PSYCHO-ONCOLOGY

Psycho-Oncology 14: 939948 (2005)

Published online 2 March 2005 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/pon.903

THE PSYCHOLOGICAL IMPACT OF

MAMMOGRAPHIC SCREENING ON WOMEN
WITH A FAMILY HISTORY OF BREAST
CANCER}A SYSTEMATIC REVIEW
EILA K. WATSONa,*, BETHAN J. HENDERSONb, JOANNE BRETTa, CLARE BANKHEADa and JOAN AUSTOKERa
a
Department of Primary Care, Cancer Research UK Primary Care Education Research Group, University of Oxford,
Old Road Campus, Headington, Oxford OX3 7LF, UK
b
Institute of Medical & Social Care Research, Wheldon Building, University of Wales, Bangor,
Gwynedd LL57 2UW, UK

SUMMARY

This systematic review aims to assess the psychological impact of mammographic screening on women with a family
history of breast cancer. Women with a family history, and hence increased risk, of breast cancer are known to
experience higher levels of anxiety about cancer. They are also often oered screening from an earlier age. The
psychological consequences of screening are therefore of particular importance for this group of women. A
comprehensive search of 4 electronic databases was conducted from 1982 to 2003, combining sets of terms relating to
(1) breast screening or mammography (breast screen; mammogra), (2) psychological impact (adverse eects;
anxi; distress; nervous; psych, psychological consequences; stress; worry) and (3) family history. Reference lists
from relevant papers were examined for additional papers. The review identied seven papers from four countries.
Overall, the ndings indicate that, similar to women in the general population, most women with a family history do
not appear to experience high levels of anxiety associated with mammographic screening. Although women who are
recalled for further tests do experience increased anxiety the levels appear to be no greater than for women without a
family history. We conclude that further research on this topic is required}this should include studies designed
specically to consider both the negative and positive impact of mammographic screening on women with a family
history, using validated measures of anxiety and worry in combination with qualitative research. Copyright # 2005
John Wiley & Sons, Ltd.
KEY WORDS: breast screening; mammography; family history; anxiety; psychological impact

INTRODUCTION certain family history criteria should be oered

Women with a family history of breast cancer
(FHBC) have an increased risk of developing the
disease (Pharaoh et al., 1997). The risk increases
according to the number of close relatives aected
with breast cancer and the age at which they are
diagnosed (Eccles et al., 2000). Current recom-
mendations in the UK are that women fullling
*Correspondence to: Department of Primary Care, Cancer
Research UK Primary Care Education Research Group,
University of Oxford, Old Road Campus, Headington, Oxford
OX3 7LF, UK. E-mail: eila.watson@dphpc.ox.ac.uk
regular mammographic surveillance from the age
of 40 (National Institute for Clinical Excellence,
2004), although there is as yet no strong evidence
of eectiveness for this approach (Routine screen-
ing in the UK begins at age 50.)
It has been shown that women with a FHBC
have high levels of cancer-specic anxiety (Lloyd
et al., 1996; Zakowski et al., 1997). In a popula-
tion-based study of rst-degree relatives of breast
cancer patients (Lerman et al., 1993), 53% of
respondents experienced intrusive thoughts about
breast cancer, with 30% of the sample indicating
that their breast cancer worries interfered with
their daily lives. It has also been reported that

