The psychological impact of breast and ovarian cancer preventive options in BRCA1 and BRCA2 mutation carriers

Patients' Perceptions and Attitudes to the Use of Artificial Intelligence in Breast Cancer Diagnosis: A Narrative Review

Breast cancer remains the most prevalent cancer among women worldwide, necessitating advancements in diagnostic methods. The integration of artificial intelligence (AI) into mammography has shown promise in enhancing diagnostic accuracy. However, understanding patient perspectives, particularly considering the psychological impact of breast cancer diagnoses, is crucial. This narrative review synthesizes literature from 2000 to 2023 to examine breast cancer patients' attitudes towards AI in breast imaging, focusing on trust, acceptance, and demographic influences on these views. Methodologically, we employed a systematic literature search across databases such as PubMed, Embase, Medline, and Scopus, selecting studies that provided insights into patients' perceptions of AI in diagnostics. Our review included a sample of seven key studies after rigorous screening, reflecting varied patient trust and acceptance levels towards AI. Overall, we found a clear preference among patients for AI to augment rather than replace the diagnostic process, emphasizing the necessity of radiologists' expertise in conjunction with AI to enhance decision-making accuracy. This paper highlights the importance of aligning AI implementation in clinical settings with patient needs and expectations, emphasizing the need for human interaction in healthcare. Our findings advocate for a model where AI augments the diagnostic process, underlining the necessity for educational efforts to mitigate concerns and enhance patient trust in AI-enhanced diagnostics.

Decision-making for bilateral risk-reducing mastectomy for an increased lifetime breast cancer risk: A qualitative metasynthesis

OBJECTIVE

Previvor is a term applied to a person with an identified, elevated lifetime cancer risk but without an actual cancer diagnosis. Previvorship entails the selection of risk management strategies. For women with a genetic mutation that increases their predisposition for a breast cancer diagnosis, bilateral risk-reducing mastectomy (BRRM) is the most effective prevention strategy. However, BRRM can change a woman's breast appearance and function. The purpose of this qualitative metasynthesis (QMS) was to better understand the decision-making process for BRRM among previvors.

METHODS

A theory-generating QMS approach was used to analyze and synthesize qualitative findings. Research reports were considered for inclusion if: (1) women over 18 years of age possessed a genetic mutation increasing lifetime breast cancer risk or a strong family history of breast cancer; (2) the sample was considering, or had completed, BRRM; (3) the results reported qualitative findings. Exclusion criteria were male gender, personal history of breast cancer, and research reports which did not separate findings based on cancer diagnosis and/or risk-reduction surgery.

RESULTS

A theory and corresponding model emerged, comprised of seven themes addressing the decision-making process for or against BRRM. While some factors to decision-making were decisive for surgery, others were more indefinite and contributed to women changing, processing, or suspending their decision-making for a period of time.

CONCLUSIONS

Regardless of the decision previvors make about BRRM, physical and psychosocial well-being should be considered and promoted through shared decision-making in the clinical setting.

Residential Locale Is Associated with Disparities in Genetic Testing-Related Outcomes Among BRCA1/2-Positive Women

BACKGROUND

While research on hereditary genetic testing for BRCA1/2 mutations continues to emerge, there remain unanswered questions regarding access to testing and cancer-related care. Our study determined the associations between race/ethnicity, residential locale, and genetic testing provider and related outcomes among US women with BRCA1/2 genetic mutations.

METHODS

One hundred ninety-three BRCA1/2-positive women from vulnerable health backgrounds were recruited via private national Facebook BRCA1/2-oriented support groups and completed an online survey. Adjusted odds ratios (aOR) and 95% confidence intervals (CIs) were estimated using multivariable logistic regression for the associations between race/ethnicity, residential locale, and genetic testing-related outcomes.

RESULTS

Women ranged in age (18-75, M = 39.5, SD = 10.7), and most were non-Hispanic white (66.3%) and lived in a suburban locale (54.9%). Women living in suburban areas were significantly less likely (aOR, .369, 95% CI, .177-.771) to receive behavioral referrals after genetic testing compared to those living in an urban locale. Women living in rural areas and suburban areas were 4.72 times more likely (95% CI, 1.48-15.1, p = .009) and 2.61 times more likely (95% CI, 1.05-6.48, p = .038), respectively, to receive genetic testing from a primary care provider versus private genetic testing office/hospital compared to women in urban locales. Associations between race/ethnicity and genetic testing outcomes were not statistically significant. Residential locale did not predict the odds of undergoing surgery for risk reduction or surveillance for early detection.

