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ORIGINAL ARTICLES |
From the Institute of Medical Genetics (K.B., J.G.), Department of Surgery (R.M.), University of Wales College of Medicine, Cardiff, United Kingdom, and School of Psychology (P.N.), Sheffield University, Sheffield, United Kingdom.
Address reprint requests to: Kate Brain, PhD, Institute of Medical Genetics, University of Wales College of Medicine, Health Park, Cardiff, CF4 4XN, UK. E:mail: brainke{at}cardiff.ac.uk
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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METHODS: A sample of at-risk women (N = 833) completed a questionnaire regarding BSE frequency, general anxiety, breast cancer worries, perceived risk of breast cancer, and family history of breast cancer. Women who self-examined infrequently (N = 211), appropriately (N = 462), or excessively (N = 156) were compared on these variables.
RESULTS: Statistical analyses indicated that general anxiety differentiated only between excessive self-examiners and less frequent self-examiners, with excessive self-examiners reporting significantly higher general anxiety. Breast cancer worries differentiated between all three groups in a linear fashion, with increasing cancer worries associated with higher levels of BSE.
CONCLUSIONS: In some at-risk women, high cancer anxiety may lead to high general anxiety and precipitate hypervigilant breast self-examination rather than avoidance. These findings are discussed in relation to psychoeducational interventions and genetic counseling services for women with a family history of breast cancer.
Key Words: breast cancer, • family history, • breast self-examination, • adherence, • general anxiety, • cancer-specific anxiety.
Abbreviations: BSE = breast self-examination;; TRACE = trial of genetic assessment for breast cancer;; STAI = Spielberger State-Trait Anxiety Inventory;; ANOVA = analysis of variance.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Although health professionals emphasize the importance of breast self-examination and "breast awareness" (8), research suggests that a substantial proportion of women with a family history of breast cancer do not adhere to recommended guidelines for either monthly breast self-examination (9–13) or mammographic screening (14–16). Concerns have been raised that anxiety experienced as a result of increased breast cancer risk may cause women to avoid screening (17–21). Studies indicate that women with a family history of breast cancer do indeed tend to perceive heightened personal susceptibility to breast cancer (22–25), and as a result may be experiencing psychological difficulties (10, 26). A number of studies have examined the role of anxiety in motivating adherence to early detection methods. However, the findings of this research seem somewhat contradictory regarding the direction of the relationship between anxiety and adherence. Although some studies indicate that high levels of anxiety and high perceived risk promote compliance with recommended cancer surveillance behaviors (11, 18, 27, 28), others suggest that they may in fact deter women from practicing breast self-examination (10, 19, 22, 29, 30) or from attending mammography (26, 31). It is unclear, then, whether high anxiety acts as a barrier or a cue to action in terms of compliance with monthly breast self-examination. Clarification of the relationship between anxiety and screening behavior in women at increased risk of breast cancer would facilitate the development of psychoeducational interventions designed to manage psychological distress in these women and thus improve adherence to medical recommendations for the early detection of breast cancer.
It has been suggested by several researchers that Fear Arousing Communications Theory (32, 33) is a useful theoretical framework for examining the association between anxiety and adherence to cancer surveillance behaviors. For example, Hailey (34) draws on the theory to predict an inverted U-shaped relationship between anxiety and screening adherence. In the case of breast self-examination, it would be predicted that moderate levels of anxiety facilitate adherence to self-examination, whereas high levels of anxiety lead to avoidance behavior. We suggest that the psychological tools used in previous studies to measure anxiety and distress may help to explain contradictory findings with regard to anxiety and breast self-examination adherence in women with a family history. When conceptualizing "anxiety," there is an important distinction to be made between general anxiety and specific anxiety. Lerman and Schwartz (20) observed that studies finding a negative linear association between anxiety and screening adherence have used measures of general anxiety and distress, whereas studies finding a positive linear relationship between anxiety and adherence have used measures of anxiety that is specific to breast cancer. According to Lerman and Schwartz (20), women who score highly on measures of general anxiety are likely to be seriously psychologically distressed and, therefore, more likely to avoid screening. However, the moderate worries assessed by measures of cancer-specific anxiety may be sufficiently high to motivate screening behavior, but not so high that they cause women to avoid screening (20). Returning to the idea of an inverted U-shaped relationship between anxiety and adherence (34), high levels of cancer-specific concern can be conceptualized as falling on the ascending side of the curve, with high levels of general anxiety falling on the descending side of the curve. Baum et al. (35) suggest that the effect of differing levels of anxiety on screening adherence requires additional investigation.
