27
_______________________________________________________________ _______________________________________________________________ 5HSRUW ,QIRUPDWLRQ IURP 3UR4XHVW 0D\ _______________________________________________________________ 0D\ 3UR4XHVW

Applying a Cognitive Behavioral Model of Health Anxiety in a Cancer Genetics Service

Embed Size (px)

DESCRIPTION

A cognitive-behavioral model of health anxiety was used to investigate reactions to genetic counseling for cancer.

Citation preview

Page 1: Applying a Cognitive Behavioral Model of Health Anxiety in a Cancer Genetics Service

_______________________________________________________________�

_______________________________________________________________�

5HSRUW�,QIRUPDWLRQ�IURP�3UR4XHVW0D\��������������_______________________________________________________________�

���0D\����� 3UR4XHVW

Page 2: Applying a Cognitive Behavioral Model of Health Anxiety in a Cancer Genetics Service

7DEOH�RI�FRQWHQWV

���$SSO\LQJ�D�FRJQLWLYH�EHKDYLRUDO�PRGHO�RI�KHDOWK�DQ[LHW\�LQ�D�FDQFHU�JHQHWLFV�VHUYLFH�������������������������������� �

%LEOLRJUDSK\������������������������������������������������������������������������������������������������������������������������������������������������������ ��

���0D\����� LL 3UR4XHVW

Page 3: Applying a Cognitive Behavioral Model of Health Anxiety in a Cancer Genetics Service

'RFXPHQW���RI�� $SSO\LQJ�D�FRJQLWLYH�EHKDYLRUDO�PRGHO�RI�KHDOWK�DQ[LHW\�LQ�D�FDQFHU�JHQHWLFV�VHUYLFH��$XWKRU��5LPHV��.DWKDULQH�$������6DONRYVNLV��3DXO�0������-RQHV��/LQGD�����/XFDVVHQ��$QQHNH�0�������'HSDUWPHQWRI�3V\FKRORJLFDO�0HGLFLQH��.LQJV�&ROOHJH�/RQGRQ��,QVWLWXWH�RI�3V\FKLDWU\��/RQGRQ��8QLWHG�.LQJGRPN�ULPHV#LRS�NFO�DF�XN���'HSDUWPHQW�RI�3V\FKRORJ\��.LQJV�&ROOHJH�/RQGRQ��,QVWLWXWH�RI�3V\FKLDWU\��/RQGRQ�8QLWHG�.LQJGRP���*HQHWLFV�6HUYLFH��&DUPDUWKHQVKLUH�1DWLRQDO�+HDOWK�6HUYLFH�7UXVW��8QLWHG�.LQJGRP���

:HVVH[�&OLQLFDO�*HQHWLFV�6HUYLFH��6RXWKDPSWRQ��8QLWHG�.LQJGRP 3XEOLFDWLRQ�LQIR��+HDOWK�3V\FKRORJ\��������0DU����������������3UR4XHVW�GRFXPHQW�OLQN $EVWUDFW��$�FRJQLWLYH�EHKDYLRUDO�PRGHO�RI�KHDOWK�DQ[LHW\�ZDV�XVHG�WR�LQYHVWLJDWH�UHDFWLRQV�WR�JHQHWLF�FRXQVHOLQJIRU�FDQFHU��3DUWLFLSDQWV��1� ������ZHUH�DVNHG�WR�FRPSOHWH�D�TXHVWLRQQDLUH�EHIRUHKDQG�DQG���PRQWKV�ODWHU�7KHUH�ZDV�DQ�RYHUDOO�GHFUHDVH�LQ�OHYHOV�RI�FDQFHU�UHODWHG�DQ[LHW\��DOWKRXJK�����RI�SDUWLFLSDQWV�VKRZHGLQFUHDVHG�FDQFHU�UHODWHG�DQ[LHW\�DW�IROORZ�XS��3HRSOH�ZKR�KDG�D�JHQHUDO�WHQGHQF\�WR�ZRUU\�DERXW�WKHLU�KHDOWKUHSRUWHG�PRUH�FDQFHU�UHODWHG�DQ[LHW\�WKDQ�WKRVH�ZKR�GLG�QRW�DW�ERWK�WLPH�SRLQWV��7KLV�KHDOWK�DQ[LRXV�JURXS�DOVRVKRZHG�D�SRVWFRXQVHOLQJ�DQ[LHW\�UHGXFWLRQ��ZKHUHDV�WKH�RWKHUV�VKRZHG�QR�VLJQLILFDQW�FKDQJH��3DUWLFLSDQWV�ZLWKEUHDVW�RU�RYDULDQ�FDQFHU�LQ�WKHLU�IDPLO\�ZHUH�PRUH�DQ[LRXV�WKDQ�SDUWLFLSDQWV�ZLWK�FRORQ�FDQFHU�LQ�WKHLU�IDPLO\�3UHH[LVWLQJ�EHOLHIV�ZHUH�VLJQLILFDQW�SUHGLFWRUV�RI�DQ[LHW\��FRQVLVWHQW�ZLWK�D�FRJQLWLYH�EHKDYLRUDO�DSSURDFK��3V\F,1)2�'DWDEDVH�5HFRUG��F�������$3$��DOO�ULJKWV�UHVHUYHG��MRXUQDO�DEVWUDFW� /LQNV��/LQNLQJ�6HUYLFH )XOO�WH[W���&RQWHQWV��

$EVWUDFW�

0HWKRGV�

3DUWLFLSDQWV�

3URFHGXUH�

0HDVXUHV�

%HOLHIV�DQG�IHHOLQJV�DERXW�FDQFHU�

*HQHUDO�PRRG�UDWLQJV�

'HPRJUDSKLF�DQG�PHGLFDO�IDPLO\�KLVWRU\�

$GGLWLRQDO�SRVWFRXQVHOLQJ�PHDVXUHV�

6WDWLVWLFDO�$QDO\VLV�

5HVXOWV�

6RFLRGHPRJUDSKLF�DQG�&OLQLFDO�&KDUDFWHULVWLFV�RI�WKH�6DPSOH�

&KDUDFWHULVWLFV�RI�3HRSOH�:KR�'LG�1RW�5HWXUQ�WKH�)ROORZ�XS�4XHVWLRQQDLUH�

,PSDFW�RI�*HQHWLF�&RXQVHOLQJ�

$FFXUDF\�RI�ULVN�SHUFHSWLRQV�

$Q[LHW\�DERXW�GHYHORSLQJ�FDQFHU�

&RPSDULVRQ�RI�$Q[LHW\�DQG�%HOLHIV�$ERXW�&DQFHU�LQ�3HRSOH�:LWK�)DPLO\�+LVWRULHV�RI�%UHDVW�DQG�RU�2YDULDQ�RU

&RORQ�&DQFHU�

*HQHUDO�JURXS�GLIIHUHQFHV�

���0D\����� 3DJH���RI��� 3UR4XHVW

Page 4: Applying a Cognitive Behavioral Model of Health Anxiety in a Cancer Genetics Service

'LG�SHRSOH�ZKR�WHQGHG�WR�ZRUU\�DERXW�WKHLU�KHDOWK�UHSRUW�PRUH�QHJDWLYH�FDQFHU�UHODWHG�EHOLHIV�DQG�DQ[LHW\�DQG

UHVSRQG�SDUWLFXODUO\�QHJDWLYHO\�WR�³LQFUHDVHG�ULVN´�LQIRUPDWLRQ"�

3UHGLFWLRQ�RI�$Q[LHW\�DQG�%HOLHIV�

3UHGLFWLRQ�RI�DQ[LHW\�DQG�EHOLHIV�IURP�PHGLFDO�IDPLO\�KLVWRU\�YDULDEOHV�

3UHGLFWLRQ�RI�EHOLHIV�DQG�DQ[LHW\�IURP�YDULDEOHV�GHULYHG�IURP�WKH�&%�PRGHO�

'LVFXVVLRQ�

6KRZ�OHVV�

)LJXUHV�DQG�7DEOHV��

)LJXUH���

7DEOH���

7DEOH���

7DEOH���

7DEOH���

7DEOH���

7DEOH���

6KRZ�OHVV�$EVWUDFW$�FRJQLWLYH�EHKDYLRUDO�PRGHO�RI�KHDOWK�DQ[LHW\�ZDV�XVHG�WR�LQYHVWLJDWH�UHDFWLRQV�WR�JHQHWLF

FRXQVHOLQJ�IRU�FDQFHU��3DUWLFLSDQWV��1�� ������ZHUH�DVNHG�WR�FRPSOHWH�D�TXHVWLRQQDLUH�EHIRUHKDQG�DQG��

PRQWKV�ODWHU��7KHUH�ZDV�DQ�RYHUDOO�GHFUHDVH�LQ�OHYHOV�RI�FDQFHU�UHODWHG�DQ[LHW\��DOWKRXJK�����RI�SDUWLFLSDQWV

VKRZHG�LQFUHDVHG�FDQFHU�UHODWHG�DQ[LHW\�DW�IROORZ�XS��3HRSOH�ZKR�KDG�D�JHQHUDO�WHQGHQF\�WR�ZRUU\�DERXW�WKHLU

KHDOWK�UHSRUWHG�PRUH�FDQFHU�UHODWHG�DQ[LHW\�WKDQ�WKRVH�ZKR�GLG�QRW�DW�ERWK�WLPH�SRLQWV��7KLV�KHDOWK�DQ[LRXV

JURXS�DOVR�VKRZHG�D�SRVWFRXQVHOLQJ�DQ[LHW\�UHGXFWLRQ��ZKHUHDV�WKH�RWKHUV�VKRZHG�QR�VLJQLILFDQW�FKDQJH�

3DUWLFLSDQWV�ZLWK�EUHDVW�RU�RYDULDQ�FDQFHU�LQ�WKHLU�IDPLO\�ZHUH�PRUH�DQ[LRXV�WKDQ�SDUWLFLSDQWV�ZLWK�FRORQ�FDQFHU

LQ�WKHLU�IDPLO\��3UHH[LVWLQJ�EHOLHIV�ZHUH�VLJQLILFDQW�SUHGLFWRUV�RI�DQ[LHW\��FRQVLVWHQW�ZLWK�D�FRJQLWLYH�EHKDYLRUDO

DSSURDFK��7KH�LPSRUWDQFH�RI�JHQHWLF�VXVFHSWLELOLW\�WR�FHUWDLQ�FDQFHUV�KDV�OHG�WR�DQ�LQFUHDVH�LQ�WKH�GHPDQG�IRU

JHQHWLF�FRXQVHOLQJ�E\�VSHFLDOLVW�JHQHWLF�VHUYLFHV��SDUWLFXODUO\�IURP�PHPEHUV�RI�IDPLOLHV�ZLWK�D�KLVWRU\�RI�EUHDVW

DQG�RU�RYDULDQ�FDQFHU�RU�FRORQ�FDQFHU��5DYLQH�6DPSVRQ���������*HQHWLF�FRXQVHOLQJ�LV�³WKH�SURFHVV�E\�ZKLFK

SDWLHQWV�RU�UHODWLYHV�DW�ULVN�RI�D�GLVRUGHU�WKDW�PD\�EH�KHUHGLWDU\�DUH�DGYLVHG�RI�WKH�FRQVHTXHQFHV�RI�WKH

GLVRUGHU��WKH�SUREDELOLW\�RI�GHYHORSLQJ�RU�WUDQVPLWWLQJ�LW�DQG�RI�WKH�ZD\V�LQ�ZKLFK�WKLV�PD\�EH�SUHYHQWHG��DYRLGHG

RU�DPHOLRUDWHG´��+DUSHU��������S������+RZHYHU��SURYLGLQJ�SDWLHQWV�ZLWK�VXFK�LQIRUPDWLRQ�GRHV�QRW�QHFHVVDULO\

HQVXUH�WKDW�WKH\�ZLOO�LQWHUSUHW�RU�UHFDOO�LW�FRUUHFWO\��:DWVRQ�HW�DO����������)XUWKHUPRUH��DOWKRXJK�JHQHWLF

FRXQVHOLQJ�PD\�EULQJ�UHDVVXUDQFH�WR�VRPH�LQGLYLGXDOV��LW�DOVR�KDV�WKH�SRWHQWLDO�WR�FDXVH�SV\FKRORJLFDO�GLVWUHVV�

7KHUHIRUH��WKH�8�.��'HSDUWPHQW�RI�+HDOWK��������KDV�UHFRPPHQGHG�WKDW�SV\FKRORJLFDO�VXSSRUW�EH�SDUW�RI�WKH

JHQHWLF�FRXQVHOLQJ�SURFHVV��DQG�DVVHVVPHQW�RI�WKH�SV\FKRORJLFDO�LPSDFW�RI�WKHVH�VHUYLFHV�KDV�EHHQ�DGYRFDWHG�

5HODWLYHO\�OLWWOH�LV�NQRZQ�DERXW�KRZ�GLIIHUHQW�SHRSOH�UHDFW�WR�JHQHWLF�FRXQVHOLQJ�RU�KRZ�DGYHUVH�UHDFWLRQV�VKRXOG

EH�KDQGOHG�7KHUH�LV�HYLGHQFH�WKDW�D�VLJQLILFDQW�PLQRULW\�RI�LQGLYLGXDOV�ZLWK�D�IDPLO\�KLVWRU\�RI�FDQFHU�H[SHULHQFH

KLJK�OHYHOV�RI�SV\FKRORJLFDO�GLVWUHVV��H�J���.DVK��+ROODQG��+DOSHU��0LOOHU��������/HUPDQ�HW�DO����������6RPH

VWXGLHV�KDYH�IRXQG�WKDW�JHQHWLF�FRXQVHOLQJ�LV�DVVRFLDWHG�ZLWK�GHFUHDVHV�LQ�RYHUDOO�OHYHOV�RI�GLVWUHVV��H�J���.HOOHU

HW�DO����������ZKHUHDV�RWKHUV�KDYH�IRXQG�QR�VLJQLILFDQW�FKDQJH��H�J���+RSZRRG��6KHQWRQ��/DOORR��(YDQV�

+RZHOO���������3URVSHFWLYH�VWXGLHV�KDYH�IRXQG�VRPH�HYLGHQFH�WKDW�LQGLYLGXDOV¶�ULVN�SHUFHSWLRQV�WHQG�WR

EHFRPH�VRPHZKDW�PRUH�DFFXUDWH�DIWHU�JHQHWLF�FRXQVHOLQJ�DOWKRXJK�WKLV�KDV�QRW�EHHQ�FRQILUPHG�LQ�UDQGRPL]HG

FRQWUROOHG�WULDOV��%UDLWKZDLWH��(PHU\��:DOWHU��3URYRVW��6XWWRQ��������0HLVHU�+DOOLGD\���������7KRVH

���0D\����� 3DJH���RI��� 3UR4XHVW

Page 5: Applying a Cognitive Behavioral Model of Health Anxiety in a Cancer Genetics Service

