The emergence of the 'waiting game': a critical examination of the psychosocial issues in diagnosing breast cancer

Emotional, cognitive, and physical well-being during the wait for breast biopsy results

OBJECTIVE

This study is a replication and extension of previous work examining the well-being of patients at a breast biopsy appointment. Expanding on a previous study, we aim to identify predictors of well-being following the appointment (i.e. waiting for results).

DESIGN

In this longitudinal study, female patients (N = 197) were surveyed at their breast biopsy appointments and then completed daily surveys assessing distress and coping during the week-long wait for results.

MAIN OUTCOME MEASURES

Surveys asked about patient characteristics, subjective health, cancer history, support availability, outcome expectations, and distress.

RESULTS/CONCLUSIONS

Consistent with the previous study, health history and demographic factors were largely unassociated with distress, this time while waiting for biopsy results. Latina ethnicity emerged one of the few predictors of coping, pointing to opportunities for differential clinical interventions that take cultural factors into account. Finally, anxiety was highest at the beginning and end of the wait for biopsy results, suggesting that interventions may be most effective following a breast biopsy and the days prior to learning one's result.

Searching for diagnostic certainty, governing risk: Patients' ambivalent experiences of medical testing

Diagnosis is pivotal to medicine's epistemic system: it serves to explain individual symptoms, classify them into recognizable conditions and determine their prognosis and treatment. Medical tests, or investigative procedures for detecting and monitoring disease, play a central role in diagnosis. While testing promises diagnostic certainty or a definitive risk assessment, it often produces uncertainties and new questions which call for yet further tests. In short, testing, regardless of its specific application, is imbued with meaning and emotionally fraught. In this article, we explore individuals' ambivalent experiences of testing as they search for diagnostic certainty, and the anxieties and frustrations of those for whom it remains elusive. Combining insights from sociological work on ambivalence and the biopolitics of health, and drawing on qualitative interviews with Australian healthcare recipients who have undergone testing in the context of clinical practice, we argue that these experiences are explicable in light of the contradictory impulses and tensions associated with what we term 'bio-subjectification'. We consider the implications of our analysis in light of the development of new tests that produce ever finer delineations between healthy and diseased populations, concluding that their use will likely multiply uncertainties and heighten rather than lessen anxieties.

The Psychological Experience of Awaiting Breast Diagnosis

BACKGROUND

Each year, over 1 million women in the USA undergo diagnostic breast biopsies, many of which culminate in a benign outcome. However, for many patients, the experience of awaiting biopsy results is far from benign, instead provoking high levels of distress.

PURPOSE

To take a multifaceted approach to understanding the psychological experience of patients undergoing a breast biopsy.

METHOD

Female patients (N = 214) were interviewed at an appointment for a breast biopsy, just prior to undergoing the biopsy procedure. Pertinent to the current investigation, the interview assessed various patient characteristics, subjective health and cancer history, support availability, outcome expectations, distress, and coping strategies.

RESULTS

The findings revealed a complex set of interrelationships among patient characteristics, markers of distress, and use of coping strategies. Patients who were more distressed engaged in more avoidant coping strategies. Regarding the correlates of distress and coping, subjective health was more strongly associated with distress and coping than was cancer history; perceptions of support availability were also reliably associated with distress.

CONCLUSION

Taken together, the results suggest that patients focus on their immediate experience (e.g., subjective health, feelings of risk, perceptions of support) in the face of the acute moment of uncertainty prompted by a biopsy procedure, relative to more distal considerations such as cancer history and demographic characteristics. These findings can guide clinicians' interactions with patients at the biopsy appointment and can serve as a foundation for interventions designed to reduce distress in this context.

Preemptively finding benefit in a breast cancer diagnosis

Objective: The current mixed-method investigation seeks to discover if and how people engage in preemptive benefit finding (i.e. seeking silver linings in a potential future outcome), specifically in the context of awaiting a breast biopsy result. Design: A total of 201 patients were interviewed just prior to undergoing a breast biopsy at a county hospital. Main outcome measures and results: A qualitative analysis identified themes in women's descriptions of preemptive benefit finding. A majority of participants (76%) reported engaging in preemptive benefit finding at their appointment, a week or more before learning their result. Patients identified two categories of benefits - self- and other-focused - and eight subcategories: health benefits, personal growth, appreciation for life, physical change, strengthening relationships, spreading awareness, supporting others, and role modelling. We also identify differences between those who engaged in self-focused and other-focused preemptive benefit finding. Conclusion: Benefit finding begins long before bad news arrives, and people find a variety of benefits in even the most dire of anticipated news. Clinicians who interact with patients during the diagnostic process (e.g. mammography technicians) may find it useful to know that their patients are already grappling with the possibility of a diagnosis, including the positive reappraisal process of identifying potential silver linings.

"We'll call you when the results are in": Preferences for how medical test results are delivered

OBJECTIVE

Whether healthy or sick, adults undergo frequent medical testing; however, no guidelines currently exist as to how patients are informed of their medical test results. This short report provides an initial look at how healthcare professionals deliver medical test results and patient preferences regarding these procedures.

METHODS

We specifically focus on two options for delivery of results: (1) open-ended timing, in which patients are contacted without warning when test results become available; or (2) closed-ended timing, in which patients are provided with a specific day and time when they will learn their test results. Participants who underwent a recent medical test indicated which delivery method their healthcare professional provided and their preferred method.

RESULTS

Findings demonstrate a large discrepancy between actual and preferred timing, stemming from a general trend towards providing open-ended timing, whereas patient preferences were evenly split between the two options.

CONCLUSION

This study provides a first step in understanding the merits of two options for delivering medical test results to patients and suggests an opportunity to improve patient care.

PRACTICE IMPLICATIONS

The findings from this study provide first steps toward the development of guidelines for delivering test results in ways that maximize the quality of patient care.

Anxiety symptoms prior to a prostate cancer diagnosis: Associations with knowledge and openness to treatment

AIM

Research suggests that anxiety may be a common response to a cancer diagnosis, but research is needed to examine anxiety before diagnosis. Anxiety before diagnosis may relate to the comprehension of relevant health information or openness to potential treatments. This study examined anxiety and these outcomes in men who were waiting to learn of a prostate cancer diagnosis.

