Psychosomatics 49:49-55, January-February 2008
doi: 10.1176/appi.psy.49.1.49
© 2008 Academy of Psychosomatic Medicine
The Role of Anxiety in a Mammography Screening Program
Jane Brown Sofair, M.D., and
Martha Lehlbach, R.N., M.A.
Received October 20, 2006; revised February 27, 2007; accepted March 16, 2007. From the Dept. of Psychiatry, Atlantic Health, Morristown, NJ. Send correspondence and reprint requests to Jane Brown Sofair, M.D., Dept. of Psychiatry, Atlantic Health, Suite 200, 35 Airport Rd., Morristown, NJ 07960. e-mail: JBSofair{at}aol.com
© 2008 The Academy of Psychosomatic Medicine
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ABSTRACT
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Fifty-eight women, at least 35 years old, without breast cancer, were approached to examine the role of anxiety in mammography compliance. Forty-seven women for pre- and 43 for pre- and post-mammography completed the analysis. Mean age was 50; 64% were Hispanic, and 83% had no health insurance. Anxiety scores decreased after mammography. Residual anxiety was associated with having more than four films taken or with "non-negative" results. Eighty-five percent intended to return as recommended. Even though 26% of the group reported post-mammography anxiety, most planned to return. Future studies should explore staff influence on compliance across cultures.
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INTRODUCTION
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Anxiety has an uncertain role in mammography compliance and cancer screening, in general.1 It has been suggested that breast cancer worry encourages mammography, particularly if the test is perceived by the patient as an effective means of preventing more serious disease.2 The evaluation of anxiety and other potential psychological barriers to screening mammography among non–English-speaking and medically underserved ethnic minorities is relatively uncharted.
Overall, mammography compliance in the United States for women at least 40 years of age more than doubled, from 29% in 1987 to 70% in 2000. However, compliance among Hispanic and other ethnic-minority groups lagged in comparison to that of white and black American women; 72% of white and 68.2% of black women reported having had a mammogram between 1998 and 2000. Only 62% of Hispanic women, 41% of recently immigrated women, and 39% of uninsured women reported having had a mammogram.3
Without a doubt, mammography compliance among low-income Hispanic women is of paramount importance in the oncology field, given their comparatively advanced tumor stage at diagnosis and increased mortality.4–7 Between 1990 and 1997, breast cancer was a leading cause of death among Hispanic women. Black women were also noted to have a higher age-adjusted breast cancer mortality, at 31.4 per 100,000 as compared with 25.3 per 100,000 for white women.5,6 Jacobellis and Cutter6 demonstrated higher incidence and prevalence of advanced breast cancer among Hispanic and black women, as compared with white women, when adjusting for age and personal cancer history. When also controlling for educational level, more advanced tumor stage for black versus white women persisted, but this was not the case for Hispanic women. Some have suggested that sociodemographic factors alone may not account for observed differences in tumor staging across ethnic groups.6
Factors associated with decreased mammography utilization include lack of insurance, lack of access to care, lack of physician prescription, fear of radiation, anticipated pain, fear of test result, language/cultural barriers, and misconceptions about cancer risk/cancer prevention.2,8
Several investigators have refuted the idea of cultural attitudes per se as a deterrent to screening. For instance, looking at a sample of Puerto Rican women in Massachusetts and using a predeveloped National Health Institute Survey, investigators found high fatalism scores among the 390 predominantly Hispanic women, age 40 and older. Health insurance, access to care, and physician prescription, were nevertheless the driving factors in ensuring a mammogram within the past 2 years.9
Although the underutilization of mammography among immigrant Hispanic women has been recognized, the role of anxiety across Latino groups’ screening decisions has not been consistently addressed.9–14 One study looked at anxiety related to the effectiveness of mammography and generalized worry in an ethnically diverse sample of 963 women. In contrast to black and white women, Hispanic women’s level of anxiety was not significantly correlated with avoidance of mammography.10 Three studies mentioned modesty, embarrassment, and nonspecific fearful attitudes as potential psychological screening deterrents among Hispanic women.11–13 A fourth study of Mexican American women did not mention psychological factors.14
We believe that our study is unique in two ways: its design is longitudinal, and it is a cross-cultural study. There is another longitudinal anxiety study conducted in England that looked at pre- and post-mammogram anxiety levels among women age 50 and older who were recruited for mammography through a government-sponsored screening program. In that study, anxiety levels did not show a significant fluctuation from pre- to post-mammography except among participants with false-positive readings, who had a threefold rise in anxiety while waiting for their soon-to-be-mailed test results.15
Our objective was to determine the direction and magnitude of change in anxiety levels before and after mammography among predominantly uninsured Hispanic women and to determine any potential effect of anxiety on follow-up mammography compliance. We hypothesized that participants would feel comparatively less anxious after the mammogram unless further work-up was indicated. It was also hypothesized that "guideline" confusion, if reported by the participant, would have minimal-to-no impact on any decision the woman might make regarding future mammograms.