FRQGXFWLQJ�SUHYLRXV�UHVHDUFK�KDYH�JHQHUDOO\�IDLOHG�WR�H[DPLQH�WKH�LPSDFW�RI�JHQHWLF�FRXQVHOLQJ�RQ�RWKHU

FDQFHU�UHODWHG�EHOLHIV�RU�WR�FRPSDUH�UHDFWLRQV�RI�SHRSOH�EHLQJ�FRXQVHOHG�IRU�GLIIHUHQW�W\SHV�RI�FDQFHU�(YHQ�LI�D

VDPSOH�DV�D�ZKROH�VKRZV�D�GHFUHDVH�RU�QR�VLJQLILFDQW�FKDQJH�RQ�PHDVXUHV�RI�GLVWUHVV�DIWHU�JHQHWLF�FRXQVHOLQJ�

SDUWLFXODU�LQGLYLGXDOV�PD\�H[SHULHQFH�VXEVWDQWLDO�LQFUHDVHV�LQ�GLVWUHVV��$V�WKH�GHPDQG�IRU�JHQHWLF�FRXQVHOLQJ

DQG�WHVWLQJ�LQFUHDVHV��SV\FKRORJLFDO�VXSSRUW�ZLOO�QHHG�WR�EH�IRFXVHG�RQ�WKRVH�DW�KLJK�ULVN�IRU�H[SHULHQFLQJ

DGYHUVH�SV\FKRORJLFDO�HIIHFWV��*URVIHOG��/LSV��%HHPHU��WHQ�.URRGH���������$�IHZ�UHVHDUFKHUV�KDYH�FRQGXFWHG

VWXGLHV�RQ�SUHFRXQVHOLQJ�SUHGLFWRUV�RI�SRVWFRXQVHOLQJ�GLVWUHVV��7KH\�KDYH�JHQHUDOO\�IRXQG�WKDW�VFRUHV�RQ�D

SUHFRXQVHOLQJ�PHDVXUH�RI�GLVWUHVV�FDQ�SUHGLFW�SRVWFRXQVHOLQJ�VFRUHV�RQ�WKH�VDPH�PHDVXUH��&XOO�HW�DO��������

/HUPDQ�HW�DO����������3UHFRXQVHOLQJ�ULVN�SHUFHSWLRQV�FDQ�DOVR�SUHGLFW�SRVWFRXQVHOLQJ�GLVWUHVV��5LWYR�HW�DO�������

���6RFLRGHPRJUDSKLF�YDULDEOHV�JHQHUDOO\�SUHGLFW�OLWWOH�RU�QR�YDULDQFH�LQ�SRVWFRXQVHOLQJ�GLVWUHVV�)HZ�DXWKRUV�RI

SXEOLVKHG�VWXGLHV�KDYH�UHSRUWHG�XVLQJ�D�SV\FKRORJLFDO�PRGHO�WR�JXLGH�WKHLU�VHDUFK�IRU�SUHFRXQVHOLQJ�SUHGLFWRUV

RI�GLVWUHVV�RU�ULVN�SHUFHSWLRQV�LQ�SHRSOH�XQGHUJRLQJ�JHQHWLF�FRXQVHOLQJ��$�QRWDEOH�H[FHSWLRQ�LV�WKH�XVH�RI

0LOOHU¶V��������PRQLWRULQJ�EOXQWLQJ�PRGHO��2QH�VWXG\��/HUPDQ�HW�DO���������IRXQG�WKDW�ZRPHQ�ZLWK�D�IDPLO\

KLVWRU\�RI�EUHDVW�FDQFHU�ZKR�KDG�D�PRQLWRULQJ�FRSLQJ�VW\OH�VKRZHG�LQFUHDVHV�LQ�JHQHUDO�GLVWUHVV�IURP�EDVHOLQH

WR�IROORZ�XS��DOWKRXJK�WKHUH�ZDV�QR�LPSDFW�RQ�FDQFHU�VSHFLILF�GLVWUHVV��+RZHYHU��D�QXPEHU�RI�VWXGLHV�KDYH

IDLOHG�WR�ILQG�DQ\�DVVRFLDWLRQ�EHWZHHQ�VFRUHV�RQ�WKH�PRQLWRULQJ�VFDOH�DQG�ULVN�SHUFHSWLRQV�RU�GLVWUHVV��H�J��

$XGUDLQ�HW�DO���������&XOO�HW�DO���������,W�KDV�EHHQ�VXJJHVWHG�WKDW�DSSO\LQJ�D�FRJQLWLYH�EHKDYLRUDO��&%��DSSURDFK

WR�WKH�XQGHUVWDQGLQJ�RI�UHDFWLRQV�WR�JHQHWLF�VFUHHQLQJ�PD\�EH�IUXLWIXO��6DONRYVNLV�5LPHV���������2QH�RI�WKH

PRVW�FRPPRQO\�REVHUYHG�SV\FKRORJLFDO�SUREOHPV�LV�DQ[LHW\�DERXW�GHYHORSLQJ�WKH�FRQGLWLRQ�LQ�TXHVWLRQ��$�&%

DSSURDFK�WR�KHDOWK�DQ[LHW\��:DUZLFN�6DONRYVNLV��������VXJJHVWV�WKDW�WKH�H[WHQW�WR�ZKLFK�SHRSOH�DUH�OLNHO\�WR

PDNH�SDUWLFXODUO\�QHJDWLYH�LQWHUSUHWDWLRQV�RI�KHDOWK�LQIRUPDWLRQ��DQG�WKHUHIRUH�WR�H[SHULHQFH�H[FHVVLYH�DQ[LHW\�

LV�GHWHUPLQHG�SDUWO\�E\�WKHLU�SUHH[LVWLQJ�JHQHUDO�EHOLHIV�DERXW�KHDOWK��WKHLU�VSHFLILF�EHOLHIV�DERXW�WKH�GLVHDVH�LQ

TXHVWLRQ��DQG�WKH�H[WHQW�WR�ZKLFK�WKHLU�LQWHUSUHWDWLRQV�WULJJHU�PDLQWDLQLQJ�IDFWRUV�VXFK�DV�FKHFNLQJ�RU

UHDVVXUDQFH�VHHNLQJ�EHKDYLRUV��$W�OHDVW�IRXU�DVSHFWV�RI�WKHLU�VSHFLILF�EHOLHIV�DERXW�WKH�LOOQHVV�DUH�WKRXJKW�WR�EH

FHQWUDO�WR�WKH�SHUFHSWLRQ�RI�WKUHDW�DQG�KHQFH�WR�WKH�DQ[LHW\�UHDFWLRQ���D��KRZ�OLNHO\�WKH\�SHUFHLYH�WKH�LOOQHVV�WR

EH���E��KRZ�VHYHUH�WKH�QHJDWLYH�FRQVHTXHQFHV�RI�WKH�LOOQHVV�ZRXOG�EH���F��KRZ�ZHOO�WKH\�WKLQN�WKH\�ZRXOG�FRSH�LI

WKH\�GHYHORSHG�WKH�LOOQHVV��DQG��G��KRZ�PXFK�H[WHUQDO�KHOS�PLJKW�EH�DYDLODEOH��H�J���KRZ�WUHDWDEOH�D�FRQGLWLRQ

PLJKW�EH���7KLV�&%�PRGHO�RI�KHDOWK�DQ[LHW\�KDV�EHHQ�VXFFHVVIXOO\�DSSOLHG�WR�WKH�SUHGLFWLRQ�RI�LQGLYLGXDO

GLIIHUHQFHV�LQ�SV\FKRORJLFDO�UHDFWLRQV�WR�D�QRQJHQHWLF�W\SH�RI�KHDOWK�DVVHVVPHQW²ERQH�GHQVLW\�VFUHHQLQJ�IRU

RVWHRSRURVLV��5LPHV�6DONRYVNLV���������)RU�H[DPSOH��LW�ZDV�IRXQG�WKDW�JUHDWHU�DQ[LHW\�DERXW�RVWHRSRURVLV

DIWHU�ERQH�GHQVLW\�VFUHHQLQJ�ZDV�DVVRFLDWHG�ZLWK�PRUH�QHJDWLYH�SUHVFDQQLQJ�EHOLHIV�DERXW�WKH�OLNHOLKRRG�RI

GHYHORSLQJ�RVWHRSRURVLV��KRZ�VHULRXV�LW�LV�WR�KDYH�ORZ�ERQH�GHQVLW\��KRZ�ZHOO�RQH�ZRXOG�FRSH�LI�RQH�KDG

RVWHRSRURVLV��WKH�OLNHOLKRRG�RI�VXFFHVVIXO�WUHDWPHQW��DQG�SUHH[LVWLQJ�WHQGHQFLHV�WR�ZRUU\�DERXW�RQH¶V�KHDOWK�DQG

WR�DYRLG�LOOQHVV�UHODWHG�PDWWHUV��6HYHUDO�RI�WKHVH�IDFWRUV�ZHUH�VWURQJHU�SUHGLFWRUV�RI�DQ[LHW\�WKDQ�WKH�VFDQQLQJ

UHVXOW�LWVHOI�7KH�PDLQ�DLPV�RI�WKH�SUHVHQW�VWXG\�ZHUH�

WR�LQYHVWLJDWH�WKH�LPSDFW�RI�JHQHWLF�FRXQVHOLQJ�RQ�DQ[LHW\�DERXW�FDQFHU�DQG�FDQFHU�UHODWHG�EHOLHIV���PRQWKV

DIWHU�FRXQVHOLQJ��

WR�LQYHVWLJDWH�ZKHWKHU�SHRSOH�ZKR�WHQGHG�WR�ZRUU\�DERXW�WKHLU�KHDOWK�ZRXOG�VKRZ�JUHDWHU�GLVWUHVV�DQG�PRUH

QHJDWLYH�FDQFHU�UHODWHG�EHOLHIV�EHIRUH�FRXQVHOLQJ�DQG�ZRXOG�VKRZ�PRUH�QHJDWLYH�UHDFWLRQV�WR�WKH�LQIRUPDWLRQ

WKH\�UHFHLYHG��DQG�

���0D\����� 3DJH���RI��� 3UR4XHVW

Rachel O'Reilly
Rachel O'Reilly
Page 6: Applying a Cognitive Behavioral Model of Health Anxiety in a Cancer Genetics Service

