second cancers. First, women with BRCA mutations (5 to 10 percent of women with breast cancer) are at increased risk of ovarian cancer, non-colonic gastrointestinal cancers, and second primary breast cancer. Women with BRCA1 and BRCA2 mutations who do not undergo prophylactic surgery have a risk of breast cancer of 45 to 84 percent by age 70 (Ford et al., 1998; Antoniou et al., 2003; King et al., 2003; Easton et al., 2004). Such women may benefit from genetic counseling, breast cancer early detection tools (i.e., breast self-examination, clinical breast examinations, annual mammograms, magnetic resonance imaging (MRI) examinations) (Warner et al., 2004), and ovarian cancer detection tools (e.g., transvaginal ultrasound, annual pelvic examination) (Isaacs et al., 2004). Counseling can be provided regarding prophylactic measures such as mastectomy and tamoxifen use to reduce the risk of breast cancer, and oophorectomy to minimize the risk of ovarian cancer. A second small group of women at significantly higher risk of second cancer are those treated with intensive-dose chemotherapy (Fisher et al., 1999). These women are at higher risk of myelodysplasia and acute myelogenous leukemia, and if symptomatic can be evaluated with blood counts.
Most of the literature on the psychosocial aspects of breast cancer suggests that the vast majority of women adjust well to the diagnosis of breast cancer, and manage the complex and sometimes aggressive treatments associated with primary treatment and recurrent disease (Maunsell et al., 1992; Schag et al., 1993; Ganz et al., 1996; Dorval et al., 1998; Ganz et al., 1998a; Hanson Frost et al., 2000; Ganz et al., 2002). When cancer-related distress occurs, it generally dissipates with time for the majority of individuals diagnosed with breast cancer.
The frequency and patterns of psychosocial distress that occur among women with breast cancer depend greatly on which concerns are included in the operational definition of distress and how it is measured. The highest distress levels appear to occur at transition points in treatment: at the time of diagnosis, awaiting treatment, during and on completion of treatment, at follow-up visits, at time of recurrence, and at time of treatment failure (Box 3-4). Taken overall, around 30 percent of women show significant distress at some point during the illness. At higher risk for psychosocial distress are