Psychosomatics 39:329-339, August 1998
© 1998 The Academy of Psychosomatic Medine
Coping With Threat
Implications for Women With a Family History of Breast Cancer
Ora Gilbar, Ph.D.
Received May 30, 1997; revised October 15, 1997; accepted October 23, 1997. From the School of Social Work, University of Haifa, and the Psychosocial Unit, Oncology Institute, Linn Clinic, Haifa, Israel. Address reprint requests to Dr. Gilbar, University of Haifa, Faculty of Social Welfare and Health Studies, School of Social Work, Mount Carmel, Haifa 31905, Israel.
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ABSTRACT
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The study aims to determine whether there are differences in coping with the threat of breast cancer between women with a family history of such cancer and those with no such history. The sample consisted of 93 women who have a family history of breast cancer and 142 women who do not have such a history (each group divided into four subgroups), all of whom were referred to a breast health clinic in northern Israel. Psychological distress was measured by the Brief Symptom Inventory, personal coping resources were measured by the Sense of Coherence scale, the coping process was measured by the Health Opinion Survey, and the denial mechanism was measured by denial scales. The results showed that women at high risk for breast cancer who came to the clinic for a regular checkup and who had a symptom showed more symptoms of psychological distress than any of the other groups. The establishment of special clinics for women with a family history of breast cancer is recommended to provide counseling in coping skills in addition to medical examinations.
Key Words: Breast Cancer • Family History • Psychological Distress • Coping Strategies • Health Opinions • Denial • Cancer • Women
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INTRODUCTION
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A diagnosis of cancer, and breast cancer in particular, induces deep-seated fear in most women, inasmuch as cancer is still a life-threatening disease. This fear is compounded by the prevalence of the disease among Israeli women. It is the most common cancer in women, striking one in nine.1
Of the known risk factors for the development of breast cancer, family history is the most prominent. Statistics show that women who have a first-degree relative (mother, sister) with breast cancer are two to three times more likely to develop the disease than women with no such family history.1–4 Today, information disseminated through the media about factors contributing to the likelihood of developing cancer generally, and breast cancer in particular, has heightened the awareness of these women to this factor (family history).5
Most of the studies that have been done on women at high risk for breast cancer compare their screening behavior (frequency of self-examination, examination by physician and mammography examination); their attitude toward and perception of the illness; or their high risk factor, vis-à-vis women with no family history of the disease.6–11 Findings have generally indicated that women with a family history of breast cancer report a greater sense of susceptibility to the illness, as well as a fear of performing breast self-examination, than women with no family history of the disease, 8–9 whereas a small number of studies have found no differences between the two groups in measures of self-confidence or frequency of self-examination.11–13 Most of the studies that have focused on frequency of mammography examination14–16 have found a difference between the two groups. The women with a family history of breast cancer had a mammography significantly more frequently. An exception in this research is Laville et al.,17 who found no such difference between the two groups. Little data exists, however, on the psychological functioning of women at high risk for breast cancer as a result of family history, compared with women who are not at high risk. Wellisch et al.18 compared 60 high-risk women (daughters) with 60 closely matched comparison subjects in a study on psychological distress, and found no differences between the groups on any clinical symptoms scale or global index. Several other studies have focused on the coping style of women at high risk. Styra et al.19 assessed 100 women upon admission to a breast cancer clinic for undiagnosed breast masses in terms of coping style. The researchers found that nonidentifiers (women who used denial as a coping mechanism) always used denial and employed three times as many avoidance coping mechanisms as identifiers (women who actively planned problem-solving strategies). The subjects with a family history of breast cancer were more likely to be identifiers. In contrast, Wellisch et al.,20 using a coping mechanism scale, found no differences between the women at high risk and those not at high risk.
Similarly, few studies deal with the psychological distress of women at high risk for breast cancer who participate in counseling programs. Kelly21,22 identified low self-esteem, denial, fear, anger, and insecurity as emotions that tend to obstruct the effectiveness of counseling in cancer prevention. Kash et al.,23 assessing the psychological distress of 217 women in a high-risk counseling program, found that 27% displayed psychological distress indices warranting psychological counseling, although the absence of a comparison group in that study does not permit drawing a conclusion as to whether the group of subjects was significantly different from other populations. Three predictors of psychological distress were found in that study: 1) the women who reported perceived barriers to screening (i.e., emotional distress, transportation problems, or the physical discomfort of mammography) had more psychological distress; 2) the women who reported more barriers to screening and fewer social supports had more psychological distress; and 3) the women who had a lower self-rating in social desirability and less denial had more psychological distress.
