Challenges in ductal carcinoma in situ risk communication and decision-making: report from an American Cancer Society and National Cancer Institute workshop

In September 2010, the American Cancer Society and National Cancer Institute convened a conference to review current issues in ductal carcinoma in situ (DCIS) risk communication and decision-making and to identify directions for future research. Specific topics included patient and health care provider knowledge and attitudes about DCIS and its treatment, how to explain DCIS to patients given the heterogeneity of the disease, consideration of nomenclature changes, and the usefulness of decision tools/aids. This report describes the proceedings of the workshop in the context of the current literature and discusses future directions. Evidence suggests that there is a lack of clarity about the implications and risks of a diagnosis of DCIS among patients, providers, and researchers. Research is needed to understand better the biology and mechanisms of the progression of DCIS to invasive breast cancer and the factors that predict those subtypes of DCIS that do not progress, as well as efforts to improve the communication and informed decision-making surrounding DCIS.

Quality of life and voice in patients treated for early laryngeal cancer

OBJECTIVES

To evaluate quality of life and voice in patients previously treated for early laryngeal cancer versus healthy controls and to assess correlations between demographic and cancer characteristics and posttreatment quality of life and voice.

MATERIAL AND METHODS

A total of 49 patients diagnosed with early (Tis-T2N0) laryngeal carcinoma, treated by radiotherapy or endoscopic surgery at least 6 months before, who were alive and free of recurrence formed study group. Postservice with questionnaires was accomplished. Quality of life was evaluated using Medical Outcomes Study 36-Item Health Survey (SF-36), Hospital Anxiety and Depression (HAD) Scale, voice quality--by Voice Handicap Index (VHI). Normative data were obtained from database or concurrently assessed healthy adult subjects.

RESULTS

Hoarseness was the most frequent complain. Majority of patients consider their health as fair (69.4%), one third--good or excellent. The means of summary of SF-36 scores for physical and mental health differ significantly from normative age-matched population (P<0.001). Emotional distress on HAD scale was found in 40.8% of patients vs. 17.0% of healthy controls. Majority (87.8%) of patients rated their voice abnormal; vast majority of them had slight to moderate dysfunction. Mean VHI scores were slight elevated for patients and differed significantly from healthy ones. Correlation analysis revealed a significant relationship between patients' physical health and some demographic-clinic factors.

CONCLUSIONS

Quality of life in patients previously treated for early laryngeal cancer was worse than healthy subjects. Psychiatric morbidity was indicated in around of one-third of the patients. Voice changes were reported in most patients with low handicap level. Physical health perception was better for patients with higher grade of cancer differentiation, not using alcohol, and treated first.

Psychometric properties of a tool for measuring hormone-related symptoms in breast cancer survivors

Hormone-related symptoms are common in breast cancer survivors and many aspects of these symptoms are currently under study. Reliable and valid assessment tools are needed to successfully study hormone-related symptoms in breast cancer survivors; however, no gold standard currently exists for measuring these symptoms. This study evaluated the psychometric properties of a shortened version of the Breast Cancer Prevention Trial (BCPT) symptom checklist in a sample of 803 breast cancer survivors. Principal factor analysis with Promax oblique rotation revealed a five-factor structure, identifying five separate hormone-related symptoms scales: vasomotor symptoms, urinary incontinence, cognitive/mood changes, vaginal symptoms, and weight gain/appearance concern. Hormone-related symptom scale scores differed by demographic and clinical characteristics according to expectations, suggesting that these five scales from the shortened BCPT checklist are reasonably reliable and valid. Symptom scale scores were only weakly correlated with health-related quality of life scores; however, the pattern of results generally supported the validity of the symptom scales. This study adds to the evidence that breast cancer survivors experience a significant number of hormone-related symptoms. Future clinical trials and quality of life and symptom management intervention studies would benefit from accurate assessment of hormone-related symptoms with the five scales from the shortened BCPT checklist.

Quality of Life for Women Diagnosed With Breast Carcinoma in Situ

Purpose

Limited data exist on long-term quality of life (QOL) for women diagnosed with breast carcinoma in situ (BCIS).

Participants and Methods

The data are on 795 BCIS participants diagnosed among female residents of Connecticut from September 15, 1994 to March 14, 1998, and 702 controls frequency-matched to the case participants by 5-year age intervals and geography. These women were participants in a large, population-based case/control study and subsequent follow-up study. Telephone interviews at follow-up were used to collect data on QOL at 5 years from initial diagnosis or contact, using the Medical Outcomes Study, Center for Epidemiologic Studies-Depression, and CAGE (Cut down, Annoyed, Guilty, Eye-opener) alcohol consumption scales. QOL outcomes were compared by case/control status and by case treatment group: lumpectomy, lumpectomy with adjuvant radiation therapy, and mastectomy.

