Available via license: CC BY
Content may be subject to copyright.
Cancer Medicine. 2023;00:1–10.
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wileyonlinelibrary.com/journal/cam4
Received: 17 May 2023
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Revised: 30 August 2023
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Accepted: 30 August 2023
DOI: 10.1002/cam4.6518
RESEARCH ARTICLE
Breast/ovarian cancer genetic counseling: Do anxiety,
depression, and health care- related fears influence cancer
worry and risk perception?
AnitaCaruso1
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GabriellaMaggi1
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CristinaVigna1
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AntonellaSavarese2
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LauraGallo1
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LaraGuariglia1
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GiuliaCasu3
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PaolaGremigni3
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided
the original work is properly cited.
© 2023 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.
1Psychology Unit, IRCCS “Regina
Elena” National Cancer Institute,
Rome, Italy
2Department of Oncology, IRCCS
“Regina Elena” National Cancer
Institute, Rome, Italy
3Department of Psychology, University
of Bologna, Bologna, Italy
Correspondence
Lara Guariglia, Psychology Unit,
IRCCS “Regina Elena” National Cancer
Institute– Via Elio Chianesi, 53 00144,
Rome, Italy.
Email: lara.guariglia@ifo.it
Funding information
Ministero della Salute, Grant/Award
Number: rc2023
Abstract
Background: The impact of family and personal cancer history and emotional
factors, such as depression and anxiety, on disease representation has received
limited attention in studies investigating the development of cancer- related worry
and risk perception within the context of genetic counseling. The current study
endeavors to fill this gap by exploring the extent to which depression and anxiety
influence cancer worry and risk perception, and the role of health care- related
fear as potential mediator in this relationship.
Methods: A sample of 178 women who underwent their first genetic coun-
seling for breast/ovarian cancer, 52% of whom had previous cancer diagnoses,
completed questionnaires assessing sociodemographic and clinical information,
emotional distress in terms of anxiety and depression, cancer- related worry, risk
perception, and health care- related fears.
Results: Results of mediation analyses showed that cancer- related worry and
risk perception increased with rising levels of depression and anxiety, with health
care- related fears acting as a mediator in the relationship of depression and anxi-
ety with cancer worry and risk perception. Covariate analysis revealed that pre-
vious cancer diagnosis increases cancer- related worry but not risk perception,
while the number of family members affected by cancer increases both outcomes.
Conclusion: These findings emphasize the need for a holistic approach in ge-
netic counseling and have implications for the clinical practice.
KEYWORDS
anxiety, BRCA 1/2 genetic mutation, cancer, cancer worry, depression, family history, genetic
counseling, health fears, psychological distress, risk perception
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CARUSO et al.
1
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INTRODUCTION
Women diagnosed with breast and/or ovarian cancer or
with a family history of these types of cancers can un-
dergo genetic counseling to investigate whether they carry
the BRCA1/2 genetic mutation. The BRCA1/2 mutation is
associated with an increased risk of breast and/or ovarian
cancer, with carriers of the mutation having a risk respec-
tively of 72% and 44% for BRCA1 and 69% and 17% for
BRCA2.1 Identification of the mutation through genetic
screening and initiation of a genetic counseling process
offers the opportunity to increase prophylaxis, risk reduc-
tion interventions, monitoring, and surveillance for these
patients.2 Within genetic counseling, attention is focused
not only on medical data but also on the psychosocial
characteristics and issues of patients.
Women potentially carrying the BRCA1/2 genetic muta-
tions may have a complex psychological profile, both as a
result of their family members' experiences and their own
illness. Scientific evidence shows that symptoms of anxiety
and depression are significantly present in those undergoing
genetic counseling.3,4 Symptoms can develop in relation to
being carriers of the mutation, having had direct illness ex-
perience,5,6 having multiple family members with a history
of breast/ovarian cancer,7 being the first tested subject in the
family,8 and having to communicate the test outcome to their
family.9 From the cited studies, it clearly emerges how the
interaction between the individual and the family contrib-
utes to increase psychological distress. In patients carrying
the genetic mutation, there are multigenerational models of
the disease manifestation that can shape the development
processes and have an impact in terms of psychological dis-
tress with manifestations of anxiety and depression.10
The family manifestation of cancer also contributes to a
specific representation of the disease, such that women with
family illness experiences generate representations associ-
ated with greater concern for cancer development.11 These
data are consistent with Leventhal's self- regulation model,12
which posits that the representation of illness is generated
from external stimuli (witnessing a family member's illness
or acquiring information from the media or doctors) and
internal stimuli (direct experience of symptoms) through
processes in which elements of both emotional and cogni-
tive nature converge. The contribution of emotional factors
to the genesis of the disease representation is confirmed by
the works of Butler and Brand.4,13 In their studies, the dis-
ease representation and the self- concept, in which stigma
and vulnerability dimensions converge, are associated with
anxious symptomatology in these patients, showing that
women with negative emotional representations present a
higher level of anxiety and distress.
