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- 1. The Role of Anxiety and Coping Style in Decision-making for Prophylactic Surgery in Women with Hereditary Breast / Ovarian Cancer Sahar Sajadi Supervisors: Karl Looper, Nora Wong
- 2. Breast / Ovarian Cancer and Genetics There is no conflict of interest to declare
- 3. Breast / Ovarian Cancer and Genetics • Breast cancer: Second leading cause of cancer death • Ovarian cancer: One of the most deadly gynecological cancers • 5-10% of breast/ovarian cases have a hereditary predisposition • Cases with BRCA1/2 mutations have a 3% annual risk of developing contralateral breast cancer
- 4. Breast/ Ovarian Cancer and Genetics • Rapid genetic counseling and testing (RGCT) • Prophylactic surgery • + Risk reduction • - Body image, sexuality • - Child bearing
- 5. Breast / Ovarian Cancer and Genetics • Previous literature • Graves et al. (2007) • Higher rate of distress is associated with higher rate of contralateral prophylactic mastectomy • Impact of Event Scale: Avoidance vs. Intrusion • Schwartz et al. (2003) • Higher rate of distress is associated with higher rate of prophylactic oophorectomy • Fang et al. (2002) • High monitoring style is associated with stronger intention to undergo prophylactic oophorectomy • Miller Scale
- 6. Breast / Ovarian Cancer and Genetics • Anxiety plays a key role • Affect heuristic theory (Schwartz et al. 2005) • Affective cues more important than pros and cons of the decision • Information seeking style theory (Miller et al. 1996) • Anxiety as a function of coping style; monitoring vs. blunting
- 7. Breast / Ovarian Cancer and Genetics Present Study • Objectives • To study role of anxiety and coping style in decision-making for prophylactic surgery in women newly diagnosed by hereditary breast/ovarian cancer • Hypothesis • Anxiety level and intrusive thoughts regarding the cancer are positively associated with decision for undergoing prophylactic surgery among carriers • Carriers with high monitoring style are more likely to opt for prophylactic surgery than those with low monitoring style
- 8. Breast / Ovarian Cancer and Genetics Present Study • Procedure • Segal Cancer Center • Participants • Women newly diagnosed with breast / ovarian cancer • High risk population
- 9. Breast / Ovarian Cancer and Genetics Present Study • Measures : • Impact of Event Scale (IES) Cronbach’s α : 0.86 • Intrusion vs. Avoidance • Brief Symptom Inventory-18 (BSI-18) α : 0.74-0.90 • Anxiety, depression, somatization • Miller Behavioral Style Scale (MBSS) α : 0.80 • Monitoring vs. Blunting
- 10. Breast / Ovarian Cancer and Genetics Present Study • Preliminary results • 17 participants: • 8 French- Canadian, 5 Ashkenazi Jewish 1 Polish, 1 Anglo- Saxon,1 Greek • Age: 51- 60 • 76% college educated, %52 married • 12 breast cancer, 5 ovarian cancer • 7 (41%) have not heard about genetic testing • 2 carriers • 2 prophylactic mastectomy: • Severe or powerful cancer impact: IES>26 • more avoidant thoughts • low level of general anxiety
- 11. Breast / Ovarian Cancer and Genetics Present Study • Preliminary results • Significant correlation between anxiety and IES • IES: • 13 severe or powerful cancer impact: >26 • more severe in breast cancer: >43 • BSI-18: • higher in breast cancer • NS difference between IES and BSI-18 scores among 2 groups • NS difference between intrusive and avoidant thoughts among 2 groups • >70 had the lowest IES and BSI • IES was higher among married women and those who had children
- 12. Breast / Ovarian Cancer and Genetics • Implications • Decision support interventions • Decision aids • Improving satisfaction and reducing decisional conflict • Future directions • Other risk-reducing strategies • Qualitative research
- 13. CPA Kiosk / Kiosque de l’APC http://ilinks.info/kiosk
