Worry about ovarian cancer risk and use of ovarian cancer screening by women at risk for ovarian cancer

Anticipatory anxiety and participation in cancer screening. A systematic review

OBJECTIVES

To synthesize current evidence on the association between anticipatory anxiety, defined as apprehension-specific negative affect that may be experienced when exposed to potential threat or uncertainty, and cancer screening to better inform strategies to maximize participation rates.

METHODS

Searches related to cancer screening and anxiety were conducted in seven electronic databases (APA PsycINFO, Scopus, Web of Science, Embase, Cochrane Library, PubMed, CINAHL), with potentially eligible papers screened in Covidence. Data extraction was conducted independently by multiple authors. Barriers to cancer screening for any type of cancer and relationships tested between anticipatory anxiety and cancer screening and intention were categorized and compared according to the form and target of anxiety and cancer types.

RESULTS

A total of 74 articles (nparticipants  = 119,990) were included, reporting 103 relationships tested between anticipatory anxiety and cancer screening and 13 instances where anticipatory anxiety was reported as a barrier to screening. Anticipatory anxiety related to a possible cancer diagnosis was often associated with increased screening, while general anxiety showed no consistent relationship. Negative relationships were often found between anxiety about the screening procedure and cancer screening.

CONCLUSION

Anticipatory anxiety about a cancer diagnosis may promote screening participation, whereas a fear of the screening procedure could be a barrier. Public health messaging and primary prevention practitioners should acknowledge the appropriate risk of cancer, while engendering screening confidence and highlighting the safety and comfort of screening tests.

Patient perspectives on risk-reducing salpingectomy with delayed oophorectomy for ovarian cancer risk-reduction: A systematic review of the literature

OBJECTIVE

Increasing evidence suggests the fallopian tube as the site of origin of BRCA1/2-associated high-grade ovarian cancers. Several ongoing trials are evaluating salpingectomy with delayed oophorectomy (RRSDO) for ovarian cancer risk reduction and patients are beginning to ask their clinicians about this surgical option. This study sought to systematically review the available literature examining patient preferences regarding RRSDO and risk-reducing salpingo-oophorectomy (RRSO) to provide clinicians with an understanding of patient values, concerns, and priorities surrounding ovarian cancer risk-reducing surgery.

METHODS

We conducted a systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO No.: CRD42023400690). We searched key electronic databases to identify studies evaluating acceptance and surgical decision-making regarding RRSO and RRSDO among patients with an increased risk of ovarian cancer.

RESULTS

The search yielded 239 results, among which six publications met the systematic review inclusion criteria. Acceptance of RRSDO was evaluated in all studies and ranged from 34% to 71%. Factors positively impacting patients' acceptance of RRSDO included: avoidance of surgical menopause, preservation of fertility, concerns about sexual dysfunction, family history of breast cancer, and avoidance of hormone replacement therapy. Factors limiting this acceptance reported by patients included concerns regarding oncologic safety, surgical timing, and surgical complications.

CONCLUSION

To date, few studies have explored patient perspectives surrounding RRSDO. Collectively, the limited data available indicate a high level of acceptance among BRCA1/2 carriers, and provides insight regarding both facilitating and limiting factors associated with patient preferences to better equip clinicians in the counseling and support of their patients.

Cancer Risk Perceptions Among People Who Check Their Skin for Skin Cancer: Results from the 2017 U.S. Health Information National Trends Survey (HINTS)

When detected early, melanoma is highly treatable and rarely fatal. Self-skin checks can identify changes in moles that could be an indicator of melanoma. Cancer risk perceptions may influence the uptake of important preventive health behaviors such as self-skin checks. The purpose of this study is to examine cancer risk perception factors associated with those who have checked their skin for signs of skin cancer using the 2017 HINTS data. Retrospective cross-sectional analysis of a nationally representative sample of U.S. adults using the Health Information National Trends Survey (HINTS). Logistic regressions were performed to identify associations between having checked skin for signs of skin cancer, risk perceptions, and demographic variables. White women over the age of 45 with a college degree and annual incomes greater than $75,000 were more likely to check their skin for signs of skin cancer. More than a third reported they would rather not know if they had cancer and more than 60% had some level of worry about having cancer. Those with a personal or family history of cancer were more likely to check. HINTS is a cross-sectional survey which provides only a glimpse of behavioral predictors. Self-skin checks are simple and cost-effective to detect melanoma early and improve outcomes. Fear and worry about cancer were significant factors in the likelihood of checking skin for signs of skin cancer. Population-based strategies could be developed to reduce concerns about early detection.

Cancer risk perception predictors for total body skin examinations: a cross-sectional study using Health Information National Trends Survey (HINTS) 2017 data

BACKGROUND

Despite the lack of national skin cancer screening recommendations, a total body skin examination by a healthcare provider may detect skin cancer earlier, allowing for more effective treatment and better outcomes.

OBJECTIVE

Examine prevalence, demographic, and cancer risk perceptions of adults who have had a skin examination performed by a healthcare provider.

METHODS

Retrospective, cross-sectional analysis of a nationally representative sample of U.S. adults using the Health Information National Trends Survey (HINTS). Logistic regressions were performed to identify associations between having a skin examination, risk perceptions, and demographic variables.