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METHOD
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Participants were recruited through the Morris County Cancer Education and Screening Initiative as part of New Jersey Cancer Education and Early Detection (NJCEED) at any of seven screening sessions conducted at Morristown Memorial Hospital from June 2003 through March 2004. NJCEED evolved from a nationwide initiative to extend breast and cervical cancer screening to medically underserved populations. Eligible subjects were required to be at least age 40, but several were younger because of symptom presentation and age-reporting discrepancies (Morris County Cancer Education and Screening Initiative for Women at Risk at Morristown Memorial Hospital [grant proposal to the Junior League of Morristown, Inc., 2002]).
Also, subjects had to be female, without a documented history of breast cancer, either English- or Spanish-speaking, scheduled for a mammogram within the upcoming month, and judged capable of understanding the informed-consent process.
After signing an Institutional Review Board (IRB)-approved informed consent, each participant was assigned a study identification number. Assessments were self-administered, and participants were encouraged to complete items without assistance from the study team. A number of participants, however, required team support to understand and complete questions.
Participants initially completed a four-part pre-mammogram individualized questionnaire (IQ), a Penn State Worry Questionnaire (PSWQ), and the Symptom Checklist-90–Revised (SCL-90–R) in their preferred language of English or Spanish. Participants were subsequently met by the investigators at the mammography site upon completion of their mammogram. After receiving their mammography result from the radiologist, participants were requested to complete a post-mammogram portion of the IQ and repeat the SCL-90–R.
The IQ included demographic information; mammography history and other health-compliance behaviors, such as breast self-examination (BSE); current emotional status, including anxiety, family breast cancer history, and perceived risk; and knowledge of mammography guidelines. The post-mammogram portion asked about current emotional status, understanding of their results, quality of the mammography experience, and intention to return for a future mammogram. The pre- and post-mammogram IQ anxiety questions were identical. The PSWQ is a 16-item Likert-scale questionnaire assessing trait anxiety.16,17 The SCL-90–R is a standardized symptom inventory with nine constructs, originally developed for pharmacology trials, and now used in a variety of clinical settings.18,19
Demographic characteristics of the convenience sample were summarized by frequency distributions in SPSS for Windows. We performed cross-tabulations between key variables with SPSS, along with paired t-tests on the pre- and post-mammogram SCL-90–R constructs Global Severity Index, Anxiety, Depression, and Somatization. Paired t-tests were used to analyze pre- and post-mammogram IQ anxiety responses. The emotional status question on the IQ was condensed into the following three ordinal variables: 1 – not nervous; 2 – nervous; 3 – extremely nervous; and a miscellaneous variable of 4 (other reported mood). A score of 2 or 3 was classified as elevated anxiety. Type I error was set 0.05, using two-tailed alpha.
Chi-square analyses in Excel were used to test the following associations: elevated pre-mammogram anxiety levels and mammography results, using the Breast Imaging Reporting And Data System (BI-RADS),20 elevated post-mammography anxiety levels and mammography results, elevated post-mammogram anxiety levels and need for more than four films (serving as a proxy for the arduousness of the procedure), and cancer risk-perception as related to positive family history.
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RESULTS
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Fifty-eight women were asked to participate; 10 declined, 9 because of time issues, and 1 otherwise excusing herself during the course of the screening education. One attendee was judged ineligible because of a suspicious breast mass as the reason for her upcoming mammogram. Forty-seven women entered into the pre-mammography arm, and 43 remained for both the pre- and post-mammography analysis, resulting in a recruitment of 81% and a total completion of 74%.
The characteristic participant was age 50 (range: 37 to 64); was married, employed, high school-educated, of Hispanic descent, uninsured, and residing in New Jersey (Table 1). Eighty-one percent reported no previous use of hormone replacement therapy (HRT), and 78.7% reported being nonsmokers. Mean sample body mass index (BMI) was 28.7 (range: 19.63 to 51.41), with most participants at the upper limits of normal.
Seventy-seven percent practiced BSE, and 21% did not, with the remaining 2% not certain. There was a trend toward increased BSE confidence with greater BSE frequency; 4 patients reported daily BSE; 5, weekly BSE; 4, bimonthly; and 12, monthly BSE.
Cross-tabulation revealed that, on a self-examination confidence scale of 0 (least confident) to 10 (most confident), all five participants who reported no self-confidence either examined themselves infrequently or not at all, whereas 5 out of 10 who reported the most self-confidence examined themselves at least monthly.
