Support needs and acceptability of psychological and peer consultation: Attitudes of 108 women who had undergone or were considering prophylactic mastectomy

May combine two claims.

The COPM group of 37 women included 13 with prior unilateral invasive breast cancer, 3 with DCIS contemplating bilateral or contralateral prophylactic mastectomy, and 21 healthy women with significant family history and/or known or suspected BRCA mutation considering bilateral prophylactic mastectomy.

“The COPM group of 37 women included 1.) women with prior diagnoses of unilateral invasive breast cancer (n=13) or DCIS (n=3) who were contemplating bilateral or contralateral PM and 2.) healthy women (n=21) with significant family history of breast cancer, and/or a known or suspected BRCA mutation who were considering bilateral PM.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

A notable proportion of subjects were employed in healthcare careers: 31% of the BPM group, 33% of the UPM group, and 24% of the COPM group.

“An unanticipated finding was that a notable proportion of subjects were employed in healthcare careers: 31% of the BPM group, 33% of UPM group, and 24% of COPM group.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Five women in the BPM group (19%) and 3 in the UPM group (7%) had previously undergone prophylactic oophorectomy; 18 in the COPM group (49%) had.

“Five women in the BPM Group (19%) and 3 in the UPM group (7%) had previously undergone prophylactic oophorectomy (removal of the ovaries to try to prevent ovarian cancer) which is recommended for consideration by BRCA1/2 mutation carriers [Burke 1997]. Eighteen of the women in the COPM group (49%) had had a prophylactic oophorectomy.”

• cites Burke 1997 sourceNot checked — no full text of the source

May combine two claims.

There was no significant difference between the three groups in educational level, income, marital status, or number of children.

“There was no significant difference between the three groups in their educational level, income, marital status or number of children (data not shown).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Subjects were 97% Caucasian and typically well-educated with high incomes.

“Subjects were 97% Caucasian and typically well-educated with high incomes.”

Probably not a substantial claim: may not pass S3 (load-bearing).

About half the women in the BPM group were either themselves health care professionals or had siblings or parents who were physicians.

“About half the women in the BPM group were either themselves health care professionals or had siblings or parents who were physicians.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Over 80% of subjects in all groups were married and most had children.

“Over 80% of subjects in all groups were married and most had children.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Women in the BPM group were an average of 4.9 years post-surgery and their mean age at surgery was 41.8 years; 73% had undergone reconstruction.

“Women in the BPM group were an average of 4.9 years post-surgery (range 1–12 years) and their mean age at surgery was 41.8 years (range 29–59 years). In that group, 73% (n=19) had undergone reconstruction.”

Probably not a substantial claim: may not pass S3 (load-bearing).

One-third of women who had undergone bilateral prophylactic mastectomy had relatives who also had undertaken this surgery.

“It also was noted that one-third of the women who had undergone bilateral PM had relatives who also had undertaken this surgery, some as long as 20–30 years earlier.”

May combine two claims.

42% of the BPM group and 25% of the UPM group considered post-surgical psychological services not necessary or not advisable.

“Such services were considered not necessary or not advisable by 42% of the BPM group and 25% of the UPM group.”

May combine two claims.

Some women met their peer face-to-face, and in some cases the peer offered to show the subject her post-surgical breasts.

“Some women met their peer face-to-face and, in some cases, the peer even offered to show the subject her post-surgical breasts.”

May combine two claims.

Fewer participants considered rehearsing feelings about PM useful, and it was unclear whether they understood this component.

“Fewer thought rehearsing their feelings about PM would be useful, but it was less clear subjects understood this component.”

May combine two claims.

Among COPM women, 81% thought post-surgical services would be helpful, 14% did not, and 5% gave uninterpretable responses.

“Of the COPM women, 81% (n=30) thought post-surgical services would be helpful, 14% (n=5) did not think so, and 2 women (5%) gave uninterpretable responses.”

May combine two claims.

The most commonly cited reasons for feeling psychological consultation would not have been useful were that the subject had already made up her mind and that support from friends and family rendered professional consultation unnecessary.

“The most commonly cited reasons for feeling psychological consultation would not have been useful were that the subject had already made up her mind and thus did not need to discuss the decision, and that the availability of support from friends and family rendered professional consultation unnecessary.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Subjects were particularly vocal about their fear that a mental health consultant seeing a patient considering prophylactic mastectomy might try to unduly exert an influence on the patient's decision based on factors unrelated to the patient.