OBJECTIVES

One goal of this study was to determine whether anxiety would increase as men came closer to learning the results of their prostate cancer biopsy. Another goal was to test whether anxiety was associated with knowledge about prostate cancer or openness to different treatments.

METHODS

Men (N = 265) who were facing a prostate cancer diagnosis were surveyed at two time points. Time 1 occurred at the time of biopsy, and Time 2 occurred immediately before men received their biopsy result. At each time point, men reported their anxiety about prostate cancer and their biopsy result. At Time 2, they completed a knowledge test of information about prostate cancer and reported their openness to different potential treatments.

RESULTS

Anxiety symptoms increased as men came closer to learning their diagnosis. Also, higher anxiety was associated with lower knowledge and greater openness to particular treatments like surgery. Interactions showed that when anxiety increased from Time 1 to Time 2, having high or low knowledge mattered less to treatment openness.

CONCLUSION

Waiting for a cancer diagnosis is an important time period in which anxiety may increase and relate to information processing and openness to treatments. Statement of contribution What is already known on this subject? Men undergoing prostate cancer screening have been found to experience high and low levels of anxiety. Research has shown that negative emotions like anxiety are common following a cancer diagnosis, but little research has examined emotions right before diagnosis. Anxiety has been associated with information processing and motivation to engage in preventive behaviours. What does this study add? Applies and tests a theoretical idea related to how anxiety may change as one approaches personally relevant threatening health feedback. Shows relationships between changes in anxiety and knowledge in the context of waiting for actual health feedback. Associates increased anxiety in the prostate cancer context with knowledge and openness to different treatments.

Health-related quality of life in patients with serious non-specific symptoms undergoing evaluation for possible cancer and their experience during the process: a mixed methods study

PURPOSE

The purpose of this research was to measure changes in HRQoL during the diagnostic evaluation of patients presenting with non-specific symptoms possibly attributable to cancer, to describe their experiences of HRQoL and to merge these findings with intent to obtain a more comprehensive understanding of their HRQoL experience during this stressful life event.

METHODS

A convergent mixed methods (MM) design was used and involved quantitative data about HRQoL measured by the EORTC-QLQ-C30 instrument and qualitative interview data about patients' HRQoL experiences. Participants completed the EORTC-QLQ-C30 questionnaire prior to and after evaluation. The baseline questionnaire informed the purposive sampling for the qualitative interview study, and open-end questions matched to the EORTC-QLQ-C30 constructs were used in the semi-structured interviews.

RESULTS

A total of 838 patients were enrolled in the quantitative study; 680 (81 %) also completed follow-up. Twenty-one patients participated in interviews. The MM findings are the meta-inferences drawn by looking across the matched quantitative and qualitative findings: physical function, social function, role function, emotional function, cognitive function, social function, symptoms and quality of life.

CONCLUSION

The survey results illustrate that HRQoL improved over time and the qualitative findings confirmed and further expanded the survey results. The MM analysis underlines that the HRQoL experience cannot be observed independently from context. Participants adapted to their situation over time, and this may change their perceptions of HRQoL. These findings can be used to enhance evidence-based care as clinicians need to be aware of how the context influences the HRQoL experience.

The experiences of health-related quality of life in patients with nonspecific symptoms who undergo a diagnostic evaluation for cancer: a qualitative interview study

The diagnostic phase of cancer can affect health-related quality of life (HRQoL). The aim of this study was to investigate how patients with nonspecific symptoms experience HRQoL while undergoing diagnostic evaluations for cancer. Twenty-one participants who had completed a fast-track evaluation for possible cancer at one of three hospitals in the Capital Region, Denmark were interviewed 2-4 weeks after completing diagnostic evaluations. The interviews were semi-structured and were supported by an interview guide based on the same themes as in The European Organisation for Research and Treatment of Cancer Quality of Life questionnaire (EORCT-QLQ-C30). Data analysis was based on qualitative content analysis by Krippendorff. The analysis generated six categories: symptoms, physical-, role-, emotional-, cognitive- and social functioning, and the diagnostic fast-track experience. From these categories, a main theme was identified: Health-related quality of life is not solely affected by the diagnostic process. The results provide a comprehensive understanding of HRQoL in the diagnostic phase of possible cancer, which can be used not only to enhance evidence-based care, but also in the interpretation of the EORTC-QLQ-C30 scores. Psycho-social support with a focus on individual informational needs during the diagnostic phase may be warranted.

A feasibility study exploring the role of pre-operative assessment when examining the mechanism of 'chemo-brain' in breast cancer patients

Background

Women receiving chemotherapy treatment for breast cancer may experience problems with their memory and attention (cognition), which is distressing and interferes with quality of life. It is unclear what causes or contributes to the problems they report: psychological distress, fatigue, coping style, or specific biological changes for example to pro inflammatory cytokines. Research shows however, that approximately a third of women with breast cancer perform poorly on tests of cognition before commencing chemotherapy. We aimed to examine the acceptability and relevance of pre-surgical assessments (bloods, brain imaging, cognitive tests and self-report questionnaires) when investigating the phenomenon of ‘chemo-brain’ and investigate whether inflammatory markers mediate chemotherapy-induced neuropsychological impairments in women treated for breast cancer.

Methods

Women with early stage breast cancer completed neuropsychological and quality of life assessments at T1 (pre-surgery), T2 (post-surgery before chemotherapy) and T3 (6 months later). Blood cytokine levels were measured at the same time points and brain imaging was performed at T1 and T3.

Results

In total, 14/58 women participated (8 chemotherapy, 6 non-chemotherapy). Prior to the start of chemotherapy a decline in cognitive performance compared to baseline was observed in one participant. At T3 women who received chemotherapy reported poorer quality of life and greater fatigue. Increases in soluble tumour necrosis factor receptor II (sTNFRII), interleukin-6, interleukin-10 and vascular endothelial growth factor occurred post chemotherapy only. Levels of sTNFRII were inversely correlated with grey matter volume (GMV) of the right posterior insula in both groups. At T3, the chemotherapy group displayed a greater reduction in GMV in the subgenual and dorsal anterior cingulate, and the inferior temporal gyrus.