�WR�LQYHVWLJDWH�ZKHWKHU�SUHFRXQVHOLQJ�EHOLHIV�DERXW�WKH�FDQFHU��GHULYHG�IURP�D�&%�DSSURDFK�WR�KHDOWK�DQ[LHW\�

ZRXOG�EH�SUHGLFWLYH�RI�DQ[LHW\�DERXW�FDQFHU��,W�ZDV�K\SRWKHVL]HG�WKDW�SUHH[LVWLQJ�EHOLHIV�ZRXOG�EH�D�EHWWHU

SUHGLFWRU�RI�SRVWFRXQVHOLQJ�DQ[LHW\�DERXW�FDQFHU�WKDQ�SDUWLFLSDQWV¶�FDOFXODWHG�OLIHWLPH�ULVN�RI�FDQFHU��

�$�IXUWKHU�DLP�ZDV�WR�FRPSDUH�WKH�SV\FKRORJLFDO�HIIHFWV�RI�JHQHWLF�FRXQVHOLQJ�RQ�SDUWLFLSDQWV�IURP�IDPLOLHV�ZLWK

EUHDVW�DQG�RU�RYDULDQ�FDQFHU�ZLWK�SHRSOH�IURP�IDPLOLHV�ZLWK�FRORQ�FDQFHU��3UHYLRXVO\�SXEOLVKHG�VWXGLHV�KDYH�QRW

FRPSDUHG�WKH�HIIHFWV�RI�JHQHWLF�FRXQVHOLQJ�RQ�SDWLHQWV�ZLWK�GLIIHUHQW�W\SHV�RI�IDPLOLDO�FDQFHU��3HRSOH�KDYH

GLIIHUHQW�EHOLHIV�DQG�OHYHOV�RI�DQ[LHW\�DERXW�WKH�YDULRXV�W\SHV�RI�FDQFHU��H�J���:URH��6DONRYVNLV�5LPHV��������

DQG�WKH�&%�PRGHO�ZRXOG�VXJJHVW�WKDW�WKH�LPSDFW�RI�JHQHWLF�FRXQVHOLQJ�ZRXOG�WKHUHIRUH�DOVR�YDU\�LQ�UHODWLRQ�WR

WKHVH�SUHH[LVWLQJ�EHOLHIV�DQG�DQ[LHW\��7KXV��LW�ZRXOG�QRW�EH�DSSURSULDWH�WR�VLPSO\�DVVXPH�WKDW�UHDFWLRQV�WR

JHQHWLF�FRXQVHOLQJ�IRU�GLIIHUHQW�IRUPV�RI�FDQFHU�DUH�VLPLODU��,I�JURXS�GLIIHUHQFHV�ZHUH�IRXQG��WKLV�LQIRUPDWLRQ�PD\

DOVR�EH�KHOSIXO�IRU�JHQHWLF�FRXQVHORUV��ZKR�RIWHQ�KDYH�WR�FRXQVHO�SHRSOH�ZLWK�GLIIHUHQW�W\SHV�RI�FDQFHU�LQ�WKHLU

IDPLO\�EDFNJURXQGV��7KHUHIRUH��LQ�WKH�SUHVHQW�VWXG\��ZH�FRPSDUHG�WKH�UHDFWLRQV�RI�SHRSOH�ZLWK�IDPLO\�KLVWRULHV

RI�FRORQ�RU�EUHDVW�DQG�RU�RYDULDQ�FDQFHU��ZKLFK�ZHUH�WKH�WZR�PRVW�FRPPRQ�W\SHV�RI�IDPLO\�FDQFHU�KLVWRU\�LQ�WKLV

VDPSOH��0HWKRGV�3DUWLFLSDQWV3DUWLFLSDQWV�ZHUH�����SHRSOH�UHIHUUHG�WR�WKH�2[IRUG�5HJLRQDO�*HQHWLFV�6HUYLFH�

&KXUFKLOO�+RVSLWDO��2[IRUG��8QLWHG�.LQJGRP��$OO�SDWLHQWV�UHIHUUHG�WR�WKH�FOLQLF�ZHUH�VHQW�WKH�SV\FKRORJLFDO

TXHVWLRQV�WRJHWKHU�ZLWK�WKH�VWDQGDUG�SUHFOLQLF�YLVLW�TXHVWLRQQDLUH��VR�HYHU\RQH�ZKR�SXUVXHG�WKHLU�UHIHUUDO

SDUWLFLSDWHG�LQ�DW�OHDVW�WKH�ILUVW�SDUW�RI�WKLV�VWXG\��3DUWLFLSDQWV�ZHUH�LQFOXGHG�LI�WKH\�ZHUH����\HDUV�RU�ROGHU�DQG

KDG�D�IDPLO\�KLVWRU\�EXW�QRW�SHUVRQDO�KLVWRU\�RI�FDQFHU��3URFHGXUH(YHU\RQH�UHIHUUHG�WR�WKH�FOLQLF�ZDV�VHQW�D

SUHFOLQLF�YLVLW�TXHVWLRQQDLUH�DERXW�IDPLO\�PHGLFDO�KLVWRU\�LQ�RUGHU�IRU�XV�WR�FDOFXODWH�WKHLU�OLIHWLPH�ULVN�RI�FDQFHU�

)RU�WKRVH�IURP�IDPLOLHV�ZLWK�EUHDVW�DQG�RU�RYDULDQ�FDQFHU��WKH�ULVN�ILJXUHV�ZHUH�GHULYHG�E\�LQWHUSRODWLQJ�WKH

&ODXV�GDWD�VHW��&ODXV��5LVFK��7KRPSVRQ��������XVLQJ�WKH�SURJUDP�&\ULOOLF��YHUVLRQ������&\ULOOLF�6RIWZDUH�

2[IRUGVKLUH��8QLWHG�.LQJGRP���������)RU�WKRVH�IURP�IDPLOLHV�ZLWK�FRORQ�FDQFHU��WKH�SUREDELOLW\�RI�D�GRPLQDQWO\

LQKHULWHG�FDQFHU�SUHGLVSRVLQJ�JHQH�ZDV�FDOFXODWHG�XVLQJ�%D\HV¶V�WKHRUHP��7KH�SUREDELOLW\�RI�GHYHORSLQJ�FDQFHU

ZDV�FDOFXODWHG�XVLQJ�WKH�SRSXODWLRQ�SUHYDOHQFH�RI�FDQFHU�DQG�WKH�SHQHWUDQFH�RI�NQRZQ�KHUHGLWDU\�QRQSRO\SRVLV

FRORUHFWDO�FDQFHU��+13&&��JHQHV�3HRSOH�ZKR�ZHUH�FDOFXODWHG�WR�KDYH�D�³ORZ�DGGLWLRQDO�ULVN´��L�H���DW�RU�QHDU

SRSXODWLRQ�ULVN��ZHUH�VHQW�D�OHWWHU�LQIRUPLQJ�WKHP�WKDW�WKHLU�ULVN�KDG�EHHQ�FDOFXODWHG�DQG�WKDW�WKH�FKDQFHV�RI�WKH

FDQFHUV�LQ�WKHLU�IDPLO\�EHLQJ�GHWHUPLQHG�E\�D�PDMRU�LQKHULWHG�JHQHWLF�FRPSRQHQW�ZHUH�YHU\�ORZ��7KHVH�OHWWHUV

FRQWDLQHG�LQIRUPDWLRQ�DERXW�JHQHWLF�LQIOXHQFHV�RQ�FDQFHU��SRSXODWLRQ�UDWHV�RI�FDQFHU��UHFRPPHQGDWLRQV��ZKHUH

DSSURSULDWH��UHJDUGLQJ�KHDOWK�EHKDYLRUV��DQG�DQ�H[SODQDWLRQ�RI�ZK\�IUHTXHQW�VFUHHQLQJ�ZDV�QRW�QHFHVVDU\�LQ

WKHLU�FDVH��3DWLHQWV�ZHUH�WROG�WKDW�WKH\�FRXOG�FRQWDFW�WKH�VHUYLFH�LI�WKH\�KDG�IXUWKHU�TXHVWLRQV��,Q�WKLV�VDPSOH�

�����Q�� �����ZHUH�VHQW�D�OHWWHU�UDWKHU�WKDQ�EHLQJ�VHHQ�LQ�FOLQLF��,QGLYLGXDOV�ZHUH�VHHQ�LQ�FOLQLF�E\�D�VSHFLDOLVW

JHQHWLFV�QXUVH�RU�SK\VLFLDQ�LI�WKHLU�FDOFXODWHG�ULVN�ZDV�QRW�ORZ�RU�LI�IXUWKHU�LQIRUPDWLRQ�ZDV�QHHGHG��)RU�WKRVH

ZKR�ZHUH�VHHQ�LQ�FOLQLF��Q�� ������������WKH�JHQHWLF�FRQVXOWDWLRQ�LQFOXGHG�LQIRUPDWLRQ�DERXW�JHQHWLF�LQIOXHQFHV

RQ�FDQFHU��SRSXODWLRQ�UDWHV�RI�FDQFHU��DQG�UHFRPPHQGDWLRQV�UHJDUGLQJ�KHDOWK�EHKDYLRUV��VXUYHLOODQFH

PHDVXUHV��DQG�JHQHWLF�WHVWLQJ��DV�DSSURSULDWH��)RU�ERWK�WKH�LQGLYLGXDOV�VHHQ�LQ�FOLQLF�DQG�WKRVH�UHFHLYLQJ�WKH

³ORZ�ULVN´�OHWWHU��VRPHWLPHV�DQ�DEVROXWH�ULVN�ILJXUH��H�J���OLIHWLPH�ULVN�RI������ZDV�SURYLGHG��EXW�PRUH�FRPPRQO\

WKHLU�ULVN�ZDV�GLVFXVVHG�LQ�UHODWLRQ�WR�WKH�JHQHUDO�SRSXODWLRQ�ULVN��$�OHWWHU�VXPPDUL]LQJ�WKH�FRQWHQW�RI�WKH

FRQVXOWDWLRQ�ZDV�VHQW�DIWHUZDUG���:KHQ�GLVFXVVLQJ�WKH�SUHVHQW�VWXG\��ZH�ZLOO�XVH�WKH�SKUDVH�³JHQHWLF

FRXQVHOLQJ´�WR�UHIHU�WR�ERWK�WKH�IDFH�WR�IDFH�FRQVXOWDWLRQ�DQG�WKH�OHWWHU�VHQW�WR�VRPH�RI�WKRVH�DW�ORZ�ULVN��)ROORZ�

XS�TXHVWLRQQDLUHV�ZHUH�SRVWHG���PRQWKV�DIWHU�WKH�WLPH�ZKHQ�WKH�SDUWLFLSDQWV�ZDV�HLWKHU�VHHQ�LQ�FOLQLF�RU�VHQW

WKH�OHWWHU�SURYLGLQJ�WKHLU�ULVN�LQIRUPDWLRQ��2QH�UHPLQGHU�ZDV�VHQW�WR�WKRVH�ZKR�GLG�QRW�UHSO\��Q�� �������������

���0D\����� 3DJH���RI��� 3UR4XHVW

Rachel O'Reilly
Page 7: Applying a Cognitive Behavioral Model of Health Anxiety in a Cancer Genetics Service

2I�WKRVH�SDUWLFLSDQWV�ZKR�ZHUH�VHQW�UHPLQGHUV�����VXEVHTXHQWO\�UHWXUQHG�WKHLU�TXHVWLRQQDLUHV��7KHVH

LQGLYLGXDOV�GLG�QRW�UHSRUW�VLJQLILFDQWO\�GLIIHUHQW�OHYHOV�RI�SRVWFRXQVHOLQJ�DQ[LHW\�WKDQ�WKRVH�ZKR�UHWXUQHG�WKHLU

TXHVWLRQQDLUH�XQSURPSWHG��W�������� ������0HDVXUHV�%HOLHIV�DQG�IHHOLQJV�DERXW�FDQFHU9LVXDO�DQDORJXH�VFDOHV

��±�����ZHUH�XVHG��VLPLODU�WR�WKRVH�XVHG�LQ�D�VWXG\�RI�WKH�SUHGLFWLRQ�RI�UHVSRQVHV�WR�ERQH�GHQVLW\�VFUHHQLQJ��

5LPHV�6DONRYVNLV���������7KH�VFDOHV�DUH�XVHG�WR�DVVHVV�IHHOLQJV�DQG�EHOLHIV�DERXW�WKH�W\SH�RI�FDQFHU�WKDW

RFFXUUHG�LQ�WKH�SDUWLFLSDQWV¶�IDPLOLHV��DQ[LHW\�DERXW�WKLV�FDQFHU��QHHG�IRU�UHDVVXUDQFH�DQG�EHOLHIV�DERXW�WKHLU�ULVN

IRU�WKLV�W\SH�RI�FDQFHU��OLNHOLKRRG�WKDW�WKH\�ZRXOG�EH�DEOH�WR�SUHYHQW�LW��KRZ�EDG�LW�ZRXOG�EH�LI�WKH\�GHYHORSHG�WKLV

FDQFHU��KRZ�ZHOO�WKH\�ZRXOG�FRSH�LI�WKH\�GHYHORSHG�WKLV�FDQFHU��DQG�KRZ�OLNHO\�LW�LV�WKDW�WKH�FDQFHU�ZRXOG�EH

VXFFHVVIXOO\�WUHDWHG�LI�WKH\�ZHUH�WR�GHYHORS�LW��)RU�UDWLQJV�RI�WKH�OLNHOLKRRG�RI�GHYHORSLQJ�FDQFHU��SDUWLFLSDQWV

ZHUH�DVNHG�WR�UHSRUW�WKHLU�³IHHOLQJV�UDWKHU�WKDQ�ZKDW�>WKH\�WKRXJKW@�D�µUDWLRQDO¶�RU�µFRUUHFW¶�UHVSRQVH�ZRXOG�EH�´

7KLV�TXHVWLRQ�ZDV�EDVHG�RQ�WKH�DVVXPSWLRQ�WKDW�SHRSOH¶V�IHHOLQJV�DERXW�WKHLU�ULVN�ZRXOG�VKRZ�D�JUHDWHU

DVVRFLDWLRQ�WR�WKHLU�DQ[LHW\�WKDQ�ZKDW�WKH\�PLJKW�UHJDUG�DV�D�³UDWLRQDO´�UHVSRQVH�LQ�ZKLFK�WKH\�GLG�QRW�UHDOO\

EHOLHYH��5LVN�SHUFHSWLRQV�DVVHVVHG�LQ�WKLV�ZD\�KDG�EHHQ�IRXQG�WR�EH�KLJKO\�SUHGLFWLYH�RI�UHDFWLRQV�WR�D�GLIIHUHQW

W\SH�RI�KHDOWK�VFUHHQLQJ�LQ�D�SUHYLRXV�VWXG\��5LPHV�6DONRYVNLV���������)RU�DOO�WKH�VFDOHV��D�KLJKHU�VFRUH

LQGLFDWHG�JUHDWHU�FRQFHUQ�RU�PRUH�QHJDWLYH�EHOLHIV��*HQHUDO�PRRG�UDWLQJV3DUWLFLSDQWV�ZHUH�DVNHG�WR�UDWH�KRZ

PXFK�WKH\�ZRUU\�DERXW�WKHLU�KHDOWK�LQ�JHQHUDO�DQG�WKHLU�FXUUHQW�PRRG��VDGQHVV�ORZ�PRRG��DQ[LHW\��XVLQJ�YLVXDO

DQDORJXH�VFDOHV�DV�GHVFULEHG�HDUOLHU��7KH�FXUUHQW�PRRG�PHDVXUHV�KDYH�EHHQ�XVHG�LQ�SUHYLRXV�UHVHDUFK�LQWR

SV\FKRORJLFDO�DVSHFWV�RI�KHDOWK�VFUHHQLQJ��H�J���5LPHV�6DONRYVNLV��������5LPHV��6DONRYVNLV��6KLSPDQ������

��:URH��6DONRYVNLV��5LPHV���������7KH\�KDYH�VKRZQ�JRRG�VHQVLWLYLW\�WR�FKDQJH�LQ�PRRG�RYHU�WLPH��IRU

H[DPSOH��UDWLQJV�RQ�WKHVH�PHDVXUHV�LQFUHDVH�LPPHGLDWHO\�DIWHU�D�³KLJK�ULVN´�UHVXOW�IURP�ERQH�PLQHUDO�GHQVLW\

VFUHHQLQJ�IRU�RVWHRSRURVLV��5LPHV�HW�DO����������7KH�PHDVXUH�RI�D�WHQGHQF\�WR�ZRUU\�DERXW�RQH¶V�KHDOWK�LQ

JHQHUDO�ZDV�GHYLVHG�IRU�WKLV�VWXG\�EHFDXVH�WKHUH�ZDV�QR�VSDFH�WR�LQFOXGH�WKH�IXOO�KHDOWK�DQ[LHW\�TXHVWLRQQDLUH

XVHG�LQ�RXU�SUHYLRXV�UHVHDUFK��'HPRJUDSKLF�DQG�PHGLFDO�IDPLO\�KLVWRU\'HPRJUDSKLF�DQG�PHGLFDO�IDPLO\�KLVWRU\

LQIRUPDWLRQ�ZDV�WDNHQ�IURP�WKH�VWDQGDUG�FOLQLFDO�TXHVWLRQQDLUH�WKDW�SDUWLFLSDQWV�ZHUH�DVNHG�WR�FRPSOHWH�E\�WKH

JHQHWLFV�FOLQLF��$GGLWLRQDO�SRVWFRXQVHOLQJ�PHDVXUHV7ZR�DGGLWLRQDO�TXHVWLRQV�ZHUH�DVNHG�DW�IROORZ�XS��7KH�ILUVW

ZDV�³'R�\RX�IHHO�PRUH�RU�OHVV�ZRUULHG�DERXW�GHYHORSLQJ�WKLV�FRQGLWLRQ�VLQFH�EHLQJ�UHIHUUHG�WR�WKH�JHQHWLFV

FOLQLF"´�5HVSRQVHV�RQ�D���SRLQW�VFDOH�UDQJHG�IURP�PXFK�OHVV�ZRUULHG��WR�PXFK�PRUH�ZRUULHG����7KH�VHFRQG

TXHVWLRQ�ZDV�³&RPSDUHG�ZLWK�WKH�µDYHUDJH�SHUVRQ�¶�KRZ�PXFK�µDW�ULVN¶�GR�\RX�IHHO�IRU�GHYHORSLQJ�WKLV�FRQGLWLRQ

LQ�WKH�IXWXUH"´�5HVSRQVHV�RQ�WKH���SRLQW�VFDOH�UDQJHG�IURP�PXFK�OHVV�DW�ULVN��WR�PXFK�PRUH�DW�ULVN����6WDWLVWLFDO

$QDO\VLV&KL�VTXDUH�DQDO\VHV�DQG�LQGHSHQGHQW�W��WHVWV�ZHUH�XVHG�WR�FRPSDUH�WKH�FKDUDFWHULVWLFV�RI�SDUWLFLSDQWV

IURP�IDPLOLHV�ZLWK�EUHDVW�DQG�RU�RYDULDQ�RU�FRORQ�FDQFHU��3HRSOH�IURP�IDPLOLHV�ZLWK�KLVWRULHV�RI�EUHDVW�RU�RYDULDQ

FDQFHU�ZHUH�FRPELQHG�EHFDXVH�VRPH�JHQHV��EUHDVW�FDQFHU�JHQHV���DQG����RU�%5&$��DQG�%5&$���KDYH�EHHQ

LGHQWLILHG�DV�RQHV�WKDW�LQFUHDVH�RQH¶V�YXOQHUDELOLW\�WR�ERWK�WKHVH�IRUPV�RI�FDQFHU��3HRSOH�ZHUH�H[FOXGHG�LI�WKH\

KDG�ERWK�FRORQ�FDQFHU�DQG�EUHDVW�RU�RYDULDQ�FDQFHU�LQ�WKHLU�IDPLO\��5HSHDWHG�PHDVXUHV�DQDO\VHV�RI�YDULDQFH

�$129$V��ZHUH�XVHG�WR�FRPSDUH�WKH�WZR�JURXSV�LQ�WHUPV�RI�WKH�SV\FKRORJLFDO�YDULDEOHV�EHIRUH�DQG�DIWHU

FRXQVHOLQJ�7R�LQYHVWLJDWH�UHVSRQVHV�RI�WKRVH�ZLWK�KLJK�DQG�ORZ�OHYHOV�RI�SUHH[LVWLQJ�JHQHUDO�KHDOWK�ZRUU\��ZH

FUHDWHG�WZR�GLFKRWRPRXV�YDULDEOHV�WR�UHSUHVHQW�KLJK�DQG�ORZ�OHYHOV�RI�JHQHUDO�KHDOWK�ZRUU\�DQG�KLJK�DQG�ORZ

FDOFXODWHG�ULVN�RI�FDQFHU��&XWRII�VFRUHV��JHQHUDO�ZRUU\�����YV��JHQHUDO�ZRUU\�����FDOFXODWHG�ULVN��������YV�

FDOFXODWHG�ULVN�!����ZHUH�FKRVHQ�WR�JLYH�VLPLODU�VL]HG�JURXSV��$129$V�ZHUH�XVHG�WR�H[DPLQH�FKDQJH�RYHU�WLPH

LQ�WKH�SV\FKRORJLFDO�YDULDEOHV��ZLWK�KHDOWK�ZRUU\�DQG�FDOFXODWHG�ULVN�DV�JURXSLQJ�YDULDEOHV�0XOWLSOH�UHJUHVVLRQ

DQDO\VHV�ZHUH�SHUIRUPHG�WR�LQYHVWLJDWH�SUHGLFWRUV�RI�DQ[LHW\�DQG�FDQFHU�UHODWHG�EHOLHIV��,Q�FDVHV�LQ�ZKLFK

���0D\����� 3DJH���RI��� 3UR4XHVW

Page 8: Applying a Cognitive Behavioral Model of Health Anxiety in a Cancer Genetics Service

