Adverse psychological effects in women attending a second-stage breast cancer screening

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Abstract

Objective: The purpose of this study was to examine the emotional and psychopathological impact associated with a second-stage screening for breast cancer. Method: We used a short-term longitudinal design. Interviews were conducted with 1195 women of 45–65 years old in three temporal conditions (premammogram, postmammogram, and follow-up). Participants included women attending for regular breast cancer screening who were recalled for a further mammogram (i.e., second-stage breast cancer screening) and women who were not recalled. Affective-cognitive concerns about cancer (worry, fear, and perceived vulnerability) were rated using a 10-point Likert scale. Psychopathology was assessed using the Hopkins Symptom Check List-Revised (SCL-90-R). Results: Women attending the second-stage screening exhibited significantly higher levels of breast cancer worries, fears, and beliefs than women attending for routine screening before obtaining the results of the mammogram. This affective-emotional impact disappeared quickly and was not relevant 2 months following the mammogram. Despite the fact that levels of psychopathological symptoms were higher in the premammogram condition, there were no differences between groups on these measures. Conclusion: These results provide support for the hypothesis that women recalled for further mammograms tend to experience high levels of affective-cognitive distress but not psychopathological symptoms. Moreover, results do not sustain the prediction that this psychological impact persists beyond receipt of a negative result. Some recommendations to reduce these psychological side effects are suggested.

Introduction

Screening programmes based on the periodic use of mammography are the most effective method for the early detection of breast cancer. The principal benefit of these programmes derives from the finding that they can allow early treatment and a reduction in breast cancer mortality. A number of studies have demonstrated substantial mortality reductions from breast cancer by about 4–40% [1], [2], [3], [4].

After recommendations by public organizations (e.g., the U.S. National Cancer Institute) promoting breast cancer screening for women of 50 or over, the percentage of women who receive regular mammography has increased progressively [5], [6], [7]. For example, as was stated by Rakowski et al. [8], “The percentage of women ages 50–75 who obtain screening mammography has increased steadily since the middle 1980s. Data from the 1992 National Health Interview Survey of Topics Related to Cancer Control indicate that about 68% of women in this age group report ever having had a mammogram and approximately 55% report having had one in the past 2 years” (p. 433).

It is, therefore, a well-known fact that mammogram acceptance and use has been increasing in North America [8], [9] as well as in Europe [7], including Spain [10]. In line with this growth, an increasing number of women who, attending breast cancer screening, receive notification of abnormal mammogram have been reported. Screening tests (i.e., mammography) regularly produce inaccuracies and false positives. The proportion of mammograms reported as inconclusive, unsatisfactory, or abnormal in large-scale screening programmes is about 10% [11], [12]. This indicates that a remarkable percentage of women who attend routine screening programmes are recalled for further mammograms. The majority of these women who need to repeat mammograms or undergo biopsy are not considered to be at high risk for developing breast cancer.

Even though breast cancer screening has been associated with health benefits, it could also produce some cost to women attending regularly, such as worktime lost, workload, fear of the radiation, pain of the mammography, etc. However, a cost that has scarcely been investigated is the possible psychological distress and morbidity associated with the screening process, particularly the psychological impact produced in women recalled for further exams where the initial mammogram was interpreted as inconclusive or abnormal [8], [13]. As Warren [14] suggested, it is possible that a number of women who receive a recall letter temporarily experience the diagnosis of cancer. According to current data, these “false positives” represent a high percentage of women attending routine screening programmes [9].

In line with Wardle and Pope's [11] suggestion that “false positive” results in breast cancer screening probably represent a major area of concern so far as psychological costs are concerned, some authors have reported that women who receive false positive results have been found to experience elevated anxiety after receiving a letter recalling them for further mammography [15] as well as a possible disturbed quality of life [16]. Similarly, Stewart-Brown and Farmer [17] have recently suggested that screening programmes could seriously damage the health. However, little research has been done to specifically investigate the psychological side effects associated with notification of an abnormal mammogram. Ellman et al. [18] found no significant differences in psychiatric morbidity between women in the false positive group and those attending for regular breast cancer screening. However, these authors reported significantly higher levels of anxiety in the false positive group, though they did not persist at a 3-month follow-up. Similarly, Clutton et al. [12] found that women who attended a routine breast cancer screening and were notified of the need to attend for further assessment of a mammographically detected abnormality showed low levels of anxiety and psychopathology 6 weeks after the second testing. Clutton et al., however, did not use a control group (e.g., a sample of women who were not recalled). In a recent study, Sandin et al. [19] found no significant differences in hypochondriacal attitudes between women attending a second-stage screening and women attending routine screening, neither just before the screening nor in the follow-up (2 months after the mammogram).