Conclusions

Pre-operative recruitment to the study was challenging; however, the lack of significant changes in blood cytokine levels and neuropsychological tests at T2 implies that post surgery may be a valid baseline assessment, but this needs further investigation in a larger study. The preliminary results support the hypothesis that chemotherapy induced fatigue is mediated by a change in peripheral cytokine levels which could explain some symptoms of ‘chemo brain’ experienced by patients.

Undergoing Diagnostic Evaluation for Possible Cancer Affects the Health-Related Quality of Life in Patients Presenting with Non-Specific Symptoms

AIM

Undergoing diagnostic evaluation for possible cancer can affect health-related quality of life (HRQoL). The aims of this study were to examine the HRQoL in patients undergoing a diagnostic evaluation for possible cancer due to non-specific symptoms and further to investigate the impact of socio-demographic and medical factors associated with HRQoL at the time of diagnosis.

METHODS

This was a prospective, multicenter survey study that included patients who were referred for a diagnostic evaluation due to non-specific cancer symptoms. Participants completed the EORTC-QLQ-C30 quality of life scale before and after completing the diagnostic evaluation. The baseline and follow-up EORTC-QLQ-C30 scores were compared with reference populations. The impact of socio-demographic and medical factors on HRQoL at follow-up was explored by bootstrapped multivariate linear regression.

RESULTS

A total of 838 patients participated in the study; 680 (81%) also completed follow-up. Twenty-two percent of the patients received a cancer diagnosis at the end of follow-up. Patients presented initially with a high burden of symptoms, less role and emotional functioning and a lower global health/QoL. Most domains improved after diagnosis and no clinically important difference between baseline and follow-up scores was found. Patients reported effects on HRQoL both at baseline and at follow-up compared with the Danish reference population and had similar scores as a cancer reference population. Co-morbidity, being unemployed and receiving a cancer diagnosis had the greatest effect on HRQoL around the time of diagnosis.

CONCLUSIONS

Patients with non-specific symptoms reported an affected HRQoL while undergoing a diagnostic evaluation for possible cancer. Morbidity, being unemployed and receiving a cancer diagnosis had the greatest effect on HRQoL around the time of diagnosis.

Assessment of activity and outcome from a one-stop clinic for men with suspected prostate cancer: Five years’ experience

Objective:

We have set up a weekly one stop prostate specific antigen (PSA) clinic to evaluate men with suspected prostate cancer (CaP) and report our five years of experience.

Methods:

Patients with an elevated PSA result, abnormal digital rectal examination, or worrisome symptoms were booked into this clinic. Prostate biopsy was done on the same day, if required. The clinic is run by a single consultant urological surgeon and an advanced nurse practitioner. A database of all patients attending this clinic has been maintained.

Results:

A total of 729 patients were seen. Rates of non-attendance were low at 2–5 patients each year, and 50.9%–67.1% of patients had a biopsy. Of these, 46.8%–56.1% were diagnosed with CaP, given their results and appropriately treated after multi-disciplinary meeting (MDT) discussion within 15 days. Patients who did not have a cancer diagnosis received a phone call from the consultant at a median time of 2.5 days. Patient and general practitioner (GP) satisfaction levels with this service were high.

Conclusions:

The one-stop clinic is feasible, efficient in quickly reassuring men without cancer, allows rapid diagnosis and starts treatment within 15 days for those who need it. This clinic reduces waiting times and the number of follow-up visits, and is highly acceptable to patients and GPs.

Anxiety prior to breast biopsy: Relationships with length of time from breast biopsy recommendation to biopsy procedure and psychosocial factors

This study investigated how time from breast biopsy recommendation to biopsy procedure affected pre-biopsy anxiety ( N = 140 women), and whether the relationship between wait time and anxiety was affected by psychosocial factors (chronic life stress, traumatic events, social support). Analyses showed a significant interaction between wait time and chronic life stress. Increased time from biopsy recommendation was associated with greater anxiety in women with low levels of life stress. Women with high levels of life stress experienced increased anxiety regardless of wait time. These results suggest that women may benefit from shorter wait times and receiving strategies for managing anxiety.

Is Waiting the Hardest Part? Comparing the Emotional Experiences of Awaiting and Receiving Bad News

Awaiting uncertain news is stressful, but is it more stressful than receiving bad news? We compared these emotional experiences in two studies. Participants in Study 1 reflected on a personal experience awaiting news that ultimately turned out badly, and participants in Study 2 were law graduates awaiting their results on the bar exam who ultimately failed the exam. In Study 1, participants were ambivalent as to whether awaiting or receiving bad news was more difficult, and emotion ratings in both studies confirmed this ambivalence. Anxiety was higher in anticipation of bad news (at least at the moment of truth) than in the face of it, whereas other negative emotions were more intense following the news than during the waiting period. Thus, whether waiting is “the hardest part” depends on whether one prefers to be racked with anxiety or afflicted with other negative emotions such as anger, disappointment, depression, and regret.

Awaiting diagnosis of breast cancer: strategies of enduring for preserving self

PURPOSE/OBJECTIVES

To explicate the emotional experiences of women undergoing breast cancer diagnosis who are waiting for the results of breast biopsy.

RESEARCH APPROACH

Glaserian Grounded Theory.

SETTING

Urban area in western Canada.

PARTICIPANTS

37 women aged 32-76 years. The breast cancer diagnosis was positive for 11 women, negative for 24 women, and two results were unclear.

METHODOLOGIC APPROACH

Unstructured, recorded telephone interviews.

FINDINGS

Undergoing breast cancer diagnosis is a profoundly distressing experience dictated by diagnostic processes and procedures. Women rapidly transitioned from wellness to frightening phases of facing cancer to continuing terror during the testing phase. While waiting to hear results, women controlled their emotions, which enabled them to get through the experience and highlighted the protective function of enduring and its necessity for survival. The basic social psychological process, preserving self, is the outcome of enduring.

CONCLUSIONS

A mid-range theory, Awaiting Diagnosis: Enduring for Preserving Self, was developed. This theory explicates the emotional responses of women who were undergoing diagnosis for breast cancer and provides a theoretical behavioral basis for responding to cues and signals of suffering.

INTERPRETATION

The Praxis Theory of Suffering enables nurses to recognize and respond according to the behaviors of suffering, and to endure with healthy, adaptive, and normalizing behaviors that enable preserving self.