RESULTS

Approximately 46% of the sample reported having a skin examination. Females, college graduates, those with a history of skin cancer, people who check their skin for signs of skin cancer, and adults over the age of 45 were more likely to have a skin examination. The people least likely to be screened were those not wanting to know their chances of getting cancer.

LIMITATIONS

HINTS is a cross-sectional survey which provides only a glimpse of predictors.

CONCLUSIONS

The findings are consistent with other studies that people sometimes avoid cancer risk information. An educational intervention focused on the benefits of early cancer detection would benefit people who report not wanting to know their chances of getting cancer.

The role of emotions in cancer patients' decision-making

Introduction

Despite the attempt to make decisions based on evidence, doctors still have to consider patients' choices which often involve other factors. In particular, emotions seem to influence the way that options and the surrounding information are interpreted and used.

Objective

The objective of the present review is to provide a brief overview of research on decision making and cancer with a specific focus on the role of emotions.

Method

Thirty-nine studies were identified and analysed. Most of the studies investigated anxiety and fear. Worry was the other psychological factor that, together with anxiety, played a crucial role in cancer-related decision-making.

Results

The roles of fear, anxiety and worry were described for detection behaviour, diagnosis, choice about prevention and curative treatments and help-seeking behaviour. Results were inconsistent among the studies. Results stressed that cognitive appraisal and emotional arousal (emotion's intensity level) interact in shaping the decision. Moderate levels of anxiety and worry improved decision-making, while low and high levels tended to have no effect or a hindering effect on decision making. Moderating factors played an under-investigated role.

Conclusions

Decision making is a complex non-linear process that is affected by several factors, such as, for example, personal knowledge, past experiences, individual differences and certainly emotions. Research studies should investigate further potential moderators of the effect of emotions on cancer-related choice. Big data and machine learning could be a good opportunity to test the interaction between a large amount of factors that is not feasible in traditional research. New technologies such as eHealth and virtual reality can offer support for the regulation of emotions and decision making.

False-positive screening events and worry influence decisions about surgery among high-risk women

OBJECTIVE

Studies of cancer screening have found that false positive screening events (FPSE) can affect worry about cancer risk and screening program use, we sought to further explore this.

METHOD

In a study of 1,100 women at high risk for ovarian cancer who participated in a previously published randomized controlled trial (RCT), we sought to explore whether worry might also influence the use of risk-reducing surgical procedures by women. Participants included 234 women with BRCA1/2 mutations and 866 women with high-risk pedigrees. We followed the women for up to 6 years.

RESULTS

Worry predicted risk reducing prophylactic bilateral salpingo-oophorectomy (pBSO) for both mutation carriers (HR = 1.74; p = .02), and women with high-risk pedigree (HR = 3.41; p < .001). FPSE also predicted subsequent pBSO among women with a high-risk pedigree (HR 2.31; p < .01). While screening may reduce worry among those who never receive a positive result, FPSE increase worry at least temporarily. Worry about ovarian cancer risk predicted use of preventative pBSO among high-risk women including those with BRCA1/2 mutations enrolled in an ovarian cancer-screening program. FPSE also predicted risk-reducing ovarian surgery among high-risk women without a known mutation at the time of screening program enrollment.

CONCLUSIONS

Physicians who offer screening should know that false positive results may increase use of pBSO, how this should effect clinical practice is unclear. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Evidencias psicométricas iniciales de una medida breve sobre preocupación por el cáncer

Objetivo: La preocupación por el cáncer está asociada con los comportamientos preventivos para la detección de esta enfermedad; sin embargo, no existe un instrumento con evidencias de validez y confiabilidad para medir este constructo en países latinoamericanos, entre ellos el Perú. Los objetivos de este estudio fueron evaluar la validez basada en la estructura interna y fiabilidad de la Cancer Worry Scale (CWS) en una muestra de personas sin diagnóstico oncológico con historia familiar de cáncer. Método: Se contó con la participación de 215 personas sanas con historia familiar de cáncer que acudían al servicio de consulta externa de dos instituciones públicas y privadas de salud de la ciudad de Chimbote con una edad promedio de 42,10 años (DT = 14,05). Para el recojo de información se utilizó una ficha sociodemográfica ad hoc y la Cancer Worry Scale. Resultados: El modelo unidimensional presentó un buen ajuste de los datos (SBχ2 (8) = 14,39; SB χ2 / df = 1,79; CFI = 0,991; SRMR = 0,025; RMSEA = 0,061 [IC90%: 0,000 -0,111]; AIC = 47,701) y una confiabilidad adecuada (ωcorregido = 0,90; IC95%: 0,88-0,92). Conclusión: Se concluye que la CWS presenta adecuadas propiedades psicométricas, siendo una medida que brinda interpretaciones válidas y fiables de la preocupación por el cáncer en el contexto peruano.

Influences on anticipated time to ovarian cancer symptom presentation in women at increased risk compared to population risk of ovarian cancer

Background

In the absence of routine ovarian cancer screening, promoting help-seeking in response to ovarian symptoms is a potential route to early diagnosis. The factors influencing women’s anticipated time to presentation with potential ovarian cancer symptoms were examined.

Methods

Cross-sectional questionnaires were completed by a sample of women at increased familial risk (n = 283) and population risk (n = 1043) for ovarian cancer. Measures included demographic characteristics, symptom knowledge, anticipated time to symptom presentation, and health beliefs (perceived susceptibility, worry, perceived threat, confidence in symptom detection, benefits and barriers to presentation). Structural equation modelling was used to identify determinants of anticipated time to symptomatic presentation in both groups.

