Simona Di Lascio1*, Elena Scaffidi1, Vincenzo Bagnardi2,3, Monica Taborelli1, Gabriella Bianchi Micheli1,5, Piercarlo Saletti1, Cinzia Cafaro-Greco1, Davide Disalvatore4 and Olivia Pagani1,5
1Genetic Counseling Service (CCGO), Institute of Oncology of Southern Switzerland (IOSI)
2Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy,
3Clinical Trial Unit of the Ente Ospedaliero Cantonale (EOC)
4European Institute of Oncology, Milan, Italy (IEO)
5Breast Unit of Southern Switzerland (CSSI)
Received: 13 July, 2017; Accepted: 24 August, 2017; Published: 28 August, 2017
Simona Di Lascio, MD, Oncology Institute of Southern Switzerland, Genetic Counseling Service (CCGO), Switzerland, Tel: +41918119039; E-mail:
Lascio SD, Scaffidi E, Bagnardi V, Taborelli M, Micheli GB, et al. (2017) Is genetic counseling for cancer predisposition always associated with distress? A pre-post intervention study to assess probands’ pre-and post-counseling level of anxiety and satisfaction. Arch Depress Anxiety 3(2): 030-037. DOI: 10.17352/2455-5460.000020
© 2017 Lascio SD, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Genetic counseling; Anxiety; Satisfaction, Breast cancer
Genetic counseling for cancer predisposition is associated with a potentially underestimated emotional impact. The Genetic Counseling Service of the Institute of Oncology of Southern Switzerland evaluated the degree of anxiety before and after counseling and its correlation with the level of satisfaction of counselees.
The STAI (State-Trait Anxiety Inventory) questionnaire was submitted to 80 counselees to measure trait (constitutive) and state (contingent) anxiety. It was submitted before and at the end of the first interview. A specific questionnaire named genetic counseling satisfaction (GCS), was developed to evaluate the quality of information, submitted to counselees at the end of the first meeting. The mean state and trait anxiety levels before the interview were respectively 41.4 and 40.7. The mean decrease after the interview was 4.3 for state anxiety (p<0.0001) and 1.2 (p=0.0054) for trait anxiety. The GCS showed that most counselees appreciated the clarity of information (85%) and the simple and understandable terminology used during counseling (88%). Higher levels of satisfaction were associated with higher level of state anxiety reduction (ρ=-0.23, p=0.03).
Genetic counseling slightly impacts trait anxiety but results in an important reduction in state anxiety. The satisfaction from the interview influences the reduction of state anxiety associated with genetic counseling for cancer predisposition.
Approximately 5-10% of all breast cancers (BC) and about 3% of all colorectal cancers (CRC) are related to inherited genetic defaults . Genetic testing became available for BC patients and their families after the identification of two BC susceptibility genes, BRCA1 and BRCA2. Inherited BRCA1/2 mutations are associated with an increased risk of both breast and ovarian cancer . Patients harboring inherited predisposition to CRC (Lynch Syndrome) can be identified by both a microsatellite instability (MSI) test and an immunohistochemistry analysis for mismatch repair (MMR) genes, performed on CRC tumor DNA. In Lynch syndrome, almost all CRCs show high (positive) MSI [3-6]. Psychological distress after BC diagnosis and treatment has been well recognized and investigated. Psychological distress was reported in 20-30% of BC patients within the first year after diagnosis . Burgess identified anxiety, depression or both in nearly 50% of BC patients in the year following the diagnosis . In addition, high frequency of intrusive thoughts and negation were noted in 18% and 14 % of BC patients six weeks after surgery, respectively . Moderate distress has been reported in patients with stage I/II CRC . Cancer genetic counseling (GC) allows to identify individuals at increased risk for hereditary breast/ovarian cancer and Lynch Syndrome and to plan surveillance programs and cancer reduction strategies [11,1]. The psychological impact of GC and testing on unaffected women with a family history of BC has been widely studied. Non-carriers derive psychological benefit from genetic testing, while no adverse effects are observed among gene carriers . In a multicenter study on the psychological impact in patients recently diagnosed with CRC, disclosure of the MSI test result was not followed by high levels of distress in the majority of patients .
