Clinical management of women at increased risk for breast cancer

Previvors' Uncertainty Management Strategies for Hereditary Breast and Ovarian Cancer

Individuals with a genetic predisposition to develop hereditary breast and ovarian cancer (HBOC), but who have not been diagnosed with cancer, are referred to as previvors. Although genetic testing may reduce previvors' worries about whether or not they have a high genetic cancer risk, testing positive produces negative emotions and long-term uncertainty-thus requiring the management of uncertainty. Existing research indicates family, friends, and social support networks are limited in their assistance for previvors' uncertainty management. Therefore, this study examined how health care providers may assist previvors in uncertainty management by asking: What strategies do BRCA-positive previvors enact with their health care providers to help manage their uncertainty about HBOC? Purposive sampling was employed to recruit participants via online social media. The final sample consisted of 34 BRCA-positive women. Interviews revealed four uncertainty management strategies-seeking health care providers as informational sources, seeking health care providers as partners for decision making, seeking health care providers for supportive communication, and seeking referrals from health care providers for social support networks. Findings indicate that health care providers who are knowledgeable about BRCA, provide information, answer questions, check understanding, and provide additional resources assist previvors in managing their uncertainties by distinguishing options and fostering meaning.

Psychological impact of health risk appraisal of Korean women at different levels of breast cancer risk: neglected aspect of the web-based cancer risk assessment tool

OBJECTIVE

Health risk appraisal is often utilized to modify individual's health behavior, especially concerning disease prevention, and web-based health risk appraisal services are being provided to the general public in Korea. However, little is known about the psychological effect of the health risk appraisal even though poorly communicated information by the web-based service may result in unintended adverse health outcomes. This study was conducted to explore the psychological effect of health risk appraisal using epidemiological risk factor profile.

METHODS

We conducted a randomized trial comparing risk factor list type health risk appraisal and risk score type health risk appraisal. We studied 60 women aged 30 years and older who had no cancer. Anxiety level was assessed using the Spielberger State-Trait Anxiety Inventory YZ.

RESULTS

The results of multivariate analysis showed that risk status was the independent predictors of increase of state anxiety after health risk appraisal intervention when age, education, health risk appraisal type, numeracy, state anxiety, trait anxiety, and health risk appraisal type by risk status interaction was adjusted. Women who had higher risk status had an odd of having increased anxiety that was about 5 times greater than women who had lower risk status.

CONCLUSIONS

Our findings indicate that communicating the risk status by individual health risk appraisal service can induce psychological sequelae, especially in women having higher risk status. Hospitals, institutes, or medical schools that are operating or planning to operate the online health risk appraisal service should take side effects such as psychological sequelae into consideration.

Redox cycling of catechol estrogens generating apurinic/apyrimidinic sites and 8-oxo-deoxyguanosine via reactive oxygen species differentiates equine and human estrogens

Metabolic activation of estrogens to catechols and further oxidation to highly reactive o-quinones generates DNA damage including apurinic/apyrimidinic (AP) sites. 4-Hydroxyequilenin (4-OHEN) is the major catechol metabolite of equine estrogens present in estrogen replacement formulations, known to cause DNA strand breaks, oxidized bases, and stable and depurinating adducts. However, the direct formation of AP sites by 4-OHEN has not been characterized. In the present study, the induction of AP sites in vitro by 4-OHEN and the endogenous catechol estrogen metabolite, 4-hydroxyestrone (4-OHE), was examined by an aldehyde reactive probe assay. Both 4-OHEN and 4-OHE can significantly enhance the levels of AP sites in calf thymus DNA in the presence of the redox cycling agents, copper ion and NADPH. The B-ring unsaturated catechol 4-OHEN induced AP sites without added copper, whereas 4-OHE required copper. AP sites were also generated much more rapidly by 4-OHEN. For both catechol estrogens, the levels of AP sites correlated linearly with 8-oxo-dG levels, implying that depuriniation resulted from reactive oxygen species (ROS) rather than depurination of estrogen-DNA adducts. ROS modulators such as catalase, which scavenges hydrogen peroxide and a Cu(I) chelator, blocked the formation of AP sites. In MCF-7 breast cancer cells, 4-OHEN significantly enhanced the formation of AP sites with added NADH. In contrast, no significant induction of AP sites was detected in 4-OHE-treated cells. The greater redox activity of the equine catechol estrogen produces rapid oxidative DNA damage via ROS, which is enhanced by redox cycling agents and interestingly by NADPH-dependent quinone oxidoreductase.

Estrogen Receptor {alpha} Enhances the Rate of Oxidative DNA Damage by Targeting an Equine Estrogen Catechol Metabolite to the Nucleus

Exposure to estrogens increases the risk of breast and endometrial cancer. It is proposed that the estrogen receptor (ER) may contribute to estrogen carcinogenesis by transduction of the hormonal signal and as a "Trojan horse" concentrating genotoxic estrogen metabolites in the nucleus to complex with DNA, enhancing DNA damage. 4-Hydroxyequilenin (4-OHEN), the major catechol metabolite of equine estrogens present in estrogen replacement formulations, autoxidizes to a redox-cycling quinone that has been shown to cause DNA damage. 4-OHEN was found to be an estrogen of nanomolar potency in cell culture using a luciferase reporter assay and, using a chromatin immunoprecipitation assay, was found to activate ERalpha binding to estrogen-responsive genes in MCF-7 cells. DNA damage was measured in cells by comparing ERalpha(+) versus ERalpha(-) cells and 4-OHEN versus menadione, a reactive oxygen species (ROS)-generating, but non-estrogenic, quinone. 4-OHEN selectively induced DNA damage in ERalpha(+) cells, whereas menadione-induced damage was not dependent on cellular ER status. The rate of 4-OHEN-induced DNA damage was significantly enhanced in ERalpha(+) cells, whereas ER status had no effect on the rate of menadione-induced damage. Imaging of ROS induced by 4-OHEN showed accumulation selective for the nucleus of ERalpha(+) cells within 5 min, whereas in ERalpha(-) or menadione-treated cells, no selectivity was observed. These data support ERalpha acting as a Trojan horse concentrating 4-OHEN in the nucleus to accelerate the rate of ROS generation and thereby amplify DNA damage. The Trojan horse mechanism may be of general importance beyond estrogen genotoxins.