Results

Associations between health beliefs and anticipated symptom presentation differed according to risk group. In increased risk women, high perceived susceptibility (r = .35***), ovarian cancer worry (r = .98**), perceived threat (r = −.18**), confidence (r = .16**) and perceiving more benefits than barriers to presentation (r = −.34**), were statistically significant in determining earlier anticipated presentation. The pattern was the same for population risk women, except ovarian cancer worry (r = .36) and perceived threat (r = −.03) were not statistically significant determinants.

Conclusions

Associations between underlying health beliefs and anticipated presentation differed according to risk group. Women at population risk had higher symptom knowledge and anticipated presenting in shorter time frames than the increased risk sample. The cancer worry component of perceived threat was a unique predictor in the increased risk group. In increased risk women, the worry component of perceived threat may be more influential than susceptibility aspects in influencing early presentation behaviour, highlighting the need for ovarian symptom awareness interventions with tailored content to minimise cancer-related worry in this population.

Electronic supplementary material

The online version of this article (10.1186/s12885-017-3835-y) contains supplementary material, which is available to authorized users.

Is attendance at an ovarian cancer screening clinic a worry-reducing event? Findings from pre- to post-screening

OBJECTIVE

Many studies have examined the relationship between worry and cancer screening. Due to methodological inconsistencies, results of these studies have varied and few conclusions can be made when generalizing across studies. The purpose of the current study was to better understand the worry-cancer screening relationship using a prospective research design.

METHOD

180 women enrolled in an annual ovarian cancer (OC) screening clinic completed surveys at three time points-pre-screening, day of screening, and post-screening-using three measures of cancer-specific worry.

RESULTS

OC worry was highest in the weeks prior to screening and mere presentation at a screening clinic was associated with a significant worry decline. Observed elevations in worry following abnormal screening were not universal and varied by the instrument used to measure worry.

CONCLUSIONS

In contrast to our hypotheses, it appears that mere presentation at a cancer screening clinic may be a worry-reducing event. Receipt of abnormal results was not necessarily associated with increased worry.

What do people fear about cancer? A systematic review and meta-synthesis of cancer fears in the general population

Background

Cancer has long inspired fear, but the effect of fear is not well understood; it seems both to facilitate and to deter early diagnosis behaviours. To elucidate fear's behavioural effects, we systematically reviewed and synthesised qualitative literature to explore what people fear about cancer.

Methods

We searched Medline, Embase, PsycInfo, Web of Science, AnthroSource, and Anthrobase for studies on cancer fear in breast, cervical, and colorectal cancer screening and analysed 102 studies from 26 countries using thematic synthesis.

Results

Fears of cancer emanated from a core view of cancer as a vicious, unpredictable, and indestructible enemy, evoking fears about its proximity, the (lack of) strategies to keep it at bay, the personal and social implications of succumbing, and fear of dying from cancer.

Conclusions

This view of cancer as ‘an enemy’ reprises the media's ‘war on cancer’ theme and may affect the acceptance of cancer early detection and prevention messages, since cancer's characteristics influenced whether ‘fight’ or ‘flight’ was considered appropriate.

The double-edged sword of ovarian cancer information for women at increased risk who have previously taken part in screening

BACKGROUND

Women at increased risk who decide not to have, or to delay, risk-reducing salpingo-oophorectomy have to rely on early diagnosis through symptom awareness and presenting to primary care as soon as possible in the absence of screening. However, little is known about the acceptability to women of this strategy. We aimed to gain an in-depth understanding of women's perceptions and previous experiences of ovarian cancer symptom management, and the influences on ovarian cancer awareness and anticipated symptom presentation.

METHOD

Qualitative interviews were conducted with eight women at increased risk of ovarian cancer who had previously taken part in ovarian cancer screening and analysed using interpretative phenomenological analysis (IPA).

RESULTS

Familial experience of ovarian cancer and perceived personal risk shaped women's perceptions and behavioural responses to disease threat. Ovarian cancer information was perceived to be a double-edged sword, regarded as either useful for increasing knowledge and confidence in discussing symptom concerns with health professionals or to be avoided due to fears about cancer.

CONCLUSION

Women may be cautious about searching for information independently and in the absence of routine ovarian screening.

PRACTICE IMPLICATIONS

Thought needs to be given to how best to create and disseminate credible ovarian cancer symptom information materials.

Cancer Risk Awareness and Concern among Women with a Family History of Breast or Ovarian Cancer

Women with a documented deleterious mutation in BRCA1 or BRCA2 are at substantially elevated risk for ovarian cancer. To understand what percentage of women with high-risk family histories know their risk is elevated we surveyed 1,885 women with a high- or moderate-risk family history and no personal history of breast or ovarian cancer, and asked about their perceived risk of breast and ovarian cancer. Among high-risk women, fewer than 20% reported use of genetic counseling, and knowledge of elevated risk of ovarian cancer was low. Prior genetic counseling was associated with greater perceived risk for ovarian cancer. Results suggest that most high-risk women (>75%) do not know their risk for ovarian cancer. Identification of potentially high-risk women for referral to genetic counseling may improve informed ovarian cancer risk management.

