Women with a history of breast cancer are more likely to suffer from a stress response syndrome that could adversely affect their willingness to participate in routine mammography or follow-up after treatment, according to a study by mental health professionals.
Published in Psychosomatic Medicine, the study was designed to assess the incidence, severity, and acute-stress response correlation in women undergoing diagnostic mammographic surveillance. The researchers also looked at the impact of physician involvement -- or lack thereof -- among these patients, particularly those who had been treated for breast cancer, had a strong family history, or may have been genetically predisposed to the disease.
"The psychological effect of mammography has been evaluated in most studies by measures of anxiety and depression. These measures do not capture the intrusive re-experiencing, avoidance, dissociation, and hyperarousal that are characteristic of stress response syndromes...(that) may meet DSM-IV criteria for an acute stress disorder (ASD)," wrote lead author Maria Gurevich, Ph.D.,(Psychosomatic Medicine, January-February 2004, Vol.66:1, pp. 104-112).
However, Gurevich emphasized that the results of her group’s work should not be viewed as a potential weapon in the ongoing litigious battles between mammographers and breast cancer patients.
"This study does not provide evidence that mammography is psychologically harmful; it merely shows that some groups of women (e.g., those with previous cancer, those with fewer psychological and socioeconomic resources) may experience more distress when undergoing this procedure, as they might undergoing other medical procedures," Gurevich explained in an e-mail to AuntMinnie.com. "If one has had cancer before, it stands to reason that one would worry about possible recurrence, and undergoing certain medical procedures would bring that worry to the fore. That does not mean that those procedures are to be avoided, since they have great diagnostic and thereby potentially life-saving utility."
Gurevich is an assistant professor in the department of psychology at Ryerson University in Toronto. Her co-authors include oncologists from Princess Margaret Hospital and the University Health Network in Toronto, as well as psychiatrists from the University of Toronto and the University of California, San Francisco.
The patient population consisted of 135 women who were divided into two groups: Group 1 consisted of breast cancer patients who were at least one year out from initial diagnosis and treatment, as well as nine months post-adjuvant treatment. Group 2 was made up of healthy women undergoing screening mammography. The latter underwent standard four-view mammograms, with notification letters sent within three weeks of the exam.
Both groups filled out a Stanford Acute Stress Reaction Questionnaire (SASRQ), which assessed ASD symptoms such as intrusion, avoidance, and anxiety. Data such as socio-demographics and medical status were collected. For Group 1, information on disease type and time of diagnosis were extracted from medical records.
In addition to an evaluation of psychiatric history, the women participated in a Social Network and Support Assessment (SNSA); were rated on a Somatosensory Amplification Scale (SSAS), which evaluates a range of uncomfortable sensations; and answered a Trauma History Questionnaire (THQ), as well as a Patient Satisfaction with Doctor Questionnaire (PSQ-MD). The latter measured perceived support and physician disengagement.
According to the results, the previous cancer patients (Group 1) were significantly older, had less education, and lower income when employed. These patients also reported significantly higher stress responses, such as arousal symptoms (25.6% versus 11.4% in Group 2), avoidance (12% vs. 7%), and intrusive thoughts (10.5% vs. 5.7%).
"In other words, previous cancer, pre-mammography breast complaints, lower income...greater somatization, greater perceived physician disengagement, and less perceived physician support were all associated with increased stress responses," the authors stated.
However, the results regarding physician support or disengagement weren’t quite so cut and dried. In Group 1, greater perceived physician support was associated with higher symptom levels. This may have been, in part, because the referring physicians were made up of two different types of doctors -- oncologists for Group 1 and radiologists for Group 2, the authors suggested.
They went on to say that this "paradoxical finding may be explained by the tendency of women with previous cancer history to experience greater distress in response to mammography...and to require or elicit greater physician support."
In a previous study, Gurevich and colleagues conducted a review of adult cancer literature in order to identify the "unique characteristics of cancer as a traumatic stressor." They found that a lack of appropriate health-related information, and difficulty in dealing with healthcare professionals, exacerbated stress response (Psychosomatics, July-August 2002, Vol. 43:4, pp. 259-281).
Elaborating on the issue of physician interest, Gurevich pointed out that determining what constitutes optimal patient support is not an easy task for mammographers and/or radiation oncologists.
"My very qualified answer would be that, given what we know from other research on the importance of communication between patients and medical care providers, better communication is always best," she said. "But this begs the question of what we mean by ‘communication’ -- is it information provision? Is it emotional or instrumental support?"
Gurevich said that she hoped the results of the latest study would encourage healthcare professionals to find novel ways to communicate, thereby encouraging women to undergo surveillance screening, while still taking into consideration that anxiety may be a major barrier.
"The message ‘Just do it because it’s good for you' may not work for women whose anxiety levels are too high," she said. "We may have to find more nuanced ways of addressing such groups of patients."
By Shalmali PalAuntMinnie.com staff writer
March 3, 2004
Related Reading
Residents leery of careers in breast imaging, December 15, 2003
Malpractice fears may initiate more false-positive mammograms in North America, September 16, 2003
Making mammographers better: The last link in the imaging chain, August 29, 2003
U.K. group accuses breast cancer screening advocates of disinformation, July 11, 2003
Breast biopsy patients may not benefit from on-the-spot education, December 15, 2000
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