Psycho-social factors influencing delay and breast self-examination in women with symptoms of breast cancer

Illness Denial in Medical Disorders: A Systematic Review

INTRODUCTION

Illness denial pertains to medical patients who do not acknowledge the presence or severity of their disease or the need of treatment.

OBJECTIVE

This systematic review was performed to clarify the clinical role and manifestations of illness denial, its impact on health attitudes and behavior, as well as on short- and long-term outcomes in patients with medical disorders.

METHODS

The systematic search according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines was conducted on PubMed, Scopus, and Web of Science.

RESULTS

The initial search yielded a total of 14,098 articles; 176 studies met the criteria for inclusion. Illness denial appeared to be a relatively common condition affecting a wide spectrum of health attitudes and behavior. In some cases, it may help a person cope with various stages of illness and treatment. In other situations, it may determine delay in seeking treatment, impaired adherence, and reduced self-management, leading to adverse outcomes. The Diagnostic Criteria for Psychosomatic Research (DCPR) were found to set a useful severity threshold for the condition. An important clinical distinction can also be made based on the DCPR for illness denial, which require the assessment of whether the patient has been provided with an adequate appraisal of the medical situation.

CONCLUSIONS

This systematic review indicates that patients with medical disorders experience and express illness denial in many forms and with varying degrees of severity. The findings suggest the need for a multidimensional assessment and provide challenging insights into the management of medical disorders.

Influences of cancer symptom knowledge, beliefs and barriers on cancer symptom presentation in relation to socioeconomic deprivation: a systematic review

BACKGROUND

People from lower socioeconomic groups have worse survival outcomes for cancer, which in part reflects later-stage disease at diagnosis. The mechanisms underlying delayed cancer symptom presentation in lower socioeconomic groups are not well understood.

METHODS

Systematic review of studies of actual or anticipated symptom presentation across all tumour sites. Included studies measured socioeconomic group, symptom presentation and one or more of the following variables: cancer symptom knowledge, beliefs about cancer, barriers/facilitators to symptom presentation.

RESULTS

A total of 60 studies was included. Symptom knowledge overall was lowest and actual presentation time was longest in lower socioeconomic groups. Knowledge for specific symptoms such as lumps and bleeding was good and encouraged timely symptom presentation, in contrast to non-specific symptoms which were not well recognised. The combination of fearful and fatalistic beliefs was typically associated with later presentation, especially in lower socioeconomic groups. Emotional barriers such as 'worry what the doctor might find' were more frequently reported in lower socioeconomic groups, and there was evidence to suggest that disclosing symptoms to family/friends could help or hinder early presentation.

CONCLUSIONS

Poor symptom knowledge, fearful and fatalistic beliefs about cancer, and emotional barriers combine to prolong symptom presentation among lower socioeconomic groups. Targeted interventions should utilise social networks to improve knowledge of non-specific symptoms, challenge negative beliefs and encourage help-seeking, in order to reduce avoidable delays and minimise socioeconomic group inequalities.

The role of emotions in time to presentation for symptoms suggestive of cancer: a systematic literature review of quantitative studies

BACKGROUND

Emotions may be important in patients' decisions to seek medical help for symptoms suggestive of cancer.

OBJECTIVES

The aim of this systematic literature review was to examine quantitative literature on the influence of emotion on patients' help-seeking for symptoms suggestive of cancer. The objectives were to identify the following: (a) which types of emotions influence help-seeking behaviour, (b) whether these form a barrier or trigger for seeking medical help and (c) how the role of emotions varies between different cancers and populations.

METHODS

We searched four electronic databases and conducted a narrative synthesis. Inclusion criteria were studies that reported primary, quantitative research that examined any emotion specific to symptom appraisal or help-seeking for symptoms suggestive of cancer.

RESULTS

Thirty-three papers were included. The studies were heterogeneous in their methods and quality, and very few had emotion as the main focus of the research. Studies reported a limited range of emotions, mainly related to fear and worry. The impact of emotions appears mixed, sometimes acting as a barrier to consultation whilst at other times being a trigger or being unrelated to time to presentation. It is plausible that different emotions play different roles at different times prior to presentation.

CONCLUSIONS

This systematic review provides some quantitative evidence for the role of emotions in help-seeking behaviour. However, it also highlighted widespread methodological, definition and design issues among the existing literature. The conflicting results around the role of emotions on time to presentation may be due to the lack of definition of each specific emotion.