Psychosocial Predictors for Cancer Prevention Behaviors in Workplace Using Protection Motivation Theory

Backgrounds. The aim of this study was to describe the preventive behaviors of industrial workers and factors influencing occupational cancer prevention behaviors using protection motivation theory. Methods. A self-administered questionnaire was completed by 161 petrochemical workers in Iran in 2014 which consisted of three sections: background information, protection motivation theory measures, and occupational cancers preventive behaviors. Results. A statistically significant positive correlation was found between PM and self-efficacy, response efficacy, and the cancer preventive behaviors. Meanwhile, statistically significant negative correlations were found between PM, cost, and reward. Conclusions. Among available PMT constructs, only self-efficacy and cost were significant predictors of preventive behaviors. Protection motivation model based health promotion interventions with focus on self-efficacy and cost would be desirable in the case of occupational cancers prevention.

Cognitive and affective influences on perceived risk of ovarian cancer

INTRODUCTION

Studies suggest that both affective and cognitive processes are involved in the perception of vulnerability to cancer and that affect has an early influence in this assessment of risk. We constructed a path model based on a conceptual framework of heuristic reasoning (affect, resemblance, and availability) coupled with cognitive processes involved in developing personal models of cancer causation.

METHODS

From an eligible cohort of 16 700 women in a managed care organization, we randomly selected 2524 women at high, elevated, and average risk of ovarian cancer and administered a questionnaire to test our model (response rate 76.3%). Path analysis delineated the relationships between personal and cognitive characteristics (number of relatives with cancer, age, ideas about cancer causation, perceived resemblance to an affected friend or relative, and ovarian cancer knowledge) and emotional constructs (closeness to an affected relative or friend, time spent processing the cancer experience, and cancer worry) on perceived risk of ovarian cancer.

RESULTS

Our final model fit the data well (root mean square error of approximation (RMSEA) = 0.028, comparative fit index (CFI) = 0.99, normed fit index (NFI) = 0.98). This final model (1) demonstrated the nature and direction of relationships between cognitive characteristics and perceived risk; (2) showed that time spent processing the cancer experience was associated with cancer worry; and (3) showed that cancer worry moderately influenced perceived risk.

DISCUSSION

Our results highlight the important role that family cancer experience has on cancer worry and shows how cancer experience translates into personal risk perceptions. This understanding informs the discordance between medical or objective risk assessment and personal risk assessment. Published in 2014. This article is a U.S. Government work and is in the public domain in the USA.

Misperceptions of ovarian cancer risk in women at increased risk for hereditary ovarian cancer

This study assessed the sociodemographic, medical and psychological predictors of accuracy of perceived risk in women at increased genetic risk for ovarian cancer. Women participating in a large cohort study who were at increased risk of ovarian and fallopian tube cancer, had no personal history of cancer and had ≥1 ovary in situ at cohort enrollment, were eligible. Women completed self-administered questionnaires and attended an interview at enrollment. Of 2,868 women unaffected with cancer at cohort enrollment, 561 were eligible. 335 women (59.8 %) overestimated their ovarian cancer risk, while 215 women (38.4 %) accurately estimated their risk, and 10 (1.8 %) underestimated it. Women who did not know their mutation status were more likely to overestimate their risk (OR 1.74, 95 % CI 1.10, 2.77, p = 0.018), as were those with higher cancer-specific anxiety (OR 1.05, 95 % CI 1.02, 1.08, p < 0.001) and/or a mother who had been diagnosed with ovarian cancer (OR 1.98, 95 % CI 1.23, 3.18, p = 0.005). Amongst the group of women who did not know their mutation status, 63.3 % overestimated their risk and the mean perceived lifetime risk of developing ovarian cancer was 42.1 %, compared to a mean objective risk of 6.4 %. A large number of women at increased risk for ovarian cancer overestimate their risk. This is of concern especially in women who are at moderately increased risk only; for this sub-group of women, interventions are needed to reduce potentially unnecessary psychological distress and minimise engagement in unnecessary surgery or screening.

Risk perception, worry, and test acceptance in average-risk women who undergo ovarian cancer screening

OBJECTIVE

We evaluated baseline knowledge of ovarian cancer risk and perceptions toward ovarian cancer screening (OCS) by initiating the normal risk ovarian screening study.

STUDY DESIGN

Average-risk, postmenopausal women were enrolled between 2001 and 2011 as they entered the normal risk ovarian screening study. Participants completed baseline surveys of risk perception, cancer worry (Cancer Worry Scale), anxiety (State-Trait Anxiety Inventory), health and well-being survey (SF-36 HEALTH SURVEY), and acceptability of OCS.

RESULTS

Of the 1242 women who were enrolled, 925 women (74.5%) completed surveys. The respondents estimated a mean lifetime risk of ovarian cancer of 29.9%, which is much higher than the actual risk of 1.4% for women in the United States. Only 2.8% of participants correctly estimated their risk; 35.4% of the participants reported their lifetime risk to be ≥50%. Cancer worry was low, with a median Cancer Worry Scale score of 7 of 24. Anxiety was comparable with published norms for women in this age group, with median STAI-State and STAI-Trait scores of 30 and 29 of 80, respectively. Overall, women reported good physical and mental well-being. In terms of OCS acceptability, 97.2% of respondents agreed or strongly agreed that "the benefits of screening outweigh the difficulties." Very few women were reluctant to undergo OCS because of time constraints (1.1%), pain (2.0%), or embarrassment (1.9%).