Received 28 May 2004

Copyright # 2005 John Wiley & Sons, Ltd. Accepted 30 November 2004
940 E.K. WATSON ET AL.
women with a FHBC have high levels of general
distress (Audrain et al., 1998; Gilbar, 1998; Kash
et al., 1992). Hence, it is important to assess the
psychological impact of mammography for this
group of women. Whilst women with a FHBC
may well derive considerable reassurance from a
normal screening result, it is possible that the
adverse consequences of being recalled for further
tests are greater in women with a FHBC,
particularly as the frequency of false positive
results may be higher in women with such a family
history (Elmore et al., 1997). This review was
carried out to assess the psychological impact of
mammography screening on women with a
FHBC. To our knowledge there are no previous
literature reviews addressing this specic topic.
METHODS
A comprehensive search of four electronic data-
bases (Medline, Cinahl, EMBASE, and Psychinfo)
was conducted from the year 1982 to 2003. The
search combined sets of terms relating to (1) breast
screening or mammography (breast screen;
mammogra), (2) psychological impact (adverse
eects; anxi; distress; nervous; psych, psycholo-
gical consequences; stress; worry) and (3) family
history (fami, inher, genetic, high risk). Refer-
ence lists from all potentially relevant papers were
examined for additional papers. We also con-
ducted hand searching of the NHS Breast Cancer
Screening Literature Updates from 1996 to 2003,
which is drawn up through extensive searches of
the relevant journals.
Fifty two papers were identied by the searches.
No additional papers were yielded through search-
ing of reference lists or hand searching. The 52
papers were screened by two reviewers. Twenty
ve papers were identied as potentially relevant
and full text copies were obtained. We included
primary research papers that investigated the
psychological impact of screening mammography
in women with a FHBC from invitation for initial
screening to re-attendance at subsequent screen-
ing. Papers were excluded if they described
patients who were diagnosed with cancer as a
result of screening or those who were symptomatic
at the time of mammography. These two groups
are likely to have dierent anxiety proles from
the population of women with a family history
attending for screening. Studies were also excluded
Copyright # 2005 John Wiley & Sons, Ltd.
if the focus was the impact of an intervention
eected on anxiety (e.g. the impact of counselling
on anxiety), or described a study where the
temporal relationship between mammographic
screening and anxiety was not clear (i.e. not clear
if women were anxious before invitation for
screening, or as a result of screening). Papers were
also excluded if they were not obtainable in
English. Eighteen papers were excluded on the
basis of one or more of these criteria.
RESULTS
A total of seven papers assessed the psychological
impact of mammographic screening in women
with a FHBC. Four studies were specically
designed to explore the psychological impact of
mammography screening on women with a FHBC
(Absetz et al., 2003; Drossaert et al., 1996; Gilbert
et al., 1998; Valdimarsdottir et al., 1995), and a
further three studies reported on the impact of
screening on women with a family history,
although this was not the primary aim of the
study (Drossaert et al., 2002; Haas et al., 2001;
Lindfors et al., 2001). These studies were very
heterogeneous in nature}using a variety of study
populations, study designs, sample sizes and out-
come measures, as well as diering degrees of
family history. The quality of the papers also
varied. A summary of the papers is presented in
Table 1 and Table 2, but due to the heterogeneity
between them the raw data have not been
included.
The psychological impact of mammography
screening on women with a family history of
breast cancer is unclear:
Short term anxiety
Two studies found that mammographic screen-
ing induced short-term anxiety (up to six weeks) in
women with normal screening results (Drossaert
et al., 1996; Valdimarsdottir et al., 1995). Dros-
saert et al. (1996) found that mammography
screening caused slightly more anxiety for women
with a FHBC, but the absolute numbers experien-
cing moderate to severe anxiety were small.
Valdimarsdottir et al. (1995) found that compared
to women in the general population without a
FHBC, women under 50 with a FHBC had higher
Psycho-Oncology 14: 939948 (2005)
 Table 1. Design of studies assessing the psychological impact of mammographic screening on women with a family history of breast cancer

Authors Aim Design Study population Sample size and response rate

Valdimarsdottir To examine psychological dis-
et al. (1995) tress in women with a FHBC
USA
Drossaert et al. To compare women with a
(1996) FHBC to those without with
The Netherlands respect to risk perception,
breast cancer anxiety and early
detection behaviours
C Women (2150 yr) with a FHBC group, out of a sample
FHBC according to established of 32, 26 (81%) completed both
guidelines (Garber et al., 1991) assessments. Population group,
who underwent mammography n=27 (recruited by advertise-
screening and received a clear ment)
result, were compared to a
group of women from the gen-
eral population who did not
have a mammogram
X Women (5069 yr) with a Out of a sample of 5325, 3684
FHBC (dened as having a (69%) returned their question-
mother or sister who had been naire, 389 had a FHBC
treated for breast cancer) were
compared to women without
FHBC six weeks after both

Copyright # 2005 John Wiley & Sons, Ltd.