YDULDEOHV�ZHUH�VHOHFWHG�DFFRUGLQJ�WR�WKH�&%�PRGHO��VWDQGDUG��VLPXOWDQHRXV��PXOWLSOH�UHJUHVVLRQ�DQDO\VLV�ZDV

XVHG��)RU�H[SORUDWRU\�DQDO\VHV�ORRNLQJ�DW�ZKHWKHU�PHGLFDO�IDPLO\�KLVWRU\�YDULDEOHV�ZHUH�DVVRFLDWHG�ZLWK�DQ[LHW\

DQG�EHOLHIV��VWHSZLVH�UHJUHVVLRQ�PHWKRGV�ZHUH�XVHG��$�YDULDEOH�ZDV�HQWHUHG�LI�WKH�VLJQLILFDQFH�OHYHO�RI�LWV�)�

ZDV�OHVV�WKDQ������DQG�ZDV�UHPRYHG�LI�WKH�VLJQLILFDQFH�OHYHO�RI�)��ZDV�JUHDWHU�WKDQ������)RU�D�QXPEHU�RI�WKH

SDUWLFLSDQWV��D�IXOO�IDPLO\�KLVWRU\�ZDV�QRW�DYDLODEOH��VR�DQDO\VHV�LQYROYLQJ�WKHVH�YDULDEOHV�W\SLFDOO\�LQYROYHG�D

VPDOOHU�QXPEHU�RI�SDUWLFLSDQWV��*HQGHU�ZDV�QRW�LQFOXGHG�LQ�WKHVH�DQDO\VHV�EHFDXVH�LW�ZRXOG�EH�FRQIRXQGHG

ZLWK�D�KLVWRU\�RI�EUHDVW�DQG�RU�RYDULDQ�FDQFHU��5HVXOWV�6RFLRGHPRJUDSKLF�DQG�&OLQLFDO�&KDUDFWHULVWLFV�RI�WKH

6DPSOH7KH�VDPSOH�FRQWDLQHG�����ZRPHQ���������DQG����PHQ����������7KH�PHDQ�DJH�RI�WKH�SDUWLFLSDQWV�ZDV

�����\HDUV��6'�� �������3DUWLFLSDQWV�ZHUH�QRW�URXWLQHO\�TXHVWLRQHG�DERXW�HWKQLFLW\�H[FHSW�ZKHWKHU�WKH\�RU

PHPEHUV�RI�WKHLU�LPPHGLDWH�IDPLO\�ZHUH�-HZLVK��EHFDXVH�-HZV�RI�$VKNHQD]L�GHVFHQW�PD\�KDYH�HOHYDWHG�ULVN

IRU�FHUWDLQ�W\SHV�RI�FDQFHUV��2I�WKH�����SDUWLFLSDQWV�IRU�ZKRP�GDWD�ZDV�DYDLODEOH�����������VDLG�WKDW�WKH\�RU

VRPHRQH�LQ�WKHLU�LPPHGLDWH�IDPLO\�ZDV�-HZLVK��,Q�NHHSLQJ�ZLWK�WKH�FRPPXQLW\�WKDW�WKH�JHQHWLFV�FOLQLF�VHUYHV�

WKH�PDMRULW\�RI�WKH�SDUWLFLSDQWV�ZHUH�RI�&DXFDVLDQ�RULJLQ�2I�WKRVH�SDUWLFLSDQWV�IRU�ZKRP�WKH�GDWD�ZHUH�DYDLODEOH�

WKH�IDPLO\�KLVWRULHV�ZHUH�DV�IROORZV��������ZLWK�EUHDVW�DQG�RU�RYDULDQ�FDQFHU��������ZLWK�FRORQ�FDQFHU������

ZLWK�ERWK�EUHDVW�DQG�RU�RYDULDQ�DQG�FRORQ�FDQFHU������ZLWK�SURVWDWH�FDQFHU������ZLWK�OXQJ�FDQFHU��DQG�����

ZLWK�WKUHH�RU�PRUH�GLIIHUHQW�FDQFHUV��)RU�VRPH�RI�WKH�DQDO\VHV�GHVFULEHG�EHORZ��SDUWLFLSDQWV�ZLWK�IDPLO\

KLVWRULHV�RI�EUHDVW�DQG�RU�RYDULDQ�FDQFHU�ZHUH�FRPSDUHG�ZLWK�SDUWLFLSDQWV�ZLWK�FRORQ�FDQFHU�LQ�WKHLU�IDPLO\�

3DUWLFLSDQWV�ZLWK�IDPLO\�KLVWRULHV�RI�EUHDVW�DQG�RU�RYDULDQ�FDQFHU�ZHUH�DOO�ZRPHQ��ZKHUHDV�����RI�WKRVH�ZLWK

FRORQ�FDQFHU�IDPLO\�KLVWRULHV�ZHUH�ZRPHQ��7KH�SDUWLFLSDQWV�LQ�WKH�EUHDVW�DQG�RU�RYDULDQ�JURXS�ZHUH�VLJQLILFDQWO\

\RXQJHU��W�������� �����S��������WKDQ�WKRVH�LQ�WKH�FRORQ�FDQFHU�JURXS���0�� �������6'�� ������DQG�0�� ������

6'�� �������UHVSHFWLYHO\���7KHUH�ZDV�QR�VLJQLILFDQW�GLIIHUHQFH��W�������� ������LQ�WKH�FDOFXODWHG�OLIHWLPH�ULVN�RI

FDQFHU�IRU�WKH�LQGLYLGXDOV�ZLWK�EUHDVW�DQG�RU�RYDULDQ�RU�FRORQ�FDQFHU�IDPLO\�KLVWRULHV��0�� �������6'�� ������DQG

0�� �������6'�� �������UHVSHFWLYHO\���$V�ZRXOG�EH�H[SHFWHG��SHRSOH�IURP�IDPLOLHV�ZLWK�EUHDVW�FDQFHU�ZHUH

VLJQLILFDQWO\�PRUH�OLNHO\�WR�KDYH�D�VDPH�JHQGHU�SDUHQW�ZKR�KDG�KDG�FDQFHU��Ȥ�������1�� ������ ������S��������KDG

PRUH�UHODWLYHV�RI�WKH�VDPH�JHQGHU�DV�WKHPVHOYHV�ZLWK�FDQFHU��W�������� ������S��������DQG�KDG�D�JUHDWHU

SURSRUWLRQ�RI�VDPH�JHQGHU�UHODWLYHV�ZLWK�FDQFHU��W�������� ������S���������7KHUH�ZHUH�QR�VLJQLILFDQW�GLIIHUHQFHV

EHWZHHQ�WKH�WZR�JURXSV�UHJDUGLQJ�WKH�QXPEHU�RU�SURSRUWLRQ�RI�UHODWLYHV�ZKR�KDG�KDG�FDQFHU��WKH�QXPEHU�RU

SURSRUWLRQ�RI�FDQFHUV�RQ�WKH�PRVW�DIIHFWHG�VLGH�RI�WKH�IDPLO\��WKH�QXPEHU�RI�SDUHQWV�ZKR�KDG�KDG�FDQFHU�

ZKHWKHU�WKH\�KDG�KDG�D�SDUHQW�ZLWK�FDQFHU�ZKR�KDG�GLHG��WKH�QXPEHU�RI�VLEOLQJV�ZKR�KDG�KDG�FDQFHU��WKH

\RXQJHVW�DJH�RI�FDQFHU�RQVHW�LQ�WKH�IDPLO\��RU�ZKHWKHU�WKH\�KDG�KDG�D�SUHYLRXV�PDMRU�LOOQHVV��&KDUDFWHULVWLFV�RI

3HRSOH�:KR�'LG�1RW�5HWXUQ�WKH�)ROORZ�XS�4XHVWLRQQDLUH&RPSDUHG�ZLWK�WKRVH�ZKR�UHWXUQHG�WKH�IROORZ�XS

TXHVWLRQQDLUH��SHRSOH�ZKR�GLG�QRW�UHWXUQ�WKH�TXHVWLRQQDLUH���������ZHUH�VLJQLILFDQWO\�\RXQJHU�DQG�KDG

VLJQLILFDQWO\�KLJKHU�SUHFRXQVHOLQJ�UDWLQJV�RI�DQ[LHW\�DERXW�FDQFHU��EHOLHI�LQ�WKH�OLNHOLKRRG�WKDW�WKH\�ZRXOG�GHYHORS

FDQFHU��QHHG�IRU�UHDVVXUDQFH��DQG�JHQHUDO�DQ[LHW\��VHH�7DEOH����7KHUH�ZDV�D�QRQVLJQLILFDQW�WUHQG�IRU�WKHP�WR

KDYH�D�KLJKHU�FDOFXODWHG�OLIHWLPH�ULVN�RI�FDQFHU��W�������� ������S�� ������

���0D\����� 3DJH���RI��� 3UR4XHVW

Page 9: Applying a Cognitive Behavioral Model of Health Anxiety in a Cancer Genetics Service

���0D\����� 3DJH���RI��� 3UR4XHVW

Page 10: Applying a Cognitive Behavioral Model of Health Anxiety in a Cancer Genetics Service

��

(QODUJH�WKLV�,PDJH��

&KDUDFWHULVWLFV�RI�3DUWLFLSDQWV�:KR�'LG�DQG�'LG�1RW�5HWXUQ�WKH�)ROORZ�8S�4XHVWLRQQDLUH�,PSDFW�RI�*HQHWLF

&RXQVHOLQJ�$FFXUDF\�RI�ULVN�SHUFHSWLRQV&RUUHODWLRQV�EHWZHHQ�ULVN�EHOLHIV�DQG�FDOFXODWHG�ULVN�ZHUH�U�� ������S��

������EHIRUH�FRXQVHOLQJ�DQG�U�� ������S����������PRQWKV�DIWHUZDUG�IRU�WKH�����SDUWLFLSDQWV�ZKR�UHSRUWHG�WKHLU�ULVN

SHUFHSWLRQV�DW�ERWK�WLPH�SRLQWV��8VLQJ�:LOOLDPV¶V��������UHYLVLRQ�RI�+RWHOOLQJ¶V�IRUPXOD�IRU�WHVWLQJ�WKH�GLIIHUHQFH

EHWZHHQ�WZR�QRQLQGHSHQGHQW�FRUUHODWLRQV��LW�ZDV�IRXQG�WKDW�WKHUH�ZDV�QR�VLJQLILFDQW�GLIIHUHQFH�EHWZHHQ�WKH

FRUUHODWLRQV�IRU�SHUFHLYHG�ULVN�DQG�FDOFXODWHG�ULVN�EHIRUH�DQG�DIWHU�JHQHWLF�FRXQVHOLQJ��W�������� �������7KH

H[WHQW�WR�ZKLFK�SDUWLFLSDQWV�XQGHU��RU�RYHUHVWLPDWHG�WKHLU�ULVN�LV�VKRZQ�LQ�7DEOH����7KH�PHDQ�DPRXQW�RI

GLVFUHSDQF\��LQ�HLWKHU�GLUHFWLRQ��EHWZHHQ�ULVN�EHOLHIV�DQG�FDOFXODWHG�ULVN�EHIRUH�WKH�FRXQVHOLQJ�ZDV�������6'��

������DQG���PRQWKV�DIWHU�WKH�FRXQVHOLQJ�ZDV�������6'�� ��������$�SDLUHG�W��WHVW�LQGLFDWHG�WKDW�WKLV�UHSUHVHQWHG�D

VLJQLILFDQW�LPSURYHPHQW�LQ�DFFXUDF\�RI�ULVN�EHOLHIV�DIWHU�FRXQVHOLQJ��W�������� ������S���������

��

(QODUJH�WKLV�,PDJH��

$FFXUDF\�RI�5LVN�3HUFHSWLRQV�%HIRUH�DQG�$IWHU�&RXQVHOLQJ��Q� ������$Q[LHW\�DERXW�GHYHORSLQJ�FDQFHU7KRVH

ZKR�FRPSOHWHG�TXHVWLRQQDLUHV�DW�ERWK�SRLQWV�VKRZHG�DQ�RYHUDOO�GHFUHDVH�LQ�DQ[LHW\�DERXW�GHYHORSLQJ�FDQFHU�

W�������� ������S����������&RKHQ¶V�G�� �������ZLWK�D�SUHFRXQVHOLQJ�PHDQ�RI�������6'�� �������DQG�D

SRVWFRXQVHOLQJ�PHDQ�RI�������6'�� ��������+RZHYHU�����������������RI�WKH�VDPSOH�KDG�KLJKHU�UDWLQJV�RI

FDQFHU�UHODWHG�DQ[LHW\�DIWHU�FRXQVHOLQJ�WKDQ�EHIRUH�FRXQVHOLQJ��LQFUHDVH�UDQJLQJ�IURP���WR����SRLQWV���

&RPSDULVRQ�RI�$Q[LHW\�DQG�%HOLHIV�$ERXW�&DQFHU�LQ�3HRSOH�:LWK�)DPLO\�+LVWRULHV�RI�%UHDVW�DQG�RU�2YDULDQ�RU

&RORQ�&DQFHU�*HQHUDO�JURXS�GLIIHUHQFHV)RU�PRVW�YDULDEOHV��WKHUH�ZDV�D�PDLQ�HIIHFW�RI�FDQFHU�W\SH��ZLWK�WKH

FRORQ�FDQFHU�JURXS�UHSRUWLQJ�ORZHU�OHYHOV�RI�DQ[LHW\�DERXW�FDQFHU��&RKHQ¶V�G�� ��������JHQHUDO�DQ[LHW\��&RKHQ¶V

G�� ��������VDGQHVV�ORZ�PRRG��&RKHQ¶V�G�� ��������DQG�QHHG�IRU�UHDVVXUDQFH��&RKHQ¶V�G�� ��������,Q�DGGLWLRQ�

WKH�FRORQ�FDQFHU�JURXS�UHSRUWHG�OHVV�QHJDWLYH�EHOLHIV�DERXW�WKH�OLNHOLKRRG�RI�GHYHORSLQJ�FDQFHU�LQ�WKH�QHDU

IXWXUH��&RKHQ¶V�G�� ��������OLNHOLKRRG�RI�GHYHORSLQJ�FDQFHU�DW�DQ\�SRLQW�LQ�WKH�IXWXUH��&RKHQ¶V�G�� ��������KRZ

EDG�LW�ZRXOG�EH�WR�GHYHORS�FDQFHU��&RKHQ¶V�G�� ��������KRZ�ZHOO�WKH\�ZRXOG�FRSH�LI�WKH\�GHYHORSHG�FDQFHU���0D\����� 3DJH���RI��� 3UR4XHVW

Page 11: Applying a Cognitive Behavioral Model of Health Anxiety in a Cancer Genetics Service

�&RKHQ¶V�G�� ��������DQG�WKH�OLNHOLKRRG�RI�VXFFHVVIXO�WUHDWPHQW��&RKHQ¶V�G�� ��������7KHUH�ZHUH�PDLQ�HIIHFWV�RI

WLPH�IRU�VHYHUDO�YDULDEOHV��ZLWK�SDUWLFLSDQWV�UHSRUWLQJ�ORZHU�OHYHOV�RI�DQ[LHW\�DERXW�GHYHORSLQJ�FDQFHU��&RKHQ¶V

G�� �������DQG�JHQHUDO�DQ[LHW\��&RKHQ¶V�G�� ��������ORZHU�SHUFHLYHG�OLNHOLKRRG�RI�GHYHORSLQJ�FDQFHU�LQ�WKH�QHDU

IXWXUH��&RKHQ¶V�G�� �������DQG�DW�DQ\�SRLQW�LQ�WKH�IXWXUH��&RKHQ¶V�G�� ��������DQG�ORZHU�QHHG�IRU�UHDVVXUDQFH

�&RKHQ¶V�G�� �������DW�WKH���PRQWK�IROORZ�XS��VHH�7DEOH���IRU�PHDQV��VWDQGDUG�GHYLDWLRQV��DQG�)��YDOXHV��

���0D\����� 3DJH���RI��� 3UR4XHVW

Page 12: Applying a Cognitive Behavioral Model of Health Anxiety in a Cancer Genetics Service

