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Psychosomatic Medicine 66:104-112 (2004)
© 2004 American Psychosomatic Society

ORIGINAL ARTICLES

Stress Response Syndromes in Women Undergoing Mammography: A Comparison of Women With and Without a History of Breast Cancer

Maria Gurevich, PhD, Gerald M. Devins, PhD, CPsych, Christine Wilson, MD, FRCP, David McCready, MD, FRCSC, Charles R. Marmar, MD, FRCP(C) and Gary M. Rodin, MD, FRCP(C)

Psychosocial Oncology and Palliative Care Program (M.G., G.M.D., G.M.R.) and Surgical Oncology (D.M.), Princess Margaret Hospital, and Medical Imaging (C.W.), University Health Network; Department of Psychology (M.G.), Ryerson University; and Department of Psychiatry (G.M.D., G.M.R.), University of Toronto, Toronto, Canada; and Department of Psychiatry (C.R.M.), University of California and Department of Veterans Affairs Medical Center, San Francisco, CA.

Address correspondence and reprint requests to Maria Gurevich, PhD, Assistant Professor, Department of Psychology, Ryerson University, 350 Victoria Street, Toronto, Ontario M5B 2K3, Canada. E-mail: mgurevic{at}ryerson.ca


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
OBJECTIVE: The purpose of this study was to assess the incidence, severity, and correlates of acute stress responses in women undergoing diagnostic mammographic surveillance and to explore the moderating impact of physician support on these symptoms.

METHODS: Sixty-six female breast cancer outpatients (at least 12 months after diagnosis and primary treatment) and 69 healthy women undergoing mammographic surveillance completed measures of: acute stress response, somatization, trauma history, psychiatric history, social support, and physician satisfaction.

RESULTS: Previous cancer, pre-mammography breast complaints, lower income, previous psychiatric medication use, greater instrumental support, greater somatization, greater perceived physician disengagement, and less perceived physician support were all associated with increased stress responses. Among women with a previous cancer diagnosis, those with greater distress reported higher levels of physician support. In contrast, among those without a previous cancer diagnosis, those with greater perceived physician support reported less distress.

CONCLUSIONS: These findings suggest that cancer-related cues, such as follow-up surveillance, may trigger a sensitizing response in women with a previous cancer diagnosis. The association of distress with physician support may arise from the responsiveness of physicians to identified distress, from increased help-seeking behavior by those who are distressed, or both. The benefit of support provided by health care professionals to those at risk of developing stress response syndromes deserves further study.

Key Words: diagnostic mammographic surveillance, • breast cancer, • stress response syndromes.

Abbreviations: ASD = acute stress disorder;; MDSS = physician disengagement;; MR = multiple regression;; PMH = Princess Margaret Hospital;; PSQ-MD = Patient Satisfaction With Doctor Questionnaire;; PSSS = perceived support;; PTSD = posttraumatic stress disorder;; SASRQ = Stanford Acute Stress Reaction Questionnaire;; SNSA = Social Network and Support Assessment;; SSAS = Somatosensory Amplification Scale;; THQ = Trauma History Questionnaire.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Mammography continues to be considered an important diagnostic tool in the early detection of breast cancer (1). However, psychological distress can arise before screening, at the time of mammography, in anticipation of results, and during or after the provision of test results (2–5). Further, post-mammography anxiety may persist for 1 to 5 months (6–8), despite the receipt of benign results. This distress may be significantly increased by recall for further testing (9–11), false-positive results (7,12), previous breast disease (4), and a family history of breast disease or cancer (4).

The psychological effect of mammography has been evaluated in most studies by measures of anxiety and depression (4). These measures do not capture the intrusive re-experiencing, avoidance, dissociation, and hyperarousal that are characteristic of stress response syndromes (13–15). The usual psychological response to trauma involves oscillation between avoidance of the event’s emotional impact and intrusive re-experiencing (14,15). Failure to resolve or assimilate traumatic experience may result in stress response symptoms that may meet DSM-IV criteria for an acute stress disorder (ASD) (16) if they persist from 2 days to 1 month and cause significant social or occupational distress. ASD often appears as a prodrome of posttraumatic stress disorder (PTSD) (17), which can be diagnosed when these symptoms persist for at least 3 months. Both threshold and subthreshold stress response syndromes (18,19) are associated with significant social, interpersonal, and physical impairment and psychiatric comorbidity (20–24).