- 14. References • Barnato Ae Fau - Llewellyn-Thomas, H. A., Llewellyn-Thomas Ha Fau - Peters, E. M., Peters Em Fau - Siminoff, L., Siminoff L Fau - Collins, E. D., Collins Ed Fau - Barry, M. J., & Barry, M. J.(2007). Communication and decision making in cancer care: setting research priorities for decision support/patients' decision aids. (0272-989X (Print)). • Fang, C., Miller, S., Daly, M., & Hurley, K. (2002). The Influence of Attentional Style and Risk Perceptions on Intentions to Undergo Prophylactic Oophorectomy Among First-Degree Relatives. Psychol Health, 17(3), 365-376. doi: 10.1080/08870440290029593 • Graves, K. D., Peshkin, B. N., Halbert, C. H., DeMarco, T. A., Isaacs, C., & Schwartz, M. D. (2007). Predictors and outcomes of contralateral prophylactic mastectomy among breast cancer survivors. Breast Cancer Res Treat, 104(3), 321-329. doi: 10.1007/s10549-006-9423-5 • Hjorleifsdottir, E., Hallberg, I. R., Bolmsjo, I. A., & Gunnarsdottir, E. D. (2006). Distress and coping in cancer patients: feasibility of the Icelandic version of BSI 18 and the WOC-CA questionnaires. Eur J Cancer Care (Engl), 15(1), 80-89. doi: 10.1111/j.1365-2354.2005.00620.x • Miller, S. M. Monitoring and blunting: validation of a questionnaire to assess styles of information seeking under threat. (0022-3514 (Print)). • Schwartz, M. D., Kaufman, E., Peshkin, B. N., Isaacs, C., Hughes, C., DeMarco, T., . . . Lerman, C. (2003). Bilateral prophylactic oophorectomy and ovarian cancer screening following BRCA1/BRCA2 mutation testing. J Clin Oncol, 21(21), 4034-4041. doi: 10.1200/jco.2003.01.088 • Thewes, B., Meiser, B., & Hickie, I. B. (2001). Psychometric properties of the Impact of Event Scale amongst women at increased risk for hereditary breast cancer. Psychooncology, 10(6), 459-468. • Tirona, M. T., Sehgal, R., & Ballester, O. (2010). Prevention of breast cancer (part I): epidemiology, risk factors, and risk assessment tools. Cancer Invest, 28(7), 743-750. doi: 10.3109/07357907.2010.494321
Notas do Editor
- Breast cancer has been known as the second leading cause of cancer death in women in North America (After lung cancer) .one in 8 women is expected to develop breast cancer during her lifetime. According to canadian cancer society 14 canadian women will die from breast cancer everyday.Ovarian:Hu(2009)Ovarian cancer is less frequent than breast cancer however it is known as one of the most deadly gynecological cancers in women.Most of the ovarian/breast cancer are sporadic. However 5-10% of breast or ovarian cancer cases are associated with hereditary predisposition and BRCA1/2 mutations are responsible for 80% of hereditary cases.Carrying a mutation in BRCA1/2 increases the lifetime risk of breast and ovarian cancer. Furthermore, breast cancer patients who carry a BRCA1/2 mutation have a 3% annual risk of developing contralateral breast cancer.Consideringthis increased risk, identification of carrier status in women diagnosed by breast/ovarian cancer can be very important since itmay influencedecision making for risk-reducing strategies among high-risk women. These risk reducing strategies can be decision for bilateral mastectomy or oophorectomy at the time of diagnosis by breast or ovarian cancer.
- In the past, it was taking several months for BRCA test results to be returned to the patients.Today, with the improvement in genetic testing technology, test results are available within 1 to 2 weeks.. This technology which is called rapid genetic testing provides information for both women and their surgeon to decide between available treatment options and type of surgery. Therefor women with a positive genetic test result can opt for risk-reducing surgery which could be prophylactic mastectomy (complete removal of unaffected breast) or prophylactic oophorectomy. CPm reduces the risk of contralateral cancer up to 90%.Prophylactic oophorectomy has been shown to significantly reduces the risk of ovarian and breast cancer. However,there are some negative consequences associated with prophylactic surgery such as its negative impact on the women think about their body image and sexuality.Also,ophorectomy is associated with decrease in child bearing ability.Considering these negative and positive aspects,decision-making for prophylactic surgery is not an easy decision and is a difficult and complex process.