���0D\����� 3DJH����RI��� 3UR4XHVW

Page 13: Applying a Cognitive Behavioral Model of Health Anxiety in a Cancer Genetics Service

��

(QODUJH�WKLV�,PDJH��

&KDQJHV�LQ�%HOLHIV�DQG�'LVWUHVV�/HYHOV�LQ�3HRSOH�:LWK�)DPLO\�+LVWRULHV�RI�%UHDVW�DQG�RU�2YDULDQ�DQG�&RORQ

&DQFHU7R�FKHFN�WKDW�WKH�JURXS�GLIIHUHQFHV�ZHUH�QRW�VLPSO\�D�UHVXOW�RI�WKH�VLJQLILFDQW�GLIIHUHQFH�LQ�DJH�EHWZHHQ

WKH�WZR�JURXSV��ZH�UHPRYHG�WKH����\RXQJHVW�SDUWLFLSDQWV�IURP�WKH�EUHDVW�FDQFHU�IDPLOLHV�DQG�WKH�WZR�ROGHVW

SDUWLFLSDQWV�IURP�WKH�FRORQ�FDQFHU�IDPLOLHV�VR�WKDW�WKH�WZR�JURXSV�ZHUH�PDWFKHG�IRU�DJH��Q�� ����DQG�Q�� ����

UHVSHFWLYHO\���7KH�$129$V�ZHUH�UHSHDWHG��DQG�WKH�VDPH�SDWWHUQV�RI�UHVXOWV�ZHUH�IRXQG��DOWKRXJK�VRPH�HIIHFWV

ZHUH�VOLJKWO\�ZHDNHU�RU�VWURQJHU�WKDQ�LQ�WKH�RULJLQDO�DQDO\VHV�%HFDXVH�WKH�JURXS�GLIIHUHQFHV�PD\�KDYH�UHVXOWHG

IURP�WKH�IDFW�WKDW�DOO�SDUWLFLSDQWV�LQ�WKH�EUHDVW�FDQFHU�JURXS�ZHUH�ZRPHQ�ZKHUHDV�SDUWLFLSDQWV�LQ�WKH�FRORQ

FDQFHU�JURXS�ZHUH�ERWK�PHQ�DQG�ZRPHQ��ZH�FRQGXFWHG�H[SORUDWRU\�DQDO\VHV�LQ�ZKLFK�WKH�$129$V�ZHUH

UHSHDWHG�XVLQJ�RQO\�WKH����IHPDOH�FRORQ�FDQFHU�SDUWLFLSDQWV��6WLOO�VLJQLILFDQW�JURXS�GLIIHUHQFHV�ZHUH�IRXQG�RQ

IHHOLQJV�FRQFHUQLQJ�WKH�OLNHOLKRRG�RI�GHYHORSLQJ�FDQFHU�DQG�KRZ�EDG�LW�ZRXOG�EH�LI�RQH�GHYHORSHG�FDQFHU��DQG

WKHUH�ZHUH�QRQVLJQLILFDQW�WUHQGV�������S���������LQ�WKH�VDPH�GLUHFWLRQ�IRU�DQ[LHW\�DERXW�FDQFHU�DQG�WKH�OLNHOLKRRG

RI�WUHDWPHQW�VXFFHVV��7KH�JURXS�GLIIHUHQFHV�FRQFHUQLQJ�WKH�QHHG�IRU�UHDVVXUDQFH�RU�RQH¶V�DELOLW\�WR�FRSH�LI�RQH

GHYHORSHG�FDQFHU�ZHUH�QR�ORQJHU�VLJQLILFDQW��+RZHYHU��WKHVH�UHVXOWV�VKRXOG�EH�YLHZHG�ZLWK�FDXWLRQ�EHFDXVH�RI

WKH�VPDOO�QXPEHU�RI�IHPDOH�SDUWLFLSDQWV�LQ�WKH�FRORQ�FDQFHU�JURXS��Q�� �����FRPSDUHG�ZLWK�WKH�QXPEHU�LQ�WKH

EUHDVW�DQG�RU�RYDULDQ�JURXS��Q�� �������'LG�SHRSOH�ZKR�WHQGHG�WR�ZRUU\�DERXW�WKHLU�KHDOWK�UHSRUW�PRUH�QHJDWLYH

FDQFHU�UHODWHG�EHOLHIV�DQG�DQ[LHW\�DQG�UHVSRQG�SDUWLFXODUO\�QHJDWLYHO\�WR�³LQFUHDVHG�ULVN´�LQIRUPDWLRQ"&RQWUDU\

WR�WKH�SUHGLFWLRQ�WKDW�SHRSOH�ZLWK�D�JHQHUDO�WHQGHQF\�WR�ZRUU\�DERXW�WKHLU�KHDOWK��KLJK�KHDOWK�DQ[LHW\�JURXS�

ZRXOG�UHDFW�SDUWLFXODUO\�QHJDWLYHO\�WR�EHLQJ�WROG�WKDW�WKH\�ZHUH�DW�LQFUHDVHG�ULVN�IRU�FDQFHU��WKHUH�ZHUH�QR

VLJQLILFDQW�+HDOWK�$Q[LHW\�î5LVN�î7LPH�LQWHUDFWLRQV��DOO�)��V�������VHH�7DEOH���IRU�PHDQV��VWDQGDUG�GHYLDWLRQV�

DQG�VLJQLILFDQW�HIIHFWV�IRU�DOO�DQDO\VHV�LQ�WKLV�VHFWLRQ���7KHUH�ZHUH�VLJQLILFDQW�+HDOWK�$Q[LHW\�î7LPH�LQWHUDFWLRQV

IRU�DQ[LHW\�DERXW�GHYHORSLQJ�FDQFHU��OLNHOLKRRG�RI�GHYHORSLQJ�FDQFHU�LQ�WKH�QHDU�IXWXUH��QHHG�IRU�UHDVVXUDQFH�

KRZ�EDG�LW�ZRXOG�EH�LI�RQH�GHYHORSHG�FDQFHU��DQG�JHQHUDO�VWDWH�DQ[LHW\�DV�ZHOO�DV�D�QRQVLJQLILFDQW�WUHQG�IRU

OLNHOLKRRG�RI�GHYHORSLQJ�FDQFHU�DW�DQ\�SRLQW�LQ�WKH�IXWXUH��)����������� ������S�� ��������3DLUHG�DQG�LQGHSHQGHQW�W�

WHVWV�ZHUH�XVHG�WR�LQYHVWLJDWH�WKHVH�HIIHFWV�IXUWKHU��ZLWK�DOSKD�OHYHOV�VHW�DW�S���������7KHVH�LQGLFDWHG�WKDW�WKH

KLJK�KHDOWK�DQ[LHW\�JURXS�VKRZHG�D�VLJQLILFDQW�UHGXFWLRQ�LQ�DQ[LHW\�DERXW�FDQFHU�DIWHU�FRXQVHOLQJ��&RKHQ¶V�G��

�������ZKHUHDV�WKH�ORZ�KHDOWK�DQ[LHW\�JURXS�VKRZHG�QR�VLJQLILFDQW�FKDQJH��&RKHQ¶V�G�� ��������VHH�)LJXUH��D�

+RZHYHU��SDUWLFLSDQWV�LQ�WKH�KLJK�KHDOWK�DQ[LHW\�JURXS�ZHUH�VLJQLILFDQWO\�PRUH�DQ[LRXV�WKDQ�WKH�ORZ�KHDOWK�

DQ[LHW\�JURXS�DW�ERWK�WLPH�SRLQWV��&RKHQ¶V�G�� ������EHIRUH�FRXQVHOLQJ�DQG������DIWHUZDUG���7KH�VDPH�SDWWHUQ

RI�UHVXOWV�ZDV�VKRZQ�IRU�JHQHUDO�VWDWH�DQ[LHW\��&RKHQ¶V�G�� ������IRU�WKH�FKDQJH�LQ�WKH�KLJK�KHDOWK�DQ[LHW\

JURXS�������IRU�WKH�FKDQJH�LQ�WKH�ORZ�KHDOWK�DQ[LHW\�JURXS�������IRU�JURXS�GLIIHUHQFHV�EHIRUH�FRXQVHOLQJ��DQG

�����DIWHUZDUG���SHUFHLYHG�OLNHOLKRRG�RI�GHYHORSLQJ�FDQFHU�LQ�WKH�QHDU�IXWXUH��&RKHQ¶V�G�� �������������������DQG

������UHVSHFWLYHO\���DQG�SHUFHLYHG�OLNHOLKRRG�RI�GHYHORSLQJ�FDQFHU�DW�DQ\�SRLQW�LQ�WKH�IXWXUH��&RKHQ¶V�G�� ������

������������DQG�������UHVSHFWLYHO\��VHH�)LJXUH��E���7KH�KLJK�KHDOWK�DQ[LHW\�JURXS�KDG�KLJKHU�UDWLQJV�RI�QHHG�IRU

UHDVVXUDQFH�ERWK�WLPH�SRLQWV��&RKHQ¶V�G�� ������EHIRUH�FRXQVHOLQJ�DQG������DIWHUZDUG���ERWK�JURXSV�VKRZHG�D

VLJQLILFDQW�GHFUHDVH�E\�WKH�IROORZ�XS��&RKHQ¶V�G�� ������IRU�WKH�KLJK�KHDOWK�DQ[LHW\�JURXS�DQG������IRU�WKH�ORZ

KHDOWK�DQ[LHW\�JURXS���DOWKRXJK�WKH�GHFUHDVH�ZDV�VLJQLILFDQWO\�ODUJHU�LQ�WKH�KLJK�KHDOWK�DQ[LHW\�JURXS�

���0D\����� 3DJH����RI��� 3UR4XHVW

Page 14: Applying a Cognitive Behavioral Model of Health Anxiety in a Cancer Genetics Service

��

(QODUJH�WKLV�,PDJH��

*UDSKV�GHSLFWLQJ��D��DQ[LHW\�DERXW�GHYHORSLQJ�FDQFHU�LQ�SHRSOH�ZLWK�KLJK�DQG�ORZ�OHYHOV�RI�KHDOWK�DQ[LHW\�DQG

FDOFXODWHG�ULVN��PHDVXUHG�EHIRUH�JHQHWLF�FRXQVHOLQJ�DQG���PRQWKV�ODWHU�DQG��E��SHUFHLYHG�OLNHOLKRRG�RI

GHYHORSLQJ�FDQFHU�DW�DQ\�SRLQW�LQ�WKH�IXWXUH�LQ�SHRSOH�ZLWK�KLJK�DQG�ORZ�OHYHOV�RI�KHDOWK�DQ[LHW\�DQG�FDOFXODWHG

ULVN

���0D\����� 3DJH����RI��� 3UR4XHVW

Page 15: Applying a Cognitive Behavioral Model of Health Anxiety in a Cancer Genetics Service

��

(QODUJH�WKLV�,PDJH��

*UDSKV�GHSLFWLQJ��D��DQ[LHW\�DERXW�GHYHORSLQJ�FDQFHU�LQ�SHRSOH�ZLWK�KLJK�DQG�ORZ�OHYHOV�RI�KHDOWK�DQ[LHW\�DQG

FDOFXODWHG�ULVN��PHDVXUHG�EHIRUH�JHQHWLF�FRXQVHOLQJ�DQG���PRQWKV�ODWHU�DQG��E��SHUFHLYHG�OLNHOLKRRG�RI

GHYHORSLQJ�FDQFHU�DW�DQ\�SRLQW�LQ�WKH�IXWXUH�LQ�SHRSOH�ZLWK�KLJK�DQG�ORZ�OHYHOV�RI�KHDOWK�DQ[LHW\�DQG�FDOFXODWHG

ULVN

���0D\����� 3DJH����RI��� 3UR4XHVW

Page 16: Applying a Cognitive Behavioral Model of Health Anxiety in a Cancer Genetics Service

���0D\����� 3DJH����RI��� 3UR4XHVW

Page 17: Applying a Cognitive Behavioral Model of Health Anxiety in a Cancer Genetics Service

��

(QODUJH�WKLV�,PDJH��

'LVWUHVV�DQG�%HOLHIV�LQ�3HRSOH�:LWK�/RZ�DQG�+LJK�/HYHOV�RI�+HDOWK�$Q[LHW\�DQG�/RZ�DQG�+LJK�&DOFXODWHG�5LVN

IRU�&DQFHU)RU�EHOLHIV�DERXW�KRZ�EDG�LW�ZRXOG�EH�LI�WKH\�GHYHORSHG�FDQFHU��WKH�KLJK�KHDOWK�DQ[LHW\�JURXS�KDG

PRUH�QHJDWLYH�UDWLQJV�DW�ERWK�WLPH�SRLQWV��&RKHQ¶V�G�� ������EHIRUH�FRXQVHOLQJ�������DIWHU���DOWKRXJK�WKH�ORZ

KHDOWK�DQ[LHW\�JURXS¶V�UDWLQJV�EHFDPH�VLJQLILFDQWO\�PRUH�QHJDWLYH�E\�WKH���PRQWK�IROORZ�XS��&RKHQ¶V�G�� ������

ZKHUHDV�WKH�KLJK�KHDOWK�DQ[LHW\�JURXS�VKRZHG�QR�VLJQLILFDQW�FKDQJH�RYHU�WLPH��&RKHQ¶V�G�� ��������7KH�KLJK

KHDOWK�DQ[LHW\�JURXS�DOVR�UHSRUWHG�JUHDWHU�VDGQHVV�ORZ�PRRG��&RKHQ¶V�G�� �������DQG�PRUH�QHJDWLYH�EHOLHIV

DERXW�KRZ�WKH\�ZRXOG�FRSH�LI�WKH\�GHYHORSHG�FDQFHU��&RKHQ¶V�G�� ��������EXW�WKHUH�ZDV�QR�LQWHUDFWLRQ�ZLWK�WLPH

IRU�WKHVH�YDULDEOHV�7KHUH�ZHUH�PDLQ�HIIHFWV�RI�ULVN�JURXS�IRU�SHUFHLYHG�OLNHOLKRRG�RI�GHYHORSLQJ�FDQFHU�DW�DQ\

SRLQW�LQ�WLPH��&RKHQ¶V�G�� �������DQG�IRU�SHUFHLYHG�ULVN�FRPSDUHG�ZLWK�³WKH�DYHUDJH�SHUVRQ´��&RKHQ¶V�G�� �������

LQGLFDWLQJ�WKDW�WKRVH�ZLWK�JUHDWHU�FDOFXODWHG�OLIHWLPH�ULVN�KDG�KLJKHU�ULVN�SHUFHSWLRQV��1R�LQWHUDFWLRQV�EHWZHHQ

ULVN�JURXS�DQG�WLPH�ZHUH�IRXQG��LQGLFDWLQJ�WKDW�WKRVH�ZLWK�ORZHU�DQG�KLJKHU�ULVN�GLG�QRW�UHVSRQG�VLJQLILFDQWO\

GLIIHUHQWO\�WR�JHQHWLF�FRXQVHOLQJ��3UHGLFWLRQ�RI�$Q[LHW\�DQG�%HOLHIV�3UHGLFWLRQ�RI�DQ[LHW\�DQG�EHOLHIV�IURP

PHGLFDO�IDPLO\�KLVWRU\�YDULDEOHV+LJKHU�SUH��DQG�SRVWFRXQVHOLQJ�UDWLQJV�RI�WKH�OLNHOLKRRG�GHYHORSLQJ�RI�FDQFHU�DW

DQ\�SRLQW�LQ�WKH�IXWXUH�ZHUH�SUHGLFWHG�E\�\RXQJHU�DJH�EXW�E\�QR�RWKHU�PHGLFDO�IDPLO\�KLVWRU\�YDULDEOHV�

6LJQLILFDQW�SUHGLFWRUV�RI�PRUH�QHJDWLYH�EHOLHIV�DERXW�KRZ�EDG�LW�ZRXOG�EH�WR�GHYHORS�FDQFHU�ZHUH�KDYLQJ�KDG�D

SDUHQW�G\LQJ�RI�FDQFHU��ZKLFK�HQWHUHG�WKH�UHJUHVVLRQ�HTXDWLRQ�ILUVW��IROORZHG�E\�KDYLQJ�KDG�D�SUHYLRXV�PDMRU

LOOQHVV��1RQH�RI�WKH�PHGLFDO�IDPLO\�KLVWRU\�YDULDEOHV�ZHUH�VLJQLILFDQW�RI�SUHGLFWRUV�RI�SUH��RU�SRVWFRXQVHOLQJ

DQ[LHW\�DERXW�GHYHORSLQJ�FDQFHU��6HH�7DEOH���IRU�GHWDLOV�RI�WKHVH�UHVXOWV�

���0D\����� 3DJH����RI��� 3UR4XHVW

Page 18: Applying a Cognitive Behavioral Model of Health Anxiety in a Cancer Genetics Service

