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

PSYCHO-SOCIAL FACTORS INFLUENCING DELAY AND BREAST SELF-EXAMINATION IN WOMEN WITH SYMPTOMS OF BREAST CANCER CHRISTOPHER

J. MAGAREY, PETER B. TODD and PETER J. BLIZARD

School of Surgery. St. George’s Hospital. Kagarah, N.S.W., Australia Abstract-Psycho-social factors influencing their delay in reporting breast symptoms and their practice of breast self-examination were studied in 90 women who were to undergo biopsy of their breasts. One quarter had delayed more than 4 months and a half had never examined their own breasts. Their delay was determined by unconscious psychological processes, including the use of the egodefences of denial and suppression, the non-use of the defence of intellectualization-isolation, the absence of anxiety reported verbally, the presence of anxiety shown non-verbally and the presence of depression reported verbally. Together, these accounted for nearly half (43.4%) of all the variance in delay. Conscious factors. including age. education, knowledge about cancer, and fear (of death, disease or breast loss) were not related to the length of delay, nor to the practice of breast self-examination. Furthermore. the evidence suggested that the presence of malignancy was related to a low level of conscious anxiety before biopsy.

The early detection of breast cancer is known to reduce its mortality [1] and delay in treatment to reduce survival [2], and many attempts have been made over the years to induce women to undergo cancer screening, to examine their own breasts regularly and to report breast symptoms without delay. Yet, still, less than one half the invited women will attend a screening centre Cl], one-eighth of women claim to examine their own breasts regularly [3] and more than a quarter of women with breast symptoms delay more than 3 months in seeking treatment [2.4,5], and breast cancer mortality has not fallen in 30 years [6]. The factors influencing the behaviour of women with breast symptoms need to be understood if this problem is to be solved and psycho-social factors are likely to be crucial. Furthermore. accumulating evidence suggests that factors such as the types of psychological defences people use, emotional disturbances such as anxiety and depression and abnormal release or suppression of emotions such as anger are related to the onset, course and outcome of cancer [4,7,8]. This study of psycho-social factors in women with breast symptoms has been carried out to provide a more rational basis for the planning of cancer education and for the management of patients with cancer symptoms. METHODS

All 90 women admitted with breast symptoms to the St. George Hospital during the time of the study were interviewed at least a day before biopsy. The clinically experienced psychologist (PBT) interviewed each woman and. after establishing rapport and gaining her consent. video-tape recorded her responses to non-directive open-ended questions encouraging her to express her fears and concerns about her breast symptoms and impending surgery. A focused but nondirective interview of this type is known to provide more valid information about subjective states and meanings than are more directed techniques [9].

Reference to the time of reporting the first symptom (length of delay) or the practice of breast selfexamination (BSE) was avoided until after the interview, when they were recorded with the age, marital status, education, clinical extent of the tumour and the outcome of the breast biopsy (Table 1). The women were then asked to complete the Spielberger Anxiety Inventory [l I], Millimet’s Manifest AnxietyDefensiveness Scale [ 111 and the depression (D) scale of the Minnesota Multiphasic Personality Inventory

w1.

Operational definitions of 40 psychological variables were developed from a previous pilot study and observation of 10 of the video-tape recordings. This provided specific behavioural criteria for rating the use of certain ego-defences, the extent of anxiety or depression expressed verbally or non-verbally, the presence of conscious fear of breast loss, death or disease and the interpersonal support experienced by the women [13]. The scores of the psychological scales contributed a further 10 variables; 43 patients completed all scales. The remaining 64 technically satisfactory videotape recordings were rated independently and then jointly by two of the authors, using the agreed behavioural critera. To avoid bias, one of the raters (the psychologist) was unaware of the biopsy outcomes and the other (the surgeon) was unaware of the lengths of delay and, furthermore, 17 of the videotapes were rated independently by another pair of psychologists who were not informed of the hypotheses to be tested. Satisfactory inter-rater reliabilities were obtained for all relevant psychological variables (Table 2). All 64 recordings were used in the study of BSE, but only those 53 who had noticed breast lumps before seeing a doctor, who had not had cancer before and who did not known whether or not they had malignancy were included in the study of delay. A planned correlation analysis was made of 61 independent variables and 3 dependent variables (delay, BSE and biopsy outcome) partialling out the influence of demographic factors such as age on the 229

CHRISTOPHER J. MAGAREY.

230

PETER B. TODD and PETER J. BLIZARD

Table I. Sample of 64 women studied. numbers of women Age I” years Education’ Delay in weeks BSE practice Size of turnour, Biopsy outcome

K-60 131

Less than 40 113) Pnmary (01 Less than 2: 135) Never 1311 Less than 2 cm (81 Bempn (411

m parentheses O\sr601231

Secondar! 158tl 2-9 114) InfrequentI) 2-5 cm (341 Malignant (23)

Tcrnar!

