This thesis presents a discursive analysis of accounts of breast cancer screening, risk and prevention. Breast cancer is currently the largest form of cancer death for women in Australia ( and many other Western nations ), but the causes are unknown. Consequently, health promotion has tended to focus on the early detection of the disease. Despite this focus, the currently available techniques for early detection of breast cancer continue to be subject to research and debate. For women at high risk of the disease due to a family history and, in some cases, a genetic predisposition, there is also discussion regarding the best course of preventative action. One option, prophylactic surgery ( or the removal of healthy breasts ), continues to be the topic of both medical and psychological research. In addition to the ongoing medical research and debate around the topics of breast cancer screening, risk and prevention, there has been extensive sociological theorising around the increased societal emphasis on risk more generally. This emphasis on risk has been argued to be one feature of governance in modern liberal democratic societies. Particularly with respect to health - care in such societies, there has been argued to be a shift towards increasing individual responsibility for health and the management of potential illness. A focus on individual responsibility is not necessarily a key feature of contemporary public health approaches. Nevertheless, it has been suggested that the emphasis on risk management, in combination with the prevalence of ' lifestyle ' diseases, has widened the gaze of public health, such that all aspects of individuals ' lives are open to scrutiny and regulation. An inevitable consequence of such shifts is the placing of increased responsibility for health on to individuals. The analysis in this thesis draws on a synthetic discursive approach to examine talk and text around the issues of breast cancer screening, risk and prevention, in light of these shifts in conceptualisations of health and health - care, and the medical debate surrounding detection and prevention techniques. In particular, three analytic chapters are concerned with three sets of data : media accounts of prophylactic mastectomy ; pamphlets promoting breast cancer screening ; and women ' s focus group talk. The analysis focuses on the discursive themes, ideological dilemmas, and subject positions deployed in the data. The following analytic findings are discussed : - the repeated positioning of individuals as ' patients without symptoms ', who are required to engage in risk management in order to prevent their ( inevitable ) future illness ; - the positioning of women in terms of traditional notions of femininity and mothering ; - the construction of a dilemmatic relationship between individuals and medical experts, whereby individuals are positioned as responsible for their own health and illness prevention, while simultaneously being reliant on medical experts who are sometimes wrong ; - the negotiation and flexible management of notions of responsibility, emotion and health behaviours in women ' s talk. The final chapter in the thesis considers implications of the analysis for public health and health promotion, and for a critical ( public ) health psychology. / Thesis (Ph.D.)--School of Psychology, 2006.

This thesis presents a discursive analysis of accounts of breast cancer screening, risk and prevention. Breast cancer is currently the largest form of cancer death for women in Australia ( and many other Western nations ), but the causes are unknown. Consequently, health promotion has tended to focus on the early detection of the disease. Despite this focus, the currently available techniques for early detection of breast cancer continue to be subject to research and debate. For women at high risk of the disease due to a family history and, in some cases, a genetic predisposition, there is also discussion regarding the best course of preventative action. One option, prophylactic surgery ( or the removal of healthy breasts ), continues to be the topic of both medical and psychological research. In addition to the ongoing medical research and debate around the topics of breast cancer screening, risk and prevention, there has been extensive sociological theorising around the increased societal emphasis on risk more generally. This emphasis on risk has been argued to be one feature of governance in modern liberal democratic societies. Particularly with respect to health - care in such societies, there has been argued to be a shift towards increasing individual responsibility for health and the management of potential illness. A focus on individual responsibility is not necessarily a key feature of contemporary public health approaches. Nevertheless, it has been suggested that the emphasis on risk management, in combination with the prevalence of ' lifestyle ' diseases, has widened the gaze of public health, such that all aspects of individuals ' lives are open to scrutiny and regulation. An inevitable consequence of such shifts is the placing of increased responsibility for health on to individuals. The analysis in this thesis draws on a synthetic discursive approach to examine talk and text around the issues of breast cancer screening, risk and prevention, in light of these shifts in conceptualisations of health and health - care, and the medical debate surrounding detection and prevention techniques. In particular, three analytic chapters are concerned with three sets of data : media accounts of prophylactic mastectomy ; pamphlets promoting breast cancer screening ; and women ' s focus group talk. The analysis focuses on the discursive themes, ideological dilemmas, and subject positions deployed in the data. The following analytic findings are discussed : - the repeated positioning of individuals as ' patients without symptoms ', who are required to engage in risk management in order to prevent their ( inevitable ) future illness ; - the positioning of women in terms of traditional notions of femininity and mothering ; - the construction of a dilemmatic relationship between individuals and medical experts, whereby individuals are positioned as responsible for their own health and illness prevention, while simultaneously being reliant on medical experts who are sometimes wrong ; - the negotiation and flexible management of notions of responsibility, emotion and health behaviours in women ' s talk. The final chapter in the thesis considers implications of the analysis for public health and health promotion, and for a critical ( public ) health psychology. / Thesis (Ph.D.)--School of Psychology, 2006.