Fifty-one percent were familiar with the American Cancer Society (ACS) guideline for a baseline mammogram at age 40, then annually thereafter.21 Thirteen percent advocated a mammogram every other year for women under 50, then annually thereafter; 9% advocated the opposite: every year until age 50, then every other year; 11% favored an individual decision, and the remaining 16% had no opinion.
In summary, half of the sample was reasonably well acquainted with breast health guidelines, practicing regular self-examinations, familiar with the ACS mammography guidelines, and agreeing to undergo a screening mammography.
Thirteen out of 46 respondents (28%) affirmed a positive family history of breast cancer, 68% denied family history, and 2 were uncertain; 2 of the 13 affirmers listed first-degree relatives with breast cancer (a mother or sister.) The majority viewed themselves as being at lower-than-average risk for developing breast cancer compared with other women (Figure 1; N: Risk Appraisal). Average-to-high self-risk appraisal was significantly associated with having a positive family history ( 2=18.75; p<0.001).
One-third of participants (N=16) expressed anxiety on initial screening. All but one participant, whose response was unknown, indicated no thoughts of canceling the mammogram (her pre-mammogram mood state was unknown). Sixty-four percent (N=30) had waited less than 1 month for their appointment; 30% had waited more than 1 month, with one participant waiting 2 months, and the remaining 6% unknown. A total of 41 participants denied unfavorable previous mammography experiences; 3 did not comment on past mammography experience; and 3 reported unfavorable mammography experiences, 1 specifically pain-related, the other two of an unknown nature.
Mammography results were available for 40 participants, three results being incomplete because of missing previous films for comparison. The majority of participants (N=26) had negative or benign readings; four had benign readings with a 6-month follow-up recommended; one had an inconclusive reading; eight participants required additional ultrasound; and one reading was suspicious for malignancy.
Pre- to post-mammography SCL-90–R symptom scores decreased along all four SCL-90–R symptom constructs (Table 2.) There were statistically significant reductions of at least 6 points from pre- to post-mammogram for all measures but anxiety (p<0.05). Missing SCL-90–R data for 23% of pre- and post-mammogram completers may have underpowered that particular anxiety analysis. Pre- to post-mammography IQ Anxiety responses showed similar trends as with the SCL-90–R: reduced scores among 42 questionnaire completers (t=1.835; p=0.074).
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TABLE 2. Comparison of Emotional State Before and After Mammography, Paired t-Tests, SCL–90-R Symptom Constructs (N=43)
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Eleven participants reported feeling nervous upon completion of the mammogram, eight of whom were more nervous after than before the mammogram. Post-mammogram anxiety was associated with a test result requiring other than an annual follow-up (2=14.33; p=0.0002) and with requiring more than four films (2=6.50; p=0.01). Pre-procedural anxiety showed no association with test result (2=0.108; NS), suggesting that anticipating a problematic mammogram did not necessarily elicit anxiety so far in advance of the procedure.
Finally, 32 women rated their mammography experience as very good; 10 rated theirs as good; and 1 rated her mammography experience as satisfactory. None indicated an unsatisfactory experience, and all affirmed either a definite (N=40) or probable (N=3) intention to return for a future mammogram. Sixty-four percent preferred to wait at the hospital for results, as opposed to receiving their results later. The unanimous affirmation of intention to return rendered statistical testing of anxiety as it related to future compliance nonmeaningful.
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DISCUSSION
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Within this sample of predominantly Hispanic, uninsured women, anxiety was not a deterrent to returning for a future mammogram. Regardless of emotional status after the mammogram, virtually all participants, including those requiring additional work-up, valued the health benefit of regular breast screening and appreciated the quality of medical care received. It would be instructive to monitor prospectively the proportion of repeat annual mammograms as intended. It would also be useful to perform a comparable study in a non-convenience sample for purposes of generalizability.