Gilbert et al. To (a) evaluate the psychologi-
(1998) cal eects of false positive
UK mammography, and (b) com-
pare the eects of recall in
women with, and without, a
FHBC
Haas et al. (2001) To examine what factors are
USA associated with anxiety among
women who receive an abnor-
mal mammogram result
groups had been scheduled to
have a mammogram
C Women (5064 yr) who were
recalled after mammography
screening. Women with a FHBC
categorized as being twice the
population risk (using criteria
provided by local medical genet-
ics dept) were compared to
those without such a FHBC
C Women (63% of whom were
postmenopausal) who were re-
called after mammography
screening. They explored the
role of FHBC (1st degree rela-
tive with breast cancer) in the
Out of a sample of 2357, 2110
(90%) completed the baseline
assessment. 122 women who
were recalled to the clinic com-
pleted the baseline assessment,
35 had a FHBC (of whom 18
were recalled solely on account
of their FHBC)
Out of a sample of 797, 449
(56%) completed the baseline
assessment, 94 had a FHBC
PSYCHOLOGICAL IMPACT OF MAMMOGRAPHIC SCREENING

amount of anxiety experienced

Lindfors et al. To compare stress experienced
(2001) by women who had false posi-
USA tive screening mammograms
and had undergone immediate
on-site diagnostic imaging with
those who were recalled for
subsequent imaging
X Women (3091 yr) who under- Out of a sample of 276, 121
went immediate on-site diag- (44%) eligible surveys were
nostic imaging were compared received. 28 had a FHBC
to those who were recalled for
subsequent imaging. They also
explored the role of family
history (1st degree relative with
breast cancer) in the amount of
941

Psycho-Oncology 14: 939948 (2005)