In the literature, it is not sufficiently clear what the re-
lationships are between psychological distress, illness
representation, risk perception, and cancer worry. The in-
vestigation of risk perception showed that these patients
may have a subjective and distorted perception of risk, but
it is not clear what the influence of emotional distress is
in this regard. Studies that have investigated the nature of
this relationship have yielded contrasting results. In Caruso
et al.,14 there were no correlations between anxiety, depres-
sion, and risk perception. In Vos et al.'s study,15 physical and
psychological changes, stigma, mastery, negativity, and can-
cer worry were correlated with risk perception not only for
oneself but also for one's relatives. In Cicero et al.'s study,16
risk perception seems to be a moderating and/or predictive
factor in the development of psychopathological symptoms,
and specifically influences anxiety levels more than depres-
sion levels. In fact, in their study,16 it is not possible to draw
definitive conclusions regarding the causal order of vari-
ables, and the directionality of significant relationships has
not been determined. The study by Lerman et al.17 indicates
the opposite, however, showing a direct influence of anxi-
ety on risk perception. The study was conducted on patients
undergoing genetic counseling and therefore adequately in-
structed on the actual risk probability associated with their
illness condition; the results indicated that counseling on
risk did not produce a better understanding in those patients
who at baseline had high levels of anxious concern.17 Thus,
anxiety seems to be a dimension that influences risk percep-
tion despite the stimuli processed at a cognitive level.
It is essential for the clinical practice to comprehend
the association between family experiences, psychological
distress, and risk perception. Risk perception is a relevant
empirical dimension as individuals who underestimate
their cancer risk are less likely to partake in health pro-
tective behaviors, while those who overestimate their risk
may worry excessively and undergo unnecessary visits
and checks.18
This study aims to investigate whether anxiety and de-
pression affect the perception of risk and worry regarding
cancer diagnosis or recurrence among those who have
had cancer, and whether health care- related fears medi-
ate these associations. In addition, the research aims to
explore how the presence/absence of the disease, consid-
ering the number of family members affected by cancer
as a covariate, influences the perceived risk of carrying
a genetic mutation or developing cancer and the level of
cancer- related worry.
2
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METHODS
2.1
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Study design and procedures
This observational, single center, cohort study focuses
on women attending a specialized outpatient clinic for
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CARUSO et al.
hereditary breast and ovarian cancer. The study considers
two subgroups of the population: asymptomatic women
without prior cancer diagnosis, and women already diag-
nosed with or having had breast or ovarian cancer, both
awaiting their first genetic counseling consultation. Inclu-
sion criteria were being 18 years or above, having at least one
first- degree relative with breast and/or ovarian cancer, hav-
ing family members who have not been previously tested
for the BRCA1/2 mutation, and not having undergone any
genetic counseling before. Exclusion criteria consisted of
women under 18 years, belonging to families already tested
for BRCA1/2 diagnosis, having previously undergone ge-
netic counseling, or waiting for a cancer screening result.
Prior to participation, potential participants were in-
formed of the study objectives and were required to com-
plete an informed consent form to take part in the study.
Participation was completely voluntary and no compen-
sation was offered. The study received formal ethical ap-
proval from the Ethical Committee of the “Regina Elena”
National Cancer Institute (RS1721/22/2699).
2.2
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Measures
The following data were collected: sociodemographic and
clinical information, data from a self- report questionnaire
on emotional distress (anxiety, depression, and health-
related fears) and a self- report questionnaire on cancer-
specific distress and personal and genetic risk perception.
The sociodemographic and clinical data included age,
educational level, information on previous cancer diag-
nosis, and the number of first- degree relatives affected by
breast, ovarian, and/or other types of cancer.
