Cancer Worry, Perceived Risk and Cancer Screening in First-Degree Relatives of Patients with Familial Gastric Cancer
Abstract
Currently, there is a lack of evidence evaluating the psychological impact of cancer-related risk perception and worry in individuals at high risk for gastric cancer. We examined the relationships between perceived risk, cancer worry and screening behaviors among first-degree relatives (FDRs) of patients with familial gastric cancer. FDRs of patients diagnosed with familial gastric cancer with a non-informative genetic analysis were identified and contacted. Participants completed a telephone interview that assessed socio-demographic information, cancer risk perception, cancer worry, impact of worry on daily functioning, and screening behaviors. Twenty-five FDRs completed the telephone interview. Participants reported high levels of comparative and absolute cancer risk perception, with an average perceived lifetime risk of 54 %. On the other hand, cancer-related worry scores were low, with a significant minority (12 %) experiencing high levels of worry. Study participants exhibited high levels of confidence (median = 70 %) in the effectiveness of screening at detecting a curable cancer. Participants that had undergone screening in the past showed significantly lower levels of cancer-related worry compared to those that had never undergone screening. In conclusion, individuals at high-risk for gastric cancer perceived a very high personal risk of cancer, but reported low levels of cancer worry. This paradoxical result may be attributed to participants’ high levels of confidence in the effectiveness of screening. These findings highlight the importance for clinicians to discuss realistic risk appraisals and expectations towards screening with unaffected members of families at risk for gastric cancer, in an effort to help mitigate anxiety and help with coping.
Introduction
Gastric cancer is the fifth most common cancer (Ferlay et al. 2013) and one of the leading causes of cancer-related deaths worldwide (Jemal et al. 2011; Parkin 1998). In 2015 alone, there will be an estimated 24,590 new cases of gastric cancer in the United States (Siegel et al. 2015). Both genetic and environmental factors are thought to contribute to the etiology of gastric cancer. Recently, there has been increasing recognition of the genetic components of gastric cancer. In approximately 10 % of cases, there is evidence of familial aggregation (Oliveira et al. 2006), but, in the majority of cases, the genetic cause remains unknown. These cases are often simply called “familial gastric cancer” (Oliveira et al. 2006). First-degree relatives (FDRs) of individuals with familial gastric cancer are suspected to be at increased risk of developing the disease compared to those in the general population, with an estimated risk of up to 12 % and up to 80 % in patients with known syndromes such as hereditary diffuse gastric cancer syndrome (La Vecchia et al. 1992).
Familial cancer can cause significant stress and psychological burden for unaffected individuals within a family. Specifically, having a FDR with cancer has been shown to be associated with increased levels of distress and poorer quality of life (QOL) (Gopie et al. 2012). In a study of sisters of women diagnosed with breast cancer, approximately 50 % of study participants were found to have moderate to severe levels of distress (Metcalfe et al. 2013). Several other studies have also found that female relatives of women diagnosed with breast cancer experience high levels of distress and increased recognition of familial risk (Schmid-Büchi et al. 2011; Raveis and Pretter 2005; Mosher et al. 2005).
A population-based study of women at high risk for breast cancer found that nearly one-third suffered from significant cancer-related distress and increased anxiety towards future screening results, compromising daily functioning and mood (Lerman et al. 1991). Similarly, increased cancer worry affecting daily life has been found in families of patients with prostate cancer (Bratt et al. 2000; Schnur et al. 2006). A possible mediator of cancer worry is perceived cancer risk. Schnur et al. (2006) found in a group of patients undergoing prostate cancer screening, that higher levels of self-perceived cancer risk correlated with higher levels of prostate cancer worry (Schnur et al. 2006). In addition, in patients with a family history of prostate cancer, higher self-perception of cancer risk was associated with depression and cancer worry (Bratt et al. 2000). Interestingly, Mellon et al. (2008) found, in a group of breast and ovarian cancer survivors, that cancer worry and perceived risk mutually affected each other.
Increased levels of cancer-related worry have also been linked to increased anxiety, emotional distress, low mood, and impaired daily functioning in relatives of patients suffering from familial diseases (Andersen et al. 2003; Cella et al. 2002; Hay et al. 2006; Lerman et al. 1991; Trask et al. 2001). Moreover, familial risk has also been shown to serve as motivation for increased cancer screening behaviors and self-reported changes in health (Murabito et al. 2001; Murff et al. 2007; Qureshi and Kai 2008; Wang et al. 2012; Zlot et al. 2009).