- Because of the various advantages and disadvantages thus decision-making about undergoing prophylactic surgery may be a difficult and complex process for women at increased risk.So far many studies, have tried to understand this decision-making process by examining the predictors of prophylactic surgery among patients diagnosed by breast/ovarian cancer.Graves (2007)They conducted this study to determine predictors of contralateral prophylactic mastectomy in the year following genetic testing.Participants of this study were women newly diagnosed by breast cancer who had undergone genetic testing. At baseline.Their level of cancer-specific distress were measured using Impact of Event Scale.Final result showed that higher rate of general distress and cancer specific distress is positively associated with higher rate of prophylactic mastectomy in the year following testing.Shwartz.In this study participants were women at risk of developing ovarin cancer who were offered free genetic testing.at the baseline their level of general distress and cancer specific distress. were measured. The final results showed that participants who did Bpo in 1 year after testing had higher general distress score and cancer specific score.Fang (2002)wiParticipants were unaffected women who had at least one first degree relatives with ovarian cancer.They were assessed for attentional style using Miller behavioral style scale.this scale measures responses for four stress evoking scenarios.For each scenario partcipants are asked to indicate which of eight potential responses would characetrize their actions. Four of the responses are each scenario are indicative of high monitoring style and four of them are indicators of low monitoring style.They were also asked about their intention to undergo prophylactic oophorectomy on a 5 items likert type scale.Results indicated that high monitoring style is associated with stronger intention to undergo prophylactic surgery
- Most of the studies that have examined predictors of prophylactic surgeryhave found that affective factors such as anxiety and cancer worry are key predictors of undergoing prophylactic surgery. This can be described by affect heuristic theory.Based on this theory,When individuals face with multiple decision options, they can become overwhelmed and therefor resort to simplifying startegies. One of these strategies is affect heuristic which is often used in situations in which an individual must make a complex decision in a short period of time.In such situation individuals my rely on affective cues rather than carefully weighting the pros and cons of the decision.Therefor when anxiety is high ,decision makers may choose an option that provides immediate anxiety reduction regardless of their true preference.Also, according to information seeking style theory it seems that anxiety level varies as a function of coping style. This theory states that when individuals face with aversive and stressful event, they differ in how they deal with information about it.Monitors are those who typically look for information and amplify the treats emotionally while blunters psychologically avoid and blunt threatening cues. Research shows that high monitors experience higher level of event-related anxiety as well as more intrusive ideation which in turn might influence their decision making.
- Although, the previous studies have shown important findings related to the predictors in decision-making for prophylactic surgery.However, most of them have studied samples including women with different risk level of developing cancer and there is not enough study about the women who were actually affected by cancer.in the present research we investigate role of anxiety and coping style in decision-making for prophylactic surgery in women newly diagnosed by breast-ovarian cancer .For that we hypothesize that Anxiety level and intrusive thoughts regarding the cancer are positively associated with decision for undergoing prophylactic mastectomy.Furthermor, we hypothesize that those with high monitoring style are more likely to opt for prophylactic mastectomy than those with low monitoring style.
- Our research will be conducted in Segal Cancer Center located at pavillon E in Jewish hospital. Segal cancer center is a state-of-art facility which provide patients with a comprehensive approach to care combining cancer prevention, diagnosis, treatment, psychosocial support, nutritional support and clinical and fundamental research in cancer. This study is done in collaboration with genetic service.Patients are chosen among women diagnosed by breast/ovarian cancer at jGH. the surgeon are then notified of the eligible participants for a rapid genetic assessment.Given the cost of testing eligible participants are those who belong to one of the high risk ethnic group where a founder mutation panel is available. (French Canadian, ashkenazijewish,Greek, eastern uropean)…paricipants should have up to age 70 for breast cancer and at any age for ovarian cancer. If they can recive the consultation in less than 3 months after referal they go through the fast-track testing route. At the genetic service they will given a questionnaire if they give consent for that.
- In this questionnare, their level of anxiety and intrusive thoughts regarding cancer will be measured using BSI-18 and IES.IES is a 15-item likert-style scale consisted of two subscale:intrusion(The extent to which individuals become overwhelmed by thoughts and feelings about the cancer e.g dreaming about that, and avoidance( the tendency to avoid these thoughts and feelings for exampple staying away from reminders of cancer).The Brief Symptom Inventory-18 (BSI) consists of 18 likert-style items covering 3 symptom dimensions for anxiety, depression and somatization during the past 7 days.Miller Behavioral Style scale: thise scale measues responses in four stress-evoking scenarios.For each scenario partcipants are asked to indicate which of eight potential responses would characetrize their actions. Four of the responses are each scenario are indicative of high monitoring style and four of them are indicators of low monitoring style.They
- This part was inconsistent with our hypothesis.It shows us that maybe some other factors rather than carrier status or anxiety level are involved in the decision making.That ‘s why we want to know more about their coping style strategy.Aslo, it is possible that those who are extremely avoidant,can’t tolerate any level of risk and they decide to remove any potential source of risk.
- 4: Severe impact event9:Powerful impact event3:Maybe affected1:No meaningful impact13 showed powerful impact event meaning that they were certainly affected by having cancer.
- We hope that by better understanding of factors that predict women decision making for undergoing prophylactic surgery we can provide a more efficient decision support interventions for these group.Interventions such as decision aids can directly support patients in making good decisions at a difficult time. They can improve knowledge, satisfaction, and participation in decision making, also help reducing decisional conflicts meaning that patients feel comfortable with their choice.We suggest for the future research to focus on the non-operative risk reducing strategies such as chemoprevention for women who prefer not to do the surgery.Also it is suggested to conduct qualitative research that can help us to have a better understanding of the the decision-making process.