Older women's experience with a benign breast biopsy—a mixed methods study

BACKGROUND

Little is known about older women's experience with a benign breast biopsy.

OBJECTIVES

To examine the psychological impact and experience of women ≥ 65 years of age with a benign breast biopsy.

DESIGN

Prospective cohort study using quantitative and qualitative methods.

SETTING

Three Boston-based breast imaging centers.

PARTICIPANTS

Ninety-four English-speaking women ≥ 65 years without dementia referred for breast biopsy as a result of an abnormal mammogram, not aware of their biopsy results at baseline, and with a subsequent negative biopsy.

MEASUREMENTS

We interviewed women at the time of breast biopsy (before women knew their results) and 6 months post-biopsy. At both interviews, participants completed the validated negative psychological consequences of screening mammography questionnaire (PCQ, scores range from 0 to 36 [high distress], PCQ ≥ 1 suggests a psychological consequence, PCQs <1 are reported at time of screening) and women responded to open-ended questions about their experience. At follow-up, participants described the quality of information received after their benign breast biopsy. We used a linear mixed effects model to examine if PCQs declined over time. We also reviewed participants' open-ended comments for themes.

RESULTS

Overall, 88% (83/94) of participants were non-Hispanic white and 33% (31/94) had a high-school degree or less. At biopsy, 76% (71/94) reported negative psychological consequences from their biopsy compared to 39% (37/94) at follow-up (p < 0.01). In open-ended comments, participants noted the anxiety (29%, 27/94) and discomfort (28%, 26/94) experienced at biopsy (especially from positioning on the biopsy table). Participants requested more information to prepare for a biopsy and to interpret their negative results. Forty-four percent (39/89) reported at least a little anxiety about future mammograms.

CONCLUSIONS

The high psychological burden of a benign breast biopsy among older women significantly diminishes with time but does not completely resolve. To reduce this burden, older women need more information about undergoing a breast biopsy.

Pre-biopsy psychological factors predict patient biopsy experience

BACKGROUND

Excisional/surgical breast biopsy has been related to anticipatory emotional distress, and anticipatory distress has been associated with worse biopsy-related outcomes (e.g., pain, physical discomfort).

PURPOSE

The present study was designed to investigate (a) whether anticipatory distress before an image-guided breast biopsy would correlate with biopsy-related outcomes (pain and physical discomfort during the biopsy) and (b) whether type of distress (i.e., general anxiety, worry about the procedure, worry about biopsy results) would differentially relate to biopsy-related outcomes.

METHODS

Fifty image-guided breast biopsy patients (mean age = 44.4 years) were administered questionnaires pre- and post-biopsy. Pre-biopsy, patients completed the Profile of Mood States-tension/anxiety subscale and two visual analog scale items (worry about the biopsy procedure, worry about the biopsy results). Post-biopsy, patients completed two visual analog scale items (pain and physical discomfort at their worst during the procedure).

RESULTS

The following results were gathered: (1) Pre-biopsy worry about the procedure was significantly related to both pain (r = 0.38, p = 0.006) and physical discomfort (r = 0.31, p = 0.026); (2) pre-biopsy general anxiety was significantly related to pain (r = 0.36, p = 0.009), but not to physical discomfort; and (3) Pre-biopsy worry about the biopsy results did not significantly relate to pain or physical discomfort.

CONCLUSIONS

Worry about the procedure was the only variable found to be significantly correlated with both biopsy-related outcomes (pain and physical discomfort). From a clinical perspective, this item could be used as a brief screening tool to identify patients who might be at risk for poorer biopsy experiences and who might benefit from brief interventions to reduce pre-biopsy worry.

Cancer patients' concerns regarding access to cancer care: perceived impact of waiting times along the diagnosis and treatment journey

Waiting times can raise significant concern for cancer patients. This study examined cancer patients' concern levels at each phase of waiting. Demographic, disease and psychosocial characteristics associated with concern at each phase were also assessed. 146 consenting outpatients (n= 146) were recruited from two hospitals in Sydney, Australia. Each completed a touch-screen computer survey, asking them to recall concern experienced regarding waiting times at each treatment phase. Approximately half (52%) reported experiencing concern during at least one treatment phase, while 8.9% reported experiencing concern at every phase. Higher proportions of patients reported concern about waiting times from: deciding to have radiotherapy to commencement of radiotherapy (31%); the first specialist appointment to receiving a cancer diagnosis (28%); and deciding to have chemotherapy to commencement of chemotherapy (28%). Patient groups more likely to report concern were those of lower socio-economic status, born outside Australia, or of younger age. Although a small proportion of patients reported very high levels of concern regarding waiting times, the experience of some concern was prevalent. Opportunities for reducing this concern are discussed. Vulnerable groups, such as younger and socio-economically disadvantaged patients, should be the focus of efforts to reduce waiting times and patient concern levels.

Nurses as patient navigators in cancer diagnosis: review, consultation and model design

The diagnostic phase of cancer care is an anxious time for patients. Patient navigation is a way of assisting and supporting individuals during this time. The aim of this review is to explore patient navigation and its role in the diagnostic phase of cancer care. We reviewed the literature for definitions and models of navigation, preparation for the role and impact on patient outcomes, specifically addressing the role of the nurse in patient navigation. Interviews and focus groups with healthcare providers and managers provided further insight from these stakeholder groups. Common to most definitions of navigation is the navigator's multifaceted role in facilitating processes of care, assisting patients to overcome barriers and providing information and support. Navigation may be provided by laypersons, clerical staff and/or healthcare professionals. In the diagnostic phase it has the potential to affect efficiency of diagnostic testing, patients' experience during this time and preparation for decision-making around treatment options. Patient care during the diagnostic phase requires various levels of navigation, according to individual informational, physical and psychosocial needs. Identifying those individuals who require more support--whether physical or psychosocial--during the diagnostic phase is of critical importance.