Non-practice of breast self examination and marital status are associated with delayed presentation with breast cancer

Delay in seeking treatment for breast cancer is a barrier to the early diagnosis and management of the disease, resulting in a poorer prognosis. We here estimated the prevalence of delayed presentation for breast cancer and identified possible influential sociodemographic factors in a cross-sectional study of 250 patients diagnosed with primary breast cancer at the Radiotherapy and Oncology Clinic in Kuala Lumpur Hospital. Data were collected by face-to-face interview using a structured questionnaire and from medical records. We examined associations between delayed presentation (presenting to a physician more than 3 months after self-discovery of a symptom) and sociodemographic characteristics, practice of breast self examination (BSE), history of benign breast disease, family history of breast cancer and type of symptom, symptom disclosure and advice from others to seek treatment using multiple logistic regression. Time from self-discovery of symptom to presentation ranged from tghe same day to 5 years. Prevalence of delayed presentation was 33.1% (95%CI: 27.4, 39.3). A significantly higher proportion of delayers presented with late stages (stage III/IV) (58.3% vs. 26.9%, p<0.001). Divorced or widowed women (OR: 2.23, 95% CI: 1.11, 4.47) had a higher risk of delayed presentation than married women and women who never performed breast self examination were more likely to delay presentation compared to those who regularly performed BSE (OR: 2.74, 95% CI: 1.33, 5.64). Our findings indicate that delayed presentation for breast cancer symptoms among Malaysian women is high and that marital status and breast self examination play major roles in treatment-seeking for breast cancer symptoms.

Specific phobia of illness: search for a new subtype

Specific phobia of illness makes its appearance in DSM-IV as a new diagnostic subtype, separate from hypochondriasis. A review of the literature indicates that, while there is some support for this new category, studies have not as yet been done that could provide validation. Illness phobia appears to be a significant problem; it is prevalent in the general population and is associated with distress and impairment, including interference with medical care. It appears to be associated with older age, physical illness, and female gender. Group comparisons are needed showing that persons with this phobia can be distinguished from hypochondriasis on the basis of these and other demographic and illness features. We outline a research agenda for demonstrating this separation.

Psychological factors and patient delay in patients with head and neck cancer

There is a rising incidence of patients presenting with advanced cancer in the head and neck region. Late presentation may be due to a delay in seeking medical attention, which is sometimes surprisingly long. The aim of the present prospective study was to investigate the association between patient delay and the psychological factors of optimism, health hardiness, overall defensive functioning, coping styles and psychological distress in 277 patients with cancer of the head and neck. Significant correlations were found between patient delay and the psychological factors. Twenty-six percent of the patients waited more than three months before seeking medical attention and they reported less optimism (P = 0.0001), less health hardiness (P = 0.008), less active coping (P = 0.019) and less seeking support as a coping style (P = 0.017) than patients presenting within three months. Excessive drinkers (5+ alcoholic drinks/day) tended to show more delay than patients who did not drink or were moderate drinkers (0-2 drinks/day) or moderate-heavy drinkers (3-4 drinks/day). Together, the psychological factors could explain 25% of the variance of patient delay in excessive drinkers compared with 21% and 6% in moderate-heavy drinkers and non-drinkers to moderate drinkers, respectively. These results suggest that psychological factors affect health-care seeking behaviour. Health education aimed at the risk group of excessive drinkers should take psychological factors into account that influence their health behaviour.

The relationship of symptoms and psychological factors to delay in seeking medical care for breast symptoms

BACKGROUND

The psychological processes involved in the delay between noticing breast symptoms and seeking medical care are not well understood.

METHODS

We evaluated 85 women referred to a specialist breast clinic prior to their clinic appointment. We assessed the relationship between delay and the type of breast symptom, immediate emotional response to the symptom, perceived risk of breast cancer, fear of breast cancer treatment, and disclosure of the breast symptom to others.

RESULTS

Delay was unrelated to demographic factors but was related to the type of breast symptom; women who had a breast lump waited a significantly shorter time period before visiting the doctor than those without a breast lump. Initial symptom distress on the discovery of the breast symptom was also significantly related to delay. Knowledge of a friend or family member with breast cancer, perceived risk of breast cancer and fear of breast cancer treatment, and disclosure of the symptom to a partner or other person were all unrelated to delay.

CONCLUSIONS

The results show the importance of the type of symptom and initial emotional distress in delay and highlight the importance of widening public perceptions of breast symptoms other than breast lumps in order to reduce delay times.

Evaluating the self-assessed support needs of women with breast cancer

AIMS OF THE STUDY

The first aim of the study was to identify the self-assessed support needs of women with breast cancer at various points of illness and, secondly, to establish if these needs formed clusters which could provide the basis for developing a standardized scale of needs for use by breast care teams in the evaluation of care.

BACKGROUND

It has been found that support given to women with breast cancer has a positive effect upon their reactions to the illness and may even prolong their survival. Given that breast cancer affects a large number of women it is obviously important that those affected receive, in addition to the best available medical treatment, the type of support that best meets their needs. This study aimed to provide information on the impact of breast cancer and the need for various types of support by examining women's own assessment of their needs at different stages of their illness.