2.3
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Cognitive behavioral
assessment- hospital form
The Cognitive Behavioral Assessment- Hospital Form
(CBA- H19) is a 147- items questionnaire formed by Cards
A, B, C, and D and is commonly used in the psychologi-
cal assessment of patients with somatic diseases or people
attending medical screening or testing. The questionnaire
was validated on a sample of 4888 Italian adults formed by
patients with various somatic diseases including different
types of cancer (breast, ovarian, lung, and colon), individu-
als submitted to oncological screening, and healthy con-
trols.19 Card A of the CBA- H19 was used in the current study
to evaluate the emotional condition of patients. It is formed
by three subscales: A1– state anxiety (SA; 9 items) meas-
ures a general anxiety state; A2- health care- related fears
(HF; 5 items) evaluates fear reactions to situations related
to health management and diagnostic/curative treatments
or medical procedures; and A3- depressive reactions (DR;
5 items) investigates the presence of depressive thoughts.
The items require a true/false response (coded 1- 0).
2.4
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Cancer worry scale- genetic
counseling
The cancer worry scale was originally developed to evalu-
ate the impact of receiving abnormal mammogram results
on women's breast cancer worries, their breast self-
examination (BSE) frequency and intentions to obtain
subsequent mammograms.20
The Italian version of the cancer worry scale– genetic
counseling (CWS- GC21) was modified to identify dimen-
sions that are relevant in the genetic counseling context,
such as worry about developing breast or ovarian cancer,
impact of worries on daily life, and risk perception in
women attending a counseling session for BRCA1/2 mu-
tations. The CWS- GC, used in the current study, was vali-
dated in a population of 304 Italian women, of whom 58%
were diagnosed for breast or ovarian cancer and the rest
were asymptomatic persons undergoing cancer genetic
testing. The CWS- GC consists of two independent indi-
ces, cancer worry (cw) and risk perception (RP). CW (five
items) measures the intensity and frequency of worries
about the possibility of developing cancer (or recurrence
for patients who have had cancer) and the impact of wor-
ries on mood and daily functioning. Items are answered
using a 5- point scale format from 0 (not at all/never) to
4 (very much/constantly). The overall cancer- related wor-
ries is obtained by adding and averaging the five items
after transforming them into a 0– 100 scale. RP (two items)
measures the perceived risk of having a genetic muta-
tion and of developing cancer (recurrently or for the first
time). Both items are evaluated through a visual analogue
scale ranging from “no perceived risk” (0%) to “highest
perceived risk” (100%). The overall perception of risk is
obtained by adding and averaging the two items.
2.5
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Data analyses
Descriptive statistics was used to describe the sociode-
mographic characteristics of participants. Preliminary
analyses were performed to calculate the correlations
(Pearson's r coefficient) between the predictors, the medi-
ator, and the dependent variables. Analysis of covariance
(ANCOVA) was run to test for the effects of having had or
not a previous diagnosis of cancer on the dependent vari-
ables (i.e., cancer worry and risk perception), taking into
consideration the number of first- degree relatives with
cancer as a covariate.
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CARUSO et al.
Two mediation models were subsequently tested:
Mediation model n. 1 with depressive reactions as the
predictor, health care- related fears as the mediator,
and cancer worry and risk perception as the dependent
variables. Mediation model n. 2 was the same as the
previous one except for the predictor that was state anx-
iety. In the mediation models were also entered as con-
founder variables having had or not a previous diagnosis
of cancer and the number of relatives with cancer, in the
case of their significant associations with the dependent
variables.
The significance level was set at p < 0.05. Statistical
analyses were performed with the software JASP version
0.16 [2013- 2021 University of Amsterdam].
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RESULTS
3.1
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Participants
The study involved 178 women, ranging in age from 27
to 77 years old, with a mean age around 52 years. Over
half of the participants had a high school qualification,
one- third held a university degree, and a minority of
them had a secondary school certificate. About half of
the participants had been diagnosed with cancer previ-
ously, in most cases unilateral breast cancer, while only
a few of them had ovarian cancer. Finally, the number
of first- degree relatives with cancer ranged from 0 to 11,
with a mean around 5. (Participants' characteristics are
reported in Table1).
3.2
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Preliminary analyses
Pearson's correlations were significant between all the
psychological variables (see Table2). In addition, the
number of first- degree relatives with cancer significantly
correlated with both cancer worry (r = 0.21; p = 0.006) and
risk perception (r = 0.28; p < 0.001).