In previous research, the focus typically has been on identifying the psychological factors associated with both infrequent and optimal (ie, monthly) self-examination. Little attention has been given to investigating the predictors of excessive breast self-examination, even though this practice may be as problematic as nonadherence. Over-adherence can make early detection of breast cancer symptoms more difficult by increasing the likelihood of making false-positive findings (11, 22, 36). In comparing the impact of general anxiety with that of cancer anxiety on breast self-examination, the present study examines the full range of BSE behavior. Although Epstein et al. (36) and Lerman et al. (37) found that first-degree relatives who over-examined had significantly higher cancer-related concerns than those who self-examined less frequently, these studies were unable to elucidate the relationship between excessive self-examination and general anxiety.
The present study reports cross-sectional data regarding breast self-examination practice and anxiety in a sample of women with a family history of breast cancer. The aim was to examine the impact of general anxiety and cancer-related anxiety on BSE frequency by comparing levels of general anxiety and cancer anxiety in women who self-examined infrequently, appropriately, or excessively. It was predicted that a) a positive linear relationship would be found between breast self-examination and cancer anxiety (ie, that breast self-examination frequency would increase as cancer-specific concerns increased), and b) a negative linear relationship would be found between breast self-examination and general anxiety (ie, that breast self-examination frequency would decrease as general anxiety increased).
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Women who were identified by District General Hospital breast surgeons as having a family history of breast cancer and who fulfilled the study entry criteria were referred into the project. A breast examination was performed by the referring surgeon to exclude any current breast disease. Entry requirements were having a first-degree relative diagnosed with breast cancer under the age of 50 years, a first-degree relative with bilateral breast cancer at any age, two first-degree relatives with breast cancer, or a first-degree relative and second-degree relative with breast cancer. Women were excluded if they had previous or current breast cancer, if they had previously received genetic counseling for breast cancer susceptibility, or if they were not resident in Wales. Women referred to the project were sent a baseline questionnaire, information sheet, and consent form. To additionally minimize the possibility of response bias, participants were informed that their responses to the questionnaire would be confidential and that medical staff would not have access to the information. They were also assured that they could withdraw from the study at any time without affecting their future medical care. To maximize the response rate, several follow-up reminders were sent to women who did not return questionnaires (39).
A total of 1000 women were referred into the study and 833 (83%) returned baseline questionnaires. Of the 167 nonresponders, 111 did not return questionnaires and 48 formally declined the study. Eight women were excluded because they did not fit the study entry criteria. Demographic characteristics of the study sample are displayed in Table 1. Participants were aged between 17 and 77 years (mean = 41.31, SD = 9.84) and 81% (N = 673) were less than 50 years old, the age at which mammographic screening is recommended. The majority of participants were white (99%), married or cohabiting (81%), and had gained qualifications at secondary education level or above (67%). The average number of relatives affected with breast cancer was two (range 1–9).
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State-Trait Anxiety Inventory. The STAI (40) was used to measure general anxiety. The Trait Anxiety scale asks respondents to indicate how they generally feel regarding 20 statements, whereas the State Anxiety scale asks respondents to describe how they currently feel regarding the same 20 statements. There is a 4-item response format ("almost never," "sometimes," "often," "almost always"). Total possible scores for each scale range from 20 to 80, with a higher score indicating higher trait anxiety or state anxiety. Extensive normative data are available in the STAI manual (40). The manual reports good retest reliability for the Trait scale (r = .77) and low retest reliability for the State scale (r = .33), although the latter coefficient is to be expected, given the transitory nature of state anxiety (40). The manual reports high internal consistency for both the Trait scale and State scale. This was replicated in the current study (Trait scale 
= .92, State scale = .93), and a highly significant positive association was found between the two scales (r = .80, p 
.001).
Breast Cancer Worries Scale.
This 6-item scale (18, 19) measures anxiety that is specific to breast cancer. It assesses frequency of concerns about developing breast cancer, and the impact of breast cancer worry on mood and daily functioning. Items are each rated on a 4-point scale. Total possible scores range from 6 to 24, with higher scores indicating higher levels of breast cancer worry. The scale has been shown to predict adherence to mammography (18). In the current study, internal consistency of the scale was satisfactory ( = .86).
Perceived Risk of Breast Cancer.
Two items were used to assess perceived personal risk of developing breast cancer, and were derived from previous research (19, 22, 41, 42). The two items were a) What level of risk do you personally think you have? and b) In your opinion, what are your chances of getting breast cancer compared with the average woman? Each item was rated on a 5-point scale. Items were summed to form a composite, which had adequate internal consistency ( = .71). For the composite scale, total possible scores range from 2 to 10. A higher score indicates higher perceived risk of developing breast cancer.
Breast Self-Examination.
Participants were asked to rate the frequency of breast self-examination using response categories: 0, "hardly ever/not at all"; 1, "once a year"; 2, "3–4 times a year"; 3, "once a month"; 4, "once a fortnight"; 5, "once a week"; and 6, "once a day or more often." Several previous studies (10, 11, 19, 43) have used similar measures of BSE frequency.