121

More thdn Y , I\\, Okrn1221

,I I,

o\rr

! cm 141

* No information on 4 women. t Of these 58, most had completed 3 or less years of secondary education $ Including those whose signs were found by a doctor. 8 Of these 15, 13 women had delayed more than 4 months. 1;No information on 6 tumours.

psychological variables. So as to avoid type I error resulting from multiple analyses on a single set of data, alpha (P < 0.05) was distributed between the 6 most crucial predictions based on hypotheses about the relationships between ego-defences, anxiety and delay (P < 0.008) and 22 other predictions of particular interest (P < 0.001). Other relationships were explored but their significance was not tested. RESULTS The predicted relationships between psychological factors and delay which were significant are shown in Table 3. The significant factors were all unconscious processes, including the marked use of avoidance ego-defences (denial of ideas, denial of affects and suppression), anxiety rated either from verbal reports of feelings experienced before the interview or from non-verbal behaviour shown during the interview, and depression rated from statements indicating hopelessness or helplessness and from non-verbal behaviour shown during the interview. None of the measured conscious factors, including education or knowledge about cancer, conscious fear of breast loss, disease or death, or the interpersonal support experienced by the women were related to the length of delay. These were just as likely to result in early presentation as they were to result in delay.

Table 2. Reliability of ratings of certain psychological variables by two independent pairs of raters over 17 video-tape recordings and by two independent raters over 64 video-

In a post-hoc analysis of the data, 5 of the psychological variables were found to correlate highly with the length of delay (Table 4) including the marked use of the ego-defences denial and suppression, the marked use of the ego-defence of intellectualizationisolation (negatively), self-reports of anxiety experienced before the interview (negatively), non-verbal signs of anxiety observed during the interview, and depression inferred from verbal responses by the women during the interview. A multiple regression analysis showed these to account, together, for 43.4”” of the total variance in delay. The size of this correlation (r = 0.659) and the significance of similar relationships (Table 3) suggest that this correlation would be significant if the study were to be repeated. Of all the variables examined, the practice of BSE seemed to be related only to the non-use of denial of ideas, the non-use of reaction-formation, helpful discussion of breast symptom or loss with sex partner and not discussing breast symptom with another female (Table 5). Conscious factors, including fear of breast loss, disease or dying did not influence the practice of BSE, although it seemed to correlate with biopsy outcome: women not doing BSE being more likely to have a malignant tumour. Another important finding in the post-hoc analysis was a negative relationship between conscious situational anxiety as measured by the Spielberger Anxiety Inventory and a malignant biopsy outcome. The two situations relating to sex (breast loss and discussing this with the sex partner) obtained correlations of -0.311 and -0.355 after partialling out the effects of age, and the other situations (operation. cancer and

tape recordings

Table 3. Relationships between psychological factors and length of delay by women in reporting breast symptoms

Rated variable

to a doctor Sum

of scores

on denial & suppressmn Score on mtellectualizauon -Isolation Anxlefy reported before mterview Anxiety reported during mterv~ew Anx,ety inferred from behawour Depreaon inferred from verbal responses Total rated depression (verbal & behawour)

0.613

0.639

0.154’

0.669

0.885

0.643

0.669

0.562

0.573

0.614

0.878

0.420

0.X68

0.620

* The ego-defence of intellectualization-isolation difficult to define operationally than other

is more

defence mechanisms and one rater, in particular, had difficulty distinguishing it from rationalization for which separate criteria were specified.

MultIpIe COrreliltlOn Pyychologul

factors

Avoidance defences and anx~ty from behawour Avoidance defaces and annety from behawour and self-reported anx~etyt and mnlgam hwp\, w~ct~mc Tolal rated dcprewoo MMPI “D” Scale C’oniz~ous luar 01 dymp Conwous fear of breast loss Consaous fear of dtsrase

coetficlenl

Probabday

0 445

P < O.M)8’

0 4x0

P <00x

,I 335 0.333 ,,o,n 0032 0 IiS

P P P P P

* Significant. allowing for type I error. t Negatively correlated with length of delay. $ For a directional test with I and 51 d.f.

c c i > <

0 Oux* OG?5 0.05 0 05 II 05

Delay in examination of breast cancer Table 4. Posf-koc analysis showing the factors (independent variables) contributing most to the variance in length of delay in reporting breast symptoms to a doctor Psycholopud Awldance

ego-d&us

variahlc

ldemal

and

suppressionl Approach

ego-delences

-0.278

(mtellectualization

Gsolationl Anxtety

reported

before

Non-verbal

signs

Depression

Inferred

Multtple

mtervieu,

of anxiety from

correlauo”

- 0.293

I” mlerwcv

verbal

combmmg

0.284 0.4x4

responses

0.659’

all five

variables * Total = 43.47,.

variance

in length

of delay

accounted

for

mutilation) obtained correlations of -0.101 to -0.251. These findings suggested a relationship between low levels of anxiety and a malignant outcome but this relationship was not included in the planned analysis and its significance was not tested but if the first two results were replicated in another study they would be significant at P < 0.05 and P < 0.02 respectively. DISCUSSION