CONCLUSION

Our study identifies disparities in genetic testing resources among women living in suburban and rural areas. These findings can be used to inform future care, research, and community resources that may impact services relating to genetic testing within these locales.

Assessing Psychological Morbidity in Cancer-Unaffected BRCA1/2 Pathogenic Variant Carriers: A Systematic Review

Female BRCA1/2 pathogenic variant carriers have an increased lifetime risk for breast and ovarian cancer. Cancer-unaffected women who are newly diagnosed with this pathogenic variant may experience psychological distress because of imminent health threat. No comprehensible review on psychological morbidity in cancer-unaffected BRCA1/2 pathogenic variant carriers is currently available. This review aims to give an overview about all available the studies in which psychological outcomes have been assessed in cancer-unaffected BRCA1/2 pathogenic variant carriers, whether as a primary outcome or secondary measurement. A systematic search across four databases (Web of Science, PubMed, ScienceDirect, and EBSCO) was conducted. Studies had to report on cancer-unaffected pathogenic variant carriers (exclusively or separately) and use a validated measure of psychological morbidity to be eligible. Measures were only included if they were used in at least three studies. The final review consisted of 45 studies from 13 countries. Distress measures, including anxiety and cancer worry, were most often assessed. Most studies found a peak of distress immediately after genetic test result disclosure, with a subsequent decline over the following months. Only some studies found elevated distress in carriers compared to non-carriers in longer follow-ups. Depression was frequently investigated but largely not found to be of clinical significance. Quality of life seemed to be largely unaffected by a positive genetic test result, although there was some evidence that younger women, especially, were less satisfied with their role functioning in life. Body image has been infrequently assessed so far, but the evidence suggested that there may be a decrease in body image after genetic test result disclosure that may decrease further for women who opt for a prophylactic mastectomy. Across all the outcomes, various versions of instruments were used, often limiting the comparability among the studies. Hence, future research should consider using frequently used instruments, as outlined by this review. Finally, while many studies included cancer-unaffected carriers, they were often not reported on separately, which made it difficult to draw specific conclusions about this population.

Cancer Anxiety Mediates the Association Between Satisfaction With Medical Communication and Psychological Quality of Life After Prophylactic Bilateral Salpingo-Oophorectomy

Background

Prophylactic Bilateral Salpingo-Oophorectomy (PBSO) reduces the risk of developing ovarian cancer. However, the psychological mechanisms that may affect post-surgery Quality of Life (QoL) among patients who underwent PBSO are still largely unknown. Thus, this study aimed at exploring the direct and indirect associations of satisfaction with medical communication and cancer anxiety on post-surgery QoL among women at high risk of developing ovarian cancer.

Method

Fifty-nine women (mean age: 50.64 ± 6.7 years) who underwent PBSO took part in this cross-sectional study, filling out a sociodemographic and clinical questionnaire, a battery of validated psychological measures and an ad hoc developed scale for the assessment of cancer anxiety. We first examined the correlations among all variables of interest, and then tested if cancer anxiety mediated the association between satisfaction with medical communication and post-surgery psychological QoL, controlling both for time from surgery and education.

Results

Post-surgery psychological QoL was unrelated from any sociodemographic or clinical variable. Cancer anxiety had a significant direct negative effect on psychological QoL, while satisfaction with medical communication had a significant positive direct effect on it. Finally, cancer anxiety significantly mediated the association between satisfaction with medical communication and post-surgery psychological QoL.

Discussion

Results suggest that post-surgery psychological QoL of patients who underwent PBSO may be increased with interventions, delivered in a genetic counselling setting, targeting quality of medical communication and cancer anxiety.

Anxiety and depression among racial/ethnic minorities and impoverished women testing positive for BRCA1/2 mutations in the United States

PURPOSE

To outline the association between race/ethnicity and poverty status and perceived anxiety and depressive symptomologies among BRCA1/2-positive United States (US) women to identify high-risk groups of mutation carriers from medically underserved backgrounds.

METHODS

A total of 211 BRCA1/2-positive women from medically underserved backgrounds were recruited through national Facebook support groups and completed an online survey. Adjusted odds ratios (aOR) and 95% confidence intervals (CIs) were estimated using multivariable logistic regression for associations between race/ethnicity, poverty status, and self-reported moderate-to-severe anxiety and depressive symptoms.

