Kyushu University TERUYOSHI ISHIDA KEIZO SUGIMACHI
Department of Surgery II Faculty of Medicine Kyushu University
Psychological Distress and Breast Cancer Screening Among Women at High Risk: Where Are We?
TOKUJIRO YANO
Department of Chest Surgery National Kyushu Cancer Center Fukuoka
References (/) BRENNER MB, MCLEAN J, DIALYNAS DP,
ET AL: Identification of a putative second T-cell receptor. Nature 322:145-149, 1986 (2) HOLOSHITZ J, KONING F, COLIOAN JE, ET
(3) HOHLFELD R, ENGEL AG,
II K, ET AL:
Polymyositis mediated by T lymphocytes that express the 7/8 receptor. N Engl J Med 324:877-881, 1991 (4) MODLIN RL, PlRMEZ C, HOFMAN FM, ET
AL: Lymphocytes bearing antigen-specific 7 8 T-cell receptors accumulate in human infectious disease lesions. Nature 339:544-548, 1989 (5) HIROMATSU K, YOSHIKAI Y, MATSUZAKI
G, ET AL: A protective role of 7/8 T cells in primary infection with Listeria monocytogenes in mice. J Exp Med 175:49-56, 1992 (6) LANIER
LL,
RUITENBERG
J,
BOLHUIS
RLH, ET AL: Structural and serological heterogeneity of 7/8 T cell antigen receptor expression in thymus and peripheral blood. Eur J Immunol 18:19851992, 1988 (7) GOODMAN
T,
LEFRANCOIS
L:
Intra-
epithelial lymphocytes. Anatomical form, not T cell receptor form, dictates phenotype and function. J Exp Med 170:1569-1581, 1989 (8) SPITS H, PALIARD X, VANDEKERCKHOVE
Y, ET AL: Functional and phenotypic differences between CD4 + and CD4- T cell receptor-7 8 clones from peripheral blood. J Immunol 147:1180-1188, 1991 (9) HAREGEWOIN A, SOMAN G, HOM RC, ET
AL: Human 7 S+ T cells respond to mycobacterial heat-shock protein. Nature 340:309-312, 1989 (10)
O ' B R I E N RL, HAPP MP,
DALLAS A, ET
AL: Stimulation of a major subset of lymphocytes expressing T cell receptor 7 8 by an antigen derived from Mycobacterium tuberculosis. Cell 57:667-674, 1989
Finally, screening recommendations for younger women at increased risk as a function of family history are difficult to determine. Despite the endorsement of BSE efficacy by Kash
1756
How do we best screen young women at high risk? While mammography may be of lower value in women less than 50 years of age, most women at increased risk report adherence (1,4). In addition, the Health Insurance Plan of Greater New York and the Breast Cancer Detection Demonstration Project data indicate some benefit for women 40-50 years of age. Independent of the ongoing Canadian trial, the benefits for an individual woman with a family history of breast cancer are likely to outweigh cost. Women immobilized by anxiety resulting in poor BSE performance (frequency and/or proficiency) may be best served by increasing the frequency of clinical breast examinations from annually to two to three times per year. While clinical breast examination proficiency is also variable, it is a behavior that, despite psychological stress, seven of 10 women adhered to in the Kash et al. study (7). Alternatively, women with low to moderate stress may well benefit from BSE teaching, given poor proficiency in this task independent of reported BSE frequency. In summary, while psychological distress is itself an important qualityof-life issue possibly associated with increased risk, the impact of this distress on screening is quite critical. It appears premature to blindly abandon any of the screening modalities potentially helpful to women at increased risk. However, we need to be aware of the limitations, sensitivity, and specificity of all three screening modalities in younger women. Finally, given the limitations of mammography in younger women, more research Journal of the National Cancer Institute
Downloaded from http://jnci.oxfordjournals.org/ at University of Lethbridge on September 6, 2015
AL: Isolation of CD4- CD8- mycobacteria-reactive T lymphocyte clones from rheumatoid arthritis synovial fluid. Nature 339:226-229, 1989
In a recent article (1) and subsequent series of exchanges regarding psychological distress and breast cancer screening among women at high risk of developing breast cancer (2,3), several important issues were raised. These issues focus on the generalizability of the findings of the study by Kash et al. (7) and on the relevance of breast self-examination (BSE) as a screening measure, particularly for the sample of younger women (mean age = 44 years) with a family history of breast cancer. Major findings by Kash et al. (7) included significant psychological distress among women at high risk, including investigation (4) assessing compliance with screening in a sample of women at high risk not attending special clinics, we found poor BSE compliance, while clinical breast examination adherence was quite high (84%), although mammography adherence in the preceding year (54%) was poor. Interestingly, only 52% of the sample (n = 125) considered themselves to have an above average risk. This percentage is not markedly different from the percentage of patients in the Kash et al. study (7) who rated themselves at high risk (41%). In contrast, women attending our clinic for women at high risk for breast cancer generally overestimate their risk and report high degrees of adherence to mammography, clinical breast examination, and BSE, although BSE proficiency is markedly below par (Stefanek M, Wilcox P, Helzelsouer K: manuscript in preparation). Thus, variables related to attendance at a clinic for women at high risk for breast cancer and knowledge of risk may be key differences in findings.