ANCOVA results regarding the effects of having or not
a diagnosis of cancer on cancer worry and risk percep-
tion, considering the number of relatives with cancer as
a covariate, were as follows. For cancer worry, the effect
of having had or not a diagnosis of cancer was significant
(F [1,173] = 6.49, p = 0.01), after controlling for the effect
of the number of relatives with cancer (F [1,173] = 10.20,
p = 0.002) (Levene's test was nonsignificant, p = 0.44).
Marginal means of cancer worry were 43.24 and 34.20
for having or not a cancer diagnosis, respectively, with
higher worries reported by patients having had a diagno-
sis of cancer. For risk perception, the effects of having had
or not a diagnosis was nonsignificant (F [1,173) = 0.40,
p = 0.53), after controlling for the effect of the number of
relatives with cancer (F [1,173) = 14.86, p < 0.001) (Lev-
ene's test was nonsignificant, p = 0.44). Marginal means
of risk perception were 49.08 and 48.95 for having had
or not a cancer diagnosis, respectively, indicating simi-
lar perception of risk between patients previously diag-
nosed and asymptomatic women attending the genetic
counseling.
Subsequently, having had or not a cancer diagnosis and
the number of relatives with cancer were both entered
into the mediation model n. 1 for cancer worry, whereas
only the number of relatives with cancer was entered into
the mediation model n. 2 for risk perception.
TABLE Participants' characteristics (n = 178).
Characteristic
Frequency
(%)
Mean (standard
deviation)
Age (years) — 52.18 (10.92)
Educational level
Secondary school 23 (12.92) —
High school 93 (52.25) —
University degree 62 (34.83) —
Previous diagnosis of
cancer (total)
93 (52.25) —
Previous ovarian cancer 7 (7.53) —
Previous breast cancer
(total)
86 (92.47) —
Unilateral 77 (89.53)
Multiple contralateral 7 (8.14)
Multiple ipsilateral 2 (2.33)
Number of relatives with
cancer
— 4.60 (2.49)
Variable SA DR HF CW
State anxiety (SA) —
Depressive reactions (DR) 0.53** —
Health care- related fears (HF) 0.62** 0.27** —
Cancer worry (CW) 0.56** 0.31** 0.57** —
Risk perception (RP) 0.37** 0.20*0.27** 0.49**
*p < 0.01; **p < 0.001.
TABLE Pearson's correlations
between psychological study variables.
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CARUSO et al.
3.3
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Mediation models
In the first mediation model, the predictor was depressive
reactions, the dependent variables were cancer worry and
risk perception, and health care- related fears acted as a
mediator. Having had or not a cancer diagnosis and the
number of relatives with cancer were confounding vari-
ables for cancer worry, and only the number of relatives
with cancer was a confounding variable for risk percep-
tion. The model explained 41% (R2 = 0.41) of the variance
in cancer worry and 16% (R2 = 0.16) of the variance in risk
perception. Health care- related fears partially mediated
the effect of depressive reactions on cancer worry and
fully mediated the effect of depressive reactions on risk
perception (see Table3 and Figure1). As depressive re-
actions increased, cancer worry and risk perception also
increased, with health care- related fears playing a partial
or full mediating role, while controlling for the effects of
having had or not cancer and the number of relatives with
cancer.
In the second mediation model, the predictor was state
anxiety, the dependent variables were cancer worry and
risk perception, and health- care related fears acted as a
mediator. Having had or not a diagnosis of cancer and the
number of relatives with cancer were confounding vari-
ables for cancer worry, and only the number of relatives
with cancer was a confounding variable for risk percep-
tion. The model explained 44% (R2 = 0.44) of the variance
in cancer worry and 20% (R2 = 0.20) of the variance in
risk perception. Health care- related fears partially medi-
ated the effect of state anxiety on cancer worry and did
not mediate the effect of state anxiety on risk perception
95% Confidence
interval
Direct effects Estimate
Std.
error z- value pLower Upper
DR→CW 0.17 0.06 2.67 0.008 0.05 0.30
DR→RP 0.16 0.08 1.92 0.06 −0.004 0.33
Indirect effects
DR→HF→CW 0.13 0.04 3.36 <0.001 0.05 0.21
DR→HF→RP 0.05 0.02 2.32 0.02 0.008 0.10
Total effects
DR→CW 0.31 0.07 4.20 <0.001 0.16 0.45
DR→RP 0.22 0.08 2.61 0.009 0.05 0.38
Note: Standardized estimates, robust standard errors, robust confidence intervals, ML estimator.