���0D\����� 3DJH����RI��� 3UR4XHVW

Page 19: Applying a Cognitive Behavioral Model of Health Anxiety in a Cancer Genetics Service

��

(QODUJH�WKLV�,PDJH��

6WHSZLVH�0XOWLSOH�5HJUHVVLRQ�$QDO\VHV�3UHGLFWLQJ�$Q[LHW\�DQG�%HOLHIV�E\�0HGLFDO�DQG�)DPLO\�+LVWRU\�9DULDEOHV�

3UHGLFWLRQ�RI�EHOLHIV�DQG�DQ[LHW\�IURP�YDULDEOHV�GHULYHG�IURP�WKH�&%�PRGHO3RVWFRXQVHOLQJ�EHOLHIV�DERXW�WKH

OLNHOLKRRG�RI�FDQFHU�DW�DQ\�SRLQW�LQ�WKH�IXWXUH�ZHUH�VLJQLILFDQWO\�SUHGLFWHG�E\�SUHFRXQVHOLQJ�OLNHOLKRRG�EHOLHIV��,Q

WKH�SUHGLFWLRQ�RI�SUHFRXQVHOLQJ�OHYHOV�RI�DQ[LHW\�DERXW�GHYHORSLQJ�FDQFHU��WKH�IROORZLQJ�SUHFRXQVHOLQJ�EHOLHIV

HQWHUHG�DV�VLJQLILFDQW�SUHGLFWRUV��EHOLHIV�DERXW�WKH�OLNHOLKRRG�RI�GHYHORSLQJ�FDQFHU�DW�DQ\�SRLQW�LQ�WKH�IXWXUH��WKH

OLNHOLKRRG�RI�GHYHORSLQJ�FDQFHU�LQ�WKH�QHDU�IXWXUH��KRZ�EDG�LW�ZRXOG�EH�LI�RQH�GHYHORSHG�FDQFHU��DQG�WKH�JHQHUDO

WHQGHQF\�WR�ZRUU\�DERXW�RQH¶V�KHDOWK��*UHDWHU�SRVWFRXQVHOLQJ�DQ[LHW\�DERXW�GHYHORSLQJ�FDQFHU�ZDV�SUHGLFWHG

E\�KLJKHU�SUHFRXQVHOLQJ�UDWLQJV�RI�WKH�OLNHOLKRRG�RI�GHYHORSLQJ�FDQFHU�DW�DQ\�SRLQW�LQ�WKH�IXWXUH��PRUH�QHJDWLYH

EHOLHIV�DERXW�RQH¶V�DELOLW\�WR�FRSH�LI�RQH�GHYHORSHG�FDQFHU��DQG�D�JHQHUDO�WHQGHQF\�WR�ZRUU\�DERXW�RQH¶V�KHDOWK�

6HH�7DEOH���IRU�GHWDLOV�RI�WKHVH�UHVXOWV�

���0D\����� 3DJH����RI��� 3UR4XHVW

Page 20: Applying a Cognitive Behavioral Model of Health Anxiety in a Cancer Genetics Service

���0D\����� 3DJH����RI��� 3UR4XHVW

Page 21: Applying a Cognitive Behavioral Model of Health Anxiety in a Cancer Genetics Service

��

(QODUJH�WKLV�,PDJH��

0XOWLSOH�5HJUHVVLRQ�$QDO\VHV�3UHGLFWLQJ�$Q[LHW\�DQG�%HOLHIV�)URP�2WKHU�3V\FKRORJLFDO�9DULDEOHV�'LVFXVVLRQ

6L[�PRQWKV�DIWHU�JHQHWLF�FRXQVHOLQJ��WKHUH�ZDV�DQ�RYHUDOO�GHFUHDVH�LQ�DQ[LHW\�DERXW�FDQFHU��DOWKRXJK�D

VLJQLILFDQW�PLQRULW\�RI�SDUWLFLSDQWV�VKRZHG�KLJKHU�OHYHOV�RI�DQ[LHW\�DIWHUZDUG��)DFWRUV�LQIOXHQFLQJ�WKH�LPSDFW�RI

WKH�FRXQVHOLQJ�LQFOXGHG�EHOLHIV�DERXW�FDQFHU��D�SUHH[LVWLQJ�WHQGHQF\�WR�ZRUU\�DERXW�RQH¶V�KHDOWK��DQG�WKH�W\SH

RI�FDQFHU�LQ�WKH�IDPLO\��$V�SUHGLFWHG��SDUWLFLSDQWV¶�SUHFRXQVHOLQJ�EHOLHIV�ZHUH�PRUH�LPSRUWDQW�SUHGLFWRUV�RI

GLVWUHVV�DIWHU�JHQHWLF�FRXQVHOLQJ�WKDQ�WKH�LQGLYLGXDOV¶�FDOFXODWHG�ULVN�RI�FDQFHU��3UHFRXQVHOLQJ�EHOLHIV�ZHUH

LQIOXHQFHG�LQ�SDUW�E\�WKH�SDUWLFLSDQWV¶�SUHYLRXV�H[SHULHQFHV�RI�LOOQHVV�7KH�UHGXFWLRQ�LQ�DQ[LHW\�DERXW�GHYHORSLQJ

FDQFHU�IRXQG�LQ�WKH�SUHVHQW�VWXG\�LV�FRQVLVWHQW�ZLWK�WKH�ILQGLQJV�RI�VRPH�SUHYLRXV�VWXGLHV�RI�FDQFHU�VSHFLILF

GLVWUHVV��H�J���%LVK�HW�DO���������DOWKRXJK�PRVW�KDYH�IRXQG�WKDW�SRVWFRXQVHOLQJ�FKDQJHV�DUH�QRW�VLJQLILFDQW�

HVSHFLDOO\�LQ�WKH�ORQJHU�WHUP��%UDLWKZDLWH�HW�DO����������2YHUDOO�JURXS�FKDQJHV�FDQ�FRQFHDO�LPSRUWDQW�LQGLYLGXDO

YDULDWLRQV��DQG�LQ�WKLV�FDVH������VKRZHG�DQ�LQFUHDVH�LQ�DQ[LHW\�DERXW�GHYHORSLQJ�FDQFHU�DW�WKH���PRQWK�SRLQW

DIWHU�FRXQVHOLQJ��7KH�FOLQLFDO�VLJQLILFDQFH�RI�WKLV�OHYHO�RI�LQFUHDVH�LV�QRW�NQRZQ��EXW�WKH�LVVXH�UHTXLUHV�IXUWKHU

LQYHVWLJDWLRQ�LQ�FDVH�VRPH�LQGLYLGXDOV�UHTXLUH�IXUWKHU�DGYLFH�RU�KHOS�7KH�H[WHQW�WR�ZKLFK�PHGLFDO�IDPLO\�KLVWRU\

YDULDEOHV�ZHUH�SUHGLFWLYH�RI�EHOLHIV�DQG�DQ[LHW\�DERXW�FDQFHU�ZHUH�LQYHVWLJDWHG�LQ�H[SORUDWRU\�DQDO\VHV��7KHVH

VKRZHG�WKDW�KDYLQJ�KDG�D�SDUHQW�ZKR�KDG�GLHG�RI�FDQFHU�DQG�KDYLQJ�KDG�D�SUHYLRXV�PDMRU�LOOQHVV�ZHUH�ERWK

VLJQLILFDQW�SUHGLFWRUV�RI�EHOLHIV�DERXW�KRZ�EDG�LW�ZRXOG�EH�WR�GHYHORS�FDQFHU��7KLV�LQGLFDWHV�WKDW�SHRSOH¶V

SUHYLRXV�H[SHULHQFH�RI�LOOQHVV��HLWKHU�LQ�WKHPVHOYHV�DQG�RWKHUV��VHHPV�WR�DIIHFW�WKHLU�EHOLHIV�DERXW�WKH

FRQVHTXHQFHV�WKDW�FDQFHU�ZRXOG�KDYH�IRU�WKHP���+RZHYHU��WKH�ILQGLQJV�RI�WKHVH�H[SORUDWRU\�DQDO\VHV�UHTXLUH

UHSOLFDWLRQ�EHFDXVH�VWHSZLVH�PXOWLSOH�UHJUHVVLRQ�PHWKRGV�ZHUH�XVHG��ZKLFK�DUH�PRUH�OLNHO\�WR�EH�DIIHFWHG�E\

FKDQFH�GLIIHUHQFHV�ZLWKLQ�D�VLQJOH�VDPSOH���,Q�FRQWUDVW��EHOLHIV�DERXW�WKH�OLNHOLKRRG�RI�GHYHORSLQJ�FDQFHU�ZHUH

QRW�SUHGLFWHG�E\�DQ\�RI�WKH�PHGLFDO�IDPLO\�KLVWRU\�YDULDEOHV�WKDW�PLJKW�EH�H[SHFWHG�WR�LQIOXHQFH�ULVN�SHUFHSWLRQV�

VXFK�DV�WKH�SHUVRQ¶V�³DFWXDO´��FDOFXODWHG��ULVN��WKH�QXPEHU�RI�SHRSOH�LQ�RQH¶V�IDPLO\�ZKR�KDYH�KDG�FDQFHU��WKH

SURSRUWLRQ�RI�UHODWLYHV�RQ�WKH�DIIHFWHG�VLGH�RI�WKH�IDPLO\�ZKR�KDYH�KDG�FDQFHU��RU�KDYLQJ�KDG�D�VLEOLQJ�ZLWK

FDQFHU��2QO\�\RXQJHU�DJH�SUHGLFWHG�KLJKHU�SUH��DQG�SRVWFRXQVHOLQJ�UDWLQJV�RI�WKH�OLNHOLKRRG�RI�GHYHORSLQJ

FDQFHU�DW�DQ\�SRLQW�LQ�WKH�IXWXUH��)XUWKHUPRUH��QRQH�RI�WKH�PHGLFDO�IDPLO\�KLVWRU\�YDULDEOHV�ZHUH�SUHGLFWRUV�RI

SUH��RU�SRVWFRXQVHOLQJ�DQ[LHW\�DERXW�GHYHORSLQJ�FDQFHU��7KLV�ILQGLQJ�PD\�EH�LPSRUWDQW�LQIRUPDWLRQ�IRU�SHRSOH

ZKR�DUH�WUDLQLQJ�WR�EHFRPH�JHQHWLF�FRXQVHORUV�WR�EHDU�LQ�PLQG��,W�VXJJHVWV�WKDW�RQH�VKRXOG�QRW�PDNH�DQ\

DVVXPSWLRQV�DERXW�SDWLHQWV¶�ULVN�SHUFHSWLRQV�RU�WKH�OHYHO�RI�DQ[LHW\�DERXW�FDQFHU�RQ�WKH�EDVLV�RI�WKHLU�DFWXDO�ULVN

RU�WKH�IDFWV�DERXW�WKHLU�IDPLO\�KLVWRU\�7KH�ILQGLQJ�WKDW�SHUFHLYHG�ULVN�EHIRUH�JHQHWLF�FRXQVHOLQJ�ZDV�VLJQLILFDQWO\

DVVRFLDWHG�ZLWK�DQ[LHW\�LV�FRQVLVWHQW�ZLWK�WKH�UHVXOWV�RI�SUHYLRXV�VWXGLHV��H�J���+RSZRRG�HW�DO���������-XOLDQ�

5H\QLHU�HW�DO����������,Q�WKH�SUHVHQW�VWXG\��ZH�DOVR�H[DPLQHG�RWKHU�EHOLHIV�DV�SUHGLFWRUV�RI�DQ[LHW\��GHULYHG�IURP

D�&%�PRGHO�RI�KHDOWK�DQ[LHW\��$V�H[SHFWHG��EHOLHIV�DERXW�KRZ�QHJDWLYH�WKH�FRQVHTXHQFHV�RI�FDQFHU�ZRXOG�EH

DQG�KRZ�ZHOO�RQH�ZRXOG�FRSH�ZLWK�FDQFHU�ZHUH�ERWK�VLJQLILFDQW�SUHGLFWRUV�RI�DQ[LHW\��+RZHYHU��UHODWLYHO\

SRVLWLYH�EHOLHIV�DERXW�WKH�OLNHOLKRRG�RI�VXFFHVVIXO�SUHYHQWLRQ�DQG�WUHDWPHQW�ZHUH�QRW�SUHGLFWLYH�RI�ORZHU�OHYHOV�RI

DQ[LHW\��SHUKDSV�EHFDXVH�WKH�SUHYHQWLRQ�DQG�WUHDWPHQW�RI�FDQFHU�FDQ�LQYROYH�PHWKRGV�WKDW�DUH�WKHPVHOYHV

DQ[LHW\�SURYRNLQJ�3HRSOH�ZLWK�IDPLO\�KLVWRULHV�RI�FRORQ�FDQFHU�UHSRUWHG�VLJQLILFDQWO\�ORZHU�OHYHOV�RI�GLVWUHVV�WKDQ

SHRSOH�ZLWK�IDPLO\�KLVWRULHV�RI�EUHDVW�DQG�RU�RYDULDQ�FDQFHU��GHVSLWH�QR�VLJQLILFDQW�JURXS�GLIIHUHQFH�LQ�REMHFWLYH

ULVN��$FFRUGLQJ�WR�FRJQLWLYH�PRGHOV�RI�DQ[LHW\��WKLV�LV�EHFDXVH�WKH�FRORQ�FDQFHU�JURXS�KDG�OHVV�QHJDWLYH�FDQFHU�

UHODWHG�EHOLHIV��L�H���DERXW�OLNHOLKRRG��QHJDWLYH�FRQVHTXHQFHV��FRSLQJ�DELOLW\��DQG�WUHDWPHQW���)DFWRUV�WKDW�PD\

���0D\����� 3DJH����RI��� 3UR4XHVW

Page 22: Applying a Cognitive Behavioral Model of Health Anxiety in a Cancer Genetics Service