RESULTS

Women ranged in age (18-75, M = 39.5, SD = 10.6). Most women were non-Hispanic white (NHW) (67.2%) and were not impoverished (76.7%). Hispanic women with BRCA1/2 mutations were 6.11 times more likely to report moderate-to-severe anxiety (95% CI, 2.16-17.2, p = 0.001) and 4.28 times more likely to report moderate-to-severe depressive symptoms (95% CI, 1.98-9.60, p < 0.001) than NHW women with these mutations. Associations were not statistically significant among other minority women. Women living in poverty were significantly less likely to report moderate-to-severe depressive symptoms than women not in poverty (aOR, 0.42, 95% CI, 0.18-0.95, p = 0.04).

CONCLUSION

Hispanic women with BRCA1/2 mutations from medically underserved backgrounds are an important population at increased risk for worse anxiety and depressive symptomology. Our findings among Hispanic women with BRCA1/2 mutations add to the growing body of literature focused on ethnic disparities experienced across the cancer control continuum.

COVID-19 experiences predicting high anxiety and depression among a sample of BRCA1/BRCA2-positive women in the US

During the COVID-19 pandemic, breast and ovarian cancer survivors experienced more anxiety and depression than before the pandemic. Studies have not investigated the similarities of this trend among BRCA1/2-positive women who are considered high risk for these cancers. The current study examines the impact of COVID-19 experiences on anxiety and depression in a sample of BRCA1/2-positive women in the U.S. 211 BRCA1/2-positive women from medically underserved backgrounds completed an online survey. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated using multivariable logistic regression for associations between COVID-19 experiences and self-reported anxiety and depression stratified by demographic factors. Overall, women who reported COVID-19 stigma or discrimination (aOR, 5.14, 95% CI [1.55, 17.0]) experienced significantly more depressive symptoms than women who did not report this experience. Racial/ethnic minority women caring for someone at home during COVID-19 were 3.70 times more likely (95% CI [1.01, 13.5]) to report high anxiety while non-Hispanic white women were less likely (aOR, 0.34, 95% CI [0.09, 1.30], p interaction = 0.011). To date, this is the first study to analyze anxiety and depression considering several COVID-19 predictors among BRCA1/2-positive women. Our findings can be used to inform future research and advise COVID-19-related mental health resources specific to these women.

Patient reported outcomes after risk-reducing surgery in patients at increased risk of ovarian cancer

OBJECTIVE

To describe the quality of life of women at an increased risk of ovarian cancer undergoing risk-reducing bilateral salpingo-oophorectomy (RRBSO).

METHODS

Patients evaluated in our gynecologic oncology ambulatory practice between January 2018-December 2019 for an increased risk of ovarian cancer were included. Patients received the EORTC QLQ-C30 and PROMIS emotional and instrumental support questionnaires along with a disease-specific measure (PROM). First and last and pre- and post-surgical PROM responses in each group were compared as were PROMs between at-risk patients and patients with other ovarian diseases.

RESULTS

195 patients with an increased risk of ovarian cancer were identified, 155 completed PROMs (79.5%). BRCA1 or BRCA2 mutations were noted in 52.8%. Also included were 469 patients with benign ovarian disease and 455 with ovarian neoplasms. Seventy-two at-risk patients (46.5%) had surgery and 36 had both pre- and post-operative PROMs. Post-operatively, these patients reported significantly less tension (p = 0.011) and health-related worry (p = 0.021) but also decreased levels of health (p = 0.018) and quality of life <7d (0.001), less interest in sex (p = 0.014) and feeling less physically attractive (p = 0.046). No differences in body image or physical/sexual health were noted in at-risk patients who did not have surgery. When compared to patients with ovarian neoplasms, at-risk patients reported lower levels of disease-related life interference and treatment burden, less worry, and better overall health.

CONCLUSIONS

In patients with an increased risk of ovarian cancer, RRBSO is associated with decreased health-related worry and tension, increased sexual dysfunction and poorer short-term quality of life. Patients with ovarian neoplasms suffer to a greater extent than at-risk patients and report higher levels of treatment burden and disease-related anxiety.

Body Image in BRCA-Positive Young Women Following Bilateral Risk-Reducing Mastectomy: A Review of the Literature

Background/Significance: The presence of a breast cancer (BRCA) gene mutation increases a woman’s lifetime risk of developing breast cancer. Bilateral risk-reducing mastectomy is a proactive treatment option which lowers that risk. However, breast removal can create a change in physical appearance. It is unclear if BRCA-positive women undergoing this surgery in young adulthood, a life stage where intimate relationships, families, and careers are being established, have the same experience with body image as women in later stages of life.