DESIGN AND METHODS

A purposive sample of 12 women with a diagnosis of breast cancer was selected in one health authority in England, United Kingdom (UK). Women selected represented a wide age range (between 26 and 58), were married or in long-term cohabiting relationships and were at different points on the illness trajectory. Women were invited to take part in a semi-structured interview about their experiences of breast cancer. The data from these interviews were analysed using the software package Qualitative Solutions and Research, Nonnumerical Data Indexing, Searching and Theorizing (QSR*NUDIST). Following this content analysis, a questionnaire was formulated which divided statements into seven categories: diagnosis, treatment, support, femininity and body image, family and friends, information and after care, to be rated on a Likert scale ranging from "of no importance" to "extremely important". Questionnaire data were analysed by means of a one-way analysis of variance (for three independent variables) or t-test for two independent variables. Results. The questionnaire was sent to 971 women and achieved a response rate of 50.4%. The mean score for statements of need reached the level of point 4 on the Likert scale (important) with three exceptions: having professional help with family problems and domestic upheaval, coping with feelings of anger and dealing with the question "why me?"

CONCLUSION

With the above three exceptions, women experienced a high level of need associated with a diagnosis of breast cancer. Studies of this kind should enable resources to be targeted to areas of highest need.

Experiences of women with a diagnosis of breast cancer: a clinical pathway approach

The study presented in this paper formed the first part of a large survey of breast cancer patients in one health authority in England, UK looking at individual needs expressed by women with a diagnosis of breast cancer. The paper provides an account of the experiences of 12 women with a diagnosis of breast cancer. The women represent a wide age range and different stages of illness. The transcribed accounts of the women were analysed by means of Qualitative Solutions and Research, Non-Numerical Unstructured Data Indexing Searching and Theorising (QSR*NUDIST). The study examined the individual experiences of women with a diagnosis of breast cancer and its aftermath as they passed through different stages related to it. The women's experiences are presented within the conceptual framework of the clinical pathway and their accounts represent their journey along the pathway. Various significant points in this journey are portrayed representing the women's reactions to diagnosis, treatment, femininity and body image, support, family and friends, information and after care.

A feminist critique of breast cancer research among Korean women

Studies indicate ethnic differences in incidence, mortality, and survival rate of breast cancer. Despite the low incidence rate of breast cancer among the Korean population, Koreans are reported to be less likely to survive breast cancer. In this article, using a feminist perspective, the reasons why Korean women have been reported to be less likely to survive breast cancer are analyzed through a critical review of research among Korean women. A total of 469 studies (145 unpublished master's theses and doctoral dissertations and 324 articles published in South Korea and in the United States) were reviewed, analyzed, and critiqued in terms of biases present in the research process. Through a feminist critique of the literature, four possible reasons are proposed: androcentric views and assumptions underlying the research, modesty issues imbedded in Korean culture, the victim-blaming tendency of Korean culture, and intense emotions without adequate support.

Delay in breast cancer care: a study in Thai women

BACKGROUND

Breast cancer is the second most common cause of cancer death in Thai women. Cancer registry data reveal a high prevalence of late-stage disease at diagnosis. The factors resulting in delay in Thailand have not yet been investigated.

OBJECTIVES

To determine the extent of, and the factors contributing to, delay in breast cancer care.

DESIGN

Women with breast cancer who were first treated at Songklanagarind Hospital between June 1994 and June 1996 were interviewed with retrospective chart audits of care.

MEASURES

Dependent variables included patient delay (symptom recognition to first care) and system delay (first care to treatment). Independent variables tested included demographic factors, help-seeking behavior, and cancer knowledge. Nonparametric rank sum tests were used for univariate analysis, and Cox regression was used for multivariate analysis.

RESULTS

Ninety-four cases were included in the study. The median patient and system delays were 4 weeks; 26.6% and 24.4% of patients, respectively, experienced patient and system delay >12 weeks. Only marital status (unmarried compared with married women) was significantly associated with patient delay (hazard ratio [HR] 2.78, 95% CI 1.23-6.25). Contacting a provincial hospital instead of a university hospital as first medical care (hazard ratio 2.50, 1.23-5.26), being given a diagnosis rather than being told nothing (HR 2.04, 1.14-3.57) and being given treatment rather than being immediately referred (HR 4.55, 2.22-9.09) were associated with system delay.

CONCLUSIONS

Patient delay and system delay in breast cancer care are important weaknesses of disease control in Thailand. Educational programs should target unmarried women, who are at higher risk of delay. System delay in hospitals outside the university needs to be improved by a good referral system.