CONCLUSION

Average-risk women who underwent OCS highly overestimated their risk of ovarian cancer. Despite this, participants reported low cancer worry and anxiety. The discrepancy between knowledge of and attitudes toward ovarian cancer risk highlights the need for educational efforts in this area.

Reasons for and against participation in studies of medicinal therapies for women with breast cancer: a debate

BACKGROUND

A special challenge for research studies of breast cancer among females is low patient participation rates. We compiled this systematic review to identify reasons why women with, or at high risk of, breast cancer do or do not participate in medicinal studies of breast cancer.

METHOD

A systematic literature search in the databases Cochrane Library, EMBASE, Medline, Pascal Biomed, ACP Journal Club and CINAHL, as well as searches through reference lists of relevant texts, was performed.

RESULTS

Of 39 relevant full texts, ultimately, nine studies (1 qualitative, 8 quantitative) were included after applying the inclusion criteria. Despite a lack of data material, it was possible to identify various factors influencing women's willingness to participate in medicinal studies and group them into three categories: person-related, study-related, and physician-related.

CONCLUSION

Reasons for or against participation in studies of medicinal therapies by women with, or at high risk of, breast cancer are multi-dimensional, and should be considered when planning such studies to garner higher participation rates. For a more comprehensive picture of factors that affect participation, further studies in this field are recommended.

Awareness of ovarian cancer risk factors, beliefs and attitudes towards screening: baseline survey of 21,715 women participating in the UK Collaborative Trial of Ovarian Cancer Screening

Background:

Women's awareness of ovarian cancer (OC) risks, their attitudes towards and beliefs about screening, together with misunderstandings or gaps in knowledge, may influence screening uptake.

Methods:

In total, 21 715 post-menopausal women completed questionnaires before randomisation into the UK Collaborative Trial of Ovarian Cancer Screening.

Results:

In all, 42.3% correctly identified their lifetime risk of OC; 87.1% knew that a family history of OC increased risk, but only 26.7% appreciated the association with a family history of breast cancer. Although 38.2% acknowledged increased risk post-menopause, only 8.8% were aware that OC diagnoses are highest in women over 65 years. Few (13.7%) recognised the association between pregnancy and reduced OC risk or protective effects of breastfeeding (6.2%). There were common misconceptions; 37.2% thought that an abnormal cervical smear and 26.4% that oral contraception increased the likelihood of OC. Although 84.4% recognised that most ovarian masses are benign, 20.2% thought having had a benign cyst increased OC risk. Most (99.4%) believed that a high uptake of OC screening would reduce mortality and (96.2%) that screen-detected cancers would have an improved prognosis.

Conclusions:

The results show a need for improved public understanding about OC risks and provide important information for GPs and health educationalists about initiatives needed for future awareness, prevention and screening programmes.

Discrimination between worry and anxiety among cancer patients: development of a Brief Cancer-Related Worry Inventory

OBJECTIVES

A psychometric scale for assessing cancer-related worry among cancer patients, called the Brief Cancer-Related Worry Inventory (BCWI), was developed.

METHODS

A cross-sectional questionnaire survey for item development was conducted of 112 Japanese patients diagnosed with breast cancer, and test-retest validation analysis was conducted using the data from another prospective study of 20 lung cancer patients. The questionnaire contained 15 newly developed items for cancer-related worry, the Hospital Anxiety and Depression Scale, The Impact of Event Scale Revised, and the Medical Outcomes Study Short Form-8.

RESULTS

Exploratory factor analysis of the 15 items yielded a 3-factor structure including (1) future prospects, (2) physical and symptomatic problems and (3) social and interpersonal problems. A second-order confirmatory factor analysis identified a second-order factor called cancer-related worry and confirmed the factor structure with an acceptable fit (chi-square (df=87)=160.16, P=0.001; GFI=0.83; CFI=0.92; RMSEA=0.09). The internal consistency and test-retest reliability were confirmed with the lung cancer sample. Multidimensional scaling found that cancer-related worry is separate from anxiety, depression, and posttraumatic stress disorder (PTSD) symptoms.

CONCLUSION

Our study succeeded in developing and confirming the validity and reliability of a BCWI. The study also confirmed the discriminable aspects of cancer-related worry from anxiety, depression, and PTSD symptoms.

Subjective and objective risk of ovarian cancer in Ashkenazi Jewish women testing for BRCA1/2 mutations

OBJECTIVE

Ovarian cancer is the leading cause of gynecological death in the United States, and 14% of ovarian cancer cases are attributed to BRCA1/2 hereditary mutations. This study examined (1) change in subjective ovarian cancer risk in response to genetic counseling and testing, (2) accuracy of subjective ovarian cancer risk estimates, and (3) new methods for conceptualizing subjective ovarian cancer risk based on Leventhal's Common Sense Model, in women at increased risk to carry BRCA1/2 mutations.

METHODS

Women (n=78) were asked their subjective risk of ovarian cancer (in terms of a percentage, estimated survival time, and projected age of onset) at pre-counseling, post-counseling, 1 week post-result, and 6 months post-result.

RESULTS

Women with a personal history of breast cancer were most inaccurate at pre- but improved post-counseling. Subjective survival time increased post-counseling. Accuracy of subjective risk improved at post-result for those with uninformative negative results. Subjective percentage risk and subjective survival time decreased at 6 months.

