PREDICTORS OF INTRUSIVE THOUGHTS AND AVOIDANCE IN WOMEN WITH FAMILY HISTORIES OF BREAST CANCER 1,2 Sandra G. Zakowski, Ph.D., Heiddis B. Valdimarsdottir, Ph.D., Dana H. Bovbjerg, Ph.D., Patrick Borgen, M.D., Jimmie Holland, M.D., and Kathryn Kash, Ph.D Memorial Sloan-Kettering Cancer Center Daniel Miller, M.D. Strang Cancer Prevention Center Julie Mitnick, M.D. Murray Hill Radiology and Mammography, New York Michael Osborne, M.D. Strang Cancer Prevention Center Kimberly Van Zee, M.D. Memorial Sloan-Kettering Cancer Center ABSTRACT Having a family history of cancer is an important predictor of lifetime cancer risk. Individuals with family histories of cancer have been reported to experience symptoms of general distress and to have frequent intrusive thoughts and avoidance regarding cancer. To date, little is known about predictors of such distress. A relation between perception of cancer risk and distress has been suggested, but the possibility that prior cancer-related events may contribute to distress in these women has received little attention. The major aim of the study was to examine the contribution of the past experience of the death of a parent from cancer to distress in women at familiar risk for breast cancer. Women with family histories of breast cancer (Risk Group, N = 46) were assessed on the day of their yearly mammography screening and four to eight weeks after normal result notification in order to confirm the generalizability of their distress. Their levels of intrusive thoughts, avoidance, and perceived lifetime risk for breast cancer were significantly higher than those of women with no family histories of cancer who were not undergoing mammography (Comparison Group, N = 43), and this was true on both assessment days. Among the women in the Risk Group, those whose parent(s) had died of cancer had the highest levels of intrusive thoughts, avoidance, and perceived risk. Results sug- i Preparation of this manuscript was supported in part by research grants from the American Cancer Society (PBR-92) and the Martell Foundation, as well as a Career Development Award (Valdimarsdottir; J-4139) and a Postdoctoral FellowshipAward (Zakowski; J-4164) from the United States Department of Defense. We are required to indicate that the content of the information contained in this report does not necessarily reflect the position or policy of the United States Government. 2 The authors want to thank Ms. Jennifer Keats and Julie Fasano for their help in conducting the study, as well as Dr. William Redd and the anonymous reviewers for their comments on an earlier draft of this manuscript. Reprint Address: S. G. Zakowski, Ph.D., Department of Psychology, Finch University of Health Sciences, Chicago Medical School, 3333 Green Bay Road, North Chicago, IL 60064-3095. 9 1997 by The Society of Behavioral Medicine. 362 gested that perceived risk mediated the effect of this event on intrusive thoughts and avoidance regarding breast cancer. The findings are discussed in terms of theories of cognitive responses to traumatic and stressful life events. Implications for future research and interventions are discussed. (AnnBehavMed 1997, 19(4):362-369) INTRODUCTION Having a family history of cancer is a significant risk factor for developing cancer in one's lifetime (l). Several recent studies, although not all (2), have shown that having a family history of cancer, including breast cancer, may be associated with elevated levels of distress (3-5). For example, Valdimarsdottir et al. (5) compared women with and without family histories of breast cancer. Those who had family histories of breast cancer had significantly higher levels of intrusive thoughts and avoidance on the Impact of Events Scale (IES) (6), as well as higher levels of general distress, anxiety, phobic anxiety, somatization, and depres- sion on the Brief Symptom Inventory (BSI). Kash et al. (3) found that 27% of women with family histories of breast cancer endorsed levels of distress on the BSI that suggested a need for psychologi- cal counselling. In a study by Lerman et al. (4), women with family histories of breast cancer reported levels of intrusive thoughts that were comparable to those found in clinical populations. In 30% of these women, worries about breast cancer interfered with their daily lives. Preliminary data also suggested that women with family histories of cancer may have mood disturbances compa- rable to those seen in patients recently diagnosed with breast cancer (7). Despite the accumulating evidence that women with family histories of cancer have higher levels of distress, it is clear that not all of these women are equally affected. While some women may have reactions severe enough to warrant clinical attention (3,4), others have less severe stress symptoms. To date, little is known about the predictors of distress in women with family histories of cancer, as only a few studies have addressed this issue. Schwartz et al. (8) showed a relation between perceived risk for cancer and intrusive thoughts, as well as an indirect relation between a monitoring coping style and intrusive thoughts. Lerman, Kash, and