Current literature on this topic focuses on high-risk non-gastrointestinal cancers such as breast and ovarian cancers. There is a lack of evidence informing our understanding of cancer worry and its effects in high-risk individuals for familial gastrointestinal (GI) cancers. GI cancers have numerous considerations related in part to treatment, prognosis, and changes to body image that may differentiate them from non-GI cancers, and thus the current literature from non-GI cancers may not be directly translatable to GI cancers. In the spectrum of familial GI cancers, gastric cancer is notably different. Firstly, gastric cancer often carries a bleaker prognosis, due to its advanced stage at detection, with an overall 5-year survival of 29 % (ranging from 71 % for stage IA to 4 % for stage IV) (American Joint Committee on Cancer 2010). Treatment is often extensive, and may involve chemotherapy, radiotherapy and radical surgery such as total gastrectomy, even at the early stages. Secondly, screening for gastric cancer tends to be less effective, and more invasive than for other cancers, which can affect screening behavior (Andersen et al. 2003; Kim et al. 2013). Finally, evidence for gastric cancer screening in asymptomatic individuals remains controversial and screening modalities and recommendations vary in different countries. In the United States, gastric cancer screening is not currently recommended as evidence has shown no reduction in mortality due to low incidence of the disease (National Cancer Institute 2015). However, in Asia, gastric cancer is the second most common cause of cancer death and national screening programs (involving upper gastrointestinal radiologic studies and endoscopy) are in place in Japan and Korea for individuals over the age of 40 (Leung et al. 2008).
Purpose of the Study
A better understanding of gastric cancer worry and its psychosocial impact on patients and their families is needed to provide appropriate counseling, mitigate worry and inform future interventions for patients and high-risk individuals. This is especially the case where genetic analysis is non-informative (no mutation found). In contrast to cases where defined mutations are found (such as hereditary diffuse gastric cancer), risks and recommendations in non-informative cases are less clearly defined and may result in greater uncertainty among family members. In this study, we aim to: 1) characterize cancer-related worry, risk perception and impact on health behaviors among FDRs of patients with familial gastric cancer with a non-informative genetic analysis, 2) assess the factors associated with cancer-related worry and its impact on daily functioning in FDRs, and 3) determine the relationships between cancer-related worry, risk perception and screening behaviors among FDRs.
Methods
Study Design and Sample
This cross-sectional study was conducted among FDRs of patients diagnosed with familial gastric cancer with a non-informative genetic analysis (no mutation found). Familial gastric cancer was defined as having three or more relatives with gastric cancer diagnosed at any age (with at least one FDR), having two or more relatives with gastric/gastroesophageal cancer (with at least one FDR), or where one relative was diagnosed at age 50 or younger. Patients were excluded if they had a personal history of gastric cancer or an established genetic diagnosis such as hereditary diffuse gastric cancer syndrome, familial adenomatous polyposis, or Lynch syndrome. FDRs were identified through the Familial Gastrointestinal Cancer Registry (FGICR) housed at Zane Cohen Centre for Digestive Diseases at Mount Sinai Hospital in Toronto, Canada. All patients registered in the FGICR were assessed by experienced genetic counselors, and family pedigrees were created. Patients with diffuse-type gastric cancer were tested for CDH1 mutations and patients with intestinal-type gastric cancer were tested for Lynch syndrome. Variants of unknown significance were considered non-informative. As genetic testing of the index patient with gastric cancer was non-informative, FDRs were not tested for genetic mutations. Additionally, no numerical estimate of future risk of gastric or other cancers were provided, and no specific screening recommendations were given. Patients and FDRs were made aware of endoscopy as a method of gastric cancer detection but were counseled on the lack of proven benefit for regular endoscopy for screening purposes in this setting. For each proband with familial gastric cancer, consent was obtained, and all living FDRs in the family were approached for recruitment into the study. FDRs were excluded from recruitment if they did not speak English, or were under the age of 18. This study was approved by the institution's Research Ethics Board.
Measures and Procedures
- Risk Perception: Perceived gastric cancer risk was assessed using both absolute and comparative measures (Lipkus et al. 2000). Absolute risk perception was measured on a scale from 0 to 100 % of developing gastric cancer during one's lifetime. Comparative risk perception was assessed using a 5-point Likert Scale, where participants were asked to compare their perceived cancer risk to the general population risk for their own age group.