CONCLUSIONS

Subjective risk changed in response to genetic counseling and testing. Common Sense Model-derived assessments of risk may be useful for understanding the impact of genetic counseling and testing.

PRACTICE IMPLICATIONS

Genetic counseling can assist women at risk of carrying BRCA1/2 mutations to understand their risk of ovarian cancer, and genetic testing further refines their risk.

Possible socioeconomic and ethnic disparities in quality of life in a cohort of breast cancer survivors

BACKGROUND

This paper describes the ethnic and socioeconomic correlates of functioning in a cohort of long-term nonrecurring breast cancer survivors.

METHODS

Participants (n = 804) in this study were women from the Health, Eating, Activity, and Lifestyle (HEAL) Study, a population-based, multicenter, multiethnic, prospective study of women newly diagnosed with in situ or Stages I to IIIA breast cancer. Measurements occurred at three timepoints following diagnosis. Outcomes included standardized measures of functioning (MOS SF-36).

RESULTS

Overall, these long-term survivors reported values on two physical function subscales of the SF-36 slightly lower than population norms. Black women reported statistically significantly lower physical functioning (PF) scores (P = 0.01), compared with White and Hispanic women, but higher mental health (MH) scores (P < 0.01) compared with White and Hispanic women. In the final adjusted model, race was significantly related to PF, with Black participants and participants in the "Other" ethnic category reporting poorer functioning compared to the White referent group (P < 0.01, 0.05). Not working outside the home, being retired or disabled and being unemployed (on leave, looking for work) were associated with poorer PF compared to currently working (both P < 0.01).

CONCLUSION

These data indicate that race/ethnicity influences psychosocial functioning in breast cancer survivors and can be used to identify need for targeted interventions to improve functioning.

Changes in cancer worry associated with participation in ovarian cancer screening

While ovarian cancer is rare and screening is not recommended for most women, it is being studied as a way to reduce ovarian cancer mortality. As effective strategies for screening emerge it will be important to understand the quality of life (QOL) effects of participation in ovarian cancer screening. In this study, we examined the effects of participation in an ovarian cancer screening program on worry about cancer risk and QOL. A randomized controlled clinical trial (n = 592) was conducted. Women without a family history suggestive of a BRCA1/2 mutation were randomly assigned to screening and risk counseling, separately and in combination. Results were compared to women randomized to usual care alone. Levels of cancer worry fell for all study groups and QOL was unaffected; no statistically significant differences were found between groups. Increased levels of worry about ovarian cancer at 2-year follow-up were found among participants in screening receiving abnormal test results. For those who receive abnormal results, screening may have long-term effects and increase worry about cancer risk. Further research will be required to examine the possibility that screening reduces worry when women receive only normal, presumably reassuring, results.

Does worry about breast cancer predict screening behaviors? A meta-analysis of the prospective evidence

OBJECTIVE

Many women worry about the possibility of developing breast cancer, but there is conflicting evidence concerning whether cancer worry acts as a facilitator or inhibitor of breast cancer screening.

METHOD

We conducted a meta-analysis of 12 prospective studies that measured worry about breast cancer at baseline and subsequent breast self-examination (BSE) or mammography utilization among 3342 high-risk and general population women.

RESULTS

The data consistently show that breast cancer worry has a small but reliable (r = 0.12) association with breast cancer screening behavior, such that greater worry predicts a greater likelihood of screening. We also found that the means for breast cancer worry were consistently in the lower third of the scales, despite differences in measurement approaches, sample utilization, or the date that the study was conducted.

CONCLUSION

The meta-analysis supports the contention that breast cancer worry may motivate screening behavior, and that high levels of breast cancer worry are uncommon.

The role of cancer worry in cancer screening: a theoretical and empirical review of the literature

This paper reviews findings regarding the influence of cancer worry on cancer screening behaviors. The role of cancer worry in motivating cancer screening has been pursued for over 30 years. Recent concerns that high levels of cancer worry may impede the screening behavior of high-risk individuals have further prioritized this area of research. Despite heavy attention in the literature, there is currently no theoretical or empirical consensus concerning whether cancer worry motivates or inhibits cancer screening behaviors. We focus the review on four questions: (1) What is cancer worry? (2) To what extent are people worried about cancer? (3) What are the predominant theoretical approaches to understanding the role of cancer worry in cancer screening behaviors? (4) What is the empirical evidence for the role of cancer worry in cancer screening behaviors? We identify factors that have hampered theoretical and empirical advancement, including divergent definitions and measurement strategies for cancer worry, low to moderate levels of cancer worry even among those at high risk, and a reliance on cross-sectional research designs. The review clarifies the current state of this literature, and proposes future research strategies, including an expanded emphasis on cancer worry and cancer screening among men and diverse racial/ethnic groups.

Depressive symptoms prescreening and postscreening among returning participants in an ovarian cancer early detection program

Ovarian cancer is the fourth leading cause of cancer mortality among women. Previous research has shown that initial ovarian cancer screening has the potential to cause depressive symptoms among women at increased risk for the disease but no study has evaluated depressive symptoms shortly after screening. This article explores depressive symptoms prescreening and postscreening in women returning to participate in an ovarian cancer early detection program. Seventy-two women, with a mean age of 48, most with a family history of ovarian cancer and/or a personal history of breast cancer, completed the Center for Epidemiologic Studies Depression Scale (CES-D) immediately prior to screening and 1 week following. CES-D scores at prescreening (13%) were significantly lower than previously reported. No statistical differences in CES-D scores before and after screening were found, although 75% of women with elevated pre-CES-D scores had scores below the cutoff at postscreening. Although our numbers are lower than reported in previous studies, they are important because they emphasize the need for continued assessment of individuals who may be at greater risk for psychological distress related to cancer screening. Internationally, nurses play an important role in the recognition and support of patients undergoing cancer screening.