Intrusive thoughts and avoidance after normal mammography results have been documented in specific subgroups, particularly in women with a family history of breast cancer or cancer-related death (25–28). Valdimarsdottir et al. (26) demonstrated that women with a familial risk of breast cancer reported higher levels of intrusive thoughts and avoidance both before and 1 month after screening, compared with low-risk women who did not undergo screening. In a similar study, women with a cancer-related parental death reported higher levels of intrusive thoughts and avoidance at the time of their yearly screening and 4 to 8 weeks after receiving normal results, compared with a community sample of women with no family history of breast cancer that did not undergo mammography screening (27). Notably, the comparison group is inadequate in this latter study. Women who receive normal mammography results have also exhibited occasional intrusive ideation at both 2-month and 12-month follow-up at levels comparable to those receiving false-positive results (28). These findings suggest that perceived vulnerability, such as that arising from a family history of cancer and cancer-related death, mediates subsequent stress response symptoms. Such screening-related stress responses are of clinical significance because they may adversely affect routine or follow-up testing (29–31), prophylactic treatments (32–34), and genetic testing (35–37). Clinically significant intrusive thoughts and avoidance have been reported by 27% to 53% of women with a high familial risk for breast cancer (29–31,38), and these symptoms are associated with less adherence to regular mammography screening (30,31,38). Intrusive thoughts have also been associated with breast examination overperformance (31,38,39), which diminishes sensitivity to abnormalities that emerge gradually (40,41).

Risk factors for stress response symptoms identified in breast cancer patients include younger age (42–50), pre-diagnosis and post-diagnosis non-cancer related trauma history and psychiatric history (50–54), lower perceived social support (52,53,55,56), dissatisfaction with cancer diagnosis communication (45), absence of diagnostic knowledge (57), and difficulty with healthcare professionals (58). Finally, women who report non-malignant breast pain score higher on somatization than pain-free patients with non-malignant breast lumps (59). Although somatization has not been explored in the specific context of cancer and traumatic stress, both retrospective (60,61) and prospective (62) studies have revealed a high incidence of somatization after traumatic events.

The purpose of this study was to assess the incidence, severity, and correlates of acute stress responses in women undergoing diagnostic mammographic surveillance for breast cancer and to explore the moderating impact of physician support on these symptoms. We hypothesized that stress response symptoms would be more common among women with: (1) a previous breast cancer diagnosis, (2) younger age, (3) a higher frequency of previous traumatic events, and (4) higher somatization levels. In addition, support from medical caregivers at the time of screening was also hypothesized to have a moderating impact on mammography-related stress response symptoms.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Participants
The sample was composed of 135 women undergoing mammographic surveillance for breast cancer at a large university-affiliated tertiary-care cancer center (Princess Margaret Hospital, PMH), all of whom received negative results at the current screening. Criteria for inclusion were as follows: (1) being 18 years of age or older, (2) having a good working knowledge of English, and (3) having undergone breast screening at PMH. Group 1 (previous cancer, N = 66) consisted of breast cancer outpatients (at least 12 months after the primary diagnosis and treatment and at least 9 months post-adjuvant treatment); group 2 (no previous cancer, N = 69) consisted of healthy women undergoing mammographic surveillance. Sample characteristics are described in Table 1.