A growing number of women undergoes GC to assess genetic predisposition to breast/ovarian cancer. Several studies show women at high BC risk due to hereditary predisposition better adhere to surveillance programs and preventive strategies recommended after GC and positive test results [14-19]. The patient-doctor relationship also proved to be important to support high-risk patients and increase their compliance to risk managing recommendations [19,20]. On the contrary, women who tested negative experienced a significant reduction in the perceived BC risk  which was associated with decreased adherence to the suggested check-up program [22,23]. This attitude in mutation negative subjects was confirmed in the 3 years following genetic testing in ≥50 year’s old women . In other series, GC and testing, regardless of their results, induce women to undergo mammography controls as compared to clinical or self-breast examination [20,14,15]. While substantial evidence is available on the short term (≤1 year) effect of genetic testing on adherence to surveillance and prevention strategies, few studies addressed the long-term impact [15,27,24]. The impact of genetic testing on prophylactic mastectomy and the related reduction on BC incidence is less clear [24,17,25,26].
From a psychological perspective, few studies explored the influence of genetic testing on acute distress in mutation negative/positive women. Some studies report a steady pre- and post-testing distress both in mutated and non-mutated subjects either in the year immediately following testing or in subsequent years [23,24,15]. Van Oostrom , on the contrary, suggests increased anxiety and depression several years after testing both in mutation positive and negative women. Butow , reports mutation carriers do not experience a significant increase in depression and anxiety, while women who tested negative feel released. In addition, while some studies found that anxiety and risk perception are associated with increased frequency of check-ups , others did not demonstrate this correlation .
Little is known about the acute psychological impact of genetic testing on BC patients who undergo DNA testing. The evidence available suggests that BC patients diagnosed <1 year before testing experienced high anxiety and BC-specific distress prior to GC and more depression after testing than patients assessed long term after diagnosis . Patients diagnosed <1 year before testing seemed as interested as patients diagnosed >1 year before testing and showed more interest when advised by a physician . So far, psychological distress during GC after a recent BC diagnosis and treatment has not been fully assessed.
The central role of communication in the relationship between patients and caregivers is well recognized. In some fields of healthcare, such as Phase I studies and GC, the increased fragility and vulnerability of the specific context mandates a special emphasis on communication aspects. The informative and relational dimensions of the complex approach to cancer predisposition can potentially impact the quality of life of patients and healthy subjects attending a cancer genetic service and possibly contribute to their level of distress and psychic suffering. Assessment of both cancer predisposition understanding and its psychological impact is therefore needed to allow more tailored and effective patient-doctor communication in this sensitive field.
In previous research projects in Phase I studies, we assessed the quality of the information given [32,33] in patients and families, concluding that it’s possible to provide clear and correct information even in difficult situations. These studies have also shown that the way information is provided influences the comprehension of the risk, the related fears and concerns and the level of anxiety. These aspects have been rarely investigated in the GC area: in particular, no prospective data is available on both the informative and anxiety domains and their possible correlations.
We investigated the informative and relational aspects that potentially influence the quality of life of individuals undergoing GC at the Genetic Counseling Service (CCGO) of the Institute of Oncology of Southern Switzerland (IOSI). Our aim was first to check the quality of the information process and then create a model for managing the counseling process while limiting the level of stress and psychic suffering.
Material and Methods
People involved in this study were patients or unaffected with a strong familiar cancer history or clinical elements suspicious for genetic predisposition to cancer. They received a first interview in person and individual with an oncologist and a psychologist or a geneticist and after that, based on the results of multidisciplinary discussion between oncologist and geneticist, eventually performed genetic test. The interview with patients were taken after acute treatment phase and in condition of clinical wellness, if possible.
At the time of this study, the GC process included a first interview in hospital, of about one hour, between the proband (patient or unaffected) and, depending on the predisposition syndrome, the oncologist and the psychologist (mainly breast/ovarian families) or the geneticist (mainly colorectal cancer). This difference was originally decided based on the typology of counselees, as subjects with a predisposition to breast/ovarian cancer were mainly unaffected and those with a predisposition to CRC were mainly patients. After collecting data on personal and family history and explaining the meaning of frequency, absolute and relative risk and the management of the information for an adequate prevention, the family tree of the proband is designed and the mutation risk calculated using mathematical models (BRCAPRO) . All the cases are then discussed multidisciplinary with the geneticist. If the overall assessment clearly demonstrates the absence of the minimum criteria to propose genetic testing, the GC process is concluded with a second explanatory interview. If a significant mutation probability is detected, the second meeting is a critical step, as the possibility of genetic testing is discussed with the counselee. In the present study, all individuals were given two different self-compilation instruments:
1. The STAI (State-Trait Anxiety Inventory) , to evaluate both state and trait anxiety
2. A questionnaire developed by the unit (GCS) to evaluate the consultation, specifically focused on the subject’s perceived quality of the information received.