“Subjects were particularly vocal about their fear that a mental health consultant seeing a patient considering PM might try to unduly exert an influence on the patient’s decision based on factors unrelated to the patient (i.e. the therapist’s views of PM).”

May combine two claims.

Reports of dissatisfaction occurred in both women with reconstruction and those without; reports of satisfaction and reduced anxiety also occurred in both groups.

“Reports of dissatisfaction were not limited only to women who had undergone reconstruction, but were also expressed by women who had opted not to have reconstruction. Similarly, there were reports of satisfaction and reduced anxiety in both groups.”

May combine two claims.

In the BPM group, 12% (n=3) knew there was a relevant mutation in their family; 23% (n=6) thought there was not; 62% (n=16) were uncertain about BRCA1/2 status.

“In the BPM group, only 12% (n= 3) knew that there was a relevant mutation in their family. Twenty-three % (n=6) thought there was not a mutation in their family and most, 62% (n=16), were uncertain about BRCA1/2 status.”

May combine two claims.

Many women felt psychological consultation would be valuable before and after PM, and had strong feelings about the therapist's role.

“While many women felt that psychological consultation would be a valuable adjunct before and after PM, they also had strong feelings about the role of the therapist.”

May combine two claims.

In the COPM group, 14% (n=5) had consulted a mental health professional and 80% found it useful.

“In the COPM group, 14% (n=5) had consulted a mental health professional and 80% found it useful.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Many subjects had prophylactic surgery on the basis of family history before the advent of genetic testing for breast cancer susceptibility.

“Many of the subjects in this study had had their prophylactic surgery on the basis of family history before the advent of genetic testing for breast cancer susceptibility.”

May combine two claims.

Patients wanted mental health professionals knowledgeable about breast/ovarian cancer genetics, PM surgical techniques, reconstruction options, post-surgical complications, and emotional aftereffects.

“In addition, patients wanted mental health professionals in the consultation role who had good knowledge of breast/ovarian cancer genetics, PM surgical techniques and reconstruction options, and post-surgical complications as well as emotional aftereffects.”

May combine two claims.

Women in the study generally reported lack of regret but also described distress in deciding about PM and in complex post-surgical adjustment affecting their self-view.

“While women in our study generally reported lack of regret, they also described distress in deciding about PM and in the complex post-surgical adjustment which PM necessitated in their view of themselves.”

May combine two claims.

Among the BPM group, 54% (n=14) said they thought it would have been useful for them to have had a psychological consultation as part of pre-surgical work-up; an additional 27% (n=7) said it might not have been useful for them but would be valuable for others; 15% (n=4) stated it would not be useful.

“Among the BPM group, 54% (n=14) said they thought it would have been useful for them to have had a psychological consultation as part of their pre-surgical work-up. An additional 27% (n=7) said that it might not have been useful for them, but would be valuable for others, either their relatives or others with needs different from their own, to have that option. Fifteen percent of the BPM group (n=”

Classified as probably not a substantial claim. May combine two claims.

Participants expressed that an effective therapist for PM-related issues must know PM surgery types, reconstruction options, common surgical complications, and emotional and physical sequelae.

“Subjects voiced the concern that to be effective, a therapist helping women deal with issues related to PM would have to be knowledgeable about the types of PM surgery and reconstruction options available and about the common complications of surgery, and to be well versed in the emotional and physical sequelae of PM surgery.”

May combine two claims.

Half of women who had undergone prophylactic mastectomy and nearly three-quarters of those considering prophylactic mastectomy had previously sought psychotherapeutic services.

“Half of the women who had undergone PM and nearly ¾ of those considering PM had previously sought psychotherapeutic services.”

May combine two claims.

Maternal death from breast cancer differed significantly among the three groups (p<0.01) with 65% in the BPM group, 11% in the UPM group, and 19% in the COPM group.

“Maternal death from breast cancer differed significantly among the three groups (p<0.01) with 65% in the BPM group having had a mother who died from breast cancer, as did 11% in the UPM group and 19% in the COPM group.”

May combine two claims.

Among UPM patients, 51% (n=23) felt a pre-surgical psychological consultation would have been useful to them; an additional 24% (n=11) felt it might have been useful for others but not for them; 24% (n=11) thought it would not be useful.

“Among the UPM patients, 51% (n=23) felt a pre-surgical psychological consultation would have been useful to them and an additional 24% (11) felt that it might have been useful for others, but would not have been for them. In this group, 24% (n=11) thought it would not be useful for women to be offered a pre-surgical psychological consultation.”

Classified as probably not a substantial claim.