Family History of Breast Cancer.
Participants were asked to indicate the number of first-degree and second-degree relatives affected with breast cancer.
Statistical Analyses
Associations between the independent variables of general anxiety (Trait and State anxiety scales), breast cancer worries, perceived risk, and family history of breast cancer were first examined by using Pearson’s product-moment correlations. To examine the differential impact of anxiety across age, correlations were also computed between the independent variables and age. On the basis of the classifications of breast self-examination frequency by Wellisch et al. (43), the variable of BSE frequency was then reduced to three categories: a) infrequent self-examination (performed hardly ever or not at all, once a year, or 3 to 4 times per year), b) appropriate self-examination (performed monthly or fortnightly), and c) excessive self-examination (performed weekly, daily, or more than once a day). One-way ANOVA was used to examine differences between the three groups of self-examiners in general anxiety, cancer anxiety, perceived risk, and family history. Significant main effects were followed up with post hoc Scheffé tests. Effect size for each of the independent variables was calculated using the 
2 statistic. A 2 value of .01 represents a weak effect, .06 a moderate effect, and .14 a strong effect (44). Before these analyses, the extent to which the data met the assumption of homogeneity of variance was assessed using the Bartlett test. The assumption was met for all variables except breast cancer worries and perceived risk (p .001). Following the recommendation of Keppel (45), a more conservative level was used ( = .025) to compensate for a potentially more liberal F test.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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Mean scores on the independent variables for each group are displayed in Table 3. One-way ANOVA indicated that there were significant differences between groups in trait anxiety and state anxiety. When age was covaried out of the analysis, these results remained significant for both trait anxiety (F(2,803) = 4.74, p .01) and state anxiety (F(2,802) = 6.55, p .01). Post hoc comparisons indicated that although excessive self-examiners had significantly higher trait anxiety scores than appropriate self-examiners, there were no other significant differences between groups in trait anxiety. Excessive self-examiners had significantly higher state anxiety scores than both appropriate and infrequent self-examiners, although the difference between appropriate and infrequent self-examiners was not significant. As Table 3 indicates, there seemed to be a nonsignificant trend toward a U-shaped relationship between breast self-examination and general anxiety, in that appropriate self-examiners reported less trait and state anxiety compared with women who under-examined and women who over-examined. The strength of the relationship between BSE frequency and general anxiety was weak for both trait anxiety (2 = .02) and state anxiety (2 = .02).
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.001). Excessive self-examiners had significantly higher scores on cancer worry than appropriate self-examiners and infrequent self-examiners. Appropriate self-examiners reported significantly higher levels of cancer worry compared with infrequent self-examiners. This pattern of results confirmed the presence of a positive linear relationship between breast self-examination and breast cancer worries. There was a strong relationship between BSE and cancer anxiety (2 = .14).
There were also significant between-groups differences in perceived risk of developing breast cancer. This effect was significant when age was covaried out (F(2,802) = 4.54, p .01). Women who performed excessive breast self-examination reported significantly higher perceived risk compared with women who self-examined appropriately and women who self-examined infrequently. The difference in perceived risk between appropriate self-examiners and infrequent self-examiners was not significant. These results indicated a trend toward a positive linear relationship between breast self-examination and perceived risk. The strength of the relationship between BSE and perceived risk was weak (2 = .03). Differences between groups in family history were not significant, a finding that remained when age was controlled (F(2,816) = 2.74, p = NS, 2 = .01).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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In the present study, the majority of women reported adhering to recommended breast self-examination frequency. Higher levels of anxiety were associated with higher rather than lower BSE frequency, and this seemed to be a function of greater subjective concern rather than more extensive family history. However, significant differences in general anxiety were found only between excessive self-examiners and less frequent self-examiners, whereas differences in breast cancer worry were found among all three groups. This pattern of results suggests that high general anxiety is related to hypervigilant breast self-examination only, whereas cancer-specific anxiety is related to BSE frequency in a positive linear fashion. That breast cancer worry seemed to be a more powerful instrument for differentiating between the three BSE groups was evidenced by the larger effect size obtained with this measure, compared with that obtained by general anxiety. Studies of the relationship between anxiety and breast self-examination should incorporate cancer-specific measures, inasmuch as general measures of psychological functioning may be less sensitive to the particular concerns of the majority of at-risk women.