The validated STAI questionnaire consists of 40 multiple-choice questions with four response options: each item, worded either positively (e.g., ‘I feel calm’) or negatively (e.g., ‘I feel strained’), measures how respondents feel on a four-point scale (from 1, ‘not at all’ to 4, ‘very much so’). Scores range from 20 to 80, with higher scores indicating greater anxiety.
The 20 first questions provide indication on the anxiety perceived during the compilation (state anxiety) and are therefore affected by the specific context. The additional 20 questions provide information about the individual anxiety characteristics which are therefore not influenced by the contextual situation (trait anxiety).
The GCS questionnaire was developed by the two psychologists of the unit and consists of 25 items. The development of the questionnaire included several phases: the instrument was built based on the theoretical model of Merweein , which assesses the quality of the interview taking into account its informative, affective and interactive dimension, and also focuses on some aspects related to the specific context, in this case the identification of cancer genetic risk. The model has already been used in the research projects assessing information in Phase I trials [32,33]. During the drafting of the questionnaire we found difficult to attribute some of the items either to the emotional or the interactive dimension and we decided to merge those questions in a single dimension, called relational. The first version of GCS consisted of 33 questions: 15 on the informative dimension, 10 on the relational dimension, 8 concerning the centrality of the subject at risk. The level of satisfaction has been measured, for each question, according to a 0-1 score (1 recording high satisfaction, 0 grouping together dissatisfaction and partial satisfaction). The level of global satisfaction has been calculated by summing the individual total questions’ scores, to a three escalating scale of global satisfaction (low <18, medium 18-20, high >20 points). In addition, we calculated the relationship between the answer to each question and the changes in the level of anxiety before and after GC.
Counseling sessions and surveys have been conducted in Italian language, native tongue for all subjects involved.
Pre-testing of the provisional questionnaire
Based on the development model of the EORTC quality-of-life questionnaires, the initial version was reviewed by the medical and coordinating staff taking part, in different ways, at the GC process (2 oncologists, 2 psychologists, 1 geneticist, 1 data manager/coordinator). The questionnaire was also tested in 20 subjects who undertook GC, who were asked to make comments and suggest changes. After discussion within the team, some questions were deleted and/or reformulated, leading to the definitive version of 25 items (Appendix 1).
The STAI and the final version of the GCS was administered to 100 consecutive individuals referring to the CCGO.
Timing of administration
Step 1: The counselee received at home a presentation letter from the CCGO and the appointment details together with the first STAI questionnaire. The purpose of this initial administration was to assess the counselee’s state and trait anxiety in a condition of relative neutrality (baseline). The CCGO coordinator checked that the counselee returned the completed questionnaire in a sealed envelope before the first interview. The counselee was not informed on purpose about the STAI questionnaire before receiving it at home to avoid any possible influence on her/his answers.
Step 2: At the end of the first interview, the counselee received the GCS questionnaire together with a 2nd STAI: in this way, any difference in the degree of the state anxiety compared to the baseline could be related to the GC interview. The counselee was not informed in advance he/she will be asked to complete both questionnaires at the end of the interview not to affect in any way the answers.
After the collection of the questionnaires was completed, the CCGO approached the Institute of Communication and Health (ICH) of the Faculty of Communication Science at the University of Southern Switzerland (USI) to analyze the results. As no previous research in the field included all the different areas investigated in the current research project, ICH first conducted a qualitative analysis of the instrument in a selected number of counselees (data not shown) that allowed to identify its weaknesses and propose possible adjustments.
The study was approved by the Institutional Ethical Committee. Participants signed an informed consent.
The eligibility criteria were: age ≥18 years, patients with BC or CRC or healthy relatives.
Differences in the distribution of subject characteristics between affected and unaffected probands were evaluated by the Chi-square test. Changes in subject-specific anxiety levels before and after GC were compared using the paired T-test. Baseline anxiety levels and changes before and after GC were compared among groups by the analysis of variance. The relationships between changes in individual state- and trait-anxiety levels and between the perceived quality of the information received during the GC and anxiety level changes were evaluated by the Pearson correlation coefficient (ρ).