Subjects felt early clarification of the therapist's neutrality about the outcome of the patient's decision would be critical.

“They felt early clarification of the therapist’s neutrality about the outcome of the patient’s decision would be critical.”

May combine two claims.

Among the BPM group, 15% (n=4) had spoken with a mental health professional about prophylactic mastectomy prior to surgery and 50% reported the consultation helpful.

“Among the BPM group, 15% (n=4) had spoken with a mental health professional about PM prior to their surgery and 50% reported that they found the consultation helpful.”

May combine two claims.

Most subjects felt that presenting the service in the context of the standard workup was preferable and reduced or eliminated any implication that the referral was based on the surgeon's suspicion about instability in the patient's general psychological state or deficiency in their decision-making ability.

“However, most subjects felt that presenting the service in the context of the standard workup was preferable and reduced or eliminated any implication that the referral was based on the surgeon’s suspicion about instability in the patient’s general psychological state or deficiency in their decision-making ability.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Subjects stated it would be important to specify that the goal of psychological consultation was to provide an opportunity for patients to consider emotional and interpersonal ramifications of prophylactic mastectomy surgery, rather than as an assessment of psychological competence or suitability for surgery.

“Subjects also stated that it would be important to specify that the goal of the psychological consultation was to provide an opportunity for patients to consider the emotional and interpersonal ramifications of their PM surgery, rather than as an assessment of psychological competence or suitability for surgery.”

May combine two claims.

Women in the UPM group were an average of 4.8 years post-surgery with mean age at surgery 49.7 years; 80% had elected breast reconstruction.

“Women in the UPM group were an average of 4.8 years post-surgery (range 2–11 years) with a mean age at surgery of 49.7 years (range 30– 83 years. Eighty percent (n=36) had elected breast reconstruction.”

May combine two claims.

In the BPM group, 65% had spoken with a peer consultant and all who did found it helpful.

“Of the women in the BPM group, 65% (n = 17) had spoken with such a peer consultant and all who did (100%) found it helpful.”

May combine two claims.

In the UPM group, 20% (n=9) had spoken to a therapist about their prophylactic mastectomy decision, and all had found this consultation useful.

“In the UPM group, 20% (n=9) had spoken to a therapist about their PM decision, and all had found this consultation useful.”

May combine two claims.

In the COPM group, 46% (n=17) said a specific BRCA1/2 mutation had been found in one or more relatives; 92% (n=34) had undergone BRCA1/2 testing; 89% (n=33) had received test result; 52% (n=19) had received a positive BRCA1/2 test result.

“In the COPM group, 46% of the women (n=17) said that a specific BRCA1/2 mutation had been found in one or more of their relatives. Among the 37 women in that group, 92% (n=34) said they themselves had undergone BRCA1/2 testing and 89% (n=33) had received their test result. In the COPM group, 52% (n=19) had received a positive BRCA1/2 test result.”

May combine two claims.

Among women who had undergone PM, 54% of the BPM group and 67% of the UPM group said it would be advisable to offer psychological services after prophylactic mastectomy.

“Of the women who had undergone PM, 54% (n=14) of the BPM group and 67% (n=30) of the UPM group said they thought it would be advisable for women to be offered psychological services following prophylactic mastectomy surgery.”

Probably not a substantial claim: may not pass S3 (load-bearing).

There was no significant difference between the BPM and UPM groups in time elapsed between surgery and interview.

“There was no significant difference between the BPM and UPM groups in time elapsed between surgery and the interview.”

May combine two claims.

In the COPM group, 51% had spoken with a peer and 84% found the consultation helpful.

“In the COPM group, 51% (n = 19) had spoken with another woman who had previously undergone PM and 84% found the consultation helpful.”

May combine two claims.

In the UPM group, 9% (n=4) said there was a known BRCA1/2 mutation in their family; 62% (n=28) did not know if there was a familial mutation; 27% (n=12) thought a BRCA1/2 mutation had not been identified.

“In the UPM group, 9% (n=4) of the women said there was a known BRCA1/2 mutation in their family. The remainder appeared either not to know if there was a familial mutation (62%, n=28) or to think that a BRCA1/2 mutation had not been identified in their family (27%, n=12).”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

COPM women were more likely to have utilized psychotherapy generally, which may have contributed to their universal endorsement for presurgical consultation.

“Women in the COPM group were also more likely to have utilized psychotherapy generally, which may have contributed to their universal endorsement for presurgical consultation.”

May combine two claims.