No description available.

Bakgrund: Profylaktisk mastektomi är en behandling där brösten avlägsnas kirurgiskt i förebyggande syfte. Det finns olika indikationer till att profylaktisk mastektomi övervägs. Begreppet beslutsfattande kräver förståelse för att kunna beskriva kvinnors beslut vid profylaktisk kirurgi med anledning av att den individuella osäkerheten kring behandlingsval ska minska. Information och stöd är viktiga aspekter för en sjuksköterska att ge för att främja patientens integritet, självbestämmande och delaktighet. Syftet med litteraturstudien var att beskriva faktorer relaterade till beslutsfattandet hos kvinnor vid profylaktisk mastektomi. Metoden som användes var en allmän litteraturstudie med induktiv ansats där tio vetenskapliga artiklar med anknytning till aktuellt syfte valdes ut för att utforma ett resultat. Resultatet utmynnade i tre olika kategorier varav en med två underkategorier och en med tre underkategorier. Oro, föräldraskap, genmutation och upplevelse av information visade sig influera beslutsfattandet. Få skillnader i beslutsfattandet påvisades mellan kvinnor som var bärare och ickebärare av genmutation. Konklusion: Kvinnor som stod inför ett beslutsfattande vid profylaktisk mastektomi var alla egna individer och hade därmed olika preferenser i avseende behov av stöd, delaktighet i beslutsfattandet, mottagandet av information samt vad som influerat beslutet. Vårdprofessionella ska presentera adekvat, evidensbaserad samt enhällig information för att underlätta kvinnors beslutfattande. / Background: Prophylactic mastectomy is a treatment where the breasts are surgically removed for preventive purposes. There are various indications why prophylactic mastectomy is being considered. Understanding the concept of decision making is required to describe women’s decision about prophylactic surgery in order to reduce individual uncertainty about treatment choices. Information and support are important aspects for a nurse to provide in order to encourage patient integrity, self-determination and participation. The aim of this literature study was to describe factors related to decision making among women regarding prophylactic mastectomy. The method was a literature study with an inductive approach. Ten scientific articles related to the current purpose were selected to form a result. The result emerged in to three different categories, one with two subcategories and one with three subcategories. Concerns, parenting, gene mutation and experience of information were found to influence the decision making. Few differences in decision making were detected between women who were carriers and non-carriers of gene mutation. Conclusion: Women who faced a decision making in prophylactic mastectomy were all individuals and there for had different preferences regarding need for support, participation in decision making, receiving information and what influenced the decision. Health care professionals should present adequat, evidence based and unanimous information to ease women’s decision making.

No description available.