FRQWULEXWH�WR�WKH�JURXS�GLIIHUHQFHV�LQ�VXFK�EHOLHIV�DUH�WKH�KLJKHU�OHYHO�RI�PDVV�PHGLD�DWWHQWLRQ�WR�EUHDVW�FDQFHU

RU�WKH�IDFW�WKDW�SHRSOH�DUH�PRUH�OLNHO\�WR�KDYH�NQRZQ�SHRSOH�RXWVLGH�WKHLU�IDPLO\�ZLWK�EUHDVW�FDQFHU�EHFDXVH�LW�LV

PRUH�FRPPRQ�LQ�WKH�JHQHUDO�SRSXODWLRQ�3DUWLFLSDQWV¶�JHQHUDO�WHQGHQF\�WR�ZRUU\�DERXW�WKHLU�KHDOWK�DOVR

SUHGLFWHG�FDQFHU�UHODWHG�DQ[LHW\�EHIRUH�DQG�DIWHU�FRXQVHOLQJ��+RZHYHU��FRQWUDU\�WR�H[SHFWDWLRQV��WKH�PRUH

KLJKO\�KHDOWK�DQ[LRXV�LQGLYLGXDOV�VKRZHG�D�VLJQLILFDQW�GHFUHDVH�LQ�DQ[LHW\�DW�IROORZ�XS��ZKHUHDV�WKRVH�ZKR�GLG

QRW�WHQG�WR�ZRUU\�DERXW�WKHLU�KHDOWK�VKRZHG�QR�VLJQLILFDQW�FKDQJH�RYHU�WLPH��7KLV�ILQGLQJ�LV�SUREDEO\�GXH�WR�WKH

IDFW�WKDW�ULVN�SHUFHSWLRQV�ZHUH�UHGXFHG�VLJQLILFDQWO\�LQ�WKH�KLJK�KHDOWK�DQ[LHW\�JURXS�EXW�QRW�LQ�WKH�ORZ�KHDOWK�

DQ[LHW\�JURXS��SHUKDSV�EHFDXVH�WKH�KLJK�KHDOWK�DQ[LHW\�JURXS�KDG�SUHYLRXVO\�EHHQ�RYHUHVWLPDWLQJ�WKHLU�ULVN�WR�D

PXFK�JUHDWHU�GHJUHH�2QH�SRVVLEOH�UHDVRQ�IRU�WKH�GLIIHUHQFH�LQ�WKHVH�ILQGLQJV�IURP�WKRVH�LQ�D�SUHYLRXV�VWXG\�RI

ERQH�GHQVLW\�VFUHHQLQJ�IRU�RVWHRSRURVLV��5LPHV�6DONRYVNLV���������LQ�ZKLFK�KHDOWK�DQ[LRXV�LQGLYLGXDOV�VKRZHG

DQ�LQFUHDVH�LQ�DQ[LHW\�DIWHU�D�KLJK�ULVN�UHVXOW��LV�WKDW�PDQ\�RI�WKH�SDUWLFLSDQWV�LQ�WKH�RVWHRSRURVLV�VWXG\�ZHUH

YROXQWHHULQJ�IRU�VFUHHQLQJ�QRW�EHFDXVH�WKH\�DOUHDG\�SHUFHLYHG�WKHPVHOYHV�WR�EH�DW�ULVN�EXW�VLPSO\�LQ�RUGHU�WR

KHOS�UHVHDUFK��:KHQ�WKRVH�SDUWLFLSDQWV�ZHUH�JLYHQ�KLJK�ULVN�LQIRUPDWLRQ��LW�ZDV�RIWHQ�D�VXUSULVH�DQG�UHVXOWHG�LQ

DQ�LQFUHDVH�LQ�WKHLU�ULVN�SHUFHSWLRQV��,Q�FRQWUDVW��SDUWLFLSDQWV�LQ�WKH�SUHVHQW�VWXG\�ZHUH�DOUHDG\�DZDUH�RI�WKHLU

LQFUHDVHG�ULVN�EHFDXVH�RI�WKHLU�IDPLO\�KLVWRU\�DQG�JHQHUDOO\�RYHUHVWLPDWHG�WKHLU�ULVN�EHIRUHKDQG��+HUH��WKH\

UHFHLYHG�QHZ�LQIRUPDWLRQ�VKRZLQJ�WKDW�WKHLU�ULVN�ZDV�XVXDOO\�PXFK�ORZHU�WKDQ�WKHLU�SUHH[LVWLQJ�ULVN�EHOLHIV�

)XUWKHUPRUH��WKHVH�SDWLHQWV�ZHUH�DOUHDG\�LQ�D�VWDWH�RI�XQFHUWDLQW\�DERXW�WKHLU�ULVN��DQG�WKH�JHQHWLF�FRXQVHOLQJ

PD\�KDYH�KHOSHG�WR�UHGXFH�WKH�DPELJXLW\��7KLV�SRLQW�KLJKOLJKWV�WKH�LPSRUWDQFH�RI�WDNLQJ�LQWR�DFFRXQW�WKH

SHUVRQ¶V�SUHH[LVWLQJ�ULVN�SHUFHSWLRQV�DQG�VWDWH�RI�XQFHUWDLQW\�ZKHQ�DWWHPSWLQJ�WR�XQGHUVWDQG�UHDFWLRQV�WR�KHDOWK

VFUHHQLQJ��7KHVH�IDFWRUV�DUH�OLNHO\�WR�GLIIHU�LQ�SRSXODWLRQ�EDVHG�VFUHHQLQJ�FRPSDUHG�ZLWK�KLJK�ULVN�SRSXODWLRQ

VFUHHQLQJ�$OWKRXJK�WKH�DFFXUDF\�RI�ULVN�SHUFHSWLRQV�LQFUHDVHG�VOLJKWO\��ERWK�JURXSV�ZHUH�VWLOO�JHQHUDOO\

RYHUHVWLPDWLQJ�WKHLU�ULVN�RI�FDQFHU�DIWHU�FRXQVHOLQJ��DV�KDV�EHHQ�IRXQG�LQ�RWKHU�VWXGLHV��3DUWLFLSDQWV¶�DFWXDO�ULVN

VWDWXV�ZDV�QRW�SUHGLFWLYH�RI�KRZ�WKH\�UHVSRQGHG²WKHUH�ZDV�QR�HYLGHQFH�RI�JUHDWHU�UHGXFWLRQV�LQ�ULVN

SHUFHSWLRQV�LQ�WKRVH�ZKR�ZHUH�WROG�WKDW�WKH\�ZHUH�DW�ORZHU�ULVN��,Q�FRQWUDVW��SUHFRXQVHOLQJ�ULVN�SHUFHSWLRQV�ZHUH

D�VWURQJ�SUHGLFWRU�RI�SRVWFRXQVHOLQJ�ULVN�SHUFHSWLRQV��7KLV�ILQGLQJ�LQGLFDWHV�WKDW�WR�DFKLHYH�PRUH�DFFXUDWH�ULVN

SHUFHSWLRQV�DIWHU�JHQHWLF�FRXQVHOLQJ��LW�PD\�EH�QHFHVVDU\�WR�LGHQWLI\�DQG�FRUUHFW�WKH�EDVHV�IRU�LQGLYLGXDOV¶

SUHH[LVWLQJ�LGLRV\QFUDWLF�EHOLHIV��LQ�DGGLWLRQ�WR�SURYLGLQJ�LQIRUPDWLRQ�DERXW�WKHLU�FDOFXODWHG�ULVN��6LPLODUO\��WR

UHGXFH�DQ[LHW\�DERXW�FDQFHU��LW�PD\�EH�KHOSIXO�WR�DGGUHVV�RWKHU�QHJDWLYH�LGLRV\QFUDWLF�EHOLHIV��IRU�H[DPSOH�

DERXW�RQH¶V�DELOLW\�WR�FRSH�LI�RQH�GHYHORSHG�FDQFHU��4XHVWLRQQDLUHV�VXFK�DV�WKH�RQH�XVHG�LQ�WKH�SUHVHQW�VWXG\

FRXOG�EH�XVHG�WR�LGHQWLI\�ZKLFK�LQGLYLGXDOV�PD\�EH�YXOQHUDEOH�WR�H[SHULHQFLQJ�SHUVLVWHQW�GLVWUHVV�DQG�ZKLFK�RI

WKHLU�EHOLHIV�DUH�SDUWLFXODUO\�QHJDWLYH��H�J���ULVN�RI�FDQFHU��FRQVHTXHQFHV��WUHDWPHQW��RQH¶V�FRSLQJ�DELOLW\��DQG�VR

RQ���7KH�JHQHWLF�FRXQVHORU�ZRXOG�WKHQ�QHHG�WR�HOLFLW�WKH�SUHFLVH�FRQWHQW�DQG�UHDVRQV�IRU�WKH�LQGLYLGXDO¶V�EHOLHIV

ZLWKLQ�WKH�VHVVLRQ�LQ�RUGHU�WR�PRGLI\�WKHP�HIIHFWLYHO\�$Q�LPSRUWDQW�SUHYLRXV�VWXG\�LGHQWLI\LQJ�SUHFRXQVHOLQJ

SUHGLFWRUV�RI�SRVWFRXQVHOLQJ�FDQFHU�VSHFLILF�GLVWUHVV�IRXQG�WKDW�SRVWFRXQVHOLQJ�VFRUHV�RQ�WKH�,PSDFW�RI�(YHQW

6FDOH��,(6��+RURZLW]��:LOQHU��$OYDUH]��������ZHUH�SUHGLFWHG�E\�EDVHOLQH�,(6�VFRUHV�DQG�WKDW�RQO\�WKH�OHVV

HGXFDWHG�ZRPHQ�VKRZHG�D�VLJQLILFDQW�GHFUHDVH�LQ�,(6�VFRUHV��/HUPDQ�HW�DO����������8VLQJ�PHDVXUHV�RI

SUHFRXQVHOLQJ�EHOLHIV�DV�SUHGLFWRUV�RI�GLVWUHVV��DV�ZH�GLG�LQ�WKH�SUHVHQW�VWXG\��PHDQV�WKDW�HOHYDWHG�VFRUHV

LQGLFDWH�QRW�RQO\�WKDW�LQWHUYHQWLRQ�PD\�EH�UHTXLUHG�EXW�WKH�QDWXUH�RI�WKDW�LQWHUYHQWLRQ²WKDW�LV��ZKLFK

G\VIXQFWLRQDO�EHOLHIV�QHHG�WR�EH�DGGUHVVHG��)XWXUH�VWXGLHV�VKRXOG�FRPELQH�WKHVH�DSSURDFKHV��XVLQJ�EHOLHI

TXHVWLRQQDLUHV�WRJHWKHU�ZLWK�ZHOO�YDOLGDWHG�PHDVXUHV�RI�V\PSWRPV�DQG�VRFLRGHPRJUDSKLF�YDULDEOHV�

3DUWLFLSDQWV�ZKR�UHWXUQHG�WKHLU�IROORZ�XS�TXHVWLRQQDLUHV�ZHUH�OHVV�DQ[LRXV�DQG�IHOW�OHVV�DW�ULVN�RI�FDQFHU�EHIRUH

���0D\����� 3DJH����RI��� 3UR4XHVW

Page 23: Applying a Cognitive Behavioral Model of Health Anxiety in a Cancer Genetics Service