Screening postmenopausal women for ovarian cancer: a systematic review

OBJECTIVES

To assess ovarian cancer screening in asymptomatic, general-risk postmenopausal women. Outcomes of interest were the screening tests assessed (predictive values, sensitivity, and specificity), the stage of screen-detected disease at diagnosis, psychological effects of screening, and survival.

METHODS

MEDLINE, CANCERLIT, and the Cochrane Library databases were searched to June 2003 using the terms "ovarian," "cancer," "neoplasms," "screening," "clinical trial," "meta-analysis," and "systematic review." Studies were included if they were clinical trials, meta-analyses, or systematic reviews that evaluated tests used to detect ovarian cancer in asymptomatic women in the general population. Studies investigating women at increased risk for ovarian cancer (e.g., family history) and those with symptoms suggestive of ovarian cancer were excluded.

TABULATION, INTEGRATION, AND RESULTS

Seventeen prospective cohort studies and 3 pilot randomized controlled trials were included in this review. Screening tests for cancer antigen 125 (CA125) and ultrasound had low positive predictive values, resulting in healthy women being recalled and a false-positive rate of 0.01% to 5.8%. Of every 10,000 women participating in an annual screening program with CA125 for 3 years, 800 will have an ultrasound scan because of an elevated CA125, 30 will undergo surgery because of an abnormal ultrasound, and 6 will have ovarian cancer detected at surgery (3 will be diagnosed at early-stage disease and have a chance of a cure).

CONCLUSION

There is insufficient evidence to support the introduction of screening for ovarian cancer in the asymptomatic general-risk postmenopausal population. Screening is associated with increased rates of surgery and patient anxiety.

Compliance of Average- and Intermediate-Risk Women to Semiannual Ovarian Cancer Screening

Objective: To report rates of compliance with an ovarian cancer screening protocol using serum CA125 and transvaginal sonography (TVS), performed semiannually on an alternating schedule, among participants at average or intermediate risk for developing ovarian cancer. Methods: Two hundred ninety-two women at average or intermediate risk for developing ovarian cancer were randomly assigned to arms of a controlled clinical trial in which they received ovarian cancer screening consisting of serum CA125 alternating with TVS performed semiannually over 18 months, either alone or in combination with ovarian cancer risk education. A computerized tracking system generated screening appointment reminder letters and monitored adherence to scheduled screening. Participants overdue for scheduled screens received follow-up telephone calls consisting of up to four reminder messages left at 1-week intervals, and one to two interim attempts to reach participants between messages. The compliance rate for each screen was calculated as a ratio of the number of participants successfully completing the screen relative to the number expected to attend. Compliance rate by screen was: screen 1 (CA125) (97.3%), screen 2 (TVS) (82.5%), screen 3 (CA125) (79.0%), and screen 4 (TVS) (64.5%). One hundred seventy-two women completed all four screens and were classified as adherent to the screening protocol. Analysis by screening modality suggests that participants were more compliant to screens involving CA125. Age, educational background, distance from screening center, personal or family history of cancer, perceived risk of ovarian cancer, pre-enrollment ovarian cancer screening behavior, receiving an abnormal screen test result, and participation in ovarian cancer risk education sessions were not associated with adherence to the screening protocol or compliance to any of the screens. Conclusions: Despite extensive follow-up, compliance of average- and intermediate-risk women to an ovarian cancer screening protocol requiring semiannual screening diminishes rapidly. We propose that a semiannual ovarian cancer screening protocol, particularly one including TVS, may be too intensive for use in this population.

Worry about ovarian cancer risk and use of screening by high-risk women: How you recruit affects what you find

Several studies have described the characteristics of women at high-risk for ovarian cancer who are participating in registry studies and high-risk screening programs. These studies have found high-risk women to report high levels of perceived risk and worry about their risk for ovarian cancer. In contrast, population based studies have found that while high-risk women did report high levels of perceived risk, they did not report high levels of worry about their risk. In this study, we examine reports of perceived risk, worry about ovarian cancer, and use of screening by high-risk women recruited to participate in a survey from several recruitment sources. These sources include self-, physician-, and affected patient relative-referral, a fundraising mailer, and a mass mailing to a commercial mailing list. High-risk women recruited via mass mailing were less likely than those recruited via physicians or affected relatives to report either worry about their risk or use of ovarian cancer screening tests.

The relationship between perceived risk, affect, and health behaviors

In this study, we examined the relationship between affect and health behaviors. The study participants were women (n = 1366), aged 18-74 years, who had not been previously diagnosed with breast cancer, who had a working telephone number and address, who spoke English, who planned to be in their present residence for at least 1 year, and who were willing to complete the survey requirements. General anxiety was a significant predictor of eating a low-fat diet, in a quadratic manner (p < .05). General anxiety and breast cancer worry were significant predictors of breast self-examination, in a quadratic fashion (p < .05). None of four independent variables, perceived risk, cancer worry, general anxiety, and general depression scores, were significantly related to mammography use, physical activity, or fruit and vegetable consumption. We must look beyond risk perceptions and family history to understand motivations for health behaviors.