Denial in cancer patients

Denial is a basic mechanism for coping with stressful themes, common in healthy and sick individuals. This article deals with the role and functions of denial in cancer, reviewing empirical studies about the effects of denial on cancer prevention, screening, undergoing tests for early detection, delay in seeking medical attention and getting treatment, complying with medical instructions, and coping with the disease in different stages. Special sections are devoted to the possible role of denial as a risk factor for cancer, the effects of denial on disease course and survival, and the relation of denial to immunocompetence. Major conclusions are that denial may have a positive effect when applied in the first phase of coping, after diagnosis, because it reduces anxiety. This holds also for the terminal stage. The negative effects of denial are that it may interfere with getting treatment (e.g., delay in going to the doctor, not showing up for follow-ups, noncompliance), may disrupt the process of assimilating the stressful event, may affect adversely interpersonal relations, and constitutes a cumulative stressor depressing even immunocompetence. The use of denial varies with the severity of the situation, the patient's personality, and his or her familial and cultural background. A large body of research examined the hypothesis that a tendency toward denial could be one of the risk factors for cancer. Despite evidence supporting the occurrence of denial as a correlate of cancer, a lot of research is necessary to clarify the role of denial in general and of anger specifically as a factor affecting the occurrence of cancer and the course of disease and survival.

The effects of major depression and phobia on stage at diagnosis of breast cancer

OBJECTIVE

To examine the longitudinal effects of major depression and phobia on stage at diagnosis of subsequent breast cancer.

METHOD

Data from the New Haven Epidemiologic Catchment Area (ECA) study were linked to the Connecticut Tumor Registry (CTR). The sample comprised of seventy-two women with a first primary breast cancer diagnosed sometime after their baseline ECA study interview. In the ECA study, lifetime psychiatric history was assessed using the Diagnostic Interview Schedule based on DSM-III criteria. Stage at diagnosis of breast cancer was taken from CTR records and dichotomized into early stage (in situ and localized tumors) versus late stage (regional and distant tumors).

RESULTS

A positive history of major depression was associated with an increased likelihood of late-stage diagnosis of breast cancer (odds ratio [OR] = 9.81, p = 0.039), whereas a positive history of phobic disorders was associated with a decreased likelihood of late-stage diagnosis (OR = 0.01, p = 0.021), controlling for sociodemographic characteristics of the sample.

CONCLUSIONS

These analyses revealed a longitudinal association between reported lifetime psychiatric history and stage at diagnosis of subsequent breast cancer. Phobia may motivate women to adhere to breast cancer screening recommendations and to report suspicious symptoms to a physician without delay. Major depression, on the other hand, was identified as an important predictor of late-stage diagnosis; proper recognition and management of depression in the primary care setting may have important implications for breast cancer detection and survival.

Coping with breast cancer: a cluster analytic approach

The aim of this study was to generate distinct clusters of women with breast cancer, and to evaluate differences between clusters with respect to decisional control, psychological adjustment, and frustration expression. Thirty-seven Stage I and 33 Stage II newly diagnosed breast cancer patients from two medical oncology clinics participated. A cluster analysis of the coping data produced three distinct patient clusters. The primary finding was that women from the low avoidance coping cluster were significantly better adjusted than women from the remaining clusters. Women from the low avoidance coping cluster also preferred more active involvement in treatment decision-making. Further research is needed to prospectively detail the mechanisms by which cognitive avoidance hampers psychological adjustment to cancer.

Psychological predictors of attendance at annual breast screening examinations

This retrospective analysis of psychological predictors of attendance studied the women from the annual screening arm of the United Kingdom Coordinating Committee on Cancer Research (UKCCCR) trial of annual screening mammography for the early detection of breast cancer. Some women attended screening at the first invitation in year 1 (attenders), others did not attend for screening at any time (non-attenders), whereas a third group delayed attending until year 2 (ambivalent attenders). A total of 147 women were recruited to the study: 80 attenders, 28 non-attenders and 39 ambivalent attenders. It proved extremely difficult to contact non-attenders to take part in the study. Non-attenders were significantly more depressed on the Hospital Anxiety and Depression Scale; had experienced more miscarriages, stillbirths or terminations of pregnancy; were less knowledgeable about mammography; and were displeased to have received an invitation to screening. Whereas non-attenders are unlikely ever to attend breast screening because of their long-standing attitudes and preferred coping styles, ambivalent attenders may become more amenable to screening with the passage of time. In this study such women were persuaded to attend in year 2 with a simple, cost-effective intervention: an additional invitation letter after a year.

Who and what influences delayed presentation in breast cancer?