These findings highlight both the divergence and the paucity of the data, especially on the psychological state of women with a family history of breast cancer, indicating the need for more research. Specifically, no extant study focuses on women with a family history of breast cancer who arrive for a medical examination with a symptom.
According to cognitive stress theory,24 an evaluation of a threat to one's life is a major factor leading to stress. Conceivably, women with a family history of breast cancer may be under continuous stress, which itself constitutes a threat to their health. This ongoing stress state begins the moment women become aware of the higher risk factor that they bear. Several classes of variables may influence adjustment to a stressful situation, as discussed by Lazarus and Folkman: 1) cognitive appraisal, 2) coping processes, and 3) personality attributes and demographic variables.24 The present study compares two classes of variables out of three for women with a family history of breast cancer against those for women with no such history. The first class of variables consists of measures of the coping processes, that is, the use of denial mechanisms, involvement in medical setting, and preferences regarding medical information. The second class consists of personality attributes, that is, a sense of coherence. This is defined as a global orientation reflecting the extent of confidence that one's internal and external environments are predictable and that there is high probability that things will work out as well as can reasonably be expected.25 The study also examines the outcome variable—psychological distress.
Based on stress theory and on existing research, an important question that arises is how women with a family history of breast cancer and a suspected symptom cope with the threat stemming from being at high risk for breast cancer. Three hypotheses may be posited: 1) women with a family history of breast cancer with a suspected symptom use less denial, are more involved in the medical setting, and seek more medical information as part of the coping process than women who have regular checkups with no symptom and women with no such history; 2) women with a family history of breast cancer with a suspected symptom have a lower sense of coherence as a personal resource than women who get regular checkups and women with no family history of breast cancer; and 3) women with a family history of breast cancer with a suspected symptom are in greater distress than women who get regular checkups with no symptom and women with no such history.
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METHODS
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Participants
The participants were women referred to a breast health clinic at an oncology institute in northern Israel during January–June 1995 by their family physician, gynecologist, surgeon, or other physician for consultation following a medical examination conducted in light of a complaint by the women that they felt "something" (discomfort or pain) in their breast. (Arab women and new immigrant women were not candidates for the study because of language barriers.) The subjects in the research complained of a single symptom only. Following the results of the examination at the institute, the oncology physician referred the women for further tests, that is, mammography or fine needle aspiration, or recommended only a follow-up checkup in the clinic.
The population in the institute consisted of women both with a family history of breast cancer and without such a history. Family history was defined in this study by kinship order and was separated into first-, second- and third-degree kinship. First-degree relatives are mother and sisters, second-degree relatives are aunts and grandmothers, and third-degree relatives are cousins and great grandmothers.
Research Design
The interview subjects were contacted 2 to 3 days before their scheduled appointment for examination at the breast health clinic based on a purely random list and were requested to come in an hour earlier to be interviewed. The interview was conducted before the examination by the physician for breast evaluation.
An average of 12 women a day are examined at this clinic 4 days per week. Of a total of 101 candidates for the interviews, 93 women with a family history of breast cancer were included in the research group (2 women refused to be interviewed, and 6 could not be interviewed because of a language barrier). When all the interviews were completed, the research population was divided into four subgroups by diagnosis: 1) 17 women referred for the first time, with no suspected symptom of breast cancer; 2) 16 women referred for the first time, with a suspected symptom; 3) 43 women who had regular checkups, with no suspected symptom; and 4) 17 women who had regular checkups, with a suspected symptom.
The control group, drawn from a total of 153 candidates, was composed of 142 women with no family history of breast cancer (4 women refused to be interviewed, and 7 were unsuitable because of a language barrier). This group, similarly, consisted of four subgroups: 1) 24 women referred for the first time, with no suspected symptom; 2) 38 women referred for the first time, with a suspected symptom; 3) 43 women who had regular checkups, with no suspected symptom; and 4) 37 women who had regular checkups, with a suspected symptom.
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Assessment Measures
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Six questionnaires were administered.
