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

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Abstract

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.

Introduction

In parallel to the ongoing debate regarding the medical value of mammographic screening 1, 2, the psychological consequences of participation in breast cancer screening have attracted increasing interest. There is no indication of increased anxiety in those women who receive normal results after a basic mammogram 3, 4, 5, 6, 7. However, being recalled for further investigation has been reported to be a stressful experience for many women 3, 5, 8. Further investigations of a suspicious screening result may vary considerably with regard to the nature and extent of performed medical examinations as well as the duration of the period before arriving at a clear result. However, only a few studies have investigated psychological consequences in subgroups of recalled women 9, 10, 11, and none of these concerns short-term effects on women's distress. Among recalled women with false-positive mammograms, general anxiety has been shown to subside within a few months after the recall visit 5, 8, but some studies indicate prolonged adverse psychological consequences related to thoughts or feelings about breast cancer 3, 9, 11, 12.

The overall aim of the present prospective study was to investigate the short- as well as long-term psychological consequences of being recalled for further examination following mammographic screening in a population-based cohort. The following specific research questions were posed: (1) How much anxiety and depression do women report in connection to a recall for further examination following mammographic screening? (2) What is the course of anxiety and depression over time in subgroups of recalled women? (3) Are there differences in anxiety and depression levels among recalled women depending on the medical examinations performed and the delay in receiving information of medical results? (4) Are there differences between women with normal versus false-positive screening mammograms with regard to anxiety and depression 3 and 12 months after screening participation?

Section snippets

Subjects

All subjects were invited in connection with their participation in a population-based mammographic screening programme in Uppsala county, Sweden [13]. During the inclusion period (1996–1997), 80% of invited women participated in the screening. All participants were informed of their test results by mail, and 3.5% of women were recalled for further investigations. The recall visit occurred within approximately 2 weeks after screening. The flow of participants throughout the study is illustrated

Anxiety and depression prior to the recall visit

The anxiety level (mean=7.7, S.D.=4.5, n=501) reported by the recalled group in the period (approximately 1 week) between receiving the recall letter and attending the recall visit was relatively high compared to anxiety (mean=4.8, S.D.=3.8) reported for a female sample of the general Swedish population [18]. Using the recommended cut-off score of 8 points or more [16], 46% of recalled women suffered probable clinical anxiety. Depression scores were lower than the anxiety mean scores (mean=3.5,

Discussion

The main findings are (a) a high prevalence of anxiety in women prior to the recall visit, (b) significant differences in short-term distress depending on the type(s) of examination and information received at the recall visit, and (c) no evidence of increased long-term distress in recalled women with false-positive mammograms.

The findings of borderline and clinically significant levels of anticipatory anxiety in nearly half of recalled women support recent results from the UK [8], and confirm

Acknowledgements

We want to express our thanks to all patients and controls for their participation, and to the staff at the Mammography Unit for their help with the data collection. This study was made possible by grants from the Vårdal Foundation and the Swedish Cancer Society.

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    Current address: Department of Oncology, Radiumhemmet, Karolinska Institute & Hospital, Stockholm, Sweden.

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