Does worry promote the practice of getting regular mammograms? In confirmation, Lerman et al.22 surveyed 308 women 50 to 74 years old at 3 months after a screening mammogram. Moderate versus low worry about breast cancer increased the odds of getting a future mammogram to 2.3 (p<0.03), and high versus low worry furthered the odds to 5.9 (p<0.09).22 Another survey, of 353 women, age 40 to 75, demonstrated a positive correlation between breast cancer worry and intent for future mammogram (p<0.01).23
However, no correlation was found between trait-anxiety, state-anxiety, and self-reported mammography compliance among 430 patients at a high-risk university breast clinic. Only 5.6% of the patients reported skipping mammograms, yet a fivefold greater percentage reported not performing regular breast self-examinations. This suggested to the investigators that, for their sample, mammography compliance was automatic, whereas BSE was intimidating, possibly because of its solitary nature.24
Some have proposed an inverted U-shaped relationship between breast cancer anxiety and screening behavior, with an optimal, moderate level of anxiety promoting compliance, and excessive worry interfering.25 A survey of 140 first-degree relatives of breast cancer patients showed that mammography compliance was inversely associated with the length of time since their relative’s initial diagnosis; 83% complied if their relative had been diagnosed with breast cancer over 1 year ago, whereas 68% complied if their relative had been diagnosed within the year (p<0.05). Knowledge of a recent diagnosis within the family evidently led to cancer fear and screening avoidance.26
Turning to the influence of medical environment on a woman’s decision for repeat mammograms, the role of healthcare staff has not been systematically explored.27 In surveying 235 mammography technologists attending a conference, Adler found that 47% of respondents reported having had their patients inform them they would not be returning for a future mammogram because of distress related to the procedure.28 Elsewhere, physician attentiveness has paradoxically augmented the level of procedural distress among breast cancer survivors, but not among their healthy peers in a non-matched Canadian sample undergoing mammography surveillance.29
Other studies have supported a positive professional interaction as an important facilitator of compliance. Registry-selected women from New Hampshire, age 50-plus, were prospectively followed over 2 years for mammography compliance. Compliers (N=274), as compared with Noncompliers (N=265), were of lower weight (BMI: 26.1 versus 27.6; p=0.003); they reported greater ease in getting an appointment (p=0.02); and were more pleased with the quality of staff interaction (p<0.05). Larger size was implicated in mammography avoidance via a hypothesized mechanism of increased pain related to greater breast-tissue density.27
In our study, trait-anxiety scores were high, which may have attenuated the "before and after" anxiety measures. The worry-prone nature of our sample is illustrated by a mean PSWQ score of 50.18, with 60% of scores ranging between 40 and 60, a score of 60 being the accepted cutoff for a formal anxiety disorder.17 Eight women who reported higher anxiety after than before the mammogram, nevertheless affirmed intent to return, coupled with a good to very good rating of their mammography experience. Of the six women whose post-procedure IQ responses rated at least moderately anxious, four affirmed the health benefit of breast-imaging. One stated that she was scared of the results because this was her first mammogram, adding "The nurse was very nice and friendly and relaxed me." Another woman, who required an additional ultrasound to visualize a lymph node, commented, "I was very grateful to have the (NJCEED) staff person accompany me today. It makes me feel better. It has made the following immediate procedure for me (a) less nervous ... situation."
The proportion of suspicious mammogram readings within our sample was 2.3%, similar to the 2.2% abnormal mammogram detection rate reported by the National Breast and Cervical Cancer Early Detection Program (NBCCEDP). NBCCEDP detection rates were adjusted for ethnicity: Whites (2.3%) > Blacks (2.0%) > Hispanics (1.8%).30
Thirty-four percent of participants expressed some degree of trepidation before the mammogram, even with 90% self-identified as low-to-average risk for breast cancer, yet none contemplating canceling the mammogram. The fact that anxiety did not affect this group’s screening decisions may reflect strong staff involvement: this staff provided screening education, scheduled mammograms, performed telephone confirmations, and ensured financial coverage for each mammogram. As mentioned, practical logistics can be better predictors of breast cancer screening compliance than ethnic, cultural, and/or other sociodemographic factors.31
Finally, guideline awareness positively influenced the decision to return for a future mammogram, but guideline confusion was of no concern. The majority of women were familiar with ACS guidelines, but seemed unconcerned about recent debates regarding age-related frequency and mortality reductions. In fact, 79% were unaware of any recent guideline controversy, and 62% denied guideline confusion within the medical community.
Sixty-four percent expressed strong faith in the value of mammograms, whereas 25.5% felt neutral about the x-rays’ value. Forty percent gave, as their reason for returning, the health benefit of mammography. To reiterate, physician prescription and belief in mammography have been repeatedly cited as more important predictors of compliance than guideline knowledge, but this question remains under investigation.32,33
Future studies should further evaluate the role of clinical staff, environment, and compliance decisions from a cultural perspective. Relevant factors might include understandability of cancer-screening education, ease of scheduling appointments, appointment wait-time, appointment location, knowledge of what to expect during the procedure, meaning of the results, quality of interaction with the radiology personnel, and what each woman brings to her mammography experience.
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ACKNOWLEDGMENTS
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The authors thank Thomas Zaubler, M.D., M.P.H., Lydia Tarta, R.N., Rubie Senie, Ph.D., Judith Jacobson, Ph.D., Stephen Albert, Ph.D., Patricia Friedmann, M.P.H., the staff of The Morris County Cancer and Screening Initiative, and The Department of Radiology at Morristown Memorial Hospital.
This study was supported by a grant from the Morristown Memorial Health Foundation, Morristown, NJ.
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REFERENCES
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ABSTRACT
INTRODUCTION