Abbreviations: CW, cancer worry; DR, depressive reactions; HF, health care- related fears; RP, risk
perception.
TABLE Parameter estimates of
mediation model n. 1.
FIGURE Path plot of mediation model n. 1. Diagnosis = having or not a diagnosis of cancer; Relatives = number of relatives with
cancer. Standardized estimates are presented.
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CARUSO et al.
(see Table4 and Figure2). As state anxiety increased, can-
cer worry and risk Perception also increased, with health
care- related fears playing a partial mediating role for can-
cer worry only, while controlling for the effects of having
had or not cancer and the number of relatives with cancer.
The comparison of the two mediation models sug-
gests that state anxiety was a slightly superior predictor
(R2 = 0.44) of cancer worry, with the partial mediation of
health care- related fears, compared to depressive reac-
tions (R2 = 0.41). In terms of risk perception, state anxiety
also appeared to be a better predictor (R2 = 0.20) than de-
pressive reactions (R2 = 0.16). However, while the relation-
ship between depressive reactions and risk perception was
fully mediated by health care- related fears, the relation-
ship between state anxiety and risk perception was only
direct and not mediated by health care- related fears.
4
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DISCUSSION
The exploration of risk perception and cancer- related
worry is a significant undertaking within the realm of psy-
chology research. Yet, the precise mechanisms underlying
these domains and the extent to which emotional and cog-
nitive factors interplay in this respect are still shrouded in
uncertainty. Current literature concerning risk perception
and psychological distress is relatively scant and outdated.
While contemporary studies have primarily examined
how emotional and cognitive dimensions correlate, they
have not delved deeply into the directionality of the as-
sociations between these variables.
The current study aimed to investigate the influence of
emotional factors, such as anxiety and depression, on the
perception of risk and cancer- related worry, and to explore
95% Confidence
interval
Direct effects Estimate
Std.
error z- value pLower Upper
SA→CW 0.30 0.09 3.41 <0.001 0.13 0.47
SA→RP 0.31 0.08 3.70 <0.001 0.15 0.48
Indirect effects
SA→HF→CW 0.23 0.05 4.64 <0.001 0.13 0.33
SA→HF→RP 0.04 0.05 0.72 0.47 −0.06 0.14
Total effects
SA→CW 0.53 0.07 7.78 <0.001 0.40 0.67
SA→RP 0.35 0.07 5.09 <0.001 0.21 0.48
Note: Standardized estimates, robust standard errors, robust confidence intervals, ML estimator.
Abbreviations: CW, cancer worry; HF, health care- related fears; RP, risk perception; SA, state anxiety.
TABLE Parameter estimates of
mediation model n. 2.
FIGURE Path plot of mediation model n. 2. Diagnosis = having or not a diagnosis of cancer; Relatives = number of relatives with
cancer. Standardized estimates are presented.
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CARUSO et al.
the mediating role of health care- related fears in these asso-
ciations. The results indicate that depression has a signifi-
cant effect on both risk perception and cancer- related worry.
As the level of depression increases, so does the intensity
and frequency of cancer- related worry as well as risk per-
ception. A previous study also found that women scoring
higher in a depression scale reported higher risk estimates
of developing breast cancer.22 Health care- related fears play
a crucial mediating role in this relationship by helping to
elucidate the effect of depression on risk perception, while
their role in mediating the association between depression
and cancer- related apprehension was comparatively minor.
Furthermore, the study found that state anxiety also has
an influence on risk perception and cancer- related worry.
As anxiety levels increase, both cancer- related worry and
risk perception also increase. Health care- related fears
have a significant mediating role in the relationship be-
tween anxiety and cancer- related worry, but they do not
mediate the effect of anxiety on risk perception.
The findings of this study are consistent with Leven-
thal's self- regulation model,12 which posits that individ-
uals' perception of illness impacts their responses to it.
Specifically, the perception of illness refers to how pa-
tients interpret information and personal experiences they
have accumulated over time. This may elucidate the role
of health care- related fears, which mediate the relation-
ship of depression and anxiety with risk perception and
cancer- related worry.