When this project was planned, no formal sample size calculation and power analysis was performed. However, a post hoc power calculation showed that this study (sample size=80) had adequate statistical power (>80%) to detect an overall mean change from baseline of anxiety levels greater than 2 points, assuming a standard deviation of the change equal to 6 and a two-sided 5% type I error rate.
Regarding the difference between two subgroups, the minimum detectable difference at 80% power was 3.4 points (assuming SD=6, two sided 5% type I error rate and balanced subgroups).
From June 2004 to March 2007, 100 consecutive probands (55 patients and 45 unaffected) undergoing GC were given both the CGS and the STAI. Respondents who completed all questionnaires were considered evaluable, for a total of 80 subjects (44 patients and 36 unaffected). The characteristics of the population are summarized in table 1. Age ranged from 18 to 75 years, with 27.5% of patients <40 years old. Counselee were sent mainly (76.3%) by medical specialist, i.e. gynecologists, oncologists, gastroenterologists. Seventy-four percent of consultants were female (21.3% counseling for breast/ovarian cancer). Sixty-two percent had high-school instruction, 32.5% a university degree.
Evaluation of anxiety (STAI)
The mean baseline values of state and trait anxiety were evaluated according to age, sex, level of education, presence or absence of the psychologist during the interviews, the specialty of the referring physician, the type of predisposition syndrome and the belonging to the patient or unaffected group.
The assessment of the trait anxiety before GC does not show significant differences between affected and unaffected counselees (score 40.2 vs. 41.2, respectively), between women and men (41.0 vs. 39.8, respectively) and by age group (18-39 years: score 42.2, 40-49 years: score 39.7, 50-75 years: score 40.4).
The baseline values found in our sample are within the average levels of the European population, indicating uniformity of our population to the average variability of the general population. (Table 2).
Overall, there is also no statistically significant difference in the distribution of baseline levels of state and trait anxiety in all the subgroups examined: only the counselees with primary education show higher trait anxiety (score 46) compared to those with middle school (score 43), high school (score 37) or university (score 42) degrees.
The state anxiety is not distributed differently than trait anxiety according to the typology of counselees (affect and unaffected), sex, and age. Regarding the level of education, subjects with primary education reached a higher score (50.7), compared to those with secondary school (42.7), high school (37.4) and university (42.5) degrees.
Interestingly, counselees who appreciated the presence of the psychologist during the interview, reported a slightly higher level of state anxiety than those who did not.
Overall, the mean decrease for state anxiety was 4.3 (p<0.0001) and 1.2 for trait anxiety (p=0.01). The 2nd STAI questionnaire, submitted after the 1st interview, showed a modest reduction in the level of trait anxiety (-1.2 overall, p=0.0054) and an important reduction in state anxiety (-4.3 overall, p<0.0001) (Figure 1). The correlation between the reduction of both state and trait anxiety was statistically significant p=0.0009, ρ 0.36.