This study aimed to examine the extent and determinants of patient and general practitioner delay in the presentation of breast cancer. One hundred and eighty-five cancer patients attending a breast unit were interviewed 2 months after diagnosis. The main outcome measures were patient delay in presentation to the general practitioner and non-referral by the general practitioner to hospital after the patient's first visit. Nineteen per cent of patients delayed > or = 12 weeks. Patient delay was related to clinical tumour size > or = 4 cm (P = 0.0002) and with a higher incidence of locally advanced and metastatic disease (P = 0.01). A number of factors predicted patient delay: initial breast symptom(s) that did not include a lump (OR 4.5, P = 0.003), not disclosing discovery of the breast symptom immediately to someone else (OR 6.0, P < 0.001), seeking help only after being prompted by others (OR 4.4, P = 0.007) and presenting to the general practitioner with a non-breast problem (OR 3.5, P = 0.03). Eighty-three per cent of patients were referred to hospital directly after their first general practitioner visit. Presenting to the GP with a breast symptom that did not include a lump independently predicted general practitioner delay (OR 3.6, P = 0.002). In view of the increasing evidence that delay adversely affects survival, a large multicentre study is now warranted to confirm these findings that may have implications for public and medical education.

Information needs, uncertainty, and anxiety in women who had a breast biopsy with benign outcome

A retrospective, descriptive study to determine the information needs of women who underwent a breast biopsy with a benign outcome and to ascertain the levels of uncertainty and anxiety they experienced was conducted in two community health care sites in Winnipeg, Manitoba. A sample of 70 women completed a four-part survey after learning the benign breast biopsy diagnosis. The survey consisted of an Information Needs Questionnaire, Mishel Uncertainty in Illness Scale--Community Form, State-Trait Anxiety Inventory, and a Demographic Questionnaire. Before the study, nine information needs were identified in a focus group composed of women (n = 9) who had a benign breast biopsy. The nine information needs were arranged in 36 pairs in the Information Needs Questionnaire. Profiles of information needs were developed through Statistical Analysis Systems analysis using Thurstone's Law of Comparative Judgement--Case V. The most important information need of women who underwent a benign breast biopsy was knowing when they would learn the diagnosis. The next four information needs were categorized as information about the risks of developing breast cancer. Information about follow-up and diagnostic tests were less important than information about the threat of breast cancer. Women experienced heightened uncertainty and anxiety levels related to the benign breast biopsy experience. Profiles of information needs were developed for women experiencing various levels of uncertainty and anxiety, women of different age groups, and women who experienced with a loved one with breast cancer.

Denial in physical illness

Denial is a concept often encountered in literature describing patients' psychological responses to physical illness. Definitions and theories of denial have drawn on clinical, cognitive, psychodynamic, organic, and interpersonal frameworks. Denial is related to other concepts such as lack of insight, self-deception, and anosognosia. Empirical studies have yielded mixed results with regard to the adaptive properties of denial. These results require interpretation in the light of: (1) the definitional complexities of denial; (2) the diversity of methods used for its assessment; and (3) the choice of different clinical samples and heterogeneous outcome measures. The clinical management of maladaptive denial poses a challenging problem which requires consideration of factors pertaining to the patient, the illness, the treating clinician, as well as the patient's social environment. To achieve further clarification of the role of denial in physical illness, future research would benefit from clearer definitions and more refined, consistent methods of assessment. A number of recommendations are outlined.

Colon cancer: personality factors predictive of onset and stage of presentation

This study examined premorbid personality correlates of colon cancer and stage of presentation of colon cancer to health care providers. Sixty-one male veterans who completed the MMPI between 1947 and 1975 and were then diagnosed with colon cancer between 1977 and 1988 were matched with control patients. A 21-factor solution of the MMPI [1] was used to seek potential personality differences between colon cancer cases and their controls in terms of presence of colon cancer and stage of presentation for this disease. A stepwise conditional regression analysis found significant differences between the colon cancer and control groups on the Aggressive Hostility variable (p < 0.018). A multivariate analysis of variance conducted across the stages of colon cancer presentation found that patients who presented later on for colon cancer had higher Phobia scores (p < 0.05). Religious Fundamentalism was also related to presentation (p < 0.05), but in a nonlinear manner. Discussion is related to previous findings regarding the relationship between personality and development of cancer, as well as to implications for patient screening.

Women's reasons for and barriers to seeking care for breast cancer symptoms

Of note, these findings are based on women who did seek care for symptoms, rather than those who did not. However, the sample does include late care seekers; 23% of participants sought care after 3 months, and 3.6% waited more than a year. Delay often is defined as seeking care 3 months after symptoms are noted. Community health workers, such as public health nurses, may be able to document barriers among women who have symptoms but have not sought care. In this sample of predominantly low-income, minimally educated participants, women were motivated to seek care for their breast symptoms to obtain consultations and diagnoses, as well as to deal with their concerns about their symptoms and possible cancer diagnoses. Clinicians can recognize women's need to know the meaning of their symptoms, providing clarification as soon as possible and reassurance as appropriate. Clinicians and families can affirm that making time for women's symptom evaluations is a priority. Knowing that women's common barriers to accessing the health care system involve financial, time, and logistical considerations can direct health care administrators' agendas. Administrators, clinicians, and women can work for changes in health policies to assure universal coverage for preventive services for all women.