The rate at which women choose mastectomy has grown dramatically, and of particular note is the increase in contralateral prophylactic mastectomy (CPM). For women with no history of breast cancer or genetic risk, CPM represents a treatment decision that does not offer better long-term outcomes than the decision not to remove a healthy breast and may be associated with increased surgical risk and interventions, increased cost to the healthcare system, and potential adverse psycho-social outcomes. To better understand the decision making process regarding the election of CPM among women with early stage unilateral breast cancer, with no family history or genetic risk, a three-phase exploratory study was conducted. Qualitative in-depth interviews were conducted with healthcare providers who have close interaction with women during the decision making process (N=3) and patients who made a surgical decision about breast cancer treatment within the past three years (N=11). These two phases informed the design of the quantitative internet survey, conducted among women diagnosed with early stage breast cancer in the process of making a surgical decision (N=336). The survey design was also guided by an existing model for treatment decision making which uses a social ecological framework (Revenson & Pranikoff, 2005). In addition to descriptive analyses, perceptual mapping was utilized to understand patients’ conceptualizations of the relative importance of factors considered during the decision making process, and AdSAM® was used to gauge emotional response. Results suggest that women more likely to elect CPM demonstrate an emotional response to a generalized fear of cancer, along with the need to take control of their situation. In addition, retrospective interviews emphasized somewhat different reasons for electing CPM, highlighting the importance of prospective research in studying the decision making process. / Public Health

Résumé Introduction L’efficacité de la mastectomie prophylactique est bien démontrée. La mastectomie NSM (nipple-sparing mastectomy) peut potentiellement améliorer les résultats esthétiques, mais elle n’est pas pratiquée d’emblée en raison de doutes face à sa sécurité oncologique. Objectif Évaluer la faisabilité et la sécurité oncologique de la NSM dans un contexte prophylactique ainsi que les résultats esthétiques et la satisfaction des patientes. Méthodologie Une étude rétrospective fut conduite chez toutes les femmes ayant subi une mastectomie prophylactique suivie d’une reconstruction mammaire immédiate au centre hospitalier de l’Université de Montréal (CHUM) entre1997 et 2008. Les données concernant les facteurs de risque de cancer, les complications post-opératoires et les incidences de cancer furent notées. La satisfaction des patientes était évaluée par questionnaire. Deux chirurgiens ont évalué les résultats esthétiques sur des photos. Résultats Soixante et onze patientes ont subi 86 mastectomies prophylactiques, dont 21 NSM et 65 SSM (skin-sparing mastectomy). Suivant une SSM, 34 CAM (complexe aréolo- mamelonaire) furent reconstruits. Une nécrose totale s’est produite dans 2 CAM préservés et dans 2 CAM reconstruits. Le taux général de complications était significativement plus élevé parmi les CAM reconstruits. La satisfaction des patientes quant à l’apparence du CAM était significativement plus élevée dans le groupe NSM et les résultats esthétiques, meilleurs. Avec un temps de suivi moyen de 50 mois, aucune incidence au niveau du CAM n’est survenue. i Conclusion Les NSM offrent de meilleures résultats, n’augmentent pas les complications post- opératoire et semblent sécuritaires au plan oncologique. / Introduction The efficiency of prophylactic mastectomy is well acknowledged. Nipple sparing mastectomy (NSM) can potentially improve cosmetic results, but it is not the current practice because of doubts regarding its oncological safety. Objectives To evaluate NSM’s feasibility and oncological safety in a prophylactic setting, as well as aesthetic results and patient satisfaction. Methods A retrospective study was conducted on every women that underwent prophylacitc mastectomy followed by immediate breast reconstruction in the centre hospitalier de l’Université de Montréal (CHUM) between 1997 and 2008. Data regarding cancer risk factors, post operative complication and cancer incidence were compiled. Patient satisfaction was evaluated using a questionnaire and two plastic surgeons rated the aesthetic results on photos. Results Seventy-one patients underwent 21 NSM et 65 skin-sparing mastectomies (SSM) for a total of 86 prophylactic procedures. Following SSM, 34 nipple areolar-complexes (NAC) were reconstructed. Necrosis was noted in 2 preserved NAC and in 2 reconstructed NAC. The overall complication rate was superior among the reconstructed NAC. Patient satisfaction regarding NAC appearance was significantly higher within the preserved NAC group and the aesthetic results were evaluated as better. With a mean follow-up time of 50 months, no incidence was noted in the NAC area. iii Conclusion NSM offer superior aesthetic results, do not increase post-operative complications and appear the be oncologicaly safe.