- Views about gastric cancer screening and susceptibility: Participants were asked a series of nine questions regarding attitudes towards gastric cancer screening and addressing risk of gastric cancer, adapted from a similar study on ovarian cancer (Fallowfield et al. 2010). Examples of questions included perceived effectiveness of gastric cancer screening in increasing survival and thoughts about the possibility of being diagnosed with gastric cancer. Responses were measured using a 4-point Likert scale: (1) strongly disagree; (2) disagree; (3) agree; (4) strongly agree. Responses (1) and (2) were aggregated to form a “disagree” category while responses (3) and (4) were aggregated to form an “agree” category.
- Lerman Cancer Worry Scale (CWS): The CWS was originally created to assess breast cancer worry (Lerman et al. 1991). The revised CWS scale consists of three questions, one question regarding the frequency of cancer worry and two questions regarding the impact of worry about gastric cancer on mood, and daily functioning, respectively. The latter two questions were averaged together to calculate a worry impact score. The responses were assessed using a 4-point Likert scale: (1) not at all/rarely; (2) sometimes; (3) often and (4) a lot. This scale has been shown to have good internal consistency (Cronbach's alpha = 0.68–0.79).
- Worry Interference Scale (WIS): The WIS is a 7-item self-report scale that was originally developed by Trask et al. (2001) to assess the effect of worrying about the risk of ovarian cancer on daily functioning. The WIS scale assesses 7 areas of daily functioning: disruptions in sleep, relationships with others, ability to work, ability to have fun, feeling sexually attractive, ability to concentrate, and ability to meet the needs of one's family. The responses ranged from “not at all” to “a lot” and were scored from 1 to 5, respectively. Summary scores were then calculated, with a minimum possible score of 7 to a maximum score of 35. Higher scores indicated higher levels of interference in daily functioning. The scale has been shown to have excellent internal consistency (Cronbach's alpha =0.89–0.94).
- Multidimensional Impact of Cancer Risk Assessment (MICRA): The MICRA questionnaire is a self-report measure originally developed by Cella et al. (2002) to assess the impact of breast cancer worry on daily life of at-risk participants. For this study, the questions were adapted to assess the impact of gastric cancer worry. The Distress and Uncertainty subscales were used in this study. Participants answered a series of 15 questions measuring general levels of distress and uncertainty about cancer in the past month, with responses assessed on a 5-point Likert scale. The aggregate scores for the two subscales were then transformed into a raw score on a scale from 0 to 100. The scales had high internal consistency (Cronbach's alpha = 0.86 for distress subscale, Cronbach's alpha = 0.77 for uncertainty subscale).
Data Analyses
Baseline characteristics of the study cohort were recorded. Scores from each of the five questionnaires were summed as described and descriptive statistics performed to describe the sample on key variables of interest including frequency of cancer worry, cancer risk perception, age, uncertainty and level of distress. Measures of central tendency and variability were computed for each scale. Mean scores and standards deviations were compared against other published values in high-risk sample populations (Lipkus et al. 2000; van Dooren et al. 2004). To examine the association between variables, two-tailed bivariate analyses were performed using Spearman rank correlations. The Mann-Whitney U test was used to compare differences between subgroups. Subgroups were created based on age, sex, screening behavior, income, relationship status, and education level. All analyses were performed using SPSS (Version 0.7.45, Chicago, Illinois).
Results
Demographic Characteristics of Sample
Of 40 eligible FDRs that initially were contacted to participate in the study, 25 (62.5 %) individuals agreed to participate; these comprised the final study cohort. The demographic characteristics of the sample are shown in Table 1. The mean age was 50 years (s.d. = 13). The majority of participants were Caucasian (92 %), female (68 %), and married or partnered (72 %). Eleven (44 %) reported being employed full-time and 12 (48 %) had completed a college or university degree. Nearly half (44 %) of the sample earned an annual income equal to or over $75,000. Three (12 %) had a personal history of non-gastric cancer (leukemia, breast cancer, and cholangiocarcinoma). The median number of relatives with gastric cancer among study participants was 3 (range: 1–5). Among first-degree relatives of study participants, 72 % had a parent with gastric cancer, 60 % had a sibling with gastric cancer and 12 % had a child with gastric cancer. The median age of diagnosis among these relatives was 53, and 50 % of them had died with a median survival of 2 years from diagnosis.
