The findings suggest that the level of psychological distress is not related to time between colorectal cancer diagnosis and MSI testing. In fact, patients diagnosed with colorectal cancer less than 1 year ago reported less psychological distress than patients diagnosed with cancer longer ago. Contemplation and consideration of the cancer is more likely to occur once active treatment for cancer in the hospital is over. Experiencing intrusive thoughts may be a signal that people are working through the implications of the cancer [
28]. In line with this, a previous study showed that 15% of patients with breast cancer became distressed not until after end of treatment, in the reentry phase [
29].
We analysed which patients were at highest risk for distress and found three risk factors: gender, religion and reduced social support including impaired family communication. In our study female patients reported higher levels of psychological distress than male patients. This fits with many other studies in which gender is found to be related to psychological distress upon genetic testing [
33] and with a review which demonstrated that female patients with colorectal cancer are most vulnerable for hereditary cancer genetic testing related distress [
34]. Unexpectedly, religious patients were found to report the highest levels of psychological distress. Previous studies showed that patients use spiritual and religious resources to understand and cope with morbidity and mortality [
35] and that this helps people cope with genetic uncertainty [
36]. We note that there are positive and negative patterns of religious coping [
35] and in this study we did not measure distinct religious coping patterns. It might be that in our study sample negative religious coping patterns dominated. In a study with participants tested for
BRCA1 mutations no significant associations between religiosity and psychological distress were observed [
37]. We conclude to this point that religious coping in the context of genetic testing is an area in which more studies are needed. Finally, low social support and difficulties with family communication were related to higher levels of psychological distress. This is consistent with a study among colorectal cancer survivors undergoing genetic testing for Lynch syndrome in which higher levels of cancer related distress was related to less social support [
38]. Genetic testing and hereditary cancer are family matters. Family system characteristics may influence the way the individual and the family as a whole copes with hereditary cancer [
39]. Our data showed that difficulties and being in need of help regarding family communication about hereditary cancer were related to psychological distress. Participants more frequently reported cancer related distress when they perceived family communication about hereditary cancer as inhibited [
40]. The quality of communication is of paramount importance where open family communication may be an important buffer against hereditary cancer distress [
40]. Patients who report difficulties regarding communicating hereditary cancer with the family seems vulnerable to high levels of psychological distress. Questioning family communication can identify these patients. Former experiences with cancer may also play an role in genetic testing responses [
41]. Experiences with cancer in the family may result in an increased psychological vulnerability during genetic testing for hereditary cancer [
25]. However, we found no relation between either cancer treatment or having a first degree relative with cancer and the level of psychological distress. The latter finding is in contrast with a study which showed that having a first degree relative with colorectal disease predicted a higher level of distress about colorectal cancer [
42]. Previous studies found being unmarried [
43] and having children [
33] as predictors of psychological distress related to genetic testing for hereditary cancer. In our study sample however, no correlations were found between marital or parental status and the level of psychological distress.To our knowledge, this is the first study that measures psychological distress in relation to time between colorectal cancer diagnosis and genetic testing for hereditary cancer. Moreover, this is the first study measuring psychological distress at the time of testing for being at high risk for Lynch syndrome by MSI-analysis. A point of attention is that response rate was low and our study sample may reflect selection-bias. Although demographic and cancer related characteristics of the participants and the non-participants did not differ significantly, psychological characteristics of the non-responders were not obtained. Other limitations of the study is the relatively small sample size and the cross-sectional design. To determine the causal effect of MSI-testing on levels of psychological distress a prospective randomized study design is preferred.
Our results suggest that high levels of psychological distress are not related to the duration of the time period between MSI-testing since CRC diagnosis. We carefully conclude that patients who are either female, religious, having low social support or those reporting difficulties in communicating hereditary colorectal cancer with relatives are at higher risk for psychological distress.