The experience of screening mammography

Journal of Family Practice, Nov, 1989 by Robert J. Wolosin

Screening mammography is an important but underutilized method for controlling breast cancer. 1-1 Studies typically find that fewer than 20% of eligible women have ever had a mammogram.(4-7) Women's negative attitudes have been cited as a powerful factor in this underutilization. Fear of cancer, of losing a breast, of pain or of radiation associated with the examination itself, and even embarrassment about breasts are said to predispose women to refuse physicians' mammography referrals, let alone obtain the test on their own.(1-11) Physician reluctance to make a mammography referral reflects failure to conduct breast examinations, ignorance of (or lack of agreement with) recommendations, and such concerns as the examination's cost, safety, reliability, and yield, and the belief that patients are unwilling to accept a referral.(1,3,12,13)

Women's reactions to the experience of screening mammography are important, as a screening method must be acceptable to the population for which it is intended. A bad experience might cause a woman to avoid future mammograms, and hence run the risk of undetected breast cancer, to speak badly of the procedure to others, and to distrust preventive measures in general. Moreover, patient reactions may be quite important for family physicians and others in primary care. Along with physicians' beliefs about safety, yield, false-positive results, and so on, patient reactions could powerfully affect physicians' likelihood and manner of recommending the procedure.

A literature search revealed three studies dealing with the issue of women's reactions to the mammography experience. The first(l4) examined reactions of 60 mammography patients at a university clinic. The study found that, on the whole, the experience was positive; most women felt some relief when it was over, verifying the notion that women undergo the examination with some anxiety. A Danish study examined patients' attitudes and reactions while they awaited the procedure." Two thirds of these women stated that they did not fear the results of their examination. In the third study, 224 women, mostly from minority groups living in Los Angeles, were interviewed immediately after a mammographic examination.16 The experience was acceptable or even positive for most of them. Thus, what is known indicates that once women get through the examination, their reported experience is neutral or positive.

The purpose of the current study was to learn about particular aspects of the experience of mammography, including women's physical and emotional reactions, as well as the role of several motivating factors, both positive and negative, that might be important. Awareness of these reactions and factors can be used by family physicians to gain insight into the patient's experience of the examination, to allay patient anxieties, and ultimately to improve patient cooperation with mammography referrals. METHODS Questionnaire

A single-page, self-administered questionnaire was devised. Its introduction requested participation. Demographic items-age, marital status, and occupation-were followed by items pertaining to the examination itself: first vs repeat mammogram, result of self-referral or physician referral; if the result of a physician's referral, the time since the referral was made and whether the patient requested the referral. Patients were then instructed to read I I attitude statements and "check all those that apply to you." The I 1 statements (Table 1) were chosen to reflect variables cited in the literature as important in women's decisions regarding mammograms, including anxiety about results," perceived vulnerability to breast cancer," the reputation of the examination,(9-15) a triggering event such as the diagnosis of breast cancer in a friend or relative,l perceived barriers to obtaining the examination,(9) seeking reassurance,(3) perceived pain relative to expectation, and overall attitude about the examination. Site Selection and Description

Sites were selected that had a large volume of screening mammograms, that were located in or near a small Midwestern city, and that represented different types of patient populations. Site I was a recently established mobile mammography unit that traveled to several community physicians' offices on a regular basis. Site 2 was an older, established radiology office serving private practitioners in a medical building. Site 3 was similar to site 2. Site 4 was a hospital-based radiology practice in a small working-class community. Site 5 was located in a large nearby city and served primarily an inner-city population. Administrators of these sites participated in the study by having their technicians distribute and collect questionnaires during the autumn of 1987. In return, they received feedback comparing their own site with the others. Procedure Personnel at each site were told to give every screening mammography patient a questionnaire after her mammograms had been taken but before they were read. Site personnel were to tell patients that participation was completely voluntary and were instructed how to answer patients' questions. Patients had as much time as they needed to complete the questionnaire, which rarely exceeded a few minutes. Site reports indicated that the only major deviation from this procedure occurred at the inner-city site, where by previous agreement the technician was instructed to exclude from the sample patients who could not read. Minor deviations, such as occasional failures to hand out questionnaires to all patients, undoubtedly occurred as well. RESULTS Demographics The distribution of the 985 respondents by site as well as data on response rates, age (median and range), and marital status is shown in Table 2. Respondents ranged in age from 21 to 87 years; the median age ranged from 51 to 55 years. Sites I through 4 were similar with regard to the distribution of marital status: roughly 80% married, 15% separated, divorced, or widowed, and the remainder single. Site 5 had many fewer married women and many more separated, divorced, widowed, and single women. The most frequently listed occupation for all sites was "homemaker." First Mammogram and Referral Data Table 3 shows the percentage of patients having their first mammogram and indicates the type of referral. Just over one half the respondents were obtaining their first mammogram.