Results

At 5 years after diagnosis, women diagnosed with BCIS report levels of physical, emotional, and mental health functioning similar with those reported in a general healthy female population. Case participants and controls did not differ in reported levels of limitations due to physical health problems, bodily pain, social functioning, or overall physical functioning. Case participants who underwent lumpectomy with radiation reported lower levels of emotional functioning, general health perceptions, vitality, sexual interest, and overall mental health, as well as more depressive symptoms than did control subjects; although, the clinical significance of these statistical differences appears to be limited.

Conclusion

At 5 years after treatment, women diagnosed with BCIS report good physical and emotional functioning relative to control populations.

Use of the female sexual function index in women with vulvar intraepithelial neoplasia

The present investigation extends the validation of the Female Sexual Function Index (FSFI; Rosen et al., 2000) to include women with vulvar excisions for vulvar intraepithelial neoplasia (VIN). No instrument previously has been validated in this population. We administered the instrument to 43 women (n = 43) with VIN treated with vulvar excision and age-matched healthy controls (n = 43). We found the FSFI to have high reliability and validity in the VIN excision population. Discriminant validity and internal consistency were within acceptable ranges. Using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ C-30; Agronson et al., 1993) and the FSFI in this population, we found a correlation between a related construct of quality of life and sexual function.

Impact of superficial bladder cancer and transurethral resection on general health-related quality of life: an SF-36 survey

OBJECTIVES

To assess the general health-related quality of life (GHQOL) of patients with superficial bladder cancer who underwent transurethral resection (TUR).

METHODS

We assessed the GHQOL a total of 178 times for 133 patients with superficial bladder cancer before multiple TURs. The GHQOL was assessed using the Medical Outcome Study Short-Form 36-item survey (SF-36). Ninety-three patients answered the questionnaire at the first TUR, 34 at the second TUR, 17 at the third TUR, and 34 at the fourth or later TUR.

RESULTS

Compared with age-matched and sex-matched Japanese norms, the general health perception was severely impaired in patients with superficial bladder cancer. Their mental health was also severely impaired at the first TUR, but gradually returned to normal as TUR was repeated. The scores of physical functioning, social functioning, and role-emotional demonstrated a nadir at the second or third TUR, and increased thereafter if TUR was repeated four or more times. Intravesical treatment for prevention of recurrence increased the score of bodily pain.

CONCLUSIONS

Although superficial bladder cancer is not frequently lethal, patients with this disease believed their general health was much impaired. Only two domains of bodily pain and vitality had no negative impact from this disease. As urologists, we should notice the considerable affect of superficial bladder cancer on the GHQOL of patients.

Impact of skin-sparing mastectomy with immediate reconstruction and breast-sparing reconstruction with miniflaps on the outcomes of oncoplastic breast surgery

BACKGROUND

The aim of this study was to compare the outcomes of skin-sparing mastectomy (SSM) with immediate myocutaneous flap reconstruction and partial mastectomy with latissimus dorsi miniflap reconstruction (LDMF) for breast cancer.

METHODS

Some 106 disease-free patients (57 SSM, 49 LDMF) who had breast reconstruction between 1991 and 1999 participated in this retrospective review. The mean duration of follow-up was 42 (range 6-102) months. Measured outcomes included surgical complications, functional disability, cosmetic result and psychological morbidity.

RESULTS

SSM outcomes were less favourable than LDMF outcomes with regard to postoperative complications (14 versus 8 per cent), further surgical interventions (79 versus 12 per cent), nipple sensory loss (98 versus 2 per cent), restricted activities (73 versus 54 per cent) and cosmetic outcome by panel assessment. Anxiety about residual cancer and ease of breast self-examination were similar in both groups.

CONCLUSION

LDMF was associated with fewer adverse surgical and physical sequelae than SSM, without compromising local control or cosmetic outcome. Both operations were associated with low psychological morbidity.

