Psychological Impact of Cancer Risk Assessment: Anxiety, Depression and Distress in an Italian Sample

Research Article

J Fam Med. 2022; 9(2): 1289.

Psychological Impact of Cancer Risk Assessment: Anxiety, Depression and Distress in an Italian Sample

Costanzo S1, De Summa S2, Romito F4, Digennaro M1, Ronchi M3, Paradiso A1,5 and PatrunoM1*

1Heredo-Familiar Cancer Unit, Experimental Oncology and Biobank Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Bari, Italy

2Molecular Diagnostics and Pharmacogenetics Unit, IRCCS - Istituto Tumori “Giovanni Paolo II”, Bari, Italy

3Unità operativa di Medicina Oncologica per la presa in carico del paziente oncologico, IRCCS - Istituto Tumori “Giovanni Paolo II”, Bari, Italy

4Psycho-Oncology Service, IRCCS Istituto Tumori “Giovanni Paolo II”, Bari, Italy

5Scientific Direction, IRCCS Istituto Tumori, “Giovanni Paolo II”, Bari, Italy

*Corresponding author: Patruno M, Heredo-Familiar Cancer Unit, Experimental Oncology and Biobank Unit, IRCCS Istituto Tumori “Giovanni Paolo II”, Viale O. Flacco n.65, 70124 Bari (BA), Italy

Received: January 04, 2022; Accepted: February 08, 2022; Published: February 15, 2022


Purpose: Evaluating whether and how anxious and depressive symptoms change from prior to Oncological Genetic Counseling (OGC) to one month following BRCA genetic test result. Short-term psychological impact of genetic test disclosure in an Italian sample was also assessed.

Methods: 106 Italian natives completed Hospital Anxiety and Depression scale (HADs) both before accessing OGC (t1) and one month following their test result (t2). In t2 they also completed the Italian translation of Multidimensional Cancer Risk Assessment (MICRA).

Results: An overall reduction of HADs scores over time in BRCA-carriers was observed. Higher distress median values (MICRA) were found in carriers than non-carriers.

Discussion: In carriers, the simultaneous presence of both a reduction of anxiety/depression and a greater distress should be explained basing on Post- Traumatic-Growth studies in cancer patients. Being a carrier may represent an explanation for cancer disease, and allow patients to access specific riskreduction programs.

Keywords: Anxiety; Cancer; Depression; Distress; Oncological Genetic Counseling; Post-traumatic Growth


HAD-A: Hospital Anxiety and Depression - Anxiety subscale; HAD-D: Hospital Anxiety and Depression - Depression Subscale; HADs: Hospital Anxiety and Depression scale; MICRA: Multidimensional Cancer Risk Assessment; OGC: Oncological Genetic counseling; PTG: Post-Traumatic Growth


With the identification of two cancer susceptibility genes, BRCA1 [1] and BRCA2 [2], genetic testing is now commonly available in clinical practice. BRCA1/2 mutations are associated with an increased risk for breast, ovarian and pancreatic cancers in females and breast, prostatic and pancreatic cancers in males [3]. Detecting BRCA1/2 carriers is necessary to offer them regular monitoring, preventive measures and to decrease cancer morbidity [4].

Oncological Genetic Counseling (OGC) and DNA-testing are offered both to affected patients (basing on their family history or on the early onset of disease) [5] and to healthy relatives of BRCA1/2 carriers.

International literature research explored the psycho-emotional impact of OGC focusing on psychological distress prior to and after results disclosure [6].

In affected and unaffected BRCA1/BRCA2 carriers changes in psychological distress after genetic testing reflect mixed results: although an increase in short-term distress has been highlighted, research has shown no long-term consequences on psychological well-being [6]. Bennett et al. [7] found short-term increases in anxiety levels that returned to baseline within 12 months; another study [8] detected high distress in women with breast cancer mostly in the year after receiving genetic results. Indeed, cancer diagnoses usually raises cancer-related distress [9] depression, anxiety and adjustment disorder [10,11].

Overall literature data seem to exclude severe anxiety, depression [12] and distress [13,14] issues due to OGC impact in BRCA1/2 carriers. However, some research reported anxiety and depression [15,16], anger and distress [17], cancer-related worry [18], vulnerability and stigma, alterations in self-perception and quality of life [19,20] after BRCA1/2 testing. All these aspects are strictly connected to cancer-related distress.