Delay versus help seeking for breast cancer symptoms: a critical review of the literature on patient and provider delay

Patient delay in seeking help for breast cancer symptoms and provider delay in treating those symptoms combine to decrease a woman's potential for breast cancer survival. This paper reviews the literature on patient and provider delay published since 1975. Meta-analysis of 12 studies using common definitions of patient delay estimates that 34% of women with breast cancer symptoms delay help seeking for 3 or more months. Provider delay appears to be both under researched and underestimated. This review identifies the factors that have been advanced as contributing to patient and provider delay, evaluating the support for each of these reported findings. Theory-based hypotheses emerging from the reviewed studies highlight foci for future investigations.

A theory of care-seeking behavior

Although much research has focused upon why people do and do not engage in recommended health behaviors, there is a need to develop more accurate theories to explain and predict engagement in health behaviors. Because health behaviors differ in important ways, it could be most fruitful to understand one type of health behavior, such as secondary prevention behavior. This paper proposes a theory of care-seeking behavior (CSB), based on a theory of general behavior by Triandis. Other popular theories about health behavior (i.e., Health Belief Model and Theory of Reasoned Action) also are reviewed. Empirical support for the variables identified in the theory of CSB is presented, drawing from the literature on secondary prevention for cancer. The theory of CSB is applied to the situation of seeking care for cancer symptoms. Directions for future research based upon this theory are delineated.

Measuring coping in breast cancer

The emotional distress associated with breast cancer varies between individual women. These variations may be accounted for by differences in cognitive and behavioural coping responses to diagnosis. This study has attempted to develop a reliable, situation-specific approach to the measurement of coping responses in women with breast cancer. It has adapted a general coping questionnaire and modified an interview-based schedule for coping with cancer. The strengths and weaknesses of the interview and self-report methods of assessment are highlighted. Consistent results from these complementary approaches have been obtained. Both indicate the extensive use of cognitive avoidance and positive reappraisal. It has been shown that the majority of patients use a wide repertoire of coping responses which challenges the notion of mutually exclusive coping styles. These measures may be employed to examine the relationship between women's thoughts and behaviours in response to the diagnosis and treatment of breast cancer and subsequent psychological outcome.

Predicting women's delay in seeking medical care after discovery of a lump in the breast: the role of personality and behavior patterns

Experts agree that the detection of breast cancer in the early stages significantly enhances the chance of recovery. Although most women are aware of this, many still delay in seeking medical care. This study examined the relationship between four personality measures--health locus of control, hopelessness, repression-sensitization, and trait anxiety--and women's delay in approaching a doctor after discovering a lump in the breast. The authors also examined the relationship between delay and behavioral manifestations of body awareness representing the extent of the women's "contact" with their bodies. Five self-report inventories were administered to 62 women who had come for a biopsy as a result of a suspected breast tumor. No significant correlations were found between the personality variables and the time that elapsed before the women approached a doctor. On the other hand, a significant correlation was found between delay in seeking medical care and the measure of the women's "contact" with her body. Possible explanations to account for these results are suggested and their application to planning health education programs is discussed.

Does delay in diagnosis of breast cancer affect survival?

1675 breast cancer patients in the Auckland regional area have been divided into two major groups according to delay in diagnosis greater or less than six weeks. Overall there is no difference in survival although the variables tumour size, skin attachment, and nipple retraction are more common in the group with longer delay, and grade III tumours in those with short delay. Three important prognostic variables (the presence of tumour steroid receptors, positive axillary nodes, and distant metastases at diagnosis) are equally distributed and have a similar effect on survival within the two delay groups. However, in a subgroup of women with negative axillary nodes, short delay is associated with poorer survival, independent of tumour size. More tumours with grade III histology and a negative progesterone receptor status are found in this subgroup. Thus, short delay may constitute a new prognostic variable of some importance when in association with negative axillary nodes.

Aspects of the psychological management of breast cancer

Psychological factors influence the survival of patients with breast cancer through the early detection of the cancer and through compliance with the treatment. There is now evidence that psychological factors also influence the immune factors which control micrometastases. In particular, stoical acceptance of cancer is associated with a shorter survival of the patient, while the expression of hostility towards the cancer is associated with a longer survival of the patient. Unrecognized psychological morbidity can impair the quality of a patient's life for years. Such psychological morbidity may be reduced by more open communication with the patient, by encouragement of the expression of feelings (especially anger), by preoperative diagnosis of the cancer by biopsy and by a greater time allowance before a mastectomy is performed. Morbidity may also be reduced by the encouragement of patients to take an active part in their treatment decisions, by the avoidance of a mastectomy, by immediate breast-reconstruction surgery, and by appropriate psychological support which includes self-help techniques, such as meditation. Breast cancer can be a positive turning-point in a person's life.