More COPM women knew their BRCA1/2 status or had relatives tested; most BPM and UPM subjects had surgery before testing availability or were from families without known mutations.

“More of the women in the COPM group knew their BRCA1/2 status or had relatives who had undergone testing; most of the bilateral and unilateral PM subjects had had surgery prior to the availability of testing or were from families without known mutations.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Permission to contact patients was granted by 97% of the 33 surgeons contacted.

“Permission was granted by 97% of the 33 surgeons we contacted.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

In that Mayo Clinic study, many women reported adverse effects in body appearance (33%), femininity (26%), and sexual relationships (23%).

“many also reported adverse effects in body appearance (33%), femininity (26%), and sexual relationships (23%) [Frost 2005].”

• cites Frost 2005Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

Among women after prophylactic mastectomy, social support is positively correlated with quality of life.

“For post-PM women, social support was positively correlated with quality of life [Metcalfe 2005].”

• cites Metcalfe 2005Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

Female BRCA1/2 mutation carriers have breast cancer risks between 56% and 85%.

“whose breast cancer risks are between 56% and 85% [Ford 1994; Struewing 1997]”

• cites Ford 1994 sourceNot checked — no full text of the source
• cites Struewing 1997Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing).

Reliability of the coding was checked by having 5% of the interviews coded by multiple coders.

“Reliability of the coding was checked by having 5% of the interviews coded by multiple coders.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

All analyses were exploratory and the resulting p-values are nominal without multiple comparison adjustment.

“All analyses were exploratory and the resulting p-values are nominal without multiple comparison adjustment.”

Probably not a substantial claim: may not pass S2 (checkable).

Psychological consultation may benefit women considering prophylactic mastectomy as part of pre-surgical decision-making and preparation.

“The pressures on women to decide about PM and reports of long-lasting, complex, post-surgical emotional distress impacting quality of life for at least a significant subset of women post-PM surgery, suggest the importance of considering the potential benefits of psychological consultation as part of pre-surgical decision-making and preparation.”

• AssumptionRests on an assumption: Decisions about prophylactic mastectomy are often made under considerable pressure.
• AssumptionRests on an assumption: Women with cancer often make the decision about prophylactic mastectomy immediately following a diagnosis of breast cancer when they are under pressure to initiate treatment.
• AssumptionRests on an assumption: Even women without breast disease but with strong family histories of breast cancer often report pressure from family members about prophylactic mastectomy.
• AssumptionRests on an assumption: High-risk women considering prophylactic mastectomy are given little guidance about how to proceed with the analysis of pros and cons.
• AssumptionRests on an assumption: Pre-surgical psychological consultation is not a routine, integrated component of pre- or post-surgical care for most women who undergo prophylactic mastectomy.

Probably not a substantial claim: may not pass S3 (load-bearing).

In a Mayo Clinic study of 583 women an average of 10 years after contralateral prophylactic mastectomy, over 80% reported no change or positive effects in self-esteem, stress level, and emotional stability.

“A Mayo Clinic study of 583 women an average of 10 years post-contralateral PM found while over 80% of the subjects reported no change or positive effects in self-esteem, stress level, and emotional stability”

• cites Frost 2005Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

Participation rates were 80% for women who had undergone prophylactic mastectomy and 57% for the COPM group.

“Participation rates were 80% for the women who had undergone PM. The rate for the COPM group was 57%.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The research was approved by the Dana-Farber Cancer Institute Institutional Review Board and by the Human Subjects Research Review Board of the U.S. Army Medical Research and Materiel Command.

“This research was approved by the Dana-Farber Cancer Institute Institutional Review Board and by the Human Subjects Research Review Board of the U.S. Army Medical Research and Materiel Command.”

Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

Such discussions are often beyond the scope and time limitations of typical pre-surgical visits but may be crucial to optimal decision-making.

“Such discussions are often beyond the scope and time limitations of typical pre-surgical visits, but may be crucial to optimal decision-making.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study included women who had one breast removed prophylactically with or after removal of the other breast for invasive cancer or DCIS.

“It is noteworthy also that we did include women who had had one breast removed prophylactically in conjunction with or following removal of the other breast for invasive cancer or DCIS.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The stress of confronting decisions raised by genetic testing and focusing on the implications of hereditary cancer has been described by others.

“The stress of confronting decisions raised by genetic testing and focusing on the implication of hereditary cancer has been described by others [Hamann 2005]; [Stiefel 1997].”

• cites [Hamann 2005]Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

• cites [Stiefel 1997]Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

May combine two claims.