The finding that women who examined themselves excessively reported higher general anxiety than women who self-examined less often contradicted the prediction of a negative linear association between general anxiety and BSE adherence. A possible explanation is that the proposed relationship between general anxiety and adherence may be obscured if the entire range of anxiety is not represented in a study sample (34). It could be argued, therefore, that women experiencing high levels of general anxiety that might lead to avoidance of breast self-examination were also deterred from participating in the current study. However, the very high response rate as well as the wide range in general anxiety scores (see Table 2) suggest that the current study sample is representative of women with a family history of breast cancer in terms of general anxiety. Therefore, some at-risk women may be experiencing high levels of general anxiety (which may or may not be a consequence of their at-risk status), but this seems to generate excessive rather than avoidant breast self-examination.
The prediction that higher cancer anxiety promotes rather than inhibits breast self-examination was confirmed in the finding of a positive linear relationship between breast cancer worries and BSE adherence, and replicated previous findings (36, 37). Women who examined themselves excessively also reported perceiving higher personal risk, consistent with previous studies that have associated higher perceived susceptibility with greater screening adherence. As Lerman and Schwartz (20) have suggested, moderate cancer worries are sufficient to motivate breast self-examination, but not so high that they cause women to avoid self-examination. In fact the current data indicate that, although cancer anxiety motivates at-risk women to perform more frequent breast self-examination, there seems to be a point at which these worries increase beyond moderate levels, leading to high levels of generalized anxiety and excessive breast-self examination. The general anxiety scores of women who over-examined were indeed higher than normative scores reported in the STAI manual (40).
The finding that higher levels of general anxiety and cancer worry were associated with over-examination gives cause for concern. Over-adherence may be as problematic as under-adherence to BSE because it renders early detection of breast cancer symptoms more difficult. According to Epstein and Lerman (46), public health campaigns emphasize the responsibility of the individual in detecting and preventing illness, and empower them to modify their preventive health behaviors. In the case of breast cancer, the message is that regular breast self-examination is an important behavior for detecting cancer at an early and treatable stage. Although this may encourage the majority of the general population to adhere to preventive health behaviors, it may generate high levels of anxiety and lead to hypervigilant health-related behavior in some at-risk individuals (46). Indeed, the current data suggest that it is possible to be too "breast aware," and appropriate concern may develop into preoccupation with breast cancer for some at-risk women. However, the cross-sectional design of the present study disallows causal inferences to be made regarding the relationship between anxiety and BSE frequency. Prospective studies should attempt to replicate the current findings and investigate whether excessive self-examination generates anxiety or whether it represents a strategy for coping with anxiety. This design may also circumvent the potential problem of shared-method variance in cross-sectional data.
The current research has implications for managing anxiety and improving screening adherence in women at increased risk. Intervention strategies include the use of telephone counseling (47) and printed materials (48, 49), but more intensive counseling may be needed for women who are experiencing high general anxiety (20) or high cancer anxiety. Interventions are typically aimed at increasing frequency of breast self-examination (50). Although this may be appropriate for some at-risk women, for others it needs to be counterbalanced with the message that examining one’s breasts every week or every day does not improve detection of breast cancer symptoms. A delicate balance needs to be achieved between managing anxiety and maintaining optimal adherence to breast self-examination. Women who over-examine may be substituting frequent yet cursory self-examinations for thorough and effective self-examinations (46). These women in particular might benefit from educational interventions that involve personal instruction in appropriate breast self-examination technique, with the focus on reducing anxiety and improving proficiency (12). Research that examines the relationship between quality of BSE technique and both general and cancer anxiety would be useful in aiding the development of interventions.
The current findings are also relevant to genetic testing for breast cancer in terms of research and service development. First, they underline the importance of examining cancer-specific anxiety in studies of the psychological impact of genetic testing (51, 52). Second, there are potential implications for the development of genetic assessment services. The main aim of familial breast cancer clinics is to counsel women and their families about personal risk, early detection, and prevention of breast cancer (53). Genetic assessment services that promote breast cancer awareness while managing excessive anxiety and cancer worry may provide important benefits in encouraging at-risk individuals to engage in appropriate screening practices.
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ACKNOWLEDGMENTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONACKNOWLEDGMENTSREFERENCES |
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We wish to thank all staff and collaborators involved in the TRACE Project.
Received for publication January 26, 1998.
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REFERENCES |
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This article has been cited by other articles:
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  K. Brain, J. Gray, P. Norman, E. France, C. Anglim, G. Barton, E. Parsons, A. Clarke, H. Sweetland, M. Tischkowitz, et al. Randomized Trial of a Specialist Genetic Assessment Service for Familial Breast Cancer J Natl Cancer Inst, August 16, 2000; 92(16): 1345 - 1351. [Abstract] [Full Text] [PDF]
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 N. Press, J. R Fishman, and B. A Koenig Collective Fear, Individualized Risk: the social and cultural context of genetic testing forbreast cancer Nursing Ethics, May 1, 2000; 7(3): 237 - 249. [Abstract] [PDF]
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