The present study provides evidence that anxiety is
a stronger predictor of cancer- related worry and risk
perception than depression. Moreover, our findings
suggest that anxiety has a direct impact on risk percep-
tion, which is not mediated by health care fears. These
results are consistent with previous research conducted
by Lerman,17 who demonstrated a correlation between
anxiety and risk perception, indicating that counseling
to correct risk perception is ineffective in women with
frequent intrusive thoughts about the disease. Women
with high levels of anxiety, according to the authors, are
less likely to perceive information as reliable, as anxi-
ety interferes with the process of attention and compre-
hension. Several subsequent studies have confirmed the
impact of anxiety on risk perception. Cull et al.23 found
that the best predictor of risk overestimation in a sam-
ple of women with a family history of ovarian cancer
was anxiety, with their health behavior being guided by
anxiety rather than objective risk. Meiser et al.24 found
that women at increased genetic risk with higher levels
of specific anxiety for cancer were more likely to overes-
timate the risk of ovarian cancer, especially if they had
a mother diagnosed with the disease. Ultimately, the
cited studies highlight the importance of considering
anxiety as a key factor in cancer- related risk perception
and suggest the need for tailored interventions to reduce
anxiety and prevent risk overestimation.
In order to fully examine the factors that contribute to
risk perception and cancer- related worry, we investigated
the potential influence of two additional variables: the
presence or absence of disease and the number of fam-
ily members affected by cancer. Previous research has
demonstrated that patients' family history of the disease
can impact their perception of risk. Chalmers et al.25
found that the timing of illness and death events within
a family can play a critical role in overestimating the risk.
Women, in particular, may develop a sense of vulnerabil-
ity through strong identification with family members
affected by cancer. A similar relationship between risk
perception and family history has also been identified in
studies of mutation carriers aged 18– 40 years.26– 30
However, despite existing research, there is a lack of
studies that have specifically examined how the presence
or absence of cancer and the number of family members
affected by cancer may impact cancer- related worry and
risk perception. Our findings suggest that the number
of family members affected by cancer does have an im-
pact on risk perception, whereas a previous cancer diag-
nosis does not. That is, the larger the number of family
members affected by cancer the higher the perceived risk
of having a genetic mutation and personally developing
cancer, consistently with the literature.25– 29 On the other
hand, patients having had cancer and asymptomatic
women attending a cancer genetic counseling manifest
the same level of perceived risk of having a genetic mu-
tation and developing cancer (recurrently or for the first
time). Conversely, both variables were found to have an
effect on cancer- related worry. That is, both having had
cancer and a larger number of family members affected
by cancer increase the worry about developing cancer and
its impact on personal daily life. It means that personal
and family experiences with cancer play a critical role in
increasing concern for one's personal health. These results
have important implications for understanding the com-
plex interplay of factors that contribute to perceptions of
risk and worry related to cancer.
In conclusion, this study provides insights into the
complex relationships between emotional factors, risk per-
ception, and cancer- related worry. Future research should
continue to investigate these areas to better understand
the underlying mechanisms and potential interventions to
improve psychological well- being in at- risk populations.
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STUDY LIMITATIONS
The present study is not without limitations, which
should be acknowledged to ensure a realistic
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CARUSO et al.
interpretation of the findings. First, the outcomes re-
lied on self- reported data, which are vulnerable to vari-
ous biases and subjectivities. Second, the uncertainty
around screening procedures may itself have induced
anxiety and fear among participants, thus complicating
the interpretation of results of the regression models.
Additionally, patients' beliefs about the effectiveness of
screening may have interacted with fear to affect their
perception of risk. Third, given that the present study
adopted a cross- sectional design, it cannot infer causal-
ity, and longitudinal research in this area is warranted.
Fourth, the generalizability of the findings is limited by
the fact that the study's participants were highly edu-
cated women who were screened at a single institution.
Therefore, caution should be exercised in generalizing
the findings to other populations or screening con-
texts. Finally, the limited sample size of the study did
not allow exploring the influence of the type of cancer
previously diagnosed (breast or ovarian cancer) on the
selected outcomes as well as running separate media-
tion models for women who had or not a diagnosis of
cancer. Indeed, the number of patients who had ovarian
cancer was too small (n = 7) to allow reliable analyses
on the associations between the type of cancer and other
psychological variables in the study. This study suggests
that having had or not cancer influence cancer worry, so
it would have been reasonable to conduct separate me-
diation models for the two subgroups of women (with or
without a cancer diagnosis) in relation to cancer worry.