Purpose: The aim of this literature review is to assess how bilateral risk-reducing mastectomy impacts body image in young BRCA-positive women less than 40 years of age, with no history of breast cancer.

Methods: Database searches were performed, yielding 402 results. Studies were considered if participants had an increased lifetime breast cancer risk/BRCA-positive diagnosis and history of bilateral risk-reducing mastectomy, body image was evaluated, and mean age was less than 40 years. A total of three qualitative studies and three quantitative studies were identified as relevant for this review.

Results: A dearth of information exists on body image in young women following bilateral risk-reducing mastectomy. It was found in this review that some women experienced a decline in body image following surgery, while in others body image was maintained or improved.

Conclusion: Understanding factors that impact body image following this risk-reducing surgery will allow clinicians to support this unique population. Open and informative discussion should be encouraged with young women considering, or who have undergone, bilateral risk-reducing mastectomy.

COVID-19 Experiences Predicting High Anxiety and Depression Among a Sample of BRCA1/BRCA2-positive Women in the US

Purpose.

During the COVID-19 pandemic, breast and ovarian cancer survivors experienced more anxiety and depression than before the pandemic. Studies have not investigated the similarities of this trend among BRCA1/2-positive women who are considered high risk for these cancers. The current study examines the impact of COVID-19 experiences on anxiety and depression in a sample of BRCA1/2-positive women in the U.S.

Methods.

211 BRCA1/2-positive women from medically underserved backgrounds completed an online survey. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were estimated using multivariable logistic regression for associations between COVID-19 experiences and self-reported anxiety and depression stratified by demographic factors.

Results.

Overall, women who reported quarantining/isolation (aOR, 0.46, 95% CI, 0.24–0.88) experienced significantly fewer depressive symptoms than women who did not report this experience. Racial/ethnic minority women caring for someone at home during COVID-19 were 3.78 times more likely (95% CI, 1.04–13.6) to report high anxiety while non-Hispanic white women were less likely (aOR, 0.36, 95% CI, 0.10–1.33, p-interaction=0.011).

Conclusions.

To date, this is the first study to analyze anxiety and depression considering several COVID-19 predictors among BRCA1/2-positive women. Our findings can be used to inform future research and advise COVID-19-related mental health resources specific to these women.

Uncertainty following an inconclusive result from the BRCA1/2 genetic test: A review about psychological outcomes

BACKGROUND

An inconclusive result from BRCA1/2 genetic testing indicates that a genetic variant of uncertain significance is detected. This case constitutes the majority of genetic test results, but studies specifically addressing the psychological adjustment of people with inconclusive results are scarce.

AIM

To examine psychological outcomes of receiving an uninformative BRCA1/2 test result.

METHODS

PubMed, PsychInfo, and Cochrane Central Register of Controlled Trials were screened for studies focusing on distress, anxiety, and depression levels in individuals with inconclusive genetic test results. This review is based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method.

RESULTS

Studies on psychological outcomes of inconclusive BRCA1/2 focused on general and specific distress, anxiety, and depression. Overall, they produced mixed results. These inconsistent findings are probably due to the uncertainty caused by this type of result, that may also influence the decisions of individuals about surveillance and prophylactic options, reducing their compliance. In addition, this review highlights specific risk and protective factors that affect psychological adjustment in individuals with an inconclusive genetic testing result.

CONCLUSION

Individuals with inconclusive genetic test results need specific educational programs and support to better understand the meaning of their results in order to be able to make decisions about surveillance and prophylactic options.

Factors that impact risk management decisions among women with pathogenic variants in moderate penetrance genes associated with hereditary breast cancer

There is limited information known about how women with pathogenic variants (PV) in moderate penetrance genes make decisions to manage their increased risk of breast cancer. This study analyzed factors that may impact decision-making surrounding management for increased breast cancer risk. Women with a PV in a moderate penetrance gene associated with increased risk for breast cancer were identified from an institutional database. Semi-structured, qualitative interviews were conducted to analyze decision-making factors. Themes were developed using deductive codes based on previous literature and inductive codes based on interviewee responses. The 16 participants (mean age = 55.9 years) included 12 women with a breast cancer diagnosis. Six women (37.5%) chose bilateral mastectomy (BM), and 10 women (62.5%) chose surveillance as management. Of the 12 women with a personal history of breast cancer, four chose to have BM (33.3%). Two women without a personal history of breast cancer chose to have BM (50.0%). Transcriptions revealed seven comprehensive themes, as well as themes unique to affected and unaffected women (Cohen's kappa = 0.80). Physician opinion was the only factor present in all interviews reported to influence risk management decision-making. Several themes were consistent with prior BRCA1/BRCA2 research (family history, risk perception, sibling influence, and physician opinions). Autonomy and insurance/finances were also important factors to participants. There were certain differences in decision-making factors between affected and unaffected women, such as partner influence. Results indicate an opportunity for providers to engage their patients in a decision-making process.