Effects of health teaching in the workplace on women's knowledge, beliefs, and practices regarding breast self-examination

This study had two primary purposes: to examine the effects of group and individual teaching by nurses in the workplace on 140 female office employees' health knowledge, beliefs, and practices regarding breast self-examination and to identify factors associated with frequency of practice. Skill in technique, confidence in the skill, and frequency of breast self-examination increased significantly with both teaching formats, but there were areas of technique that needed further improvement. Perceived susceptibility to breast cancer and perceived benefits of breast self-examination increased significantly only with individual teaching; knowledge was not increased with either teaching format.

Older women's attitudes towards breast disease, self examination, and screening facilities: implications for communication

Qualitative research techniques were used in two studies in Edinburgh to explore older women's attitudes and motivations towards breast disease, self examination, and screening, with a view to identifying appropriate strategies for communication. The results indicated that knowledge of breast disease and screening facilities was poor and that many psychological and emotional issues inhibited self examination. Increasing information about self examination and clinics is unlikely to influence uptake unless it is presented together with emotional support rather than through conventional mass media channels. Such support may best be provided by setting breast screening within general health screening rather than emphasising the single disease.

Development of a method for rating cognitive responses to a diagnosis of cancer

The development of a method for rating cognitive responses to the diagnosis of early breast cancer, lymphoma and Hodgkin's disease is described in the context both of recent coping theory and a previous study by this Unit relating outcome to response to diagnosis. The ratings are defined in a manual using simple language and avoiding assumptions about the functions of responses; examples are given.

The relationship of psychosocial factors to prognostic indicators in cutaneous malignant melanoma

This study investigated the relationship between prognosis (estimated by histopathologic indicators) in cutaneous malignant melanoma and a comprehensive set of physical risk, demographic, psychosocial, and situational variables. These variables were derived from the medical examination, the pathology report, psychosocial self-report measures, and an hour-long videotaped interview with 59 patients from two melanoma clinics in San Francisco. Variables significantly correlated with tumor thickness were: darker skin/hair/eye coloring, longer patient delay in seeking medical attention, two correlated dimensions within an operationally defined 'Type C' constellation of characteristics, two character style measures, and less previous knowledge of melanoma and understanding of its treatment. Of these variables, delay was the most significant in a hierarchical multiple regression analysis in which tumor thickness was the dependent variable. Associations between tumor thickness and psychosocial measures of Type C were considerably stronger and more significant for subjects less than age 55, suggesting that the role of behavioral and psychosocial factors in the course of malignant melanoma is more potent for younger than for older subjects.

Cue enhancement and the long-term practice of breast self-examination

This study investigates the stimulus control of breast self-examination (BSE) using two methods of cue enhancement: self-managed use of calendars with sticker reminders and monthly reminder postcards. One hundred eighty-nine women patient volunteers with or without menstrual cycles ("cyclic" or "non-cyclic") were randomly assigned to experimental conditions after an initial interview and teaching session. Their monthly BSE records, returned by mail during the 6-month experimental period, constituted the major dependent measure of the study. Results indicate an overall positive effect of postcard reminders and a positive effect for self-management for the cyclic women only. In addition, noncyclic women practiced BSE at a higher rate than cyclic women. A subsequent analysis clarified these results substantially by showing that timing of the postcard and use of self-management account for these group differences. Thus, the interventions seem to be extraordinarily effective in obtaining high rates of BSE over 6 months provided only that they can be appropriately instituted. During the postexperimental period, the rate of BSE practice declined, especially in the postcard conditions. Results are discussed in terms of the applicability of behavioral analysis to intractable problems of patient compliance.

Reaction to a diagnosis of breast cancer. Relationship between denial, delay and rates of psychological morbidity

Psychological responses were measured in a newly diagnosed group of breast cancer patients during their hospital stay for primary surgical treatment by mastectomy. The aim was to assess the extent to which patients responded to the stress of a cancer diagnosis by denying the seriousness of the illness, and how this related to both level of distress and prior delay in seeking treatment. The data indicated that patients who denied the seriousness of a cancer diagnosis experienced significantly less mood disturbance during this period than those who were more accepting of the implications of this diagnosis. These findings suggest that a denial rather than a confrontation-coping-response may effectively reduce the short-term distress experienced during this initial period of hospitalization. Contrary to predictions, we failed to show an association between the length of delay in seeking treatment and denial of the diagnosis.

Breast cancer and breast self-examination: what do Scottish women know?