However, mediation conclusions are dependent on sam-
ple size. Using a sample that is too small may pose a
hindrance to adequately demonstrating the total effect.
Consequently, it is advised to employ moderate sample
sizes in mediation models.31 In our study, we deemed a
sample size ranging between 100 and 200 to be moder-
ate, while performing separate median models on the
two halves of our sample, both with a sample size below
100, might not give the researchers sufficient statistical
power to detect the total effect. Future research should
address this issue by involving a larger number of par-
ticipants, in order to reliably compare asymptomatic pa-
tients awaiting genetic screening with cancer patients,
also differentiating patients based on the type of cancer
using subgroups with appropriate sample sizes.
6
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CLINICAL IMPLICATIONS
The information presented offers valuable insights for
health care professionals regarding the impact that
emotional well- being may have on cognitive function-
ing and accurate perception of reality. In light of this,
it is crucial for clinicians to adopt a holistic approach
to patient care that takes into account both the physi-
cal and psychological aspects of their patients' health.
To achieve this, effective communication strategies that
acknowledge and respect patients' subjectivity should
be prioritized while preserving their quality of life. Ad-
ditionally, psychologists have a critical role to play in
implementing targeted psychological interventions, in-
cluding patient assessment, facilitating communication
between health care teams and patients, and providing
treatment when necessary.
Failure to adopt a comprehensive approach to patient
care that accounts for psychological factors can lead to
significant negative impacts on the decision- making
process. In particular, this may result in inappropri-
ate allocation of medical care and diagnostic tests, as
well as inadequate control over preventive therapy op-
tions. Therefore, health care providers must prioritize a
patient- centered approach that addresses broader health
concerns and applies a multidisciplinary approach for
optimal patient management.
7
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CONCLUSIONS
The scenario under consideration presents a clear com-
plexity, that can be discerned through a careful analysis
of the available data. Specifically, the patients' life expe-
riences, shaped by their own encounters with cancer or
those of their family members, engender a multifaceted
representation of the disease. This representation is char-
acterized by emotional factors such as anxiety and depres-
sion, as well as health care- related elements like fears
related to surgical intervention, medical testing, and in-
teractions with physicians. Such an interpretation of the
patient's condition is further augmented by their anxiety
and depression, which can exacerbate their perception of
personal vulnerability in terms of risk and concerns re-
lated to cancer.
AUTHOR CONTRIBUTIONS
Anita Caruso: Conceptualization (equal); data curation
(equal); investigation (equal); methodology (equal); pro-
ject administration (equal); resources (equal); supervision
(equal); validation (equal); writing – original draft (equal);
writing – review and editing (equal). Gabriella Maggi:
Conceptualization (equal); investigation (equal); writing –
original draft (equal); writing – review and editing (equal).
Cristina Vigna: Data curation (equal); writing – review
and editing (equal). Antonella Savarese: Writing – origi-
nal draft (equal); writing – review and editing (equal).
Laura Gallo- : Writing – original draft (equal); writing –
review and editing (equal). Lara Guariglia: Concep-
tualization (equal); investigation (equal); methodology
|
9
CARUSO et al.
(equal); validation (equal); writing – original draft (equal);
writing – review and editing (equal). Giulia Casu: Data
curation (equal); formal analysis (equal); investigation
(equal); methodology (equal); supervision (equal); writ-
ing – original draft (equal); writing – review and editing
(equal). Paola Gremigni: Conceptualization (equal);
data curation (equal); formal analysis (lead); investigation
(equal); methodology (equal); software (equal); supervi-
sion (equal); writing – original draft (equal); writing – re-
view and editing (equal).
ACKNOWLEDGMENTS
We thank Federica Falcioni, Administrative Assistant,
Scientific Direction, IRE. Open access funding provided
by BIBLIOSAN.
FUNDING INFORMATION
This work was financially supported through funding
from the institutional “Ricerca Corrente 2023.”
CONFLICT OF INTEREST STATEMENT
The authors declare that they have no competing interests.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are avail-
able from the corresponding author upon reasonable
request.
ORCID
Lara Guariglia https://orcid.org/0000-0001-7010-3716
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How to cite this article: Caruso A, Maggi G,
Vigna C, et al. Breast/ovarian cancer genetic
counseling: Do anxiety, depression, and health
care- related fears influence cancer worry and risk
perception? Cancer Med. 2023;00:1-10. doi:10.1002/
cam4.6518