1. The Denial Questionnaire
The Denial Questionnaire, developed for patients awaiting angioplasty (Rosinger A: Denial in the face of health threat: Denial as a personality characteristic, and threat-specific denial processes as predictors of distress prior to heart catherization. Unpublished MA thesis, Haifa, Israel, University of Haifa, 1992), is based on two out of the seven types of denial in the Breznitz model: denial of information and denial of feelings.26 The questionnaire consists of 24 statements adapted for cancer patients, half of them formulated along general lines, such as: "I am afraid of a deterioration in my health," and the other half formulated explicitly, for example, "I may die of cancer." The respondent notes the degree of applicability to her on a four-point scale: 4 (applies) to 1 (does not apply). A high measure of internal consistency has been reported for this test. Cronbach's alpha range is 0.87–0.96.
2. The Health Opinion Survey (HOS)
The HOS, developed by Krantz et al.,27 measures coping process. It is composed of two separable components of attitudes toward treatment approaches: behavioral involvement (i.e., attitudes toward self-care and an active role in medical care) and information (i.e., a desire to ask questions and be informed about, and involved in, medical decisions). These two components, which are relatively independent of one another, have been shown to predict behavior. The questionnaire consists of 16 items, each rated in a binary agree–disagree format. The test yields scores for two a priori subscales and a total score measuring composite attitudes toward treatment approaches. High scores represent favorable attitudes toward self-directed and informed treatment. Notably, these items generally refer to routine aspects of medical care, not to severe or traumatic illness. The reliabilities for the HOS components were 0.74 for behavioral involvement (B) and 0.71 for the information subscale (I).
3. The Sense of Coherence (SOC)
The SOC, developed by Antonovsky, assesses personal coping resources in dealing with a stressful situation.25 Antonovsky notes that coping resources determine behavior and that endurance stems from overall coping resources characterized by a high level of rationality, flexibility, and farsightedness. Such coping resources are an important generalized resistance element. According to this analysis, people with a strong sense of coherence will perceive environmental stressors as challenges worth facing, whereas those with a weak sense of coherence will perceive them as stressful.
The scale contains 29 items. Eleven items relate to comprehensibility—the perception that one's internal and external environments are structured, predictable, and explicable. Ten items relate to manageability—the perception that resources are available to meet the demands posed by the stimuli. Eight items relate to meaningfulness—the perception that such demands are challenges worthy of investment and engagement. A high measure of internal consistency has been reported for this test (Cronbach's alpha range is 0.84–0.93).
4. The Brief Symptom Inventory (BSI)
The BSI, developed by Derogatis, assesses psychosocial distress.28 The BSI is composed of 53 items, each describing a feeling or thought, and is scored on a five-point scale: 0 (no such problem) to 4 (severe problem). The inventory is composed of nine symptom areas: somatization, obsessive-compulsive, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism.
A distress score—the Global Severity Index (GSI)—is obtained for each subject by combining the quantity and intensity of reported symptoms. High scores denote greater psychological distress. Internal consistency (Cronbach's alpha) for the nine BSI dimensions ranges from a median of 0.75 for the psychoticism dimension to a high of 0.85 for the depression dimension. The test–retest reliability of the GSI score is 0.90. Several validation studies of the BSI have been conducted establishing the internal structure of the instrument.29
5. The Behavioral Questionnaire
This questionnaire was developed by the author (O.G.) for the purpose of the present research on all the subgroups. Questions such as "How much time elapsed between the discovery of the symptom and a visit to a physician?" and "Who referred you to an oncologist?" were tailored to a population being studied for some aspect of cancer, while certain questions were developed specifically for high-risk groups, such as "How old were you when your relative was diagnosed with cancer?" "Is the relative alive?" and "What was the cause of death?"
6. The Demographic Questionnaire
This questionnaire covers age, education, family status, and place of birth.
Data Analysis
A chi-square test analysis was used to assess differences between the eight subgroups in terms of demographic and behavioral variables (Table 1). Analysis of variance (ANOVA), followed by a Scheffe test, was used to analyze the differences between the eight subgroups in terms of age and education (see Table 1). A chi-square test was also used to assess differences between the four subgroups of women with a family history of breast cancer in terms of variables related to the relative with breast cancer as well as variables related to the subject (see Table 2).