Patient reluctance toward tamoxifen use for breast cancer primary prevention

BACKGROUND

The National Surgical Adjuvant Breast and Bowel Project (NSABP) P-1 trial demonstrated that tamoxifen reduces the incidence of new breast cancers by 49% in women at increased risk for breast cancer development. Tamoxifen does have side effects, however, including marginally increased risks of endometrial cancer and thromboembolic events. In this study, women at increased risk for breast cancer development were offered tamoxifen. Their knowledge of tamoxifen as a chemopreventive agent was assessed, and factors influencing their acceptance of tamoxifen and willingness to take it were determined.

METHODS

Forty-three patients were identified who qualified to take tamoxifen for primary prevention. Patients qualified by having at least a 1.7% 5-year risk of developing breast cancer, the criteria for entry into the NSABP P-1 trial. Patients initially completed questionnaires designed to assess their knowledge of tamoxifen and its associated risks and benefits. Patients were then provided neutral educational sessions and literature delineating the actual risks and benefits of tamoxifen. Subsequently, patients' decisions regarding taking tamoxifen were reassessed.

RESULTS

Mean patient age was 52.8 years, with a range of 39 to 74 years. Ten patients (23.2%) qualified based on the presence of lobular carcinoma in situ (LCIS), seven patients (16.3%) qualified based on increased risk secondary to age >60 years, and 26 patients (60.5%) age range 35 to 59 qualified based on risk profiles demonstrating significantly increased risk. Of the total 43 patients, two (4.7%) elected to start taking tamoxifen. Fifteen patients (34.8%) declined immediately, and 26 patients (60.5%) were undecided initially but ultimately declined. Educational sessions did not influence patients' decisions. Fear of side effects, including endometrial cancer, thromboembolic events, and menopausal symptoms, was the most commonly cited reason for declining to take tamoxifen.

CONCLUSIONS

In this study, the vast majority of patients at increased risk for breast cancer perceived that the risks of taking tamoxifen outweighed the benefits and declined to take it.

[Of what significance is abnormal result of smear test? Anxiety because of insufficient information in connection with abnormal result of cervical smear test]

The purpose of the study was to investigate possible differences in psychological response between two groups of women after pathological cervical smear tests (CIN I or recurrent CIN I and/or CIN II-III respectively). 43 women participated. A standardised questionnaire was used. In 75 percent of the cases the result was given over the telephone. The number of women who reacted with medium to strong anxiety in the CIN I group (15/22) did not differ from those in the group with CIN II-III (15/21). 45 percent of the women in the CIN I group thought their lesions to be malignant. 64 percent of the women in the CIN I group, as compared to 38 percent of the women in the CIN II-III group, benefitted from the additional information they asked for and received. A majority of the women would have liked more information as well as the opportunity to discuss the findings in a more personal way.

Responsiveness to threats and incentives, expectancy of recurrence, and distress and disengagement: moderator effects in women with early stage breast cancer

Models of neurobiological systems linking personality, motivation, and emotion can be integrated with the expectancy construct to suggest hypotheses about distress and giving up in response to adversity. In 220 women with breast cancer, threat responsiveness-sensitivity of the behavioral inhibition system (BIS)-and incentive responsiveness-sensitivity of the behavioral activation system (BAS)-and expectancies about cancer recurrence were measured. It was predicted and found that high BIS sensitivity interacted with recurrence expectancy to predict elevated distress and disengagement. Low BAS sensitivity (reward responsiveness) also interacted with expectancy of recurrence to predict elevated disengagement. In contrast, high BAS sensitivity (fun seeking) interacted with recurrence expectancy to predict elevated distress. Discussion centers on theoretical implications and possible applications.

[Surgical treatment and quality of life in patients with carcinoma of the penis]

Penile carcinoma is a rare disease with the annual incidence of 1-2 cases per 100,000 men. About 95% of all penile malignancies are squamous cell carcinoma. At the Clinic of Urology in the period 1988-1998 we treated 58 patients with penile carcinoma. Nine of these (15.5%) were subjected to total penectomy due to the extent of the lesion, while partial amputation of the penis was performed in 84.5% (49 cases). The aim of the therapy was to completely remove the primary lesion with adequate margins. Postoperative follow-up comprised, among other things, evaluation of the quality of life as reflected in pain, sexuality and emotional distress. Quality of life of patients subjected to partial penectomy where no cases of relapse were recorded, was satisfactory, while in cases of total penectomy about 24% (14 patients) suffered marked emotional distress induced by the loss of the mark of male sexuality and sexual impotence. In the light of the prominent problems related to the quality of life induced by severe psychological influence of penis amputation, local excision, Mohs's operation and laser therapy are increasingly used in the treatment of penile carcinoma.