Presurgery psychological factors predict pain, nausea, and fatigue one week after breast cancer surgery

Before scheduled surgery, breast cancer surgical patients frequently experience high levels of distress and expect a variety of postsurgery symptoms. Previous literature has supported the view that presurgery distress and response expectancies are predictive of postsurgery outcomes. However, the contributions of distress and response expectancies to postsurgical side effect outcomes have rarely been examined together within the same study. Furthermore, studies on the effects of response expectancies in the surgical setting have typically focused on the immediate postsurgical setting rather than the longer-term setting. The purpose of the present study was to test the contribution of presurgery distress and response expectancies to common postsurgery side effects (pain, nausea, and fatigue). Female patients (n=101) undergoing breast cancer surgery were recruited to a prospective study. Results indicated that presurgery distress uniquely contributed to patients' postsurgery pain severity (P<0.05) and fatigue (P<0.003) one week after surgery. Response expectancies uniquely contributed to pain severity (P<0.001), nausea (P<0.012), and fatigue (P<0.010) one week after surgery. Sobel tests indicated that response expectancies partially mediated the effects of distress on pain severity (P<0.03) and fatigue (P<0.03). Response expectancies also mediated the effects of age on pain severity, nausea, and fatigue. Results highlight the contribution of presurgery psychological factors to postsurgery side effects, the importance of including both emotional and cognitive factors within studies as predictors of postsurgery side effects, and suggest presurgical clinical targets for improving patients' postoperative experiences of side effects.

Patterns of 'balancing between hope and despair' in the diagnostic phase: a grounded theory study of patients on a gastroenterology ward

AIM

The aim of the study was to learn how patients going through the diagnostic phase experienced and handled their situation.

BACKGROUND

Many studies report about the stressful diagnostic phase; however, none has presented a conceptual theory where the concepts are sufficiently related to each other. The Theory of Preparative Waiting has previously been published as a descriptive grounded theory and describes the experience of a group of gastroenterology patients going through the diagnostic phase.

METHOD

A classical grounded theory design was used, with data derived from 18 in-depth interviews with 15 patients in a gastroenterology ward at a Norwegian University Hospital. Interviews were conducted during 2002-2003.

FINDINGS

Participants' main concern was found to be how they could prepare themselves for the concluding interview and life after diagnosis. The theoretical code of 'balancing' had four patterns; controlling pain, rational awaiting, denial, and accepting. These patterns of 'balancing' guided how participants used the categories of 'Preparative Waiting Theory''seeking and giving information', 'interpreting clues', 'handling existential threats' and 'seeking respite'. Patterns were strategies, so one person could use more than one pattern.

CONCLUSION

The diagnostic phase was a difficult time for the participants and the 'Preparative Waiting Theory' can assist nurses in assessing how patients prepare themselves differently for getting a diagnosis. All patients would find it helpful to be followed up by a designated contact person at the ward; however, patients using mostly the patterns of controlling pain and denial would benefit most from such support.

Anticipatory psychological distress in women scheduled for diagnostic and curative breast cancer surgery

BACKGROUND

Psychological distress is a central experience for women facing diagnostic and curative breast cancer surgery.

PURPOSE

The present study was designed to predict anticipatory distress in 187 women scheduled to undergo excisional breast biopsy or lumpectomy.

METHOD

Participants completed questionnaires assessing emotional distress and predictors of this distress (surgery type, worry about the surgical procedure, and worry about what the surgeon will find).

RESULTS

The study found that lumpectomy patients experienced greater anticipatory distress than excisional breast biopsy patients on three of the four distress measures (all ps < 0.05) and that worry about what the surgeon might find partially mediated these effects.

CONCLUSION

The results suggest that although women awaiting lumpectomy are more distressed than women awaiting biopsy, both groups report substantial distress, and, consequently, psychosocial interventions are recommended for both groups.

Waiting for healthcare: a concept analysis

AIM

This paper is a report of an analysis of the concept of waiting for health care from the client's perspective.

BACKGROUND

Waiting is commonplace in many areas of health care and has become a topical and politically important issue in the provision of healthcare services. Whilst managers and governments search for solutions to this problem, it is important that this aspect of clients' healthcare experience is examined to evaluate its impact and implications for nursing practice.

METHODS

The PubMed and CINAHL databases (dating from 1950 and 1982 to 2007 respectively) were searched using the keywords 'health care' and 'waiting'. The reference lists of papers identified were also checked and this revealed literature from a number of other disciplines related to the concept.

RESULTS

Waiting for health care is identified as an unspecified yet measurable period of time between identification of a healthcare problem and its diagnosis and treatment, when clients experience uncertainty and powerlessness whilst anticipating a disease outcome. The critical attributes of waiting for health care are: a period of measured time, subjective interpretation of the perceived significance of the measured time, feeling uncertain and powerless and anticipation of a response to the healthcare need.

CONCLUSION

Strategies that facilitate contact with clients through pre-assessment clinics and giving written information and a contact point may seem obvious but are currently overlooked in busy healthcare environments. This is an area where nurses can lead in the delivery of person-centred care and could potentially increase satisfaction with how waiting is managed.

Hypnosis decreases presurgical distress in excisional breast biopsy patients

BACKGROUND

Excisional breast biopsy is associated with presurgical psychological distress. Such distress is emotionally taxing, and may have negative implications for postsurgical side effects and satisfaction with anesthesia. We investigated the ability of a brief hypnosis session to reduce presurgical psychological distress in excisional breast biopsy patients.

METHODS

Ninety patients presenting for excisional breast biopsy were randomly assigned to receive either a 15-minute presurgery hypnosis session (n = 49, mean age: 46.4 (95% CI: 42.3-50.4)) or a 15-minute presurgery attention control session (n = 41, mean age: 45.0 (95% CI: 40.8-49.2)). The hypnosis session involved suggestions for increased relaxation and decreased distress. The attention control session involved nondirective empathic listening. Presurgery distress was measured using visual analog scales (VAS) and the short version of the Profile of Mood States (SV-POMS). Data were analyzed using analysis of variance and chi2 procedures.

RESULTS

Groups did not differ in terms of the following: demographics (age, education, ethnicity, marital status, all P's > 0.28); medical variables (presurgery diagnosis, previous excisional biopsy, previous breast cancer, all P's > 0.11); or preintervention distress (SV-POMS P > 0.74) assessed on the day of surgery. Postintervention, and before surgery, patients in the hypnosis group had significantly lower mean values for presurgery VAS emotional upset (16.5 vs 38.2, P < 0.0001, d = .85), VAS depressed mood (6.6 vs 19.9, P < 0.02, d = .67), and SV-POMS anxiety (10.0 vs 5.0, P < 0.0001, d = 0.85); and significantly higher levels for VAS relaxation (75.7 vs 54.2, P < 0.001, d = -0.76) than attention controls.