The study included women at many points along the PM experience continuum, including those still weighing pros and cons and those 1-12 years post-surgery.

“Our study did, however, include women at many points along the continuum of experience with PM, including women still weighing the pros and cons and women whose surgery ranged from 1–12 years in the past.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The higher percentage of COPM women with personal or family history of ovarian cancer reflects increasing awareness of the hereditary ovarian-breast cancer link.

“The higher percentage of women in the COPM group with personal or family history of ovarian cancer reflects increasing awareness of the link between hereditary ovarian and breast cancer.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The demographics and family cancer histories of the subjects illustrate changing dynamics among PM patients.

“The demographics and family cancer histories of the subjects in this research illustrate changing dynamics among PM patients.”

Probably not a substantial claim: may not pass S2 (checkable).

Matching characteristics could be optimized if done following a psychological consultation that explores the value and limitations of peer consultation for the particular patient.

“Matching of the characteristics that were most pertinent for the woman considering PM to learn from her peer consultant could be optimized if the matching were done following the psychological consultation which could explore the value and limitations of the peer consultation for the particular patient.”

May combine two claims.

Australian researchers found that clinicians were more likely to discuss PM as an option if the woman had medical or allied health training, suggesting a possible physician-associated bias.

“Researchers in Australia have also found that clinicians conducting an initial genetic counseling consultation to women from families with a high risk of breast cancer were more likely to discuss PM as an option if the woman had medical or allied health training [Lobb 2004], suggesting that there may be a physician-associated bias as well.”

• cites [Lobb 2004] sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S2 (checkable).

This suggests a need for additional specialized training of psycho-oncologists for the growing number of BRCA1/2 carriers.

“This suggests a need for additional specialized training of psycho-oncologists, who could provide targeted psychological services to the growing number of BRCA1/2 mutation carriers.”

Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

During the period without hard data on PM efficacy, the decision to undergo PM may have been easier for those from families with a strong intrinsic belief in medicine.

“During the period when there were no hard data about the efficacy of PM, it may have been easier to make a decision to undergo PM if one came from a family which had a strong, intrinsic belief in the power of medicine.”

May combine two claims.

High levels of endorsement for psychological consultation before and after PM suggest heavy emotional burden of PM decision-making and significant emotional impact after surgery.

“Our results showing high levels of endorsement for the provision of or, at minimum, the ready availability of psychological consultation before and after prophylactic mastectomy suggests the heavy emotional burden of decision-making regarding PM and the significant emotional impact following surgery.”

• AssumptionRests on an assumption: Women's self-reported attitudes about psychological consultation reflect their actual support needs and likely use of services.

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

Information-seeking and family support may differ in medical families compared with families with less direct access to medical information.

“Information-seeking and family support may be quite different in such families than in families with less direct access to medical information.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Concern that a therapist might override an individual's decision may be a projection of negative views about PM from family and friends reported by women.

“The concern that a therapist might try to override an individual’s decision may be a projection onto the therapist of the negative views about PM from family and friends, which were reported by a number of women.”

Probably not a substantial claim: may not pass S2 (checkable).

Several different specialized psychological consultation models may be needed to address the needs of all women who consider PM.

“It is also likely that several different specialized psychological consultation models may be needed to address the needs of all women who consider PM.”

Classified as probably not a substantial claim. May combine two claims.

It is possible that participants were more conflicted or distressed about PM decision than nonparticipants, so interest in psychological services might be overrepresented.

“It is possible that those participating were women more conflicted or distressed about the PM decision than those who chose not to participate and, thus, interest in the use of psychological services might be overrepresented.”

May combine two claims.

Even if none of the decliners were similar, uniform endorsement among participants means interest among women considering PM would still be above 50%.

“However, given the uniform endorsement of psychological consultation among participants in this group, even if none of the decliners were of a similar mind, interest among women considering PM would still be above 50%.”

May combine two claims.

The study was limited by its retrospective inquiry and by including subjects from only three institutions within one hospital system.

“This study was limited by the retrospective nature of our inquiry to women who had undergone PM and by the fact that it involved subjects from only three institutions within one hospital system.”

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

Women from hereditary cancer families with multiple losses may have different issues than women with little or no family history who learn mutation status after breast cancer diagnosis.

“Those from hereditary cancer families with multiple experiences of loss due to breast or ovarian cancer who consider PM might be expected to have different issues arise from, say, women with little or no family history who learn of their mutation status just after being diagnosed with breast cancer.”

May combine two claims.