(3), the issues related to BSE sensitivity and specificity are far from resolved (5). While mammography may be less helpful for younger women, we should not assume that BSE is preferable, given the very low occurrence of breast cancer in younger women (particularly among those aged 20-30 years) and the high frequency, psychological sequelae, and possible negative impact of falsepositive results on subsequent breast cancer screening.
to increase sensitivity and specificity in BSE and clinical breast examination is critically needed. Women at high risk for breast cancer may be best served by their physicians making recommendations for screening on an individual basis. In making these recommendations, the physicians should be sensitive to issues such as quality of individual mammograms, the clinical breast examination proficiency of the health care providers, and the individual psychological distress as the latter impacts on adherence to each of the screening modalities.
References (/)
KASH KM, HOLLAND JC, HALPER MS, ET
AL: Psychological distress and surveillance behaviors of women with a family history of breast cancer. J Natl Cancer Inst 84:2430, 1992 (2) VOGEL VG, BONDY M: Women with a
history of breast cancer. J Natl Cancer Inst 84:724-725, 1992 (3) KASH KM: Breast cancer detection methods: Debate continues. J Natl Cancer Inst 84:726-727, 1992 (4) STEFANEK ME, WILCOX P: First degree
relatives of breast cancer patients: Screening practices and provision of risk information. Cancer Detect Prev 15:379-384, 1991 (5) MORRISON AS: Is self examination effective in screening for breast cancer? J Natl Cancer Inst 83:222-227, 1991
Response In response to Dr. Stefanek's correspondence, there are three issues to be addressed regarding psychological distress and breast cancer surveillance among women with family histories of breast cancer. First is the issue of what is meant by "high risk" for developing breast cancer. It is important to distinguish between women who have only one first-degree relative with postmenopausal unilateral breast cancer and women who have stronger family histories. Women who attend our breast surveillance program are a genetically enriched population and are less likely to have a sporadic
Vol. 84, No. 22, November 18, 1992
women at high risk were anxious and that this trait interfered with their surveillance behaviors. Wellisch et al. (2) investigated the psychological functioning of daughters of breast cancer patients. They found, as we found, that an immobilizing anxiety was one of the emotional themes of women with family histories of breast cancer. Similarly, Wellisch et al. found high levels of psychological distress consistent with the need for counseling. In both studies, reliable and valid instruments were used to measure anxiety and psychological distress. I would submit that further research into the causes of psychological distress in women at high risk for breast cancer requires attention to the use of such measures.
Second, we have endorsed all three methods of early detection (breast self-examination [BSE], clinical breast examination, and mammography) as important for women with family histories of breast cancer. We do not believe that BSE is preferable to either clinical breast examination or mammography, since there are false-negative and false-positive results with all of these procedures. We encourage women in our program for high-risk women to come in for a clinical breast examination every 6 months, have regularly scheduled mammograms (usually yearly, depending on age), and perform monthly BSE. The psychological impact of a false-negative result can be as devastating to a woman as a falsepositive result. By using all three early detection methods in a younger population such as ours (mean age = 44 years), we minimize the likelihood of false outcomes and the resulting psychological sequelae. The last issue addresses anxiety and psychological distress of women at high risk. In our study, we found that
References
KATHRYN M. KASH, P H . D .