| Characteristic | Value |
|---|---|
| Age (years) | |
| Median | 50.0 |
| Mean | 50.2 |
| Sex, % male | 32 % |
| Education level | |
| High School | 20 % |
| Some College/University | 24 % |
| College/University Degree | 48 % |
| Graduate School | 8 % |
| Annual income | |
| 0-$40,000 | 32 % |
| $40,000-$75,000 | 24 % |
| ≥ $75,000 | 44 % |
| Employment type | |
| Full-Time | 44 % |
| Part-Time | 4 % |
| Retired | 28 % |
| Not-Employed | 20 % |
| Student | 4 % |
| Relationship status | |
| Married/Partnered | 72 % |
| Divorced | 8 % |
| Widowed | 8 % |
| Single | 12 % |
| Living situation | |
| Spouse/Partner | 28 % |
| Self | 20 % |
| Children | 4 % |
| Spouse/Partner + Children | 40 % |
| First Degree Relativesa | 8 % |
- aNot including children
Cancer Worry and Risk Perception
On average, participants reported a self-perceived absolute lifetime risk of gastric cancer of 54 % (s.d. = 21.3 %) with a median score of 50 %, representing a four- to five-fold increase compared to an estimate in the literature of 12 % (La Vecchia et al. 1992). Participants believed that their risks of cancer were higher than the average person their age in the general population (mean = 4.36, s.d. = 0.76, where 3 = the same risk as the general population on a scale of 1–5, Table 2). On the other hand, participants had relatively low scores for frequency of worry about getting gastric cancer on the cancer worry impact scale (mean = 1.76, s.d. = 0.78), as well as low scores for distress (mean = 33.2/100, s.d. = 24) and uncertainty (32.4/100, s.d. = 19.9) related to the impact of cancer risk on the MICRA scale. Overall, 48 % of participants agreed with the following statement: “The older I get, the more I think about the possibility of getting gastric cancer” (Table 3). Sixty-eight percent of the sample acknowledged that hearing about friends and relatives being diagnosed with cancer increased their own level of cancer worry. Eighty-four percent of participants agreed with the opinion that diagnosing gastric cancer via screening would result in a better prognosis. Other participant responses regarding attitudes and beliefs about gastric cancer screening are reported in Table 3.
| Scale (Range) | Mean | Median | SD |
|---|---|---|---|
| Risk perception | |||
| Absolute risk perception (lifetime) | 54 % | 50 % | 21.3 % |
| Comparative risk perception (1–5) | 4.36 | 4.00 | 0.76 |
| Lerman cancer worry scale | |||
| Frequency of worry scale (1–4) | 1.76 | 2.00 | 0.78 |
| Impact of worry on mood and daily activities (1–4) | 1.18 | 1.00 | 0.45 |
| Worry interference scale (7–35) | 10.24 | 8.00 | 5.01 |
| MICRA | |||
| Distress scale (0–100) | 33.21 | 36.67 | 24.0 |
| Uncertainty scale (0–100) | 32.43 | 31.11 | 19.9 |
- SD standard deviation, MICRA multidimensional impact of cancer risk assessment
| Question (N = 25) | Strongly agree/agree, % |
|---|---|
| If more people went for stomach cancer screening there would be fewer deaths from stomach cancer | 84 % |
| If I was found to have stomach cancer by screening the chances of it being cured are higher. | 84 % |
| If I look out for symptoms of stomach cancer I might find something sooner than if I go for screening | 52 % |
| If a cancer is found in my stomach it is usually too late to do anything about it | 32 % |
| Coming for screening would/has only made me worry (unnecessarily) about stomach cancer | 12 % |
| Whenever I hear of a friend/relative or public figure getting stomach cancer I realize I could get it too | 68 % |
| The older I get, the more I think about the possibility of getting stomach cancer | 48 % |
| There are so many things that could happen to me, it is pointless to think about stomach cancer | 32 % |
| My health is too good at present even to consider thinking that I might get stomach cancer | 44 % |
On the cancer worry impact scale, participants had a relatively low score for the impact of cancer worry on their mood and daily functioning (mean = 1.18, s.d. = 0.45, Table 2). On the Worry Interference Scale (Table 2), the mean summary score was 10.24 (maximum 35). The median score was 8, where 60 % of the population scored less than 10 (implying minimal interference from cancer worry), 28 % had intermediate scores between 10 and 14, and 12 % scored over 15 (implying a high impact of worry on mood and functioning).