The Effect of Prophylactic Adnexectomy on the Quality of Life and Psychosocial Functioning of Women with the BRCA1/BRCA2 Mutations

The main purpose of this study was to analyze the effect of risk-reducing salpingo-oophorectomy (RRSO) on the quality of life (QoL) and psychosocial functioning of patients with the BRCA1/BRCA2 mutations. This survey-based study was conducted using the Blatt-Kupperman Index, the Women’s Health Questionnaire, the Perceived Stress Scale, the State-Trait Anxiety Inventory, the Beck Depression Inventory-II, and the authors’ questionnaire. All calculations were done using Statistica 13.3. The QoL after RRSO was statistically significantly lower in most domains compared with the state before surgery. The greatest decline in the QoL was observed in the vasomotor symptoms domain (d = 0.953) and the smallest in the memory/concentration domain (d = 0.167). We observed a statistically significant decrease in the level of anxiety as a state (d = 0.381), as well as a statistically significant increase in the severity of climacteric symptoms (d = 0.315) and depressive symptoms (d = 0.125). Prophylactic surgeries of the reproductive organs have a negative effect on the QoL and psychosocial functioning of women with the BRCA1/2 mutations, as they increase the severity of depressive and climacteric symptoms. At the same time, these surgeries reduce anxiety as a state, which may be associated with the elimination of cancerophobia.

Psychological aspects, risk and protective factors related to BRCA genetic testing: a review of the literature

PURPOSE

The primary aim of the present study was to conduct a systematic review of short-, intermediate- and long-term psychological effects, such as anxiety, depression and distress, on individuals undergoing genetic testing to determine BRCA1 and BRCA2 gene mutation. The different instruments used for the measurement of each construct were reported. In addition, risk and protective factors associated with psychological outcomes of genetic tests were explored.

METHODS

Bibliographic databases were searched for studies published over the period 1998-2018. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method, 21 articles were selected for the current review.

RESULTS

Overall, the collected data revealed rather diverse results, although most studies reported higher levels of distress, anxiety and depression in carriers, as compared to non-carriers. The two genders were not equally represented, with men constituting only 6% of the sample. Risk factors and protective factors that may influence psychological outcomes and adjustment to genetic tests are highlighted and discussed in this review.

CONCLUSIONS

The increased risk of developing cancer associated with positive genetic testing results may be experienced as traumatic by many patients, although not all individuals with positive genetic testing results will experience increased distress. Hence, future studies should consider specific risk factors in order to select those who are more likely to be in need of psychological support. Finally, it is necessary to increase the number of male samples to better understand the male experience related to genetic testing outcomes.

Correlates of Dominicans' Identification of Cancer as a Worrisome Health Problem

There is a paucity of studies centering on the correlates of cancer worry among Hispanics from the Dominican Republic and the potential informatics strategies to address such worries. Data were analyzed using descriptive and correlational statistics, and logistic regression with the dependent variable of cancer worry. Independent variables for the regression were: age, gender, marital status, education, socioeconomic status, previous diagnosis of cancer, anxiety, depression, sleep disturbance, and chronic burden. Four variables significantly increased cancer worry: married marital status (OR = 1.19 [95% CI 1.01, 1.41]), younger age (OR = .992 [95% CI 0.987, 0.997]), less depression (OR = .96 [95% CI 0.94, 0.98]), and cancer diagnosis (OR = 2.12 [95% CI 1.24, 3.65]). New knowledge was generated on the contextual factors that influence these health concerns in a major Hispanic sub-group. Implications for practice, research and education are discussed.

Risk-reducing mastectomy for the prevention of primary breast cancer

BACKGROUND

Recent progress in understanding the genetic basis of breast cancer and widely publicized reports of celebrities undergoing risk-reducing mastectomy (RRM) have increased interest in RRM as a method of preventing breast cancer. This is an update of a Cochrane Review first published in 2004 and previously updated in 2006 and 2010.