The study sample was not culturally diverse, reflecting that most women tested for BRCA1/2 to date are well-educated, high-income Caucasian women.

“Like most studies of genetic testing for breast cancer, our study sample was not culturally diverse, a reflection of the fact that a preponderance of women tested to date for BRCA1/2 are well-educated, high income Caucasian women [Halbert 2005].”

• cites [Halbert 2005]Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

Differences in time to consider PM and family awareness of cancer risk may affect how women decide and react after surgery.

“Differences in time to consider PM and in family awareness of the relevant cancer risk may affect how women make their decision and how they react following surgery.”

Classified as probably not a substantial claim.

Endorsers were conservatively counted only if they unequivocally endorsed psychological consultation for PM, separating those who thought it advisable for others but not themselves.

“We also have conservatively counted as endorsers only those who unequivocally endorsed psychological consultation for PM, separating out those who felt it would be advisable for others, but that they would not have benefited.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The study reports attitudes toward utilization of psychological consultation, not actual acceptance of services.

“Finally, our study reports attitudes towards utilization of psychological consultation, not actual acceptance of services.”

Probably not a substantial claim: may not pass S2 (checkable).

The techniques yielded narrative depth that provided a more rounded picture of the PM experience than currently available.

“Our techniques yielded a narrative depth which provided a much more rounded picture of the PM experience than that currently available.”

Classified as probably not a substantial claim. May combine two claims.

The findings suggest a preference for standardizing a mental health visit in the presurgical work-up and a neutral therapist stance about PM and possible consultation components.

“They suggest a preference for standardizing inclusion of a mental health visit as part of the presurgical work-up and suggest a neutral therapist stance about PM and possible components of the consultation.”

Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

As genetic medicine integrates into general practice, multidisciplinary collaboration between physicians, surgeons, and mental health professionals may help optimize outcomes for high-risk patients.

“As genetic medicine becomes more integrated into general medical practice, multidisciplinary collaboration between physicians, surgeons, and mental health professionals in the provision of services targeted to high-risk patients may help optimize patient outcomes.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The sample size is small by quantitative standards but large for an in-depth, largely qualitative study.

“Our sample size, while small by typical standards for quantitative research, is large for an in-depth, largely qualitative study.”

Probably not a substantial claim: may not pass S3 (load-bearing).

These factors can affect the clarity and certainty with which women approach PM surgery.

“These factors can affect the clarity and certainty with which women approach PM surgery.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Comparisons across subjects were optimized by combining open-ended questions with standard probes and some structured questions about acceptability and preferred nature of psychological services.

“We optimized comparisons across subjects by combining open-ended questions with standard probes with some more structured questions about the acceptability and preferred nature of psychological services.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Interviews conducted by psychologists might have led to higher reported interest in psychological consultation than otherwise.

“We are also aware that it is possible that the fact that the interviews were conducted by psychologists might have led to reporting of a higher level of interest in psychological consultation than might have been the case otherwise.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The qualitative approach deepens understanding and uncovers unforeseen outcomes but can complicate reporting of findings.

“Such a qualitative approach, while greatly deepening our understanding of the impact of PM and allowing room for uncovering of unforeseen areas of positive and negative outcomes can complicate reporting of findings.”

Classified as probably not a substantial claim.

The findings support development of interventions offering psychological support to women considering PM and those opting for PM, before and after surgery.

“Our findings support the development of interventions offering psychological support to women who consider PM and to those who opt for PM, both pre- and postsurgery.”

• AssumptionRests on an assumption: Women's self-reported attitudes about psychological consultation reflect their actual support needs and likely use of services.

Probably not a substantial claim: may not pass S2 (checkable).

Additional targeting may be needed for the varied needs of women with and without personal cancer histories and early cancer-related loss.

“Additional targeting may be needed to meet the varied needs of women with and without personal cancer histories and with and without early experiences of breast and ovarian cancer-related loss.”

May combine two claims.

Cost was not considered a barrier by women in the relatively affluent sample, but may be in lower-income or less-insured groups.

“While cost was not considered by women in our relatively affluent sample to be a barrier to acceptance of psychological services, this may not be the case in groups with lower average incomes or less access to health insurance.”

Probably not a substantial claim: may not pass S2 (checkable).

Differences suggest careful comparison of demographic and family history between samples will be important for understanding PM outcomes across studies.

“These differences suggest that as PM is offered to a growing group of women who seek cancer genetic counseling or testing, careful comparison of demographic and family history information between samples will be important as a basis for understanding similarities or differences in PM outcomes between studies.”