Response of human mammary epithelial cells to DNA damage induced by 4-hydroxyequilenin: Lack of p53-mediated G1 arrest

Long-term exposure to synthetic and endogenous estrogens has been associated with the development of cancer in several tissues. One potential mechanism of estrogen carcinogenesis involves catechol formation and these catechols are further oxidized to electrophilic/redox active o-quinones, which have the potential to both initiate and promote the carcinogenic process. 4-Hydroxyequilenin (4-OHEN), a major phase I metabolite of several estrogens present in Premarin, is considerably more cytotoxic, carcinogenic, and mutagenic as compared to the catechol estrogen metabolites of endogenous estrogens. Previously, we showed that 4-OHEN autoxidized to an o-quinone and caused a variety of damage to DNA. Allowing more time between the induction of DNA damage and the entry of a damaged cell into the DNA synthetic phase of the cell cycle protects that cell from mutagenesis. Central to this response is the establishment of a G1 checkpoint. This checkpoint is mediated by the cyclin-dependent kinase inhibitor p21WAF1, a direct downstream target for transcriptional activation by p53. In this study, we investigated this signaling pathway. Surprisingly, exposure of the human MCF-10A immortalized nontransformed mammary epithelial cell line to 4-OHEN did not induce a p53-induced G1 arrest. A 24 h treatment with 4-OHEN significantly induced p53 and p21WAF1 protein expression at 10 and 20 microM, as well as significantly induced the transactivation of a p53-luciferase reporter gene at 20 microM. Significant decreases in cell proliferation were also observed with concentrations of 5 microM and higher of 4-OHEN. However, 4-OHEN did not induce a G1 checkpoint and cells with damaged DNA accumulated in the S phase. This S phase delay could be beneficial for the survival of the damaged cells which could contribute to the carcinogenic process.

A randomized trial of breast cancer risk counseling: the impact on self-reported mammography use

OBJECTIVES

We evaluated the impact of individualized breast cancer risk counseling on mammography use among women at risk for breast cancer.

METHODS

Participants (n = 508) were randomized to the breast cancer risk counseling intervention or a general health education control intervention, and 85% completed follow-up.

RESULTS

In multivariate modeling, a significant group-by-education interaction demonstrated that among less-educated participants, breast cancer risk counseling led to reduced mammography use. There was no intervention effect among the more-educated participants.

CONCLUSIONS

These results suggest that standard breast cancer risk counseling could have an adverse impact on the health behaviors of less-educated women.

Communicating cancer risk information: the challenges of uncertainty

Developments in predictive testing for inherited cancers have focused attention on the accurate and sensitive communication of risk information. Although sharing risk information is often equated with genetic testing, it is important to acknowledge that the need for risk information related to familial cancer is also relevant to those not eligible for, or interested in, testing. Communicating cancer risk information is germane to a number of health professions including physicians, geneticists, genetic counsellors, psychologists, nurses, health educators and social workers. Based on a literature review of 75 research reports, expert opinion papers and clinical protocols, we provide a synthesis of what is known about the communication of cancer risk information and make recommendations for the enhancement of knowledge and practice in the field.

Cancer genetics clinics: target population and consultees' expectations

The aim of this study was to determine in healthy consultees attending cancer genetics clinics their risk status, their pathways leading to the clinics, their expectations and perception of cancer risk. In 1994, the consultees at six French centres completed a questionnaire before their first oncogenetic consultation. The oncogeneticists subsequently filled in a standardised form giving their risk assessment. Among the 206 healthy consultees, 91.3% were women, 92.2% had at least one cancer-affected first-degree relative and 73% had a "cancer family risk" as assessed by the oncogeneticist. Sixty-nine per cent of the consultees were referred to the clinics by a physician, 10.4% by their family and 18.8% on their own initiative: 83.5% of the sample perceived their family risk of cancer as being high and this belief was confirmed in 74.3% of the cases studied by the oncogeneticist. The families of self-referred consultees were less often at risk than those of consultees referred by a physician or by their family (P = 0.012). The majority (78%) expected to be informed about cancer prevention and screening, and this expectation depended on the consultee's level of education (P = 0.001). This study shows that medical pathways are more effective than the media as a means of reaching the members of the general population who are genuinely at risk, and shows that fuller information about prevention needs to be provided at cancer genetic consultations.

[Hormone replacement therapy in menopause and cancers]

The long term outcome analysis of estrogen replacement therapy shows that the carcinologic risk is far more inferior than the osseous and cardiovascular risks of which the prevention is ensured by estrogen. In the same way, the quality of life improvement during the years following menopause is important. For a female population without personal risk of breast cancer, the substitutive hormone therapy offers numerous advantages which have been for a long time refused to women with previously treated breast cancer. Any dogmatic behaviour is presently justified. On the contrary, the hormonal replacement therapy requires beforehand an analysis as exact as possible of the risks of its prescription as of its non-prescription and a responsibility taking shared between the physician and his patient. The progresses of the molecular biology and the expansion of randomized trials will permit with no doubt to recognize more easily for each patient, even the one who would have been previously treated for a breast cancer, the respective impact of carcinologic, cardiovascular and osseous risks.