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  		TABLE 1. Descriptive Statistics: Sociodemographic and Medical Variables
 
Measures
Acute Stress Responses
The Stanford Acute Stress Reaction Questionnaire (SASRQ) (63,64), a 30-item, DSM-IV–correspondent scale, assesses symptoms of ASD, including dissociation, intrusion, avoidance, and hyperarousal or anxiety. An impairment subscale is also included to assess the level of overall disruption resulting from acute stress responses. The extent to which each symptom has been experienced is rated on a 6-point scale, ranging from 0 (not experienced) to 5 (very often experienced). The SASRQ is internally consistent ({alpha} = 0.92) and has adequate test–retest reliability in the absence of intervening traumas (rtt = 0.78) (64). Predictive validity for various versions of the scale has been demonstrated in relation to a variety of traumatic events, including earthquakes (65), fires (66), and witnessing an execution (67). Construct, discriminant, and convergent validity across diverse samples have also been demonstrated (68). The critical event specified for this study was mammography and the receipt of test results. No time frame is specified on the scale for the presence of symptoms. Scores can be calculated continuously as the sum for each subscale or all items or both, or dichotomously for the presence of symptoms, with scores of 3 or higher being indicative of a symptom (68).

Medical Status and Demographics
Socio-demographic (age, education, income, partner status) and medical status (reasons for mammography) data were collected. For group 1 (previous cancer), disease type at diagnosis, time since diagnosis, and time since primary and adjuvant treatment completion were assessed; these data were abstracted from patients’ medical records. A question inquiring about family history of breast cancer was also included for both groups. Family history was a dichotomous variable, with first-degree relatives as alternatives: mother, sister. We assigned a score of 1 (some family history) if a respondent indicated that any one or more of such relatives had cancer; a score of 0 was assigned if a respondent indicated that no first-degree relatives had had cancer.

Somatization
The Somatosensory Amplification Scale (SSAS) (69,70), an 11-item, self-report instrument, assesses sensitivity to a range of somatic and visceral sensations that are uncomfortable but not typically indicative of serious physical disease. The degree to which each sensation is endorsed is rated on a 6-point scale, ranging from 1 (not at all true) to 5 (extremely true). The scale has adequate test–retest reliability (rtt = 0.79) over a median interval of 74 days and high internal consistency (Cronbach {alpha} = 0.82) (69,70). Total scores are calculated based on the mean across all items. Scores of 2 or higher represent clinically relevant amplification. No time frame is specified for the presence of symptoms.

Trauma History
The Trauma History Questionnaire (THQ) (71) is a 24-item self-report inventory based on the high-magnitude stressor events interview used for the DSM-IV field trials for PTSD (71). Three general areas are tapped: crime-related events, general disaster and trauma, and unwanted physical and sexual experiences. Items are rated based on the frequency of each event and the age of occurrence. The THQ showed good reliability and validity using 423 college students and 186 psychiatric patients (72), in addition to recent data on 160 breast cancer survivors (44). Frequencies are calculated for each of the three trauma areas and for the total number of traumatic events across all domains.

Psychiatric History
Psychiatric history was assessed via the following four questions:

(1) Have you ever experienced severe depression, anxiety or another psychological condition?
(2) Have you ever consulted a physician, a social worker, a psychologist or another mental health professional for depression, anxiety or another psychological condition?
(3) Have you ever been prescribed any medication for depression, anxiety or another psychological condition?
(4) Have you ever been hospitalized (voluntarily or involuntarily) for depression, anxiety or another psychological condition?

A separate dichotomous variable was created for each of the corresponding questions: psychological history, psychiatric treatment, psychiatric medication, and psychiatric hospitalization. A score of 1 was assigned if a respondent answered yes to each of the questions; a score of 0 was assigned if a respondent answered no to each question. A composite score composed of each of these dichotomous variables was also calculated.

Support From Social Network
The Social Network and Support Assessment (SNSA) (73), adapted from the 29-item Yale Social Support Index (74), assesses instrumental and emotional social support received from friends, relatives, and partners. Responses range from "never" (1) to "frequently" (4). Both structural (availability) and functional (adequacy) aspects of support are measured. The SNSA also assesses negative aspects of social relationships using the demands/criticisms subscale (73). It shows good validity and test–retest reliability over a 2-week period (rtt = 0.77 to rtt = 0.86) (73). Separate subscales were computed for positive emotional support, negative emotional support, and instrumental support. No time frame is specified for the presence of symptoms.