Bilateral Prophylactic Oophorectomy and Ovarian Cancer Screening Following BRCA1/BRCA2 Mutation Testing

Purpose: Despite the widespread availability of genetic testing for BRCA1/BRCA2 mutations, little is known about the impact of testing on ovarian cancer prevention and screening. For mutation testing to effect cancer mortality, positive test results must be followed by appropriate behavior change. In this study, we prospectively examined the impact of BRCA1/2 testing on the utilization of prophylactic oophorectomy and ovarian cancer screening.

Participants and Methods: Participants were 289 high-risk women who underwent genetic counseling and testing for alterations in the BRCA1/2 genes. We measured self-reported receipt of bilateral prophylactic oophorectomy (BPO) and utilization of CA-125 and transvaginal ultrasound (TVU) in the year following testing, and examined the impact of test results on these outcomes. In addition, we examined the role of sociodemographic, medical, family history, and psychological variables on the receipt of BPO, CA-125, and TVU.

Results: Twenty-seven percent of mutation carriers, 5% of uninformative patients, and 2% of noncarriers received a BPO in the year following testing. In addition to test results, perceived risk for ovarian cancer and family history of ovarian cancer independently predicted receipt of BPO. The receipt of a positive test result was associated with increased utilization of CA-125 and TVU. Additional predictors included perceived risk for ovarian cancer (both CA-125 and TVU) and state anxiety (CA-125).

Conclusion: These results demonstrate the significant behavioral impact of receiving a positive BRCA1/2 test result. The increased rate of oophorectomy among mutation carriers suggests that testing for BRCA1/2 mutations may ultimately impact ovarian cancer mortality.

Ovarian cancer screening

In an ongoing effort to design an efficacious, cost-effective ovarian cancer screening method, the existing tests, CA 125 and transvaginal sonography, are being optimized and combined in a multimodal strategy, and new promising serum markers, such as mesothelin and HE4, are being developed and evaluated. Detection has been found to improve when multiple serum markers are used in a longitudinal logarithm. The parametric empirical Bayes approach improves screening algorithms by capturing the stability of markers over time in a heterogeneous population. It also has relatively simple extensions to multiple markers. The evaluation of markers increasingly accounts for characteristics of a woman that may affect her marker levels and accounts for the cancer's characteristics, histology, and grade. Receiver operating characteristic curves are helpful for evaluation because they relate a marker's sensitivity to the specificity at which it operates. Large, well-designed randomized controlled trials are under way to gauge the performance of existing screening methods.

Patients' views on follow up of colorectal cancer: implications for risk communication and decision making

BACKGROUND

Medical views about the clinical value and potential detrimental effect on quality of life of postoperative follow up are divided. There is no literature on the views of British patients with colorectal cancer towards the follow up process.

AIM

To investigate patients' views and experiences of follow up of colorectal cancer, and to assess their attitudes towards suggested changes to follow up policy.

PATIENTS AND METHODS

A total of 156 asymptomatic and disease-free patients with colorectal cancer were identified from the follow up clinic. Recurrence-free status was confirmed through retrieval of computerised clinic letters. A postal survey using a 39 item piloted questionnaire was undertaken. Data analysis generated descriptive statistics and logistic regression models.

RESULTS

A response rate of 61% (95) was obtained. Among these respondents, 63% (60) had undergone initial surgery within three years of the time of the survey, and 86% (82) patients expected a further follow up appointment. Majorities of the sample, ranging from 71% (67) to 96% (91), expressed satisfaction with respect to clinic delays, staff conduct and knowledge about their case, consultation time, and being able to discuss personal problems freely. However some patients reported difficulty in discussing sexual problems at the clinic. Appointment imminence caused anxiety, sleep problems, and decreased appetite in 35% (35), 27% (26), and 8 % (8) of patients respectively. However, 78% (74) patients felt reassured and optimistic for the future after receiving results. Such optimism is not necessarily justified in terms of estimated mortality risks. A majority (78%, 66) stated that they would value finding out about the presence of recurrence even if there would be no survival benefit. Nearly half of the sample (48%, 43) felt that they would disagree with the cessation of follow up in any circumstances. Only 47% (42) and 27% (24) indicated that they would accept follow up by a specialist nurse or their general practitioner, respectively. Attitude to follow up was unrelated to reported anxiety before appointments. Only 22% (19) of the sample could identify risk indicators for recurrence, but 64% (61) agreed that they would like to be told what to look for.

DISCUSSION

A sample of patients with colorectal cancer expressed a high degree of satisfaction with hospital follow up. Although a substantial minority reported suffering from pre-visit anxiety, most felt that this disadvantage was compensated for by reassuring results, and believed that investigations did not have a significant negative impact on their quality of life. Respondents valued hospital follow up, and half would reject complete discharge or alternative forms of follow up. These findings demonstrate that patients have a different perception of the risk of recurrence than clinicians who would consider the survival prospects for most patients to be more or less unaffected by follow up interventions. Attempted modifications to follow up policies should be introduced with caution, and should take account of patient understanding of medical reasoning. The findings also raise questions about risk communication with patients.