Flap repair: an effective strategy for minimising sexual morbidity associated with the surgical management of vulval intra epithelial neoplasia

OBJECTIVE

To assess the sexual function after local excision and flap repair for symptomatic vulval intraepithelial neoplasia (VIN).

STUDY DESIGN

A retrospective analysis of five sexually active women who had persistent, symptomatic VIN diagnosed in a dedicated tertiary referral vulval clinic and treated with local excision and flap repair. Sexual function was assessed using a modified version of the Sabbatsberg Sexual Self-Rating Scoring (SRS) system.

RESULTS

The mean age of the cohort was 32 years (range 30 to 51). Four patients had previously been unsuccessfully treated with local excision. Follow up ranged from 5 to 33 months. The SRS scores were 90, 90, 81, 72 and 25. Endogenous depression may explain this last score. There has been no recurrence of VIN.

CONCLUSION

In sexually active women with symptomatic VIN III, a flap reconstruction should be considered in addition to local excision as the treatment of choice.

The minimization to clients of screen-detected breast cancer: a qualitative analysis

Previous research has shown a low incidence of psychological morbidity in women with screen-detected breast cancer when compared to women with symptomatic breast cancer. Farmer et al. suggested that this might be due to the way the diagnosis of breast cancer is given to women with screen-detected disease. In order to test this hypothesis a detailed, in-depth, qualitative study was undertaken. The sample consisted of women with symptomatic breast cancer (n=5), women with screen-detected invasive breast cancer (n=6) and women with screen-detected in-situ breast cancer (n=5). The 'bad news consultations' with the surgeons, and subsequent meetings with the breast care nurses (BCN), were tape recorded. The women were also interviewed in their own homes within 7 days. The results suggested that the women with screen-detected breast cancer received more reassurance than the women with symptomatic breast cancer and that the benefits of breast screening were emphasized by the surgeons and the BCNs. This led to minimization of the significance of screen-detected disease. Women were found to draw on a new conceptual model of early curable breast cancer which appears to be associated with a low incidence of psychological morbidity.

Ductal carcinoma in situ (DCIS) of the breast: the need for psychosocial research

Since the introduction of the National Health Service Breast Screening Programme (NHSBSP), the number of ductal carcinoma in situ (DCIS) cases has increased considerably. Despite its increased incidence, some NHS leaflets and reports do not mention it, and the general public seems largely unaware of its existence. There are numerous biological studies dealing with this condition, but its psychosocial aspects seem to have been neglected. We have only been able to locate two British studies (Farmer, A. 1996. Unpublished PhD thesis, University of Southampton; Webb, C. and Koch, T. 1997. J. Adv. Nurs., 25, 154-525) that address some of the psychosocial issues associated with DCIS. This paper starts by defining DCIS and explaining its usual presentation, natural history and epidemiology. The treatment options for DCIS are described, together with the great deal of confusion and lack of agreement that accompanies them. The psychological issues that women with screen-detected DCIS have to deal with are different from those affecting women diagnosed with symptomatic breast cancer, and a summary of these issues is given. Finally, some suggestions for future psychosocial research are provided. Because the UK as a whole was not covered by the NHSBSP until 1990 (Baum, M. 1995. Lancet, 346, 436; Gage and Fouquet, 1997), the main focus will be on papers published from that year onwards, although some key papers published before then will also be included. The papers reviewed here were found in MEDLINE, EMBASE and BIDS (ISI).

Discussing disease progression and end-of-life decisions

Because most patients now want to know the truth about their diagnosis and prognosis, the ability to discuss the cancer diagnosis, disease recurrence, or treatment failure, and to solicit patients' views about resuscitation or hospice care, are important verbal skills for oncologists and other oncology health care providers. Moreover, the ability to clearly articulate a treatment plan or elicit patient preferences for treatment are a prerequisite to informed consent. Despite these imperatives, clinicians do not routinely receive training in key communication skills that could enable them to accomplish these tasks. A body of literature is available, however, that identifies communication strategies that can (1) facilitate the establishment of a close rapport with the patient, (2) identify the patient's information preferences, (3) ensure comprehension of key knowledge and information, (4) address the patient's emotions in a supportive fashion, (5) elicit the patient's key concerns, and (6) involve the patient in the treatment plan. In this article, we use dialogues between a physician and a hypothetical patient with advanced ovarian cancer to illustrate how communication techniques can be applied to accomplish these goals. We identify important benefits of the use of these techniques for both the physician and patient, and pose several questions regarding the training of physicians in this area.