Support From Medical Caregivers
The Patient Satisfaction With Doctor Questionnaire (PSQ-MD) (75), a 24-item, self-administered outpatient satisfaction questionnaire, is specific to cancer outpatients and is based on a previous 29-item scale (76). The revised 24-item scale assesses two complementary domains of patient satisfaction: perceived support (PSSS) and physician disengagement (MDSS), therefore tapping both positive and negative features of support. The scale ranges from 4 (strongly agree) to 1 (strongly disagree), with a "not applicable" category. Using a sample of 87 oncology outpatients, the internal consistency of the 24-item PSQ-MD is supported by moderate Cronbach {alpha} values for the total ({alpha} = 0.70) and high Cronbach {alpha} values for the subscale scores (physician disengagement, {alpha} = 0.92; physician perceived support, {alpha} = 0.85) (75). The test–retest reliability is adequate for the total score (rtt = 0.60) and the physician disengagement (rtt = 0.79) and the physician perceived support (rtt = 0.76) subscales over a 3-day to 5-day retest interval. Convergent and discriminant validity have also been established (75). Respondents are asked to refer to their most recent visit in completing this measure.

Procedure
Participants were enrolled in this study at the time of mammography. The radio-oncology technicians who conducted mammographies informed all women who met study inclusion criteria about the study via an introductory letter inviting their participation. Two hundred and ninety-two eligible women were approached, and 135 (46%) agreed to participate and returned completed questionnaires. Informed consent was obtained by a member of the research team who was not involved in the patients’ clinical care. All measures were self-administered (completed at home), took approximately 50 minutes to complete, and were returned by mail within 3 weeks after receipt of the mammography results. Women were asked to defer the completion of assessment until after the receipt of results. During the mammography procedure, all women receive four views, two of each breast. Whether women treated with previous lumpectomy receive additional views of the relevant side is at the discretion of the radiologist. All mammographic examinations are based on physician referrals, and patients are notified of the results by the referring physician within 2 to 3 weeks of the examination. Further work-up is performed either at the time of the examination or within a few days.

Data Analyses
Descriptive statistics were calculated for all variables. Student t tests (for continuous data) and {chi}2 tests (for categorical data) were used to assess differences between the previous cancer and no previous cancer groups. Pearson (for continuous data) and point-biserial correlations (for dichotomous data) were calculated to assess the intercorrelations among all measures. Alphas coefficients were calculated for all scales to assess reliability. Hierarchical multiple regression (MR) analyses were used to examine the relative contribution of hypothesized factors associated with acute stress response symptoms after mammography. Hierarchical MR was also used to test our hypothesis about the moderating effect of satisfaction with medical caregivers on mammography-related stress response symptom development. This was achieved by entering the group by perceived satisfaction subscale interaction effects as partialed products in the final step of the hierarchical MR analysis (77). Separate regression equations were examined for each of the criterion variables (ie, the acute stress-response symptom subscales and total score).


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Socio-demographic and medical descriptive information are summarized in Table 1. Compared with the no previous cancer group, the previous breast cancer patients were significantly older, less highly educated, and less often employed, and had lower incomes.

All measures demonstrated good reliability, with Cronbach coefficients for each scale as follows: SASRQ (total score, {alpha} = 0.96; dissociation, {alpha} = 0.91; re-experiencing, {alpha} = 0.88; arousal, {alpha} = 0.90; avoidance, {alpha} = 0.89; impairment, {alpha} = 0.67), PSQ-MD (total score, {alpha} = 0.93; physician disengagement, {alpha} = 0.95; physician perceived support, {alpha} = 0.88), SNSA ({alpha} = 0.69), THQ ({alpha} = 0.71), and SSAS ({alpha} = 0.68).