Breast cancer is the most common cancer among women in the United States with over 60% of cases diagnosed as early stage disease. For those women without prohibiting clinical or cosmetic concerns, a choice between breast-conserving surgery and mastectomy can be made. Either choice confers equivalent survival. The decision-making process also involves consideration of recurrence risk as well as management of the unaffected, contralateral breast for both future surveillance and risk reduction. In recent years, increasing rates of mastectomy with contralateral prophylactic mastectomy have been reported among women with unilateral, early stage breast cancer. If eligible for a choice among surgical options, a woman’s decision becomes one of personal preference. The decision-making process is complex and involves consideration of potential benefits and harms with each option. The purpose of this dissertation was to: 1) analyze the psychometric properties of the Anxiety Subscale of the Depression Anxiety Stress Scale, 2) critically review Decisional Conflict Scales and 3) prospectively identify demographic, clinical, cognitive and affective factors influencing a woman’s decision to choose either breast conserving surgery or mastectomy with contralateral prophylactic mastectomy and to identify self-reported sources of information in the surgical decision-making process. Three manuscripts make up the dissertation. A secondary data analysis was conducted to test the psychometric properties of the Anxiety Subscale of the Depression Anxiety Stress Scale (DASS). The results of this analysis supported the reliability and validity of the DASS anxiety subscale. A critical review of decisional conflict measures for use with early stage breast cancer patients making surgical treatment decisions was conducted. The results of this review supported the use of Decisional Conflict Scales from a clinical and research perspective. Existing Decisional Conflict Scales show moderate to acceptable reliability. The first two manuscripts provided background and support for the use of scales included in the research study described in the third manuscript. This study was a prospective, exploratory, cross-sectional, mixed-methods study describing factors influencing preference for surgical choice among women with early stage breast cancer. A sample of 78 participants enrolled in the study, 47 who chose breast conserving surgery and 31 who chose mastectomy with contralateral prophylactic mastectomy. Differences were tested between the groups. Women who chose mastectomy with contralateral prophylactic mastectomy were younger, more likely to work full or part-time, had larger tumors and participated in preoperative genetic counselling. Women who chose breast conserving surgery were more likely to have participated in preoperative breast magnetic resonance imaging. Overall, women choosing either surgery were not experiencing severe levels of distress, depression, anxiety or stress although there were individual variations. Women choosing mastectomy with contralateral prophylactic mastectomy were more anxious and had more frequent intrusive thoughts about the diagnosis. They also had less decisional conflict as compared to women choosing breast conserving surgery. Information sources were similar but the most influential information source differed among the two groups. In both groups, intention for surgical choice was matched by the final decision. There are many factors influencing surgical choice among women with early stage breast cancer. Previous work has focused on clinical, demographic and diagnostic processes influencing the decision. With this study, evidence regarding the influence of cognitive and affective factors is described.