Next, an ANOVA, followed by a Scheffe test, was used to compare the differences between the means of all eight subgroups in terms of the BSI, SOC, HOS, and denial subscales. Statistically significant results were found only in the BSI subscales.
Thereafter, covariant analysis was used to determine the overall significance of the results of each of the variables in the BSI subscales that showed statistical significance with respect to the eight subgroups (Table 3), together with three additional variables: time since discovery of the symptom, source of referral, and frequency of checkups (Table 1). This was done to preclude possible differences between the groups due to these additional variables.
The final step was to perform an ANOVA to determine the overall significance of the results of the four subgroups of women at high risk for breast cancer. The BSI subscales were analyzed with respect to the four groups of women with a family history of breast cancer and additional variables: relative's viability/morbidity, age of subject when relative died, age of subject when relative's cancer was discovered, and cause of relative's death.
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RESULTS
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The distribution of demographic and behavioral variables is shown in Table 1. An ANOVA, followed by a Scheffe test, showed no statistical differences between the groups in terms of age or education. A chi-square test revealed no statistical differences between the groups in terms of place of birth or marital status.
The chi-square test did, however, reveal statistically significant differences between the groups in the health behavioral variables—frequency of checkups (P<0.001), time since discovery of the symptom (P<0.001), and source of referral for examination (P<0.01). The women who had regular checkups with a family history of breast cancer with no symptom, as well as those with no such history and no symptom (half of all the women), tended to have regular checkups every 6 months. In terms of time elapsed since discovery of the symptom, most of the patients in both groups (high-risk and ordinary risk) who had regular checkups but no symptom waited over 6 months until they arranged an examination with a physician (82%), whereas only 50% of the women in both groups who had a symptom waited that long to arrange an examination.
The distribution of variables of a relative (mother, sister, aunt, grandmother, and cousin) with breast cancer in relation to those of the four subgroups with a family history of the disease is shown in Table 2. A chi-square test revealed no statistically significant differences between the groups in terms of family relatedness, age of subject when relative's cancer was discovered, relative's viability/morbidity, age of subject when relative died, and cause of relative's death. More than half the women were in the first-degree high-risk group for breast cancer. Forty percent of the women with a symptom who had a relative with breast cancer were ages 30–39 when their relative's cancer was discovered, in contrast to the other three groups, in which less than half of whom were in that age span when their relative was diagnosed (18% first-time referral with symptom, 13% first-time referral with a symptom, and 24% regular checkups with no symptom). Most of the regular checkup subjects with a symptom (83%) were ages 40–49 when their relative had died.
An ANOVA, followed by a Scheffe test, was performed to compare the differences between the means of the eight subgroups in terms of the BSI, SOC, and HOS subscales and denial measures. The results indicated differences in four BSI subscales: somatization (F[7,235]=3.82, P<0.001), depression (F[7,235]=3.84, P<0.0001), hostility (F[7,235]=2.56, P<0.01), and paranoid ideation (F[7,235]=2.76, P<0.001), as well as the GSI (F[7,235]=2.11, P<0.01). (See Table 3.) The means in these four subscales and in the GSI for the women with a family history of breast cancer were higher than those for the other seven groups. No statistical differences were found between the groups in the SOC and HOS subscales and in denial measures.
A multiple ANOVA of the BSI subscales of the eight subgroups, along with several additional variables (time since discovery, source of referral, and frequency of checkups), revealed significant differences with respect to somatization (P<0.001), depression (P<0.001), paranoid ideation (P<0.001), and GSI (P<0.01). None of the additional variables proved significant.
An ANOVA of the BSI subscales of the four groups of women at high risk for breast cancer together with additional variables—age of subject when relative discovered, relative's viability/morbidity, age of subject when relative died, and cause of relative's death—revealed statistical significance only for depression (P<0.001).
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DISCUSSION AND CONCLUSIONS
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The BSI, SOC, HOS, and denial scales were completed by 93 women with a family history of breast cancer and 142 women without such a history (each group divided into four subgroups: first-time referral with no symptom, first-time referral with a symptom, regular checkups with no symptom, and regular checkups with a symptom), all of whom were referred to a breast health clinic. The study revealed that women at high risk for breast cancer who came in for a regular checkup and who had a symptom showed greater psychological distress than all the other groups.