Factors significantly associated with increased frequency of cancer worry, as measured by the cancer worry scale, were self-perceived risk of gastric cancer (r = 0.48, p = 0.015) and the number of FDRs with gastric cancer (r = 0.50, p = 0.012). There were no significant associations between cancer worry and age, gender, employment, or education. Increasing age was, however, correlated with the level of distress on the MICRA scale (r = 0.41, p = 0.040). The frequency of cancer worry was significantly associated with the degree of worry interference as measured by the WIS (r = 0.64, p = 0.001), and the level of uncertainty on the MICRA (r = 0.42, p = 0.037).
Screening Behaviors and Views About Gastric Cancer Screening
The vast majority of study participants (80 %) had already undergone some screening modality for gastric cancer. The specific frequencies of gastric cancer screening among participants are shown in Table 4. In addition, 32 % of participants reported undergoing self-directed annual or biannual investigations for the purpose of gastric cancer detection. Participants had a high degree of confidence in the effectiveness of gastric cancer screening, with a median score of 70 % confidence that screening would detect a curable cancer (interquartile range 45–80 %). Twenty-one (84 %) participants believed that fewer deaths would result from gastric cancer if more people underwent gastric cancer screening, with only 3 (12 %) believing that going for screening made them worry unnecessarily about gastric cancer (Table 3). Furthermore, 36 % of participants stated they would continue with their current screening practices for gastric cancer even if they found out these were ineffective at detecting a curable cancer (Table 4).
| Confidence that screening will detect a curable cancer (0–100 %) (N = 25) | ||
| Mean (S.D.) | 60.6 (25.2) | |
| Median | 70.0 (10–98) | |
| If you learned that screening for gastric cancer was NOT effective, would you continue to do your current screening practices?a | ||
| Frequency | Percentage (%) | |
| Yes | 9 | 36 % |
| No | 12 | 48 % |
| Maybe | 4 | 16 % |
| Total | 25 | 100 % |
| Types of screening behaviorb | ||
| Frequency | Percentage (%) | |
| None | 5 | 20 % |
| Endoscopy | 18 | 72 % |
| CT + Endoscopy | 1 | 4 % |
| Barium Swallow | 1 | 4 % |
| Frequency of screening for gastric cancer | ||
| Frequency | Percentage (%) | |
| Never | 5 | 20 % |
| Once before | 8 | 32 % |
| Once every 5 years/Large gaps between screenings | 3 | 12 % |
| Once every 2 years | 2 | 8 % |
| Once every year | 6 | 24 % |
| More than once per year | 1 | 4 % |
- aExact question was asked in telephone interview bParticipants could choose multiple screening practices (only one participant selected more than one behavior, i.e. CT + endoscopy)
Significantly higher levels of worry interference were found in individuals who had never been screened compared to individuals who had undergone screening at least once in their lives (mean = 20.80 versus 11.06; p = 0.006). There were no significant associations between confidence in screening, frequency in screening, and risk perception.
Discussion
This study examined, for the first time, the impact of familial gastric cancer on cancer-related worry, risk perception, and screening attitudes in relatives of affected individuals. We showed that FDRs of patients with familial gastric cancer had high comparative and absolute cancer risk perceptions. Although we found significant positive associations between frequency of cancer worry, absolute risk perception and worry interference, the absolute degree of cancer-related worry and worry interference were low overall. Interestingly, we found that participants exhibited a falsely high confidence in gastric cancer screening modalities, and participants who had undergone gastric cancer screening had lower levels of worry interference.
On average, participants estimated their absolute lifetime risk of gastric cancer to be 54 %. This is likely a marked overestimation, as La Vecchia et al. (1992) estimated the lifetime risk in this population to be closer to 12 %. Compared to other studies involving risk perception of high-risk individuals in familial disease such as breast cancer, participants in the present study had higher absolute and comparative risk perceptions. For example, Lipkus et al. (2000) reported that the average self-perceived lifetime risk of breast cancer in their population was 34.4 %. In another study by van Dooren et al. (2004), only 25 % of women with a family history of breast cancer over-estimated their risk of cancer. Therefore, the majority of participants in the present study had an unrealistically high perception of lifetime risk of cancer compared to other high-risk individuals with familial diseases.