OBJECTIVES

(i) To determine whether risk-reducing mastectomy reduces death rates from any cause in women who have never had breast cancer and in women who have a history of breast cancer in one breast, and (ii) to examine the effect of risk-reducing mastectomy on other endpoints, including breast cancer incidence, breast cancer mortality, disease-free survival, physical morbidity, and psychosocial outcomes.

SEARCH METHODS

For this Review update, we searched Cochrane Breast Cancer's Specialized Register, MEDLINE, Embase and the WHO International Clinical Trials Registry Platform (ICTRP) on 9 July 2016. We included studies in English.

SELECTION CRITERIA

Participants included women at risk for breast cancer in at least one breast. Interventions included all types of mastectomy performed for the purpose of preventing breast cancer.

DATA COLLECTION AND ANALYSIS

At least two review authors independently abstracted data from each report. We summarized data descriptively; quantitative meta-analysis was not feasible due to heterogeneity of study designs and insufficient reporting. We analyzed data separately for bilateral risk-reducing mastectomy (BRRM) and contralateral risk-reducing mastectomy (CRRM). Four review authors assessed the methodological quality to determine whether or not the methods used sufficiently minimized selection bias, performance bias, detection bias, and attrition bias.

MAIN RESULTS

All 61 included studies were observational studies with some methodological limitations; randomized trials were absent. The studies presented data on 15,077 women with a wide range of risk factors for breast cancer, who underwent RRM.Twenty-one BRRM studies looking at the incidence of breast cancer or disease-specific mortality, or both, reported reductions after BRRM, particularly for those women with BRCA1/2 mutations. Twenty-six CRRM studies consistently reported reductions in incidence of contralateral breast cancer but were inconsistent about improvements in disease-specific survival. Seven studies attempted to control for multiple differences between intervention groups and showed no overall survival advantage for CRRM. Another study showed significantly improved survival following CRRM, but after adjusting for bilateral risk-reducing salpingo-oophorectomy (BRRSO), the CRRM effect on all-cause mortality was no longer significant.Twenty studies assessed psychosocial measures; most reported high levels of satisfaction with the decision to have RRM but greater variation in satisfaction with cosmetic results. Worry over breast cancer was significantly reduced after BRRM when compared both to baseline worry levels and to the groups who opted for surveillance rather than BRRM, but there was diminished satisfaction with body image and sexual feelings.Seventeen case series reporting on adverse events from RRM with or without reconstruction reported rates of unanticipated reoperations from 4% in those without reconstruction to 64% in participants with reconstruction.In women who have had cancer in one breast, removing the other breast may reduce the incidence of cancer in that other breast, but there is insufficient evidence that this improves survival because of the continuing risk of recurrence or metastases from the original cancer. Additionally, thought should be given to other options to reduce breast cancer risk, such as BRRSO and chemoprevention, when considering RRM.

AUTHORS' CONCLUSIONS

While published observational studies demonstrated that BRRM was effective in reducing both the incidence of, and death from, breast cancer, more rigorous prospective studies are suggested. BRRM should be considered only among those at high risk of disease, for example, BRCA1/2 carriers. CRRM was shown to reduce the incidence of contralateral breast cancer, but there is insufficient evidence that CRRM improves survival, and studies that control for multiple confounding variables are recommended. It is possible that selection bias in terms of healthier, younger women being recommended for or choosing CRRM produces better overall survival numbers for CRRM. Given the number of women who may be over-treated with BRRM/CRRM, it is critical that women and clinicians understand the true risk for each individual woman before considering surgery. Additionally, thought should be given to other options to reduce breast cancer risk, such as BRRSO and chemoprevention when considering RRM.

Evaluation of psychosocial aspects in participants of cancer genetic counseling

Background

The instrument called “Hospital Anxiety and Depression Scale” (HADS) is frequently used to evaluate anxious and depressive symptomatology in patients who receive Cancer Genetic Counseling (CGC). However, this instrument cannot identify all of the psychosocial factors, such as the antecedents of the patients’ emotional states or their concerns. The objective of the present research was to compare cases detected with psychosocial alterations by means of HADS and a Psychological Health Interview (PHI).

Methods

A transversal analytical design was used. One hundred ten participants were included (97.3% females and 2.7% males). The average age was 45 years ±10 years.

Results

The PHI identified twice the amount of participants with psychosocial alterations than did HADS, which only detected 43% of these participants.

Conclusions

The results of our study suggest that the PHI should be applied in addition to HADS to identify participants who would require psychological support due to recurrent concerns.