- Schneider R, Schneider C, Kloor M, Fürst A, Möslein G (2012) Lynch syndrome: clinical, pathological, and genetic insights. Langenbecks Arch Surg 397: 513-525. Link: https://goo.gl/ueukg3
- Blackwood MA, Weber BL (1998) BRCA1 and BRCA2: From Molecular Genetics to Clinical Medicine. J Clin Oncol 16: 103-110. Link: https://goo.gl/qVjLEu
- Barnetson RA, Tenesa A, Farrington SM, Nicholl ID, Cetnarskyj R, et al. (2006) Identification and survival of carriers of mutations in DNA mismatch-repair genes in colon cancer. N Engl J Med 354: 2751-2763. Link: https://goo.gl/1KkBPf
- Hampel H, Frankel WL, Martin E, Arnold M, Khanduja K, et al. (2005) Screening for the Lynch syndrome (hereditary non polyposis colorectal cancer). N Engl J Med 352: 1851-1860. Link: https://goo.gl/ro68bH
- Kievit W, de Bruin JH, Adang EM, Severens JL, Kleibeuker JH, et al. (2005) Cost effectiveness of a new strategy to identify HNPCC patients. Gut 54: 97-102. Link: https://goo.gl/HZyNvj
- Niessen RC, Berends MJ, Wu Y, Sijmons SH, Hollema H, et al. (2006) Identification of mismatch repair gene mutations in young patients with colorectal cancer and in patients with multiple tumors associated with hereditary non-polyposis colorectal cancer. Gut 55: 1781-1788. Link: https://goo.gl/1R7Hjk
- Irvine D, Brown B, Crooks D, Roberts J, Browne G (1991) Psychosocial adjustement in women with breast cancer. Cancer 67: 1097-1117. Link: https://goo.gl/Zp287G
- Burgess C, Cornelius V, Love S, Graham J, Richards M, et al. (2005) Depression and anxiety in women with early breast cancer:five year observational cohort study. Brit Med J 330: 702-705. Link: https://goo.gl/M65oKP
- Tjemsland L, Soreide JA, Malt UF (1998) Posttraumatic distress symptoms in operable breast cancer III: status one year after surgery. Breast Cancer Res Treat 47: 141-151. Link: https://goo.gl/9ZQ9R2
- Geirdal AØ, Dahl AA (2008) The relationship between psychological distress and personality in women from families with familial breast/ovarian or hereditary non-polyposis colorectal cancer in the absence of demonstrated mutations. J Genet Couns 17: 384-393. Link: https://goo.gl/kt6GTE
- Christinat A, Pagani O (2013) Practical Aspects of Genetic Counseling in Breast Cancer: lights and shadows. Breast 22: 375-382. Link: https://goo.gl/1jw2Cx
- Meiser B (2005) Psychological impact of genetic testing for cancer susceptibility: an update of literature. Psycho Oncol 14: 1060-1074. Link: https://goo.gl/pLsGLs
- Landsbergen KM, Prins JB, Brunner HG, van Duijvendijk P, Nagengast FM, et al. (2012) Psychological distress in newly diagnosed colorectal cancer patients following microsatellite instability testing for Lynch syndrome on the pathologist's initiative. Fam Cancer 11: 259-267. Link: https://goo.gl/fLcv6t
- Campitelli MA, Chiarelli AM, Mirea L, Stewart L, Glendon G, et al. (2011) Adherence to breast and ovarian cancer screening recommendations for female relatives form the Ontario site of the Breast Cancer Family Register. Eur J Cancer Prev 20: 492-500. Link: https://goo.gl/ytuzzN
- Hayat RA, Rosenquist R, Lampic C, Nordin K (2009) Cancer Genetic Couselees’ Self-Reported Psychological Distress, Changes in Life, and Adherence to Recommended Surveillance Program 3-7 Years Post Counseling. Journal of Genetic Counseling 18: 185-194. Link: https://goo.gl/awPQJq
- Isaacs C, Peshkin BN, Schwartz M, Demarco TA, Main D, et al. (2002) Breast and ovarian cancer screening practices in healthy women with a strong family history of breast or ovarian cancer. Breast Cancer Res Treat 71: 103-112. Link: https://goo.gl/ajDvUu
- Lerman C, Hughes C, Croyle RT, Main D, Durham C, et al. (2000) Prophylactic Surgery Decisions and Surveillance Practices One Year Following BRCA1/2 Testing. Prev Med 31: 75-80. Link: https://goo.gl/4tceP4
- Peshkin BN, Schwartz MD, Isaacs C, Hughes C, Main D, et al. (2002) Utilization of Breast Cancer Screening in a Clinically Based Sample of Women after BRCA1/2 Testing. Cancer Epidemiol Biomarkers Prev 11: 1115-1118. Link: https://goo.gl/eiSxPa