Quality of life in patients with ductal carcinoma in situ of the breast treated with conservative surgery and postoperative irradiation

AIM OF THE STUDY

To evaluate the quality of life (QL) in patients with ductal carcinoma in situ of the breast treated with conservative surgery and postoperative irradiation.

MATERIAL AND METHODS

A self-completed questionnaire covering many disease-, symptom-, and treatment-specific issues was administered to 106 conservatively treated patients affected by non-infiltrating breast cancer. The questionnaire was based on a series of 34 items assessing five main fields of post-treatment adjustment: physical well being, sexual adaptation, aesthetic outcome, emotional/psychological well being, relational behaviour. Furthermore, the patients were requested to evaluate the degree of information provided by the medical staff concerning surgical procedures and radiation therapy, and to evaluate the effects of the treatment on their social and overall life.

RESULTS

The questionnaire was completed by 83 patients (78%), who had a median follow-up of 54.5 months. This final sample had a median age of 50 years (range 29-88) at the time of treatment and 54 years (range 32-94) at the time of study. The patients claimed to be in good physical condition. Data relating to sexual life were provided by 93% of the sample. Some limitations in sexuality, some interference with sexual desire, and some modifications during intercourse were reported by 5, 6, and 5 patients, respectively. The subjective evaluations of the cosmetic results of the therapies were generally good. Only 13 patients (16%) reported the perception of a worsened body image. Forty-six percent of the sample (38 patients) declared that they felt tense, 48% (39 patients) nervous, 29% (38 patients) lonely, 59% (41 patients) anxious, and 41% (34 patients) depressed. Only seven patients (8%) declared that the treatment had had a bad effect on their social life, and 15 (18%) thought that their current life had been affected by the treatment. The amount of information received concerning the disease and treatment (surgery and radiotherapy) was considered sufficient by 79%, 75%, and 79% of the sample, respectively.

CONCLUSIONS

This study revealed a good QL in patients treated with breast conservation and postoperative irradiation, with a preserved favourable body image and a lack of negative impact on sexuality. Radiation therapy did not lead to any significant additional problems capable of affecting the QL.

Psychological profile related to malignant tumours of different histopathology

In a previous preoperative study of patients with gliomas, we made the original observation that patients with high grade as opposed to those with low-grade gliomas have a psychological profile marked by extreme emotional reactivity. In this postoperative study of the psychological profiles of patients with breast cancer, the main funding was unexpectedly analogous with the findings in the brain tumour study. The patients with poorly differentiated ductal carcinomas showed a specific and, compared to the patients with well differentiated carcinomas, outstanding psychological profile marked by extreme emotional reactivity as well as by genuine creativity. Some of the present patients with well differentiated carcinomas showed personality profiles marked by compulsive inhibition, also described earlier in the literature of patients with breast cancer. The psychobiological relations between emotional reactivity and aggressiveness of tumour growth are discussed.

The reproductive imperative: a case report highlighting the possibility of using chemotherapy to conserve the testis in patients with testis cancer

This report examines the dilemma that a patient, who was a doctor, faced on discovering that he was developing a second primary testicular tumour (seminoma) in a solitary testis. The usual treatment for this is radical orchidectomy. He rejected this on the grounds that he wanted to have children, and eventually decided on the use of single-agent carboplatin chemotherapy. Seventeen months after treatment, there was no evidence of tumour on MRI or ultrasound scanning and there is some recovery of spermatogenesis. So far, 13 of 14 patients treated with chemotherapy for metastatic disease (with the primary tumour being left in situ), which has normalized following treatment, have survived for more than 5 years without evidence of tumour recurrence. This approach could be a viable option for men with tumours in a solitary testis who have not completed their families. However, a larger prospective study is essential to determine whether this approach is safe, so that these patients will not have to bear the psychological burden of choosing between their chances of survival and the possibility of fathering children.

Women's experiences of non-invasive breast cancer: literature review and study report