CONCLUSIONS

The study results indicate that a brief presurgery hypnosis intervention can be an effective means of controlling presurgical distress in women awaiting diagnostic breast cancer surgery.

Breast biopsy and distress: feasibility of testing a Reiki intervention

PURPOSE

The purpose of this randomized pilot was to determine feasibility of testing Reiki, a complementary therapy intervention, for women undergoing breast biopsy (BB).

BACKGROUND

Increasingly women face the possibility of BB, the definitive test for breast cancer. Psychological distress associated with BB includes anxiety and depression. Reiki was proposed as an intervention to decrease anxiety and promote relaxation.

METHOD

Thirty-two women scheduled for BB were randomized to Reiki intervention versus conventional care control. Anxiety and depression were evaluated using self-report questionnaires.

FINDINGS

Analysis found no significant mean differences between groups over time. Comparably low baseline anxiety levels (possible selection bias) decreased naturally with time allowing little room for observing treatment effect.

CONCLUSIONS

Reiki, when administered in the naturalistic setting of a complementary therapy office, did not suggest evidence of efficacy. An intervention offered within the bounds of the conventional care setting may be more feasible for addressing BB distress.

Ultrasound-guided core needle biopsy of the breast: does frozen section give an accurate diagnosis?

Reducing the period of uncertainty between the discovery of a breast tumor and histological diagnosis alleviates the psychological impact of breast cancer to an important degree. We aimed to verify whether histological results obtained with frozen sections of core needle biopsies (CNBs) offer an accurate and reliable tool for minimising this period. In 2619 cases we compared histological diagnosis on frozen sections with those on paraffin sections of CNB and finally with the results of open biopsies. Of the cases 49% were proved malignant and 51% benign. In 99.3% of the malignant lesions preceding CNB was correctly classified as B5 (n = 1185, 92.9%) or at least B4 (n = 82, 6.4%) in frozen and in paraffin sections. There were seven false-negative cases in frozen (false-negative rate = 0.5%) and five false-negative cases (false-negative rate = 0.4%) in paraffin sections of CNB. On frozen sections complete sensitivity was 99.5% and the positive predictive value of B5 was 99.9%. There was one false-positive case in frozen sections and one in paraffin sections. False-positive rate = 0.08%, negative predictive value for B2 = 99.4% for frozen and 99.6% for paraffin sections; full specificity was 85.9 for frozen and 85.8 for paraffin sections of CNBs. Immediate investigation of CNB in frozen sections is an accurate diagnostic method and an important step in reducing psychological strain on patients with breast tumors and may be offered by specialised Breast Assessment Units.

Predictors of expectancies for post-surgical pain and fatigue in breast cancer surgical patients

Expectancies for post-surgical pain and fatigue have previously been found to predict pain and fatigue among breast cancer surgery patients. However, the study of predictors of these expectancies has been neglected. The present study was designed to investigate predictors of expectancies for post-surgical pain and fatigue among breast cancer surgery patients.Four hundred and eighteen women (M = 48.3 years, SD = 13.66 years) scheduled to undergo excisional breast biopsy or lumpectomy completed questionnaires assessing demographics/medical history, pre-surgical distress, stable personality characteristics, pre-surgical pain and fatigue, and expectancies for post-surgical pain and fatigue.Path analysis revealed: expectancies for post-surgical pain were significantly predicted by trait anxiety, acute pre-surgical distress, and age; and expectancies for post-surgical fatigue were significantly predicted by acute pre-surgical distress, acute pre-surgical fatigue, previous experience with the same surgical procedure, and education (all ps < .05). Examination of an alternative model revealed that the effects of the aforementioned predictors on expectancies were not mediated by acute pre-surgical distress, clarifying the directionality of the distress-expectancy relationship.Expectancies for post-surgical pain and fatigue are influenced by distress, treatment history, stable personality characteristics, extant symptoms, and demographic factors. These variables should be considered in designing clinical interventions to manipulate expectancies for patient benefit.

'Preparative waiting' and coping theory with patients going through gastric diagnosis

AIM

This paper reports a study of how hospitalized patients with gastro-intestinal problems going through diagnostic workups experience and handle the situation. It presents a theory of 'preparative waiting' and discusses it in relation to Lazarus' theory of appraisal, stress and coping.

BACKGROUND

The pre-diagnostic phase is reported to be the most stressful time of the illness for patients, but there is little research on this with patients in gastric units. According to Lazarus, appraisal and coping are concurrent, and stress must be understood as both an intra- and an inter-personal process.

METHOD

A grounded theory design was chosen to conduct and analyse 18 in-depth interviews with 15 patients in a gastric unit at a Norwegian university hospital. The data were collected in 2002-2003.

FINDINGS

Participants' main concern was found to be how to prepare themselves for the results of the investigation and for life afterwards. The substantive grounded theory of 'Preparative waiting' presented here explains how they acted to do so. To be in the diagnostic phase meant to be in a process of continuously attempting to make sense of one's situation. Participants could judge their case to be harmful, a threat, a challenge, a benefit, or combinations of these. Their searches for realistic interpretation were balanced with searches for hopeful signs. This, together with lowering and rising of awareness, prevented them from despair. The process of understanding and handling the situation was concurrent, and was influenced by their relationships with family, friends, fellow patients, healthcare personnel and God.

CONCLUSION

To the degree that patients trusted that nurses understood and were sensitive to the complex processes of appraising and coping, they became patients' key support persons. By providing adjusted information, coordinating care and examinations, respecting privacy, and inquiring about existential concerns, nurses could promote patients' ability to prepare for receiving the diagnosis and life after.

Coping with a possible breast cancer diagnosis: demographic factors and social support

AIM

This paper reports a study examining the relationships between demographic characteristics, social support, anxiety, coping and defence among women with possible breast cancer.