Relevant conscious and unconscious factors were successfully measured in people under stress (women with breast symptoms) in a real situation (about to undergo biopsy). retaining empathy and allowing free expression of feelings. By using the method of videotape recording of non-directive interviews and subsequent objective analysis of the women’s behaviour, based upon operational definitions of relevant variables, a high degree of reliability was achieved, without the subjects feeling themselves to be manipulated into providing information which was not their own. On the contrary, the interviews were frequently therapeutic and several women even took the trouble after their operations to call and thank the research psychologist for his help. Five independent, psychological factors have been identified which determine the delay of women in reporting breast lumps which might be malignant, to a doctor. All of these are unconscious mental processes. The ability to predict behaviour from the measured psychological variables demonstrates the validity of the method and the negative relationship between self-reported anxiety and non-verbal signs of anxiety provides strong evidence for the validity of the psychoanalytic concept of denial which predicts a discrepancy between behavioural and self-reported Table 5. Relationships between psycholological and other factors in the practice of breast self-examination Vauable Dsmal

of Ideas

- 0.309

Reacuon-formation Tolal

rated

b!

aKea

depressron

-0.267 0.115

D~ccussm”

wth

sex partner

0.266

Dwxssmn

wth

partner

0.260

wth

other

Dlscussio” Length

helpful female

of delq

Mahgnanr

hmpsy

- 0.258 - 0.256

ouu,me

-0.261

231

evidence of anxiety in response to threat. The negative relationship between the ego-defence of intellectualization-isolation and delay provides equally strong evidence for the concept of this defence which predicts approach rather than avoidance in response to threat. The apparent relationship between low levels of situational anxiety (as measured by the Spielberger Anxiety Inventory) and a malignant biopsy outcome is of further theoretical interest. especially when no relationship was found between depression and malignancy even though three separate methods were used to measure depression (verbal expressions and behaviour observed on the video-tapes, and the D scale of the MMPI). Although these findings must be regarded as provisional, they are consistent with the views of Bahnson and Bahnson [ 14,151 who maintain that in cancer patients the phenomenological state of depression is denied and repressed, and discharged instead somatically within the organism; with the findings of Greer and Morris [4] that while breast cancer patients, compared to a control group of women with benign breast disease, are characterized by abnormal suppression of anger and other emotions there is no association between breast cancer and depression; and with the data of Kissen et al. [16] indicating that lung cancer patients have diminished outlets for emotional discharge. If the practice of breast self-examination and the delay of women with breast symptoms are determined by factors beyond conscious awareness and control so is the attendance of women at breast cancer screening centres likely to be. This is not only of interest as a way in which psychological factors influence the outcome of cancer but it is of considerable relevance to public cancer education programmes. If a significant reduction in delay. in reporting cancer symptoms, increase in cancer detection behaviour such as the practice of BSE and attendance at cancer screening clinics and, probably, other behaviours such as stopping smoking are to be achieved, attention must be directed towards non-rational, unconscious factors, especially ego-defences and depression. This is consistent with the findings of studies such as those of Lazarus and Alfert [17] and Averill [18] which demonstrate that the effectiveness of communications designed to reduce threat depends upon the compatibility of messages with the defensive dispositions of the subjects. Cancer educators should design messages and use channels of communication which take into account individual differences in styles of defending against threat. Women who avoid threats by denial and suppression, for example, will avoid cancer education messages by changing television channels or ignoring public advertisements about cancer, so that only those women who would report their symptoms early anyway receive the messages. Those particular women who are likely to delay in reporting cancer symptoms and to whom the messages are directed will be the very women who ignore or avoid the messages. More subtle messages are required. such as those used with success by the advertising industry. Doctors and health professionals can contribute directly to the early detection of cancer by their own behaviour. For example. demonstration and actual instruction in the art of breast self-examination by a

232

CHRISTOPHER J.

MAGAREY,PETER-LI. TODD and

professional is far more effective than simply providing knowledge, in achieving the regular practice of BSE [3]. Doctors and others could be more active in examining women’s breasts, whatever their presenting symptoms. Indeed, the relationships we have found between self-reported anxiety, depression and delay suggest that women presenting with a bland indifferent attitude towards breast symptoms but showing non-verbal signs of anxiety and women prone to depression might by regarded as a high risk group for breast cancer screening, since it is amongst these women that the longest delays are likely to occur in diagnosis. Acknowledgements-This work was supported by a grant from the Clive and Vera Ramaciotti Foundation of New South Wales and was carried out with the advice and help of Dr. Roger Bartrop, Mr. Kevin Bird, Mr. Alex Blaszcynski, Mr. Peter Brandon, MS Suzanne Down, Mr. Wayne Hall, Mr. Bill Hopes, Mr. Charles Kenna, Mr. Tom McKinnon and Mrs. June Martin of the Schools of Psychiatry and Psychology of the University of New South Wales.

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BLIZARD

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