A review of the post-1990 literature on breast cancer has identified a large body of psychosocial research focusing on coping styles, quality of life and women's participation in choice of treatment. However, numerous methodological problems were found, including a variety of different diagnoses included in samples both within studies and between studies, making comparisons difficult. In particular, no article was traced which focused on non-invasive breast cancer, or ductal carcinoma in situ (DCIS). Therefore a small exploratory study was conducted using qualitative methods to explore women's experience of DCIS, in an attempt to begin exploration of possible similarities or differences in the way women experience invasive and non-invasive breast cancer. A convenience sample of 10 women treated at two hospitals in an Australian state capital city was interviewed, and three themes which emerged from these interviews are discussed in this article. These are discovering the problem, reaction to the diagnosis, and information. Most women unexpectedly reacted in a calm and accepting way to receiving the diagnosis of DCIS, and this may be because they had had no signs of disease but been recalled for further tests after routine screening. They felt well and had no cause to assume a poor prognosis. It is possible also that their reactions were affected by a television health education campaign at the time, which gave a very optimistic picture of the benefits of early detection of breast cancer. Information-giving, as reported by the women, seemed deficient. None of them knew that they had had a non-invasive condition, one thought her disease had been benign, and another that hers was "evasive'. Findings are discussed in relation to the literature on information-giving and on the role of the nurse in this area, and suggestions are made for further research to systematically compare women's reactions to having invasive and non-invasive breast cancer in order that nurses may be aware of their possibly different needs and respond to them appropriately.

Alexithymia, immunity and cervical intraepithelial neoplasia: replication

BACKGROUND

In a previous study [Psychother Psychosom 1994;61:199-204] we investigated the relationship between alexithymia, carcinogenesis and immunity in a group of women who were unconscious sufferers from precancerous lesions of the cervix (CIN). The results of this study showed a high level of association between alexithymia and CIN and, an even more interesting fact, between alexithymia and reduced levels of immunity.

METHODS

The aim of the present study is to check the results of the previous one by testing a larger group (43 women affected by cervical dysplasia and 67 healthy women) and by the use of a self-administered test for detection of alexithymia, the well-validated Twenty-Item Toronto Alexithymia Scale (TAS-20).

RESULTS

The results confirm that women suffering from CIN have higher average TAS-20 ratings (55) than normal women (47.32) and that the level of alexithymia detected in the group of women suffering from dysplasia (42.5%) is higher than that of normal women (12.85%). Moreover, the present study confirms that alexithymic women have lower rates of a number of lymphocyte subsets than non-alexithymic women.

CONCLUSIONS

This study fully confirms the results of our previous work and those of a number of other studies: (1) personality might be one of the factors jointly responsible for the outbreak of cancer; (2) the immune system appears to play an important part as a mediator between personality and cancer.

Clinical trials--a brave new partnership?

The need for informed consent is considered from the patient's viewpoint by an examination of the shortcomings of the UK Ductal Carcinoma In Situ (DCIS) trial and its failure satisfactorily to accrue both profession and patient. The impersonal, negative aspects of the informed consent process in the research situation are contrasted with the positive benefits of confidence fostered by the traditional doctor/patient relationship. The need for new research with a partnership between patient and profession, the necessity for rigorous re-assessment of treatments and care both within and outside of trials to avoid waste by the perpetration of unnecessary treatments together with the need for evaluation of the efficacy of treatments employed outside of trials, especially in 'new' conditions, to foster progress and maintain public confidence in the profession, is advocated.

Sexual function and somatopsychic reactions after local excision of vulvar intra-epithelial neoplasia

Eighteen patients, under the age of 60 years, who have been treated with local excision of the vulva, participated in the study in which sexual function and somatopsychic reactions were evaluated by personal interviews. Furthermore both objective and subjective cosmetic results were registered. After this type of operation, fewer than one-third of the patients had postoperative sexual and somatopsychic problems, whereas more than half of the patients undergoing vulvectomy did report such problems. Fourteen out of 18 patients were satisfied with the cosmetic result and in 12 of the patients no disfiguration was found. This study shows that local excision of intra-epithelial neoplasia of the vulva is far less sexually traumatic than is vulvectomy.

Stress and hopelessness in the promotion of cervical intraepithelial neoplasia to invasive squamous cell carcinoma of the cervix

Stress and hopelessness have been associated with the development of invasive cervical cancer by previous research. Subjects in this study were recruited from a colposcopy clinic awaiting work-up of an abnormal pap smear and from those admitted to an in-patient gynecology ward for cone biopsy of the cervix or hysterectomy to treat a symptomatic pelvic mass thought to be uterine leiomyomas. After data collection, pathology reports and colposcopic findings were used to determine group assignment independent of subjects' knowledge of their diagnosis. A modest stress-promotion correlation was derived, which was greatly enhanced by significant interactions with low levels of cooperative coping style and for high levels of premorbid pessimism, future despair, somatic anxiety, and life threat reactivity. These stress-moderator interactions are discussed in terms of immune system deficit with concomitant enhancement of promotion of CIN to invasive squamous cell cervical cancer.