The identification of emotional, cognitive, and behavioral variables connected to OGC impact is crucial to promote patients’ adherence to monitoring programs, increase their empowerment and strengthen their health-decision-making process [21,22]. Therefore, primary aim of the present paper was evaluating whether and how anxious and depressive symptoms could change from prior to one month after genetic counseling and testing.

Second goal was to assess the short-term impact of genetic test disclosure in an Italian sample using for the first time the Multidimensional Impact of Cancer Risk Assessment (MICRA) [23], a self-report tool specifically designed to measure socio-psychological concerns associated with genetic counselling and testing for cancer [24,25]. Third aim was to understand possible associations between anxiety and depression and the short-term impact of OGC.


The study enrolled 106 consecutive Caucasian patients who underwent OGC and Testing in IRCCS Istituto Tumori “Giovanni Paolo II”. All participants were Italian Natives, both index patients (i.e., oncological patients who initiate a counseling process for their family) and relatives (i.e., relatives of an index patient). Other inclusion criteria were being >18 years old and absence of psychiatric diagnosis that may hinder the questionnaire completions. The total sample analyzed included 106 participants and all participants signed an informed consent.

Patients accessing OGC underwent a psychological assessment and received an in-person pre-test counseling session to evaluate their oncological risk, based on their personal and/or family medical history [26]. Pre-test counseling sessions revealed the indication to perform a BRCA1/2 genetic test for all patients. Blood samples were collected in the Hospital Laboratory. Genetic-testing results were available within 3 months and were discussed during an in-person post-test counseling session.

All participants completed HADs prior to pre-test OGC (t1) and 1 month following their test disclosure (t2). At t2, participants also completed the Italian translation of MICRA. The time for completion was about 30min.


Data collected included a specifically developed sociodemographic form assessing the following variables: age, gender, civil status, number of children, cancer history, mutational status, being an index/relative. One self-report item was taken to investigate previous psychological suffering since it is a well-known factor of concern for the development of anxious/depressive symptoms following a cancer diagnosis [27,28].

HADs is a renowed emotional distress self-report measure and it is one of the most frequently used in oncological settings as well as in other somatic diseases [29]. It composed of 14 items to which patients answer through a 4-point Likert-scale referring to overt symptoms within the last week. It is consists in two scales - HAD-A for anxiety (7 items) and HAD-D for depression (7 items). Its global score is derived by summing responses for each of the two subscales. Higher scores indicate greater levels of anxiety or depression.

MICRAis a 25-item instrument designed to assess the specific impact of result disclosure after genetic testing. It assesses both negative and positive responses to testing experience [23]. Each item is measured on a 4-point Likert-scale. It is composed by three subscales: Distress, Uncertainty and Positive Experience. Except for Positive Experience, higher scores indicate more genetic test-related distress. Two items dropped out of the subscales: items 13 and 21 must be considered as individual items and are respectively measuring choices for prevention and early detection, and feeling regret since receiving the risk information. The instrument also includes other two subscales: one (2 items) regarding worry about children and one (2 items) regarding coping with current or previous cancer diagnosis. The three subscales and the items named above show acceptable internal consistencies [30]. Although the Italian translation of MICRA is accessible on, no scientific literature about the Italian Validation of MICRA is available.

The study has been approved by the Institute Ethical Committee.

Statistical methods

Data were analyzed with R (version 3.6.2). Check for normality assumption (Shapiro-Wilk normality test) and for extreme outliers have been performed with “rstatix” package. Data were preliminarily evaluated to check if the normality assumption was accomplished. Shapiro-Wilk test was significant and thus non-parametric statistics have been used. Moreover, no extreme outlier was identified.

Qqplot for visual inspection have been drown with “ggpubr” package. Aligned Ranks Transformation ANOVA was the test used to analyze HADs score as repeated measures. Wilcoxon test (“rstatix” R package) has been used to compare MICRA scores between groups. Graphs have been depicted through “ggplot2” R package. a Cronbach has been evaluated through “psych” R package.

All results have been considered as significant when p-values<0.05.


The cohort (N=106) was analyzed in two different time points: prior to (t1) and one month after (t2) genetic test disclosure.. Participants are aged between 21 and 78 and have an average age of 50 years old and socio-demographic information is shown in Table 1.