Lerman et al. [9] analyzed the psychological side effects of receiving abnormal mammogram results on women's anxiety and breast cancer worries. The authors assessed psychological variables on a sample of 308 women over 50 by means of telephone surveys conducted 3 months following a screening mammogram. Subjects included women with normal mammograms (N), nonsuspicious abnormal mammograms (A2), and suspicious abnormal mammograms (A3). Lerman et al. found a positive relationship between the index of suspicion of the mammogram and the levels of anxiety and worry. They observed consistent upward trends in negative psychological impact as levels of mammogram suspicion increased from N to A2 to A3 and concluded saying that because “concerns persisted even after these women had received additional tests ruling out cancer suggests than women with abnormal mammograms perceive themselves to be at elevated risk of developing breast cancer in the future” (p. 265). So, in contrast to the Ellman et al.'s [18] report, Lerman's group found that the psychological impact of receiving abnormal mammogram results persists beyond receipt of the negative result (i.e., after knowing that they did not have cancer).

In a more recent study, Cockburn et al. [20] reported that women who attended a breast cancer screening and were recalled for a further mammogram exhibited higher levels of psychological dysfunction than women who were not recalled. This psychological impact, which was measured 1 week after obtaining notification that there was no sign of cancer, suggests that at least a short-term psychological side effect associated to the second-stage screening could be present beyond possible adverse psychological effects related with routine screening.

In spite of some relevant and suggestive studies, existing research on the psychological impact associated to “false positive” results in breast cancer screening is not convincing. Problems with some of the published reports include the use of low samples of women and cross-sectional methodology. The present study was designed to examine the psychological impact of receiving abnormal mammogram results in women attending the Breast Cancer Detection Programme (BCDP) of Navarra (Spain). Consistent with the existing literature, we predicted that three affective-cognitive measures of psychological distress associated to breast cancer screening, i.e., worry about breast cancer, fear of breast cancer, and perceived vulnerability, would be higher in women recalled for further mammograms than in women attending regular screening. We also predicted greater levels of psychopathological symptoms in the first group than in women with normal mammograms (i.e., women attending routine screening). The study used a short-term longitudinal design with a large sample of women who had attended the breast cancer screening programme.

Section snippets

Subjects

Participants in this study were women, 45–65 years old, attending the BCDP of Navarra (Spain) for regular breast cancer screening or for a rescreening (a second-stage mammography). According to these two types of participants, we created two different groups, i.e., a routine screening (RS) group and a second-stage screening (SSS) group. All of the subjects were consecutively recruited.

The RS group consisted of 600 women attending for regular screening. These women were not recalled for further

Cognitive-affective impact

Table 1 shows the proportions of SSS and RS women who reported moderate to severe breast cancer worries, fears, and beliefs before the screening mammogram. The majority of women of both groups reported worry and fear related to breast cancer, but only a low percentage of women reported the belief of having breast cancer in the premammogram condition. The SSS subjects suffered more frequently from worry (P<.001), fear (P<.001), and negative beliefs (P<.001) than did the RS women.

However, at

Discussion

In the present study, we examined differences between women attending a second-stage breast cancer screening and women attending routine screening on affective-cognitive distress and psychopathology. We also examined whether the psychological impact is only temporarily related to the period that precedes the mammography or persists beyond receipt of the negative result (i.e., being informed that there was no sign of cancer).

A major finding of this research is that, according to our prediction,

Acknowledgements

This research was supported by the Grant No. 2204 resolución 634/96 from the Departamento de Salud del Gobierno de Navarra (Spain). We thank Drs. Nieves Ascunce and Angel Del Moral for their help with this work and their invaluable suggestions and Olga Fernández Soto for her collaboration with data collection.

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