Stress-Response Symptom Levels
Women with a previous cancer diagnosis reported significantly higher stress responses (Table 2). Using the symptom method of scoring (scores of 3 or higher indicate a symptom) (68), 3% to 25.6% of women with a previous diagnosis exceeded the critical threshold on at least one of the SASRQ subscales. In contrast, 1.4% to 11.4% of women with no previous cancer exceeded these thresholds. Effect sizes were moderately high for most subscales and the total scores (78). Arousal symptoms were the most frequently reported by both women with a previous diagnosis (25.6%) and those with no previous cancer (11.4%). Avoidance and impairment symptoms, respectively, were endorsed by approximately 12% of women with previous cancer; 7% and 8.6% of women with no previous cancer reported these symptoms. Intrusive thoughts were reported by 10.5% of the women with previous cancer and by 5.7% of women with no previous cancer. Dissociative symptoms were reported by a minority of women (previous cancer, 3%; no cancer, 1.4%). Using the continuous method of scoring (based on total scale scores), the means for the total SASRQ for each group were as follows: previous cancer, mean = 39.68 (SD = 30.37); no previous cancer, mean = 19.97 (SD = 26.37); t(128) = -3.96; p < .001.


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  		TABLE 2. Stress-Response Symptom Levels
 
Correlates of Stress-Response Symptoms
Bivariate analyses were used to determine which socio-demographic and psychological (ie, somatization) variables should be retained as covariates in the regression models. The retention criterion was a statistically significant association, as indicated by Pearson and point-biserial correlations (0.05 was the criterion used). The following variables were significantly correlated with some or all of the stress response scores: cancer group, r(130) = 0.21 to 0.35 (minimum p < .05); pre-mammography breast complaints, r(130) = 0.17 to 0.23 (minimum p < .05); total income, r(113) = -0.19 to -0.25 (minimum p < .05); psychiatric medication use, r(130) = 0.22 to 0.25 (p < .05); instrumental support, r(64) = 0.25 to 0.27 (p < .05); somatization, r(129) = 0.27 to 0.34 (p < .01); physician disengagement, r(111) = -0.20 to -0.30 (minimum p < .05); and perceived physician support, r(88) = -0.22 to -0.30 (minimum p < .05; Table 3). In other words, previous cancer, pre-mammography breast complaints, lower income, previous psychiatric medication use, greater instrumental support, greater somatization, greater perceived physician disengagement, and less perceived physician support were all associated with increased stress responses.


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  		TABLE 3. Correlations Between Explanatory and Stress Response Variables
 
Covariate Identification and the Hierarchical Multiple Regression Model
The variables that were significantly correlated were retained as covariates. When income was entered into the regression equation, it was no longer significantly related to the stress response symptoms, which may reflect collinearity with other covariates. To conserve degrees of freedom, income was deleted for all subsequent MR analyses. Accordingly, for each dependent variable, in each regression model, pre-mammography breast complaints, previous psychiatric medication use, somatization, and instrumental support were entered as the covariates in the first step to control for their association with the criterion variables. Cancer group (previous cancer/no previous cancer), physician disengagement, and physician perceived support were entered as the main effects in the second step, and cancer group by physician disengagement and cancer group by physician perceived support interactions were entered in step three. In the case of statistically significant interaction effects, we repeated the analysis including only variables relevant to that specific result to provide a simpler examination of the effect. The results of these pared analyses, which were consistent with the omnibus analyses, were used to plot significant interaction effects.

Total Acute Stress
When total acute stress was the criterion variable, controlling for significant effects for pre-mammography breast complaints, psychiatric medication use, somatization, and instrumental support, a significant main effect was obtained for the cancer group (R2 change = 0.11, F(3,127) = 6.32, p = .0001).

1In each case, the R2 change is for the block of variables entered in each of the three steps, not for individual variables.

Dissociation
Table 4 shows that a main effect was again observed for the cancer group after controlling for pre-mammography breast complaints, psychiatric medication use, somatization, and instrumental support. The main effect was qualified by a cancer group by perceived physician support interaction (p = .05). Given the comparatively small sample size, pared analyses, as described above, were performed. Results of this analysis indicated that the interaction effect was statistically significant (R2 change = 0.02, F(1,128) = 4.22, p < .04). Figure 1 illustrates this interaction. Regression lines are plotted for the two groups, no previous cancer and previous cancer, at 1 SD above and below the mean for physician support (77). Whereas dissociation decreased with increasing perceived physician support in the no previous cancer group, the reverse trend was apparent for the previous cancer patients. Dissociation appears to be associated with increasing physician support among women with a previous cancer diagnosis.