Bearing out cognitive stress theory, the findings indicated that the assumption that women with a family history of breast cancer would cope differently during the waiting period for a breast examination, compared with the women without such a history, was erroneous. More specifically, the findings did not confirm two of the hypotheses, showing instead that the women with a family history of breast cancer who came in for a regular checkup, whether with a suspected symptom or with no suspected symptom, coped no differently from the women with no history of breast cancer both in terms of personal attribute (i.e., sense of coherence) or in coping process (the use of a denial mechanism, involvement in medical treatment, and preference for medical information). However, some of the interviewees did react differently emotionally: the women with a family history of breast cancer who came in for a regular checkup with a suspected symptom were in significantly more psychological distress than the seven other subgroups.
One explanation for the absence of differences in the coping process (denial, involvement in medical setting, preference for medical information) may be that waiting for a breast cancer examination is a stressful situation for every woman. The odds of becoming a breast cancer patient are highly threatening for the entire women's population, so that being part of a high-risk group is a less dominant factor in this situation, and the coping process is therefore the same.
Another explanation for the absence of differences in coping may lie in the limitation of the scales in measuring subtle differences in the coping process in this generally threatening situation.
In contrast, significant differences between the groups in behavioral variables— time since discovery of the symptom and frequency of checkups—may be explained by denial. The women at high risk for breast cancer did not have more frequent preventive checkups than the women with no such history. This finding, however, is less extreme than that of Josten et al.,30 which indicated that women at high risk for breast cancer tend to participate less in preventive programs or seek less medical advice when they suspect a symptom than the general population.
The absence of differences in sense of coherence may be explained both by the fact that few of the women with a family history of breast cancer were first-degree relatives of the ill family member, so that the impact of the relative's cancer diagnosis on the development of sense of coherence was not similar, and by the fact that many of the mothers had been diagnosed after their daughter reached age 30. Antonovsky25 emphasizes that sense of coherence is a decisive element in the structure of an individual's personality that develops dynamically and coalesces around the age of 30. Moreover, public awareness of family history as a risk factor has become widespread only in the past 10 years at most, so that the impact of this kind of continuous stress may not have influenced the sense of coherence strategy of the older women.
The main finding of this study, however, confirms the author's third hypothesis, that women with a family history of breast cancer who come in for regular checkups and have a symptom show more psychological distress than the women who come in for regular checkups with no suspected symptom and with no such history.
Clearly, the explanation for the greater psychological distress of the women with a family history of breast cancer who go for a regular checkup with a symptom is that they feel they are in the most threatening situation of all the groups. In addition to being in a high-risk group, these women have a tendency to develop cysts and are in stress whenever they feel a growth. Thus, when they await a medical examination they are in a more stressful situation, fearing that this time the diagnosis will be breast cancer. The regular checkup may contribute a sense of security to women with no family history of breast cancer, but this is less so for women with a family history of the illness. While I had no data on the relative's experience with the medical system at the time of the discovery of the illness, we can assume that this experience serves to exacerbate the psychological distress that the high-risk women already feel.
Moreover, the ambiguous message they receive from the physician may cause these women to perceive their medical situation as having worsened and thus increase their anxiety.31 The physician's diagnosis that the suspected symptom is once again only a cyst and that everything is allright is offset by the immediate arrangement for another examination, in most cases in 3 to 6 months, re-entrenching their fear that the cysts might become cancerous.
According to Holland,32 this group of women is in fact at high risk for developing cancerphobia. Holland has enumerated several situations that predispose individuals to develop cancerphobia: major coverage in the media of a particular cancer risk, an anxiety-producing life crisis, and close personal contact with cancer through the illness or death of a relative or close friend. In these stressful situations, a symptom that would ordinarily be ignored becomes a source of anxiety. This conclusion, however, requires more research focusing on the assessment of women with a family history of breast cancer who go for regular examinations and have a symptom.
A discussion of the differences in psychological distress between the four groups of women who are at high risk for breast cancer and the four groups who are not at high risk must embrace a larger number of studies involving a larger number of subjects. Nevertheless, recommendations in the literature to establish special clinics for women with a family history of breast cancer33 are supported by the results of the present research. Such clinics ought to offer counseling in coping skills, in addition to medical examinations, an educational program, and psychological evaluations.
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ABSTRACT
INTRODUCTION