BACKGROUND

Awaiting a possible breast cancer diagnosis is an anxiety-provoking situation that demands coping. Social support and demographic characteristics have been reported to influence coping and well-being, but the interconnection is insufficiently understood.

DESIGN

A survey design was used, and self-administrated questionnaires were returned by a convenience sample of 117 women in Norway who had undergone breast biopsy. The data were collected from September 1998 to February 2000.

INSTRUMENTS

The instruments consisted of: the Social Provisions Scale, State-Trait Anxiety Scale, Utrecht Coping List and Defence Mechanisms Inventory. In addition, data on age, level of education, employment, marital status, and household status were collected.

RESULTS

Social support was positively related to instrumental-oriented coping and emotion-focused coping, unrelated to cognitive defence and defensive hostility. Educational level was positively related to instrumental-oriented coping. Educational level, employment and marital status were negatively related to cognitive defence. Educational level was the most important contributor to social support. Attachment and education were the most important contributors to instrumental-oriented coping, with education as the strongest predictor.

CONCLUSION

Better coping was linked primarily to education, and secondly to attachment. Unemployment, low level of education and single/divorced/widowed status were related to greater use of cognitive defence. Women who used a defensive hostile style tended to receive poor social support. Nurses need to be aware of the influence of demographic characteristics on social support, coping and defence and to identify poor copers, as these patients are most in need of professional support.

Psychological distress associated with waiting for results of diagnostic investigations for breast disease

This paper presents the results of a multi-method research project investigating the psychological distress associated with waiting for results of diagnostic investigations in a delayed-results breast clinic. A cohort of 126 women completed standardized psychometric instruments to assess anxiety, mood and coping over 3 days. Semi-structured interviews were conducted with 20 respondents. The findings indicate that waiting sustained but did not exacerbate psychological distress. Peri-diagnostic anxiety, depression, uncertainty and confusion were associated with anxiety levels immediately following triple assessment. Women leaving the clinic with low anxiety retained this composure throughout the peri-diagnostic period. Those in the moderate and high anxiety groups recorded sustained anxiety, depression, uncertainty and confusion, with mean scores comparable to and exceeding those reported by psychiatric out-patients. Coping during the waiting period was typically accomplished by emotion-focused strategies. Qualitative data suggested the delayed-results clinic structure may facilitate psychological preparation for test results.

Waiting for a breast biopsy. Psychosocial consequences and coping strategies

OBJECTIVE

The aim of this pilot/feasibility study was to describe the experience of women presenting with a suspicious mammogram who are waiting for a breast biopsy and to identify those at risk for distress.

METHODS

Participants (n=25) were interviewed at two time points: immediately after being put on the waiting list (T1) and again immediately before their biopsy approximately 6 weeks later (T2). Self-report measures of distress and coping were used. Perceived personal risk of a positive biopsy finding and information needs were assessed through open-ended questions.

RESULTS

Distress levels were high in this sample. Using cognitive-avoidant coping strategies, being employed, history of previous biopsies, and having a family history of breast cancer were associated with greater distress. Perceived personal risk of a positive biopsy finding was overestimated in one half of the cases and was correlated with greater distress.

CONCLUSION

Waiting period between suspicious mammogram and breast biopsy may be a time of high distress for many women.

The experience of waiting and life during breast cancer follow-up

Much research exists on quality of life issues with breast cancer survivors. However, there has been little done on the waiting experience itself, and on the experience of follow-up from the women's perspective. Women who have been diagnosed and treated for breast cancer live with the condition for a minimum of 5 years, waiting for the next medical intervention; waiting for the next battery of tests; waiting for the next physician check-up. Throughout most of these years they may feel healthy, but they experience visits to cancer clinics, medical testing, and physician interactions. Women's accounts of their experiences of waiting and life during follow-up for breast cancer has not been the focus of research on the quality of life of breast cancer survivors. In particular research that uses a qualitative approach, in which women recount their experiences in their own language, has been missing. This study used a phenomenological approach, telling the stories of waiting and life throughout follow-up of nine women. The women's experiences are captured in four themes: life-changing; a sense of belonging; uncertainty; needing to know.

The Experience of Waiting for Diagnosis After an Abnormal Mammogram

In order to better understand the experience of women following abnormal screening mammogram and before definitive diagnosis, we undertook a series of focus group interviews in six geographic areas in the province of British Columbia, Canada. While all 33 participants had experienced abnormal mammograms within the previous year, each group included women with a range of ages and diagnostic outcomes. Verbatim transcripts of all focus groups were subjected to qualitative secondary analysis using interpretive descriptive methods. Through a process of grounded inductive analysis, conceptual themes within the data were identified and tested. The findings of this study provide an experiential account of common patterns within the structure and process of waiting for diagnosis. The accounts depict the way the women experienced time, their individual and common responses to waiting, and the impact of health system factors, including provider communication. These findings confirm that, regardless of its outcome, waiting for definitive diagnosis after an abnormal screening mammogram is an intense and often agonizing experience for the women involved and for their families. Furthermore, our results highlight the relevance of such issues as information systems, support, coordination of services, and health care communication, and underscore the important role that service delivery factors can play in making such experiences bearable.

Brief presurgery hypnosis reduces distress and pain in excisional breast biopsy patients

Each year, hundreds of thousands of women undergo excisional breast biopsies for definitive diagnosis. Not only do these patients experience pain associated with the procedure, but they also endure distress associated with the threat of cancer. Hypnosis has been demonstrated as effective for controlling patients' pain in other surgical settings, but breast surgery patients have received little attention. To determine the impact of brief presurgical hypnosis on these patients' postsurgery pain and distress and to explore possible mediating mechanisms of these effects, 20 excisional breast biopsy patients were randomly assigned to a hypnosis or control group (standard care). Hypnosis reduced postsurgery pain and distress. Initial evidence suggested that the effects of hypnosis were mediated by presurgery expectations.

Women's lived experience of breast biopsy: a phenomenological study

This study aimed to explore Irish women's lived experience of breast biopsy with a view to gaining a deeper understanding of their individual experiences and the meanings that it holds for them. A phenomenological approach from a Heideggerian hermeneutical perspective was used. Study participants were eight women aged 22-54 years who had experienced a recent breast biopsy with benign diagnosis. Data were collected using in-depth interviewing. The work of Benner (1994), together with guidelines from Morse & Field (1996) and Burnard (1991) were used to guide the process of data analysis. Themes which emerged from the data were: 'Finding the lump', 'Waiting, not knowing', 'knowing', 'Getting back to normal' and 'Reflections'. Women's feelings of initial distress followed by relief permeate these themes.