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  		TABLE 4. Hierarchical Regression Analysis for the Dissociative Subscale (DISSASRQ)
 


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  		Fig. 1. Cancer group by perceived physician support interaction: dissociation (DISSASRQ).

 
Re-Experiencing
A significant main effect was again observed for the cancer group, controlling for pre-mammography breast complaints, psychiatric medication use, somatization, and instrumental support (R2 change = 0.09, F(3,127) = 4.65, p = .004). No significant interactions were obtained.

Avoidance
The main effect for cancer group was not significant for avoidance after controlling for pre-mammography breast complaints, psychiatric medication use, somatization, and instrumental support (R2 change = 0.03, F(3,127) = 1.65, p = .18). The interactions also did not reach statistical significance.

Arousal
The main effect of cancer group reached significance after controlling for pre-mammography breast complaints, psychiatric medication use, somatization, and instrumental support (Table 5). This effect was qualified by a significant cancer group by perceived physician support interaction (R2 change = 0.02, F(1,128) = 3.93, p < .05). The interaction is depicted in Figure 2. Regression lines are plotted for the two groups, no previous cancer and previous cancer, at 1 SD above and below the mean for physician support. The form of this interaction was the same as observed for the dissociation subscale: among women with no previous cancer, increasing perceived physician support was associated with decreasing arousal, but the opposite was evident among women with a previous cancer diagnosis.


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  		TABLE 5. Hierarchical Regression Analysis for the Arousal Subscale, (ARSASRQ)
 


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  		Fig. 2. Cancer group by perceived support interaction: arousal (SASRQ).

 
Impairment
With impairment as the criterion variable, cancer group was the only significant main effect after controlling for pre-mammography breast complaints, psychiatric medication use, somatization, and instrumental support (R2 change = 0.07, F(3,127) = 3.63, p = .02). No significant interaction effects were found.


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
This study provides confirmation that a previous cancer history may potentiate anxiety in the context of certain cues, such as follow-up examinations and surveillance mammography. The moderating effect of social support for some aspects of mammography-related stress responses was also confirmed. Women with a previous cancer diagnosis reported two to four times as many acute stress symptoms as women with no previous cancer. This finding is consistent with other research showing that familial cancer and cancer-related parental death (25–28) may predispose to distress associated with mammography, even when the results are negative. This result also concurs with evidence that women with a previous cancer diagnosis (disease-free for 4 years) reported higher levels of cancer-related distress in response to visits to a physician and non-cancer related somatic symptoms (headaches, fatigue) (41). Compared with those with no history of cancer, the meaning and experience of mammography surveillance and cancer-related medical follow-ups are likely to be different in survivors of breast cancer, who are at higher risk for developing new primary breast cancer or a recurrence (79,80). This "accumulated burden of adversity" (81,82) has also been observed in other medical conditions (82,83), suggesting that past stressors negatively affect the appraisal of present stressors (84).

Arousal reactions were the most common stress response symptoms, with one quarter of the women with previous cancer meeting clinical threshold criteria. Arousal symptoms have also been shown in other studies to be the most frequent in the acute trauma phase (66) and are important mediators of posttraumatic adjustment (85,86). Dissociative symptoms were the least common in our study (3%), consistent with other studies of the acute phase of trauma (66,86). The relatively low threat of the critical event in the present study (ie, non-malignant mammography results) may also account for the low levels of dissociative symptoms.

Notably, the mean score for the total SASRQ (mean = 39.7, SD = 30.4) in our sample with previous cancer was somewhat higher than that reported in a sample of newly diagnosed breast cancer patients (mean = 34.5, SD = 27.9) (45). The women in our sample, on average 6.5 years after diagnosis and treatment, should be at relatively low risk for recurrence (87); two thirds of them, who had only local disease at the time of diagnosis, may anticipate favorable outcomes (87). However, the experience of previous cancer may have a persistent influence on health-related threats and events, even in the absence of recurring disease.