Psychiatry Service Memorial Sloan-Kettering Cancer Center Strang Cancer Prevention Center 1275 York Ave. New York, NY 10021
(/) STEFANEK ME, WILCOX P: First degree
relatives of breast cancer patients: Screening practices and provision of risk information. Cancer Detect Prev 15:379-384, 1991 (2) WELLISCH DK, GRITZ ER, SCHAIN W, ET
AL: Psychological functioning of daughters of breast cancer patients. Part II: Characterizing the distressed daughter of the breast cancer patient. Psychosomatics 33:171-179, 1992
Unproven Therapies in the Treatment of Cancer Why would anyone consider using unproven therapies? With one million cases of cancer per year, thousands of doctors have tested every reasonable treatment on every type of cancer for many years. They know what works and what does not. But those who believe that only surgery, radiation, or chemotherapy hold hope for treating someone unfortunate enough to be stricken with cancer are living 20 years in the past.
CORRESPONDENCE 1757
Downloaded from http://jnci.oxfordjournals.org/ at University of Lethbridge on September 6, 2015
MICHAEL E. STEFANEK, P H . D .
The Johns Hopkins Oncology Center 550 North Broadway, Suite 1003 Baltimore, MD 21205
breast cancer case in their family histories. The criteria for joining the Strang Cancer Prevention Center's Breast Surveillance Program are as follows: 1) one first-degree relative with premenopausal bilateral breast cancer, 2) a mother and a maternal grandmother with breast cancer; or 3) two or more first-degree relatives with breast cancer. It is difficult to compare the women in our program with the women in Dr. Stefanek's sample (i), since his study involved women who had only one first-degree relative with breast cancer and 61% of the women in his sample had postmenopausal unilateral breast cancer. Only 5% of the women in his sample had premenopausal bilateral breast cancer in contrast to 28% of the women in our sample. Also, 25% of the women in our sample had at least two first-degree relatives with breast cancer. In summary, Dr. Stefanek's sample population may have risk levels closer to those found in the general population and not comparable with ours.
Department of Surgery II Faculty of Medicine Kyushu University
Psychological Distress and Breast Cancer Screening Among Women at High Risk: Where Are We?
TOKUJIRO YANO
Department of Chest Surgery National Kyushu Cancer Center Fukuoka
References (/) BRENNER MB, MCLEAN J, DIALYNAS DP,
ET AL: Identification of a putative second T-cell receptor. Nature 322:145-149, 1986 (2) HOLOSHITZ J, KONING F, COLIOAN JE, ET
(3) HOHLFELD R, ENGEL AG,
II K, ET AL:
Polymyositis mediated by T lymphocytes that express the 7/8 receptor. N Engl J Med 324:877-881, 1991 (4) MODLIN RL, PlRMEZ C, HOFMAN FM, ET
AL: Lymphocytes bearing antigen-specific 7 8 T-cell receptors accumulate in human infectious disease lesions. Nature 339:544-548, 1989 (5) HIROMATSU K, YOSHIKAI Y, MATSUZAKI
G, ET AL: A protective role of 7/8 T cells in primary infection with Listeria monocytogenes in mice. J Exp Med 175:49-56, 1992 (6) LANIER
LL,
RUITENBERG
J,
BOLHUIS
RLH, ET AL: Structural and serological heterogeneity of 7/8 T cell antigen receptor expression in thymus and peripheral blood. Eur J Immunol 18:19851992, 1988 (7) GOODMAN
T,
LEFRANCOIS
L:
Intra-
epithelial lymphocytes. Anatomical form, not T cell receptor form, dictates phenotype and function. J Exp Med 170:1569-1581, 1989 (8) SPITS H, PALIARD X, VANDEKERCKHOVE
Y, ET AL: Functional and phenotypic differences between CD4 + and CD4- T cell receptor-7 8 clones from peripheral blood. J Immunol 147:1180-1188, 1991 (9) HAREGEWOIN A, SOMAN G, HOM RC, ET
AL: Human 7 S+ T cells respond to mycobacterial heat-shock protein. Nature 340:309-312, 1989 (10)
O ' B R I E N RL, HAPP MP,
DALLAS A, ET
AL: Stimulation of a major subset of lymphocytes expressing T cell receptor 7 8 by an antigen derived from Mycobacterium tuberculosis. Cell 57:667-674, 1989
Finally, screening recommendations for younger women at increased risk as a function of family history are difficult to determine. Despite the endorsement of BSE efficacy by Kash
1756