Heritable pulmonary hypertension: from bench to bedside

Mutations in the BMPR2 gene, and more rarely in ACVRL1, endoglin, caveolin-1, KCNK3 and TBX4 genes predispose to heritable pulmonary arterial hypertension, an autosomal dominant disease with incomplete penetrance. Bi-allelic mutations in the EIF2AK4 gene predispose to heritable pulmonary veno-occlusive disease/pulmonary capillary haemangiomatosis, an autosomal recessive disease with an unknown penetrance.

In France, the national pulmonary hypertension referral centre offers genetic counselling and testing to adults and children. Predictive testing is also proposed to adult relatives at risk of carrying a predisposing mutation. In that context, we offer all asymptomatic BMPR2 mutation carriers a programme to detect pulmonary arterial hypertension at an early phase, as recommended by the 2015 European Society Society of Cardiology/European Respiratory Society pulmonary hypertension guidelines. Finally, pre-implantation genetic diagnosis has been conducted on five embryos from two couples in which the fathers were carriers of a pathogenic BMPR2 mutation.

Factors associated with deciding between risk-reducing salpingo-oophorectomy and ovarian cancer screening among high-risk women enrolled in GOG-0199: An NRG Oncology/Gynecologic Oncology Group study

OBJECTIVES

Women at increased genetic risk of ovarian cancer (OC) are recommended to have risk-reducing salpingo-oophorectomy (RRSO) after completion of reproductive planning. Effective screening has not been established, and novel screening modalities are being evaluated.

METHODS

Participants chose either RRSO or a novel OC screening regimen (OCS) as their risk management option, and provided demographic and other data on BRCA mutation status, cancer worry, perceived intervention risks/benefits, perceived cancer risk, and quality-of-life at enrollment. We performed univariate and multivariate analyses to evaluate factors influencing decision between RRSO and OCS.

RESULTS

Of 2287 participants enrolled, 904 (40%) chose RRSO and 1383 (60%) chose OCS. Compared with participants choosing OCS, participants choosing RRSO were older (p<0.0001), more likely to carry deleterious BRCA1/2 mutations (p<0.0001), perceive RRSO as effective, be more concerned about surgical harms and OCS limitations, and report higher perceived OC risk and OC-related worry. OCS participants were more likely to perceive screening as effective, be more concerned about menopausal symptoms, infertility, and loss of femininity, and report better overall quality-of-life. Twenty-four percent of participants believed they would definitely develop OC, and half estimated their lifetime OC risk as >50%, both higher than objective risk estimates.

CONCLUSIONS

Cancer worry, BRCA1/2 mutation status, and perceived intervention-related risks and benefits were associated with choosing between RRSO and OCS. Efforts to promote individualized, evidence-based, shared medical decision-making among high-risk women facing management choices should focus on conveying accurate OC risk estimates, clarifying the current understanding of intervention-related benefits and limitations, and addressing OC worry.

A Psychological Perspective on Factors Predicting Prophylactic Salpingo-Oophorectomy in a Sample of Italian Women from the General Population. Results from a Hypothetical Study in the Context of BRCA Mutations

The aim of this study was to assess attitudes toward ovarian cancer risk management options for BRCA mutation carriers in healthy Italian women, and to identify predictors of the preference for risk reducing salpingo-oophorectomy (RRSO) over surveillance. One hundred eighty-one women aged 30-45 completed a questionnaire about preferences, knowledge, risk perception, and socio-demographic information. Participants were randomly presented with a pamphlet about BRCA1 or BRCA2 mutation-specific testing, consequences of testing and preventive options for carriers, and they were stratified by having children or not and by age group. Surveillance was the preferred option (64.6%), followed by RRSO (24.3%). Although RRSO is the only effective strategy available to BRCA carriers, most healthy women faced for the first time with this option may not consider it as their preferred choice. Predictors associated with a higher likelihood to prefer surgery over surveillance were: knowing that life expectancy is longer with surgery, perceived comprehension of the consequences of testing, previous knowledge about BRCA testing, anticipated worry about developing cancer, and feelings of risk. Childbearing intentions and the effect of childbearing intentions on choice were associated with a lower preference for surgery. Further research is needed to confirm the role of the factors identified in this study in order to promote informed decision-making about RRSO.