Short- and long-term anxiety and depression in women recalled after breast cancer screening

The aim was to investigate the psychological consequences of further investigation after breast cancer screening. Study participants include 509 women (61%) recalled due to suspicious findings on screening mammograms, and a matched control group of 285 women (68%) with normal mammograms. Psychological distress was prospectively assessed with the Hospital Anxiety and Depression Scale (HADS). 46% of the women reported borderline or clinically significant anxiety prior to the recall visit. A few days after the visit, anxiety and depression had decreased significantly (P<0.01) in women informed about normal or benign results at the recall clinic, while reported distress remained at relatively high levels in women referred to surgical biopsy. The results demonstrate the adverse short-term effect of a delay in receiving false-positive results, but do not indicate that the recall experience results in long-term anxiety or depression for a majority of women.

The impact of prostate biopsy on patient well-being: a prospective study of pain, anxiety and erectile dysfunction

PURPOSE

We prospectively studied the impact of transrectal ultrasound guided prostate biopsy on patient well-being.

MATERIALS AND METHODS

We enrolled 211 consecutive men who underwent a total of 218 biopsy events in a questionnaire based survey focusing on pain, anxiety and erectile dysfunction risk factors. Surveys were administered before, and immediately, 1 week and 1 month after biopsy. Quantitative information on the intensity of symptoms and signs was obtained using a uniform grading system.

RESULTS

Intraoperative pain considered severe in 20% of the biopsy events was associated with pain in the first 24 hours postoperatively, leading to analgesic use in 10%. Inflammatory infiltrate in the biopsy core and younger patient age correlated with persistent pain on days 2 and 7 after biopsy, respectively. Preoperative anxiety was reported in 64% of biopsy events and predictive of intraoperative pain. Anxiety peaked before result disclosure. Erectile dysfunction attributed to anxiety in anticipation of biopsy was reported in 7% of cases. At days 7 and 30, 15% of previously potent patients reported erectile dysfunction.

CONCLUSIONS

The impact of prostate biopsy on patient well-being begins while waiting for the scheduled procedure. Shortening the anticipation period before results are disclosed and administering pre-biopsy anxiety decreasing measures may benefit patients. Analgesic therapy is recommended in younger patients, those reporting moderate to severe intraoperative pain and those with known prostatic inflammatory infiltrate. The risk of acute erectile dysfunction should be discussed cautiously with patients who are potent before biopsy.

Women's experience of breast conserving treatment for breast cancer

The implementation of the National Breast Screening Programme in the UK, and subsequent increase in early detection of small cancers, has facilitated breast conserving treatment for more women with a breast cancer diagnosis than ever before. While a substantial body of literature has evolved regarding psychosocial morbidity and support needs of women at diagnosis and during treatment, there are specific gaps in the current knowledge base. The purpose of this study was to describe the experiences of women who had breast conserving treatment for early breast cancer, focusing on issues related to diagnosis, surgery, and radiotherapy. The study was designed within the context of clinical audit, with a view to informing service development. Seventy-six women who had undergone breast conserving surgery within the last 3-12 months, completed a self-report questionnaire. Findings indicated that although the majority of women expressed satisfaction with their treatment overall, a number of specific areas require attention from healthcare professionals. Further research is required to validate these findings and to explore: potential implications of different referral routes; information and support needs preceding definitive diagnosis; particular needs of those women with ductal carcinoma in situ (DCIS) vs. invasive disease; 'end of treatment' and ongoing information and support needs.

The 'cues' to diagnosis: describing the monitoring activities of women undergoing diagnostic investigations for breast disease

Waiting to ascertain the nature of an undiagnosed breast abnormality is an intensely stressful experience for many women. Uncertainty surrounding the aetiology of symptoms is underpinned by the threat of malignancy, and the 'need to know' the diagnosis is of primary concern at this time. Seeking out threat-relevant information through a process known as 'monitoring' attempts to fulfil this need. This paper details the qualitative phase of a multimethod research study that investigated the psychological impact of diagnosing breast disease. This involved focus interviews with a subset of 40 women from the original study cohort. Several types of threat-related cues were identified by respondents and were categorized as temporal, interpersonal, procedural and spatial. In the context of uncertainty (and in some cases suspicion) these cues were interpreted as 'indicators' of the pending diagnosis. The manner in which particular aspects of the environment are identified, interpreted and designated as 'threat-relevant' cues is discussed. Furthermore, the implications for health professionals working with patients during this stage of 'pre-diagnosis' are considered.

Specialist nurse counsellor interventions at the time of diagnosis of breast cancer: comparing 'advocacy' with a conventional approach

Over recent years, specialist breast care nurses have become increasingly recognized as core members of any breast care team within the UK. Part of the role is to support patients at the highly stressful stage of receiving a diagnosis. This paper describes an 'advocacy' style of nurse counsellor intervention which aims to improve patients' preparation for, and involvement in, the diagnostic consultation and provides a framework for future counselling support. One hundred and three women undergoing surgery following diagnosis of breast cancer or a benign breast lump were supported using either this advocacy intervention or a more conventional model of care. The aim was to identify the most effective and appropriate method of intervening at this important stage. Assessment took place before surgery, with 2-week and 6-month follow-ups, and included the Hospital Anxiety and Depression Scale, Rotterdam Symptom Check List and semi-structured interviews addressing perceived quality of care, involvement in decision-making and psycho-social functioning. Whilst the results of many measures were similar for women in the two intervention groups, qualitative data support the implementation of the advocacy method by the breast care nurse.

Breast cancer

Infiltrating ductal carcinoma is the most common form of breast cancer, and major risk factors are nonmodifiable. Current screening recommendations offer the best chance of early diagnosis. Staging takes into account the size of primary tumor, number of positive lymph nodes at surgery, and location of distant metastases. Treatment options include various combinations of surgical procedures, radiotherapy, chemotherapy, and endocrine therapy.