The present study also suggests that perceived physician support may moderate some aspects of screening-related stress. Specifically, for women with no previous cancer, dissociative and arousal symptoms were lower in the presence of high perceived physician support. However, among women with previous cancer, greater perceived physician support was associated with higher symptom levels than in those with low perceived support. Notably, the medical differences between the two groups (ie, the women with the previous breast cancer history referred to support by the treating oncologist, whereas the no previous cancer group referred to the radiologist) limit the comparability of the groups. That is, the roles of the two types of physicians are likely to be different, thereby engendering different responses on the part of the patient and physician alike. This may explain this seemingly paradoxical finding. It may also be explained by the tendency of women with previous cancer history to experience greater distress in response to mammography (4) and to require or elicit greater physician support. This explanation of these paradoxical findings requires replication and direct investigation to confirm its validity. Longer-term arousal and dissociation among women with previous cancer should also be examined to test our speculation that oncologists were responding to increased distress evident among women with a previous experience with cancer. A finding of subsequent reductions in stress responses in this group would, for example, support our interpretation of the findings. The credibility of this interpretation is buttressed, however, by the widely reported finding that social support exerts a buffering effect (88) among patients with cancer (89) and other medical conditions (90). This beneficial effect of physician support may account for findings that primary physician support (91,92) and satisfaction with the communication aspects of physician interactions (93) are among the key variables predicting regular participation in mammography.

Physician disengagement did not moderate the impact of previous cancer on post-mammography distress. This component of physician support may be more relevant in the case of more prominent threats, such as a recent cancer diagnosis or false-positive or ambiguous results requiring further investigation and decision making. In such cases, informational and procedural aspects may become more central (94,95), and different supportive functions may be required. For instance, involvement in decision making about the use of testing for recurrent disease as part of follow-up care for women with a cancer diagnosis contributed to improved quality of life (95). Therefore, the absence of appropriate physician involvement may have more deleterious consequences in such instances.

Very little research has focused on interventions to reduce mammography-related distress. However, the findings of the present study indicate that stress response symptoms at the time of mammography, even when the results are negative, may be as great as at the time of diagnosis of breast cancer. Support of medical caregivers may be an important ameliorating factor for some groups of women, although our results were equivocal in this regard. Mammography-related distress is important because it may negatively affect adherence to regular follow-up, although the empirical evidence for this is currently lacking. Despite recommendations of annual mammography for survivors of breast cancer (96,97), one study has shown that 30% of these women had not received a mammogram in the preceding year, and 41% could not recall whether they had a mammogram in the preceding 2 years (98). Such self-reports have also been shown to underestimate actual examinations undertaken (99,100). The evidence for the impact of cancer-related distress on mammography use is limited and mixed, with a few studies indicating that anxiety reduces surveillance behaviors (100,101), whereas several others suggest that moderate levels of distress may actually facilitate adherence (102,103).

In summary, the results of this study suggest that survivors of breast cancer may experience heightened cancer-related fears, even after they have received negative mammography results. Physician support was associated with greater distress in women with previous cancer, and with less distress in women with no previous cancer diagnosis. The extent to which support is a response to distress or a protective factor deserves further exploration. One possibility is that physician support may serve a differentially protective function, depending on cancer history. Another possibility is that different physician roles (eg, treating oncologist vs. radiologist) engender different responses on the part of patient and physician alike. This study contains the following limitations: relatively small sample sizes relative to the number of predictor variables explored, the reliance on a single cross-sectional assessment, lack of pretest matching between the two study groups on potentially key variables (eg, history of breast cancer in first-degree relatives, age, response rate), and the lack of documentation regarding the precise timing of questionnaire completion after notification of results (although notification of results was within 2–3 weeks after mammography). Nonetheless, stress-related symptoms in response to mammography are important to detect because they may adversely affect surveillance behaviors (ie, regular mammography, clinical breast examinations, and breast self-examinations) and health-related decision making (eg, genetic testing, adjuvant and prophylactic treatments). These issues, in particular, warrant empirical and clinical attention.

Received for publication July 21, 2003.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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