- Tinley ST, Houfek J, Watson P, Wenzel L, Clark MB, et al. (2004) Screening Adherence in BRCA1/2 Families is Associated with primary physicians’ behavior. Am J Med Genet A 125 A: 5-11. Link: https://goo.gl/YJTX6d
- Price MA, Butow PN, Charles M, Bullen T, Meiser B, et al. (2010) Predictors of breast cancer screening behavior in women with a strong family history of the disease. Breast Cancer Res Treat 124: 509-519. Link: https://goo.gl/DmXpKC
- McInerney-Leo A. et al. (2006) BRCA1/2 Testing in Hereditary Breat and Ovarian Cancer Families III: Risk Perception and Screening. Am J Med Genet A 140: 2198-2206. Link: https://goo.gl/8mZg9S
- Domchek SM, Gaudet MM, Stopfer JE, Fleischaut MH, Powers J, et al (2010) Breast Cancer risks in individuals testing negative for a known family mutation in BRCA1 or BRCA2. Breast Cancer Res Treat 119: 409-414. Link: https://goo.gl/GZ6yE1
- Schwartz MD, Peshkin BN, Hughes C, Main D, Isaacs C, et al. (2002) Impact of BRCA1/BRCA2 Mutation Testing on Psychological Distress in a Clinical-Based Sample. J Clin Oncol 20: 514-520. Link: https://goo.gl/aTodb4
- Foster C, Watson M, Eeles R, Eccles D, Ashley S, et al. (2007) Predictive genetic testing for BRCA1/2 in a UK clinical cohort: three-year follow-up. Br J Cancer 96: 718-724. Link: https://goo.gl/W3cuzm
- Schwartz MD, Lerman C, Brogan B, Peshkin BN, Halbert CH, et al. (2004) Impact of BRCA1/BRCA2 Counseling and Testing on Newly Diagnosed Breast Cancer Patients. Journal of Clinical Oncology 22: 1823-1829. Link: https://goo.gl/d1zjsi
- Wainberg S, Husted J (2004) Utilization of Screening and Prevention Surgery Among Unaffected Carriers of a BRCA1 or BRCA2 Gene Mutation. Cancer Epidemiol Biomarkers Prev 13: 1989-1995. Link: https://goo.gl/QK9V1m
- Van Oostrom I, Meijers-Heijboer H, Lodder LN, Duivenvoorden HJ, van Gool AR, et al. (2003) Long-term psychological impact of carrying a BRCA1/2 mutation and psychological surgery: a 5-year follow-up study. J Clin Oncol 21: 3867-3874. Link: https://goo.gl/BrCDhj
- Butow PN, Lobb EA, Meiser B, Barratt A, Tucker KM (2003) Psychological outcomes and risk perception after genetic testing and counselling in breast cancer: a systematic review. Med J Aust 178: 77-81. Link: https://goo.gl/oeFQWD
- Katapodi MC, Lee KA, Facione NC, Dodd MJ (2004) Predictors of perceived breast cancer risk and the relation between perceived risk and breast cancer screening: A meta-analytic review. Prev Med 38: 388-402. Link: https://goo.gl/nuYDUm
- Schlich-Bakker KJ, ten Kroode HFJ, Ausem MGEM (2006) A literature review of the psychological impact of genetic testing on breast cancer patients. Patient Educ Couns 62: 13-20. Link: https://goo.gl/8MaS1f
- Bluman LG, Rimer BK, Berry DA, et al. (1999) Attitudes, knowledge,and risk perceptions of women with breast and/or ovarian cancer considering testing for BRCA1 and BRCA2. J Clin Oncol 17: 1040-1046. Link: https://goo.gl/YmZSg3
- Tomamichel M, Sessa C, Herzig S, de Jong J, Pagani O, et al. (1995) Informed consent for phase I studies: evaluation of quantity and quality of information provided to patients. Ann Oncol 6: 363-369. Link: https://goo.gl/wrJagt
- Tomamichel M, Jaime H, Degrate A, de Jong J, Pagani O, et al. (2000) Proposing phase I studies: patients', relatives', nurses' and specialists' perceptions. Ann Oncol 11: 289-294. Link: https://goo.gl/CEbD82
- Berry DA, Iversen ES Jr, Gudbjartsson DF, Hiller EH, Garber JE, et al. (2002) BRCAPRO validation, sensitivity of genetic testing of BRCA1/BRCA2, and prevalence of other breast cancer susceptibility genes. J Clin Oncol 20: 2701-2712. Link: https://goo.gl/ospnSK
- Spielberger CD, Gorssuch RL, Lushene PR, Vagg PR, Jacobs GA (1983) Manual for the State-Trait Anxiety Inventory. Consulting Psychologists Press. Link: https://goo.gl/Smis1Q
- Meerwein F (1985) Das Erstgspräch auf der Abteilung für medizinische Onkologie. In: Das therapeutische Gespräch mit Krebskranken. Bern: Huber Verlag 41-669. Link: https://goo.gl/LUix6X
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