To aid the design of a health education campaign centred around a breast screening programme, a survey of knowledge about breast cancer and breast self-examination was carried out in 810 women selected randomly from the electoral registers in Edinburgh and Aberdeen. On the whole, the level of knowledge was poor, but was strongly related to age, social class, previous experience of breast problems and preventive health behaviour. Very few women knew of signs to look for other than a lump or of any treatments other than mastectomy or radiotherapy. Although 57% had tried or were practising self-examination, only a small minority knew of the correct technique and when to do it. There may be several reasons for our findings, including previous lack of appropriate information from professional sources, avoidance due to fear and anxiety about breast cancer or lack of motivation because this disease is not seen as an important single threat. These results will be compared with a later survey as part of the evaluation of our health education campaign.

Cancer and the mind. Maudsley Bequest Lecture delivered before the Royal College of Psychiatrists, February 1983

1848, as every student of history knows, was a revolutionary year in Europe. During that year, a minor, long forgotten revolution occurred in London medical circles when a physician, John Elliotson, published a paper entitled ‘Cure of a true cancer of the female breast with mesmerism’ (Elliotson, 1848). It is, as far as I can ascertain, the first recorded case of its kind. The author hypnotized his patient, a 42-year-old single woman, for “5 years and upwards … and for the greater part of the period three times a day”; during that time, Elliotson observed a ‘cancerous tumour’ in her right breast shrink away completely. No less than seven physicians and surgeons independently attested to the diagnosis of breast cancer, but no pathological examination was carried out. Elliotson was roundly abused, not for using hypnosis to treat cancer, but for using hypnosis at all—a practice condemned by certain physicians of fervid imagination as “indecent, disgraceful … liable to excite lascivious passions … an infernal system … the workings of Satan” (Elliotson, 1848).

The practice and efficacy of breast self-examination: a critical review

Evaluation of the results of breast self-examination (BSE) is inconclusive. Studies which address the question of proper method of BSE find that most women do not know how to carry out the procedure correctly. Socio-demographic characteristics most consistently related to BSE practice are age and education. New research on BSE must not only take into account such correlates but also provide some verification of the procedure to determine the importance of BSE in the detection and control of breast cancer.

Integration of theory, practitioner standards, literature findings, and baseline data: a case study in planning breast self-examination education

Delineation of the planning process necessary for designing sound education programs aimed at changes in health behavior continues to be a primary concern of health educators. Careful planning will ultimately maximize the application of existing evidence and identify areas in need of further research and evaluation. This paper discusses the preliminary and refinement planning phases involved in the design of an educational program for a three-year breast self-examination demonstration/evaluation project. The initial phase involved review of empirical data of previous studies, and application of behavioral science theory and standards of professional practice. The refinement phase involved the application of results from a community diagnostic baseline survey of the target population. Factors found to correlate with BSE practice were integrated into the educational strategies: group sessions in classes and informal workshops, a breast exam clinic, and mass media activities.

Psychological concomitants of cancer: current state of research

An increasing interest in the psychological concomitants of neoplastic diseases has led to a burgeoning literature in recent years. The present review identifies five major areas of psychiatric research, documents the current state of knowledge, and indicates fruitful avenues for further study.

Psychological implications of mastectomy

Some recent studies on the psychological trauma endured by patients with breast disease are summarized and a number of conclusions are drawn. There appear to be a number of stages through which a patient with a breast lump passes psychologically. Breast cancer attitudes in a community are dependent upon accumulated experience and cannot be changed overnight. Delay in presentation results from unconscious factors which may not be amenable to rational public health appeals. It is possible to identity a group of patients high at risk in breast surgery, although human resilience is such that the outcome if often satisfactory. There is a great need for controlled prospective studies in many areas of breast surgery rehabilitation. Some personal observations are included to stimulate discussion and interest in the area.

Changing trends in breast carcinoma

In view of the more open medical and public discussion of breast cancer, and considering the general dissatisfaction with radical forms of surgery and radiotherapy, we examined computer records of 1,014 patients with carcinoma documented by the Tasmanian Breast Survey between 1956 and 1976. In the two epochs, 1956 to 1966 and 1967 to 1976, there was a 14% increase in the proportion of patients presenting with Stage I carcinoma, and a 9% decrease in the proportion of patients with Stage II (P = 0.0075) but there was no change in the proportion of patients with Stages III and IV. The utilization of radical mastectomy decreased markedly, irrespective of stage (P = 0.0000), as did the utilization of radiotherapy (P = 0.0000). The mean age at presentation did not change significantly.

Psychological enquiry: a contribution to cancer research

A review of psychological contributions to cancer research is presented and a theoretical framework of heuristic value for such investigations is suggested. The author's study of women with breast cancer is described and methodological limitations are considered. There is evidence that psychological and psychobiological studies can make a useful contribution to cancer research, providing they are based on rigorous scientific methods.