Résumé Introduction L’efficacité de la mastectomie prophylactique est bien démontrée. La mastectomie NSM (nipple-sparing mastectomy) peut potentiellement améliorer les résultats esthétiques, mais elle n’est pas pratiquée d’emblée en raison de doutes face à sa sécurité oncologique. Objectif Évaluer la faisabilité et la sécurité oncologique de la NSM dans un contexte prophylactique ainsi que les résultats esthétiques et la satisfaction des patientes. Méthodologie Une étude rétrospective fut conduite chez toutes les femmes ayant subi une mastectomie prophylactique suivie d’une reconstruction mammaire immédiate au centre hospitalier de l’Université de Montréal (CHUM) entre1997 et 2008. Les données concernant les facteurs de risque de cancer, les complications post-opératoires et les incidences de cancer furent notées. La satisfaction des patientes était évaluée par questionnaire. Deux chirurgiens ont évalué les résultats esthétiques sur des photos. Résultats Soixante et onze patientes ont subi 86 mastectomies prophylactiques, dont 21 NSM et 65 SSM (skin-sparing mastectomy). Suivant une SSM, 34 CAM (complexe aréolo- mamelonaire) furent reconstruits. Une nécrose totale s’est produite dans 2 CAM préservés et dans 2 CAM reconstruits. Le taux général de complications était significativement plus élevé parmi les CAM reconstruits. La satisfaction des patientes quant à l’apparence du CAM était significativement plus élevée dans le groupe NSM et les résultats esthétiques, meilleurs. Avec un temps de suivi moyen de 50 mois, aucune incidence au niveau du CAM n’est survenue. i Conclusion Les NSM offrent de meilleures résultats, n’augmentent pas les complications post- opératoire et semblent sécuritaires au plan oncologique. / Introduction The efficiency of prophylactic mastectomy is well acknowledged. Nipple sparing mastectomy (NSM) can potentially improve cosmetic results, but it is not the current practice because of doubts regarding its oncological safety. Objectives To evaluate NSM’s feasibility and oncological safety in a prophylactic setting, as well as aesthetic results and patient satisfaction. Methods A retrospective study was conducted on every women that underwent prophylacitc mastectomy followed by immediate breast reconstruction in the centre hospitalier de l’Université de Montréal (CHUM) between 1997 and 2008. Data regarding cancer risk factors, post operative complication and cancer incidence were compiled. Patient satisfaction was evaluated using a questionnaire and two plastic surgeons rated the aesthetic results on photos. Results Seventy-one patients underwent 21 NSM et 65 skin-sparing mastectomies (SSM) for a total of 86 prophylactic procedures. Following SSM, 34 nipple areolar-complexes (NAC) were reconstructed. Necrosis was noted in 2 preserved NAC and in 2 reconstructed NAC. The overall complication rate was superior among the reconstructed NAC. Patient satisfaction regarding NAC appearance was significantly higher within the preserved NAC group and the aesthetic results were evaluated as better. With a mean follow-up time of 50 months, no incidence was noted in the NAC area. iii Conclusion NSM offer superior aesthetic results, do not increase post-operative complications and appear the be oncologicaly safe.

Background: Prophylactic mastectomies in carriers of mutations in BRCA1 or BRCA2 are becoming increasingly more accepted. We investigated the outcome after prophylactic mastectomy, especially regarding satisfaction with the procedure, in a monocenter study. Methods: BRCA1/2 mutation carriers and non-carriers with elevated pedigree-based cancer risk were followed prospectively in a structured surveillance program between 2000 and 2017. A retrospective telephone survey was conducted among all patients with documented prophylactic mastectomy. Complications and satisfaction with the decision for prophylactic mastectomy were recorded. Results: 39 patients who opted for a prophylactic mastectomy (38 BRCA1/2 mutation carriers and 1 noncarrier) were interviewed. Mostly nipple-sparing mastectomy with reconstruction was performed (87%). Half of the patients (22/39; 56.4%) had a history of unilateral breast cancer. The median time since prophylactic mastectomy was 5.6 years. While 61.5% did not report any complications, flap loss was seen in 15% (3/20) and moderate limitations in everyday life were present in 20% (7/35). An improvement in quality of life was noticed by 82% after prophylactic mastectomy and no patient expressed regret with regard to the decision. Conclusions: Prophylactic mastectomy is a procedure with risk for long-term complications in some cases. Our results confirm high satisfaction with the decision and improved quality of life.