study investigates factors that might influence decision making regarding prophylactic surgeries among women with BRCA mutations.

STUDY DESIGN

Unaffected BRCA mutation carriers who were counseled at our center and either underwent prophylactic surgery or participated in a high-risk surveillance program at our institution from 1998 through 2010 were included in the study. Medical records were reviewed and data collected included age, family history, parity, mutation type, history of breast biopsy or cosmetic surgery, and uptake of prophylactic surgeries.

RESULTS

Among 136 unaffected women with BRCA mutations, uptake of RRM was 42% and uptake of RRBSO was 52%. Family history of first- and second-degree relatives being deceased from breast cancer was predictive of uptake of RRM and of RRBSO (odds ratio [OR], 11.0; P = .005; and OR, 15.8; P = .023, respectively), and history of a mother lost to pelvic cancer was predictive of uptake of RRBSO (OR, 7.9; P = .001). Parity also predicted both RRM and RRBSO uptake (OR, 4.2; P = .001; and OR, 5.4; P = .003, respectively). Age at the time of genetic testing and history of breast biopsy or cosmetic surgery were not predictive of RRM uptake.

CONCLUSION

Perceptions of cancer risk are heavily influenced by particular features of an individual's family history and may be motivators in preventive surgery more than actual cancer risk estimations themselves. Awareness of subtle factors beyond the statistical risk for cancers is relevant when counseling at-risk women.