How do we best screen young women at high risk? While mammography may be of lower value in women less than 50 years of age, most women at increased risk report adherence (1,4). In addition, the Health Insurance Plan of Greater New York and the Breast Cancer Detection Demonstration Project data indicate some benefit for women 40-50 years of age. Independent of the ongoing Canadian trial, the benefits for an individual woman with a family history of breast cancer are likely to outweigh cost. Women immobilized by anxiety resulting in poor BSE performance (frequency and/or proficiency) may be best served by increasing the frequency of clinical breast examinations from annually to two to three times per year. While clinical breast examination proficiency is also variable, it is a behavior that, despite psychological stress, seven of 10 women adhered to in the Kash et al. study (7). Alternatively, women with low to moderate stress may well benefit from BSE teaching, given poor proficiency in this task independent of reported BSE frequency. In summary, while psychological distress is itself an important qualityof-life issue possibly associated with increased risk, the impact of this distress on screening is quite critical. It appears premature to blindly abandon any of the screening modalities potentially helpful to women at increased risk. However, we need to be aware of the limitations, sensitivity, and specificity of all three screening modalities in younger women. Finally, given the limitations of mammography in younger women, more research Journal of the National Cancer Institute
Downloaded from http://jnci.oxfordjournals.org/ at University of Lethbridge on September 6, 2015
AL: Isolation of CD4- CD8- mycobacteria-reactive T lymphocyte clones from rheumatoid arthritis synovial fluid. Nature 339:226-229, 1989
In a recent article (1) and subsequent series of exchanges regarding psychological distress and breast cancer screening among women at high risk of developing breast cancer (2,3), several important issues were raised. These issues focus on the generalizability of the findings of the study by Kash et al. (7) and on the relevance of breast self-examination (BSE) as a screening measure, particularly for the sample of younger women (mean age = 44 years) with a family history of breast cancer. Major findings by Kash et al. (7) included significant psychological distress among women at high risk, including investigation (4) assessing compliance with screening in a sample of women at high risk not attending special clinics, we found poor BSE compliance, while clinical breast examination adherence was quite high (84%), although mammography adherence in the preceding year (54%) was poor. Interestingly, only 52% of the sample (n = 125) considered themselves to have an above average risk. This percentage is not markedly different from the percentage of patients in the Kash et al. study (7) who rated themselves at high risk (41%). In contrast, women attending our clinic for women at high risk for breast cancer generally overestimate their risk and report high degrees of adherence to mammography, clinical breast examination, and BSE, although BSE proficiency is markedly below par (Stefanek M, Wilcox P, Helzelsouer K: manuscript in preparation). Thus, variables related to attendance at a clinic for women at high risk for breast cancer and knowledge of risk may be key differences in findings.
(3), the issues related to BSE sensitivity and specificity are far from resolved (5). While mammography may be less helpful for younger women, we should not assume that BSE is preferable, given the very low occurrence of breast cancer in younger women (particularly among those aged 20-30 years) and the high frequency, psychological sequelae, and possible negative impact of falsepositive results on subsequent breast cancer screening.
to increase sensitivity and specificity in BSE and clinical breast examination is critically needed. Women at high risk for breast cancer may be best served by their physicians making recommendations for screening on an individual basis. In making these recommendations, the physicians should be sensitive to issues such as quality of individual mammograms, the clinical breast examination proficiency of the health care providers, and the individual psychological distress as the latter impacts on adherence to each of the screening modalities.