The diagnosis of cancer in a family might have a significant psychological impact on FDRs with cancer-related worry and perceived risk as contributing factors. Our results show a significant positive association between absolute risk perception and cancer worry among FDRs. This finding is consistent with other literature on high-risk cancer samples. For example, several studies on high-risk individuals for breast and ovarian cancer have found a significant positive relationship between cancer-related worry and risk perception (Lipkus et al. 2000; Mellon et al. 2008; van Dooren et al. 2004). However, the frequency of cancer worry in the FDRs in our study was low. Absolute levels of worry interference were also low overall, with a significant minority (12 %) of participants exhibiting high levels of worry interference. Mean worry scores were comparable to other studies on high-risk individuals for pancreatic and breast cancer (Brain et al. 2002; Hart et al. 2012). A possible explanation for the paradoxical finding of high perceived risk but low worry scores could be that although participants believed they were at above-average risk of developing gastric cancer, they may have viewed the approximately 50 % perceived risk as a “coin toss” – that they were equally likely to not develop gastric cancer in their lifetime. This outlook may have helped reduce worry levels. Additionally, we hypothesize that an individual's high confidence in screening practices might help to mitigate cancer-related worry despite a higher risk perception. This hypothesis is supported by significantly lower levels of worry interference in individuals that had undergone screening at least once before compared to those that had never completed any type of gastric cancer screening.
Our sample had a high degree of confidence (70 %) in the effectiveness of gastric cancer screening at detecting a curable cancer. Interestingly, 36 % of our population would continue screening even if screening were known to be ineffective. Although screening programs for gastric cancer exist in countries where incidence rates of gastric cancer are higher (such as Japan and South Korea), screening in Western countries is not considered effective in the general population (Lin 2014). Given the increased prevalence of diffuse-type gastric cancer in the familial gastric cancer population and the reduced utility of endoscopy in this type of cancer, the sensitivity and cost-effectiveness of screening in this North American group is likely more limited than the confidence levels exhibited by our sample. Therefore, conversations with high-risk individuals about the effectiveness of screening in gastric cancer may be needed in order to set more realistic expectations in regards to screening modalities.
Study Limitations
When interpreting the results of this study, several limitations must be considered. The present study design was cross-sectional, and thus temporal changes in worry relative to the time of diagnosis could not be determined. Our sample was predominately Caucasian (92 %) and female (68 %), and therefore may not be reflective of high-risk gastric cancer populations in other ethno-demographic groups. Similarly, the measures used to assess psychosocial outcomes for FDRs, while internally valid, may not be directly generalizable to other types of cancers. In this study, we conducted several exploratory analyses, which may increase the likelihood that some of the findings may be due to chance. In addition, our sample size is small which reduced the power for stastistical analysis, but is reflective of the relatively low prevalence of this condition. Nevertheless, to our knowledge, this is the first study to examine this issue in any type of gastrointestinal cancer, and has demonstrated that the issues surrounding cancer worry that have previously been elicited in breast, ovarian and prostate cancer cannot be directly extrapolated to gastrointestinal cancers.
Practice Implications
In summary, our study examined, for the first time, the psychosocial outcomes for FDRs of patients with familial gastric cancer in the areas of cancer-related worry, risk perception and QOL. Overall, we found that participants had falsely elevated perceptions of their risk of gastric cancer. Although their risk perceptions were positively correlated to level of cancer worry, this sample had generally low absolute levels of cancer worry and worry interference, with a significant minority exhibiting high levels of worry. We hypothesize that this paradoxical result may be secondary to falsely high confidence in the success of gastric cancer screening in this population. These findings underscore the importance of clinicians addressing concerns of unaffected family members at increased risk of gastric cancer. Discussing such concerns in a clinical setting may help identify those with high levels of worry, and mitigate anxiety and poor coping in these high-risk individuals. Specifically, family members may need assistance in having realistic risk appraisals, and making informed decisions about surveillance options.
Research Recommendations
Further research is required to elucidate how perceived risk and cancer-related worry can affect health decisions such as screening. Future qualitative studies regarding the attitudes and concerns of FDRs of patients with familial gastric cancer could also provide additional insight. The discordance in findings between our study and those on familial breast and ovarian cancer also warrants further study of other gastrointestinal malignancies and comparison with families with known genetic mutations, where there may be less uncertainty about cancer risk and surveillance.
Compliance with Ethical Standards
Conflict of Interest
Authors Jenny Li, Tae L. Hart, Melyssa Aronson, Cassandra Crangle, and Anand Govindarajan declare that they have no conflict of interest.
Human Studies and Informed Consent
This study was approved by the Research Ethics Board at Mount Sinai Hospital. All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 (5). Informed consent was obtained from all patients for being included in the study.
Animal Studies
No animal studies were carried out by the authors for this article.