The Impact of Mental Illness on Uptake of Genetic Counseling for Hereditary Breast Cancer and Ovarian Cancer in a Multiethnic Cohort of Breast Cancer Patients

We evaluated whether mental illness is a barrier to genetic counseling for hereditary breast and ovarian cancer (HBOC) in multiethnic breast cancer patients. We conducted a retrospective analysis of 308 women with newly diagnosed breast cancer and eligible for HBOC genetic testing seen in the breast clinic of an academic, urban medical center from 2007 to 2015. Uptake of genetic services and history of mental health disorder (MHD), defined as a psychiatric diagnosis or treatment with an antidepressant, mood stabilizer, anxiolytic, or antipsychotic medication, were ascertained by medical chart review. The mean age at breast cancer diagnosis was 56 years, with 44% non-Hispanic whites, 37% Hispanics, and 15% non-Hispanic blacks. Ninety-nine (32%) women met study criteria for MHD, 73% had a genetics referral, 57% had genetic counseling, and 54% completed BRCA testing. Uptake of genetic counseling services did not differ by race/ethnicity or presence of MHD. In multivariable analysis, younger age at diagnosis, Ashkenazi Jewish heritage, and family history of breast cancer were associated with HBOC genetic counseling. A relatively high proportion of breast cancer patients eligible for HBOC genetic testing were referred to a genetic counselor and referral status did not vary by MHD or race/ethnicity.

Risk Perception and Psychological Distress in Genetic Counselling for Hereditary Breast and/or Ovarian Cancer

Oncological Genetic Counselling (CGO) allows the identification of a genetic component that increases the risk of developing a cancer. Individuals' psychological reactions are influenced by both the content of the received information and the subjective perception of their own risk of becoming ill or being a carrier of a genetic mutation. This study included 120 participants who underwent genetic counselling for breast and/or ovarian cancer. The aim of the study was to examine the relation between their cancer risk perception and the genetic risk during CGO before receiving genetic test results, considering the influence of some psychological variables, in particular distress, anxiety and depression. Participants completed the following tools during a psychological interview: a socio-demographic form, Cancer Risk Perception (CRP) and Genetic Risk Perception (GRP), Hospital Anxiety and Depression Scale (HADS) and Distress Thermometer (DT). The data seem to confirm our hypothesis. Positive and significant correlations were found between the observed variables. Moreover, genetic risk perception determined an increase in depressive symptomatology and cancer risk perception led to an increase in anxious symptomatology, specifically in participants during cancer treatment. The present results suggest the importance of assessing genetic and cancer risk perception in individuals who undergo CGO, to identify those who are at risk of a decrease in psychological well-being and of developing greater psychological distress.

Breast Cancer Genetic Counseling: A Surgeon's Perspective

As surgeons who care for patients with breast cancer, the possibility of a cancer diagnosis being related to a hereditary predisposition is always a consideration. Not only are we as surgeons always trying to identify these patients and families but also we are often asked about a potential hereditary component by the patients and their family members. It is therefore critical that we accurately assess patients to determine who may benefit from genetic testing. Importantly, the potential benefit for identifying a hereditary breast cancer extends beyond the patient to other family members and the risk may not be only for the development of breast cancers, but for other cancers as well. This review was written from the perspective of a surgeon with additional training in cancer genetics in an effort to provide a unique perspective on the issue and feel that a review of some of the more practical considerations is important.

A targeted approach to genetic counseling in breast cancer patients: the experience of an Italian local project

AIMS AND BACKGROUND

Patients with hereditary breast cancer (BC) may benefit from genetic counseling and testing for detection of causative mutations, definition of therapeutic and preventive strategies, and identification of at-risk relatives. Italy has few oncogenetic centers and genetic evaluation of all patients with BC is not feasible. Moreover, lack of uniformity in the selection of patients generates inappropriate referral to the geneticist. We designed a model that may represent a reproducible way to select patients at risk for hereditary BC, with the aims of rationalizing access to genetic centers and improving clinical management and surveillance.

METHODS

The genetic unit of a Cancer Center and the Departments of Oncology from 2 public Hospitals in Milan were involved in the project. After training sessions at the genetic unit, operators from the 2 hospitals evaluated all patients with BC attending a first oncologic visit, through a specific interview. Patients considered at risk of hereditary BC attended counseling at the genetic unit.

RESULTS

Of 419 patients, 61 (14.5%) were eligible for genetic counseling after the interview. Of these, 46 (10.9%) strictly met testing criteria. Overall, 52 (12.4%) patients underwent genetic counseling and 47 were tested for BRCA1/BRCA2 mutation. After genetic test results, the available options for treatment/surveillance were discussed by a multidisciplinary team, according to the level of genetic risk.

CONCLUSIONS

It is possible to improve the process of referring patients with suspected hereditary BC for genetic risk assessment. The application of clinical screening reduced the genetics unit's workload and enabled optimization of time and resources.