FRXQVHOLQJ�WKDQ�WKRVH�ZKR�GLG�QRW�UHWXUQ�WKH�VHFRQG�TXHVWLRQQDLUH��7KLV�ILQGLQJ�PHDQV�WKDW�WKH�QHJDWLYH�HIIHFWV

RI�JHQHWLF�FRXQVHOLQJ�ZHUH�SUREDEO\�XQGHUHVWLPDWHG�LQ�WKH�VWXG\��$�IXUWKHU�OLPLWDWLRQ�LV�WKDW�SRVWFRXQVHOLQJ

DVVHVVPHQWV�ZHUH�RQO\�WDNHQ�DW���PRQWKV��DQG�LPPHGLDWH�RU�ORQJHU�WHUP�UHDFWLRQV�PD\�KDYH�VKRZQ�D�GLIIHUHQW

SDWWHUQ�RI�UHVXOWV��7KH�IDFW�WKDW�WKH�SDWLHQWV�ZHUH�DOO�VHHQ�ZLWKLQ�D�VLQJOH�FOLQLF�PD\�DOVR�OLPLW�WKH�JHQHUDOL]DELOLW\

RI�WKH�UHVXOWV��)XUWKHUPRUH��WKH�HWKQLFLW\��HGXFDWLRQ�OHYHO��DQG�VRFLDO�FODVV�RI�WKH�SDUWLFLSDQWV�ZHUH�QRW

DVVHVVHG��ZKLFK�PDNHV�LW�PRUH�GLIILFXOW�WR�FRPSDUH�WKHVH�UHVXOWV�ZLWK�WKRVH�RI�RWKHU�VWXGLHV�WKDW�PD\�KDYH�KDG

GLIIHUHQW�SDUWLFLSDQW�SURILOHV�7KH�TXHVWLRQQDLUH�PHDVXUHV�ZHUH�DGDSWHG�IURP�PHDVXUHV�LQ�D�SUHYLRXV�VWXG\

H[DPLQLQJ�UHVSRQVHV�WR�KHDOWK�VFUHHQLQJ��5LPHV�6DONRYVNLV���������$OWKRXJK�LW�ZRXOG�KDYH�EHHQ�SUHIHUDEOH�WR

XVH�ZHOO�YDOLGDWHG�PHDVXUHV��QR�VXFK�PHDVXUHV�ZHUH�DYDLODEOH�DW�WKH�WLPH�RI�WKH�VWXG\�WKDW�ZHUH�EULHI�HQRXJK

IRU�XVH�LQ�WKDW�FRQWH[W��6LPLODU�PHDVXUHV�KDYH�EHHQ�VKRZQ�WR�EH�SUHGLFWLYH�RI�UHVSRQVHV�WR�KHDOWK�VFUHHQLQJ

DQG�KDYH�JRRG�FRUUHODWLRQV�ZLWK�ORQJHU�PHDVXUHV�RI�KHDOWK�DQ[LHW\��5LPHV�6DONRYVNLV���������+RZHYHU��LQ

IXWXUH�UHVHDUFK��LW�ZLOO�EH�LPSRUWDQW�WR�UHSOLFDWH�WKH�ILQGLQJV�XVLQJ�EHWWHU�YDOLGDWHG�TXHVWLRQQDLUHV�,Q�VHUYLFHV

VXFK�DV�WKH�RQH�VWXGLHG�LQ�WKH�SUHVHQW�VWXG\��JHQHWLF�LQIRUPDWLRQ�LV�RIIHUHG�LQ�D�UDQJH�RI�ZD\V��YDU\LQJ�IURP

OHWWHUV�DERXW�JHQHWLF�ULVN�DQG�RWKHU�UHOHYDQW�LVVXHV�VHQW�WR�WKRVH�DW�REYLRXVO\�ORZ�ULVN�WR�IDFH�WR�IDFH�FRXQVHOLQJ

SURYLGHG�WR�WKRVH�DW�DPELJXRXV�RU�KLJK�ULVN��,Q�WKH�SUHVHQW�VWXG\��ZH�ZLVKHG�WR�HYDOXDWH�DOO�RI�WKRVH�UHIHUUHG�WR

WKH�VHUYLFH��WKDW�LV��WKRVH�DW�DOO�OHYHOV�RI�ULVN��VR�WKH�LQWHUYHQWLRQ�LQHYLWDEO\�FRQWDLQHG�WKLV�UDQJH�RI�FRPSRQHQWV�

7KH�DSSOLFDELOLW\�RI�WKLV�UHVHDUFK�WR�URXWLQH�FOLQLFDO�SUDFWLFH�LV�VWUHQJWKHQHG�E\�WKH�VWXG\¶V�VHWWLQJ�DQG

PHWKRGRORJ\�7KH�&%�PRGHO�RI�KHDOWK�DQ[LHW\�IRFXVHV�SULPDULO\�RQ�WKH�SHUFHSWLRQ�RI�WKUHDW��LQFOXGLQJ�EXW�QRW

FRQILQHG�WR�ULVN��DQG�WKH�DVVRFLDWHG�HPRWLRQDO�UHVSRQVHV��,QWHJUDO�WR�WKLV�WKHRU\�DUH�EHKDYLRUDO�UHVSRQVHV�LQ�WKH

IRUP�RI�VDIHW\�VHHNLQJ�EHKDYLRUV��UDQJLQJ�IURP�DYRLGDQFH�RI�WKUHDWHQLQJ�PHGLFDO�LQIRUPDWLRQ�WR�H[FHVVLYH

UHDVVXUDQFH�VHHNLQJ�EHKDYLRUV��+RZHYHU��WKH�VSHFLILF�SUHGLFWLRQ�RI�PHGLFDOO\�LPSRUWDQW�EHKDYLRUV��H�J��

SUHYHQWLYH�DQG�VXUYHLOODQFH�EHKDYLRUV��LV�RXWVLGH�WKH�IRFXV�RI�WKLV�PRGHO�DQG�PD\�ZHOO�EH�EHVW�YLHZHG�IURP

DQRWKHU�SHUVSHFWLYH��)RU�H[DPSOH��WKH�DVVRFLDWLRQ�EHWZHHQ�DQ[LHW\�DQG�KHDOWK�UHODWHG�EHKDYLRU�FKDQJH�KDV

EHHQ�IRXQG�WR�EH�ZHDN�DQG�LQFRQVLVWHQW�LQ�WKH�FRQWH[W�RI�KHDOWK�VFUHHQLQJ�GHFLVLRQ�PDNLQJ�UHVHDUFK��H�J��

:URH�HW�DO����������������LQ�ZKLFK�DQRWKHU�FRJQLWLYH�WKHRU\��WKH�PRGLILHG�VXEMHFWLYH�H[SHFWHG�XWLOLW\�WKHRU\��PD\

SURYLGH�D�EHWWHU�DFFRXQW�RI�EHKDYLRU�FKDQJH�,Q�FRQFOXVLRQ��DOWKRXJK�JHQHWLF�FRXQVHOLQJ�ZDV�DVVRFLDWHG�ZLWK�DQ

RYHUDOO�GHFUHDVH�LQ�DQ[LHW\�DERXW�GHYHORSLQJ�FDQFHU��PRVW�SHRSOH�FRQWLQXHG�WR�RYHUHVWLPDWH�WKHLU�ULVN�IRU�WKH

GLVHDVH�DQG�VRPH�EHFDPH�PRUH�GLVWUHVVHG��$V�SUHGLFWHG�E\�D�&%�PRGHO�RI�KHDOWK�DQ[LHW\��LQGLYLGXDOV¶

SUHH[LVWLQJ�EHOLHIV�DERXW�FDQFHU�ZHUH�VLJQLILFDQW�SUHGLFWRUV�RI�GLVWUHVV�DQG�ULVN�SHUFHSWLRQV�DIWHU�JHQHWLF

FRXQVHOLQJ��,W�LV�SRVVLEOH�WKDW�JHQHWLF�FRXQVHOLQJ�ZRXOG�UHVXOW�LQ�D�JUHDWHU�DFFXUDF\�LQ�ULVN�SHUFHSWLRQV�DQG

ODUJHU�UHGXFWLRQV�LQ�DQ[LHW\�LI�WKH�EDVHV�IRU�WKHVH�LGLRV\QFUDWLF�EHOLHIV�ZHUH�DGGUHVVHG�ZLWKLQ�WKH�FRQVXOWDWLRQ��$

&%�PRGHO�RI�KHDOWK�DQ[LHW\�KDV�QRZ�EHHQ�VKRZQ�WR�EH�XVHIXO�LQ�XQGHUVWDQGLQJ�DQG�SUHGLFWLQJ�UHDFWLRQV�WR�WZR

W\SHV�RI�KHDOWK�VFUHHQLQJ²ERQH�GHQVLW\�VFUHHQLQJ�IRU�RVWHRSRURVLV�DQG�JHQHWLF�FRXQVHOLQJ�IRU�FDQFHU��)XUWKHU

UHVHDUFK�LV�QHHGHG�WR�LQYHVWLJDWH�ZKHWKHU�LW�LV�DOVR�XVHIXO�LQ�SUHGLFWLQJ�UHDFWLRQV�WR�RWKHU�W\SHV�RI�KHDOWK

VFUHHQLQJ���

5HIHUHQFHV���

���$XGUDLQ��-����6FKZDUW]��0��'����/HUPDQ��&����+XJKHV��&����3HVKNLQ��%��1�����%LHVHFNHU��%�����������$QQDOV�RI

%HKDYLRUDO�0HGLFLQH���

���%LVK��$����6XWWRQ��6����-DFREV��&����/HYHQ��6����5DPLUH]��$�����+RGJVRQ��6�����������%ULWLVK�-RXUQDO�RI�&DQFHU���

���%UDLWKZDLWH��'����(PHU\��-����:DOWHU��)����3UHYRVW��$��7�����6XWWRQ��6�����������-RXUQDO�RI�WKH�1DWLRQDO�&DQFHU

���0D\����� 3DJH����RI��� 3UR4XHVW

Page 24: Applying a Cognitive Behavioral Model of Health Anxiety in a Cancer Genetics Service

,QVWLWXWH���

���&ODXV��(��%����5LVFK��1�����7KRPSVRQ��:��'�����������&DQFHU���

���&XOO��$����$QGHUVRQ��(��'��&����&DPSEHOO��6����0DFND\��-����6P\WK��(�����6WHHO��0�����������%ULWLVK�-RXUQDO�RI

&DQFHU���

���*URVIHOG��)��-��0����/LSV��&��-��0����%HHPHU��)��$�����WHQ�.URRGH��+��)��-�����������-RXUQDO�RI�*HQHWLF

&RXQVHOLQJ���

���+DUSHU��3�����������3UDFWLFDO�JHQHWLF�FRXQVHOOLQJ��2[IRUG��(QJODQG��%XWWHUZRUWK�+HLQHPDQQ���

���+RSZRRG��3����6KHQWRQ��$����/DOORR��)����(YDQV��'��*�����+RZHOO��$�����������-RXUQDO�RI�0HGLFDO�*HQHWLFV���

���+RURZLW]��0����:LOQHU��1�����$OYDUH]��:�����������3V\FKRVRPDWLF�0HGLFLQH���

����-XOLDQ�5H\QLHU��&����(LVLQJHU��)����&KDEDO��)����$XUUHDQ��<����%LJQRQ��<�-�����0DFKHODUG�

5RXPDJQDF��0�����������3V\FKRORJ\�DQG�+HDOWK���

����.DVK��.��0����+ROODQG��-��&����+DOSHU��0��6�����0LOOHU��'��*�����������-RXUQDO�RI�WKH�1DWLRQDO�&DQFHU�,QVWLWXWH���

����.HOOHU��0����-RVW��5����+DXQVWHWWHU��&��0����.LHQOH��3����.QDHEHO��+��3�����*HEHUW��-�����������*HQHWLF�7HVWLQJ���

����/HUPDQ��&����'DO\��0����6DQGV��&����%DOVKHP��$����/XVWEDGHU��(�����+HJJDQ��7�����������-RXUQDO�RI�WKH

1DWLRQDO�&DQFHU�,QVWLWXWH���

����/HUPDQ��&����6FKZDUW]��0��'����0LOOHU��6��0����'DO\��0����6DQGV��&�����5LPHU��%��.�����������+HDOWK

3V\FKRORJ\���

����0HLVHU��%�����+DOOLGD\��-��/�����������6RFLDO�6FLHQFH�DQG�0HGLFLQH���

����0LOOHU��6��0�����������-RXUQDO�RI�3HUVRQDOLW\�DQG�6RFLDO�3V\FKRORJ\���

����5DYLQH��'�����6DPSVRQ��-�����������%ULWLVK�0HGLFDO�-RXUQDO���

����5LPHV��.��$�����6DONRYVNLV��3��0�����������%HKDYLRXU�5HVHDUFK�DQG�7KHUDS\���

����5LPHV��.��$����6DONRYVNLV��3��0�����6KLSPDQ��$��-�����������3V\FKRORJ\�DQG�+HDOWK���

����5LWYR��3����5RELQVRQ��*����,UYLQH��-����%URZQ��/����0DWWKHZ��$�����0XUSK\��.��-�����������3DWLHQW�(GXFDWLRQ�DQG

&RXQVHOLQJ���

����6DONRYVNLV��3��0�����5LPHV��.��$�����������-RXUQDO�RI�3V\FKRVRPDWLF�5HVHDUFK���

�������������*HQHWLFV�DQG�FDQFHU�VHUYLFHV��5HSRUW�RI�D�ZRUNLQJ�JURXS�IRU�WKH�&KLHI�0HGLFDO�2IILFHU�

/RQGRQ��$XWKRU���

����:DUZLFN��+��0��&�����6DONRYVNLV��3��0�����������%HKDYLRXU�5HVHDUFK�DQG�7KHUDS\���

����:DWVRQ��0����'XYLYLHU��9����:DGH

:DOVK��0����$VKOH\��6����'DYLGVRQ��-�����3DSDLNRQRPRX��0�����������-RXUQDO�RI�0HGLFDO�*HQHWLFV���

����:LOOLDPV��(��-�����������-RXUQDO�RI�WKH�5R\DO�6WDWLVWLFDO�6RFLHW\��6HULHV�%���

����:URH��$��/����6DONRYVNLV��3��0�����5LPHV��.��$�����������%HKDYLRXU�5HVHDUFK�7KHUDS\���

����:URH��$��/����6DONRYVNLV��3��0�����5LPHV��.��$�����������+HDOWK�3V\FKRORJ\���

6KRZ�OHVV�

$GGUHVV�IRU�&RUUHVSRQGHQFH�.DWKDULQH�5LPHV��'HSDUWPHQW�RI�3V\FKRORJLFDO�0HGLFLQH��6HFWLRQ�RI�*HQHUDO

+RVSLWDO�3V\FKLDWU\��3������.LQJ¶V�&ROOHJH�/RQGRQ��,QVWLWXWH�RI�3V\FKLDWU\��:HVWRQ�(GXFDWLRQ�&HQWUH���UG

)ORRU������&XWFRPEH�5RDG��/RQGRQ��8QLWHG�.LQJGRP�6(���5-�

(PDLO�N�ULPHV#LRS�NFO�DF�XN�

�������$PHULFDQ�3V\FKRORJLFDO�$VVRFLDWLRQ�

���0D\����� 3DJH����RI��� 3UR4XHVW

Page 25: Applying a Cognitive Behavioral Model of Health Anxiety in a Cancer Genetics Service

� 6XEMHFW��$Q[LHW\��PDMRU���&RJQLWLYH�7KHUDS\��PDMRU���*HQHWLF�&RXQVHOLQJ��PDMRU���1HRSODVPV��PDMRU���5LVN3HUFHSWLRQ��PDMRU���*HQHWLFV��+HDOWK &ODVVLILFDWLRQ��������&DQFHU��������&RJQLWLYH�7KHUDS\ $JH��$GXOWKRRG�����\UV��ROGHU� 3RSXODWLRQ��+XPDQ��0DOH��)HPDOH /RFDWLRQ��8QLWHG�.LQJGRP ,GHQWLILHU��NH\ZRUG���FRJQLWLYH�EHKDYLRUDO�PRGHO��KHDOWK�DQ[LHW\��ULVN�SHUFHSWLRQV��JHQHWLF�FRXQVHOLQJ��FDQFHU 7HVW�DQG�PHDVXUH��9LVXDO�$QDORJXH�6FDOH 0HWKRGRORJ\��(PSLULFDO�6WXG\��)ROORZXS�6WXG\��4XDQWLWDWLYH�6WXG\ $XWKRU�H�PDLO�DGGUHVV��N�ULPHV#LRS�NFO�DF�XN &RQWDFW�LQGLYLGXDO��5LPHV��.DWKDULQH�$���'HSDUWPHQW�RI�3V\FKRORJLFDO�0HGLFLQH��6HFWLRQ�RI�*HQHUDO�+RVSLWDO3V\FKLDWU\��3������.LQJV�&ROOHJH�/RQGRQ��,QVWLWXWH�RI�3V\FKLDWU\��:HVWRQ�(GXFDWLRQ�&HQWUH�����&XWFRPEH5RDG�����UG�)ORRU���/RQGRQ��6(���5-��8QLWHG�.LQJGRP���N�ULPHV#LRS�NFO�DF�XN 3XEOLFDWLRQ�WLWOH��+HDOWK�3V\FKRORJ\ 9ROXPH���� ,VVXH��� 3DJHV��������� 3XEOLFDWLRQ�GDWH��0DU����� )RUPDW�FRYHUHG��(OHFWURQLF 3XEOLVKHU��$PHULFDQ�3V\FKRORJLFDO�$VVRFLDWLRQ &RXQWU\�RI�SXEOLFDWLRQ��8QLWHG�6WDWHV ,661����������� H,661����������� 3HHU�UHYLHZHG��<HV /DQJXDJH��(QJOLVK 'RFXPHQW�W\SH��-RXUQDO��-RXUQDO�$UWLFOH��3HHU�5HYLHZHG�-RXUQDO 1XPEHU�RI�UHIHUHQFHV���� '2,��KWWS���G[�GRL�RUJ��������������������������� 5HOHDVH�GDWH�����0DU�������3V\F,1)2������-XO�������3V\F$57,&/(6� &RUUHFWLRQ�GDWH�����1RY�������3V\F,1)2� $FFHVVLRQ�QXPEHU���������������� 3XE0HG�,'���������� 3UR4XHVW�GRFXPHQW�,'����������� 'RFXPHQW�85/�KWWSV���IJXO�LGP�RFOF�RUJ�ORJLQ"XUO KWWS���VHDUFK�SURTXHVW�FRP�GRFYLHZ����������"DFFRXQWLG �����

���0D\����� 3DJH����RI��� 3UR4XHVW

Page 26: Applying a Cognitive Behavioral Model of Health Anxiety in a Cancer Genetics Service

&RS\ULJKW����$PHULFDQ�3V\FKRORJLFDO�$VVRFLDWLRQ����� 'DWDEDVH��3V\F$57,&/(6

���0D\����� 3DJH����RI��� 3UR4XHVW

Page 27: Applying a Cognitive Behavioral Model of Health Anxiety in a Cancer Genetics Service

%LEOLRJUDSK\&LWDWLRQ�VW\OH��$3$��WK���$PHULFDQ�3V\FKRORJLFDO�$VVRFLDWLRQ���WK�(GLWLRQ�

5LPHV��.��$���6DONRYVNLV��3��0���-RQHV��/����/XFDVVHQ��$��0����������$SSO\LQJ�D�FRJQLWLYH�EHKDYLRUDO�PRGHO�RIKHDOWK�DQ[LHW\�LQ�D�FDQFHU�JHQHWLFV�VHUYLFH��+HDOWK�3V\FKRORJ\�����������������GRL�KWWS���G[�GRL�RUJ����������������������������

_______________________________________________________________ &RQWDFW�3UR4XHVW &RS\ULJKW�������3UR4XHVW�//&��$OO�ULJKWV�UHVHUYHG����7HUPV�DQG�&RQGLWLRQV

���0D\����� 3DJH����RI��� 3UR4XHVW