References (/)
KASH KM, HOLLAND JC, HALPER MS, ET
AL: Psychological distress and surveillance behaviors of women with a family history of breast cancer. J Natl Cancer Inst 84:2430, 1992 (2) VOGEL VG, BONDY M: Women with a
history of breast cancer. J Natl Cancer Inst 84:724-725, 1992 (3) KASH KM: Breast cancer detection methods: Debate continues. J Natl Cancer Inst 84:726-727, 1992 (4) STEFANEK ME, WILCOX P: First degree
relatives of breast cancer patients: Screening practices and provision of risk information. Cancer Detect Prev 15:379-384, 1991 (5) MORRISON AS: Is self examination effective in screening for breast cancer? J Natl Cancer Inst 83:222-227, 1991
Response In response to Dr. Stefanek's correspondence, there are three issues to be addressed regarding psychological distress and breast cancer surveillance among women with family histories of breast cancer. First is the issue of what is meant by "high risk" for developing breast cancer. It is important to distinguish between women who have only one first-degree relative with postmenopausal unilateral breast cancer and women who have stronger family histories. Women who attend our breast surveillance program are a genetically enriched population and are less likely to have a sporadic
Vol. 84, No. 22, November 18, 1992
women at high risk were anxious and that this trait interfered with their surveillance behaviors. Wellisch et al. (2) investigated the psychological functioning of daughters of breast cancer patients. They found, as we found, that an immobilizing anxiety was one of the emotional themes of women with family histories of breast cancer. Similarly, Wellisch et al. found high levels of psychological distress consistent with the need for counseling. In both studies, reliable and valid instruments were used to measure anxiety and psychological distress. I would submit that further research into the causes of psychological distress in women at high risk for breast cancer requires attention to the use of such measures.
Second, we have endorsed all three methods of early detection (breast self-examination [BSE], clinical breast examination, and mammography) as important for women with family histories of breast cancer. We do not believe that BSE is preferable to either clinical breast examination or mammography, since there are false-negative and false-positive results with all of these procedures. We encourage women in our program for high-risk women to come in for a clinical breast examination every 6 months, have regularly scheduled mammograms (usually yearly, depending on age), and perform monthly BSE. The psychological impact of a false-negative result can be as devastating to a woman as a falsepositive result. By using all three early detection methods in a younger population such as ours (mean age = 44 years), we minimize the likelihood of false outcomes and the resulting psychological sequelae. The last issue addresses anxiety and psychological distress of women at high risk. In our study, we found that
References
KATHRYN M. KASH, P H . D .
Psychiatry Service Memorial Sloan-Kettering Cancer Center Strang Cancer Prevention Center 1275 York Ave. New York, NY 10021
(/) STEFANEK ME, WILCOX P: First degree
relatives of breast cancer patients: Screening practices and provision of risk information. Cancer Detect Prev 15:379-384, 1991 (2) WELLISCH DK, GRITZ ER, SCHAIN W, ET
AL: Psychological functioning of daughters of breast cancer patients. Part II: Characterizing the distressed daughter of the breast cancer patient. Psychosomatics 33:171-179, 1992
Unproven Therapies in the Treatment of Cancer Why would anyone consider using unproven therapies? With one million cases of cancer per year, thousands of doctors have tested every reasonable treatment on every type of cancer for many years. They know what works and what does not. But those who believe that only surgery, radiation, or chemotherapy hold hope for treating someone unfortunate enough to be stricken with cancer are living 20 years in the past.
CORRESPONDENCE 1757
Downloaded from http://jnci.oxfordjournals.org/ at University of Lethbridge on September 6, 2015
MICHAEL E. STEFANEK, P H . D .
The Johns Hopkins Oncology Center 550 North Broadway, Suite 1003 Baltimore, MD 21205
breast cancer case in their family histories. The criteria for joining the Strang Cancer Prevention Center's Breast Surveillance Program are as follows: 1) one first-degree relative with premenopausal bilateral breast cancer, 2) a mother and a maternal grandmother with breast cancer; or 3) two or more first-degree relatives with breast cancer. It is difficult to compare the women in our program with the women in Dr. Stefanek's sample (i), since his study involved women who had only one first-degree relative with breast cancer and 61% of the women in his sample had postmenopausal unilateral breast cancer. Only 5% of the women in his sample had premenopausal bilateral breast cancer in contrast to 28% of the women in our sample. Also, 25% of the women in our sample had at least two first-degree relatives with breast cancer. In summary, Dr. Stefanek's sample population may have risk levels closer to those found in the general population and not comparable with ours.