stress experienced
 Table 1. (Continued).
Authors Aim
Drossaert et al. To (a) monitor experiences of
(2002) women during 3 rounds of
The Netherlands breast screening; (b) examine
the impact of previous experi-
ences of reattendance; and (c)
examine which factors are asso-
ciated with the pain and distress
during screening
Absetz et al. To examine whether the psy-
(2003) chological impact of organized
Finland mammography screening is in-
uenced by womens pre-exist-
ing experience with breast
cancer and perceived suscept-
ibility to the disease
Copyright # 2005 John Wiley & Sons, Ltd.
Abbreviations: FHBC=family history of breast cancer; C=cohort study; X=cross-sectional study.
Psycho-Oncology 14: 939948 (2005)
Design Study population
C Women (mean age 58.3 yr). A
FHBC (dened as having a
mother or sister who had been
treated for breast cancer) was
examined to see whether it was
related to distress
C Women (50 yr) at their rst
screening appointment, who
were recalled after screening
were compared to women with
a normal result. Women who
had experience of breast cancer
at close range (i.e. a 1st degree
relative, or knew someone else
with breast cancer) were com-
pared to women with no ex-
perience
942
Sample size and response rate
Out of a sample of 4711, 3148
(67%) completed the baseline
assessment. 346 had a FHBC
Study population=1942, 535
had been recalled. Response
rate for rst question-
naire=63%. 70 had a 1st de-
gree relative with breast cancer
and 381 knew someone else
with breast cancer
E.K. WATSON ET AL.
 Table 2. Main outcomes of included studies
Authors Methods of data collection
Valdimarsdottir The FHBC group completed a
et al. (1995) clinic questionnaire on the day
of their mammogram, and one
month later. The population
group completed question-
naires (administration method
not specied) at two compar-
able time points one month
apart
Copyright # 2005 John Wiley & Sons, Ltd.
Drossaert et al. Postal questionnaire sent ap-
(1996) proximately 6 weeks after they
had been scheduled for a mam-
mogram
Psycho-Oncology 14: 939948 (2005)
Measures
Acute distress}POMS. Non-
specic distress}BSI. Cancer
specic distress}IES
Cancer specic distress}the
authors shortened the scale
used by Boer (1993) to 4 items.
Distress caused by mammogra-
phy}this was measured by 7
items designed for the study
Summary of ndings Limitations
Compared to the population The comparison group were
group, women with a FHBC not undergoing mammography
had higher levels of acute dis- screening. Small sample sizes.
tress when they were assessed No long term follow-up
immediately before mammo-
graphy, but not when assessed
following notication of nor-
mal results. Despite notication
of normal results, the FHBC
group continued to have higher
levels of non-specic distress,
avoidance, intrusive thoughts
about breast cancer. However,
distress levels at time point 2
were signicantly lower than
distress levels at time point 1
for the FHBC group. To con-
clude, women with a FHBC
have higher levels of non-spe-
cic distress and intrusive
thoughts of breast cancer one
month after screening com-
pared to women without a
FHBC who did not undergo
screening
Women with a FHBC were The Boer scale seems to be a
signicantly more anxious fear of cancer measure rather
about breast cancer than wo- than a measure of the impact of
men without a FHBC. The cancer worry on individuals
mammography caused slightly lives. Do not report validity of
more psychological distress for shortening Boer scale. Reliabil-
PSYCHOLOGICAL IMPACT OF MAMMOGRAPHIC SCREENING
women with a FHBC. But ity of measuring mammogram
overall, the percentages that anxiety 6 weeks after mammo-
experienced moderate to severe gram appointment
distress were small in all sub-
groups, indicating that the
screening program in general
did not lead to unacceptable
distress. To conclude, negative
consequences of knowing to be
943
at increased risk of breast
 Table 2. (Continued).
Authors Methods of data collection
Gilbert et al. (a) Postal questionnaire (PQ) 6
(1998) weeks prior to receipt of screen-
ing invitation letter (b) Clinic
questionnaire (CQ) immedi-
ately prior to mammography/
immediately after in some cases
(c) CQ at recall appointment
(d) PQ 5 weeks (e) PQ 4 months
later
Copyright # 2005 John Wiley & Sons, Ltd.
Haas et al. (2001) (a) Structured telephone inter-
view at 2 months post abnor-
mal mammogram result (b)
Structured interview at 8
months post mammogram ult
Lindfors et al. Postal questionnaire 6 weeks
(2001) after the completion of diag-
Psycho-Oncology 14: 939948 (2005)
nostic imaging
Measures
Non-specic distress}HADS
at all time points. Acute dis-
tress}Health Questionnaire
(Walker et al., 1994)
Women were asked to rate their
anxiety about their abnormal
mammogram result on a 3-
point scale. This information
was then dichotomized into
very anxious versus less anxious
Screening related stress}ques-
tions designed for the study
about the stressfulness of the
944
Summary of ndings Limitations
cancer, in terms of extreme
breast cancer anxiety or high
psychological distress caused by
mammography, were not found
At recall, women (irrespective No measures of cancer specic
of FHBC) were more likely to distress. Some women were
have borderline or clinically recalled solely on account of
signicant anxiety than at base- their family history and not
line or screening. This raised because of an abnormal mam-
anxiety appeared to be rela- mogram. Only included women
tively transient and was not who were recalled, not women
detected 5 weeks post-recall. with normal ndings
Compared with women without
a FHBC, women with a FHBC
experienced less acute screening
related stress. However, they
were more anxious 4 months
after recall, although their an-
xiety scores tended to be lower
than at baseline. To conclude,
regardless of FH, recall was
found to induce relatively tran-
E.K. WATSON ET AL.
sient anxiety
26% of women reported being One item measure of anxiety.
very anxious about their abnor- No validated measures of dis-
mal mammogram result at time tress. Only included women
1 and 22% reported persistent who were recalled not women
anxiety at time 2. At time 2 with normal ndings. No base-
women with a FHBC were line data (before women had
signicantly less anxious about screening) was collected
their mammography result than
women without a FHBC. To
conclude, at long term follow-
up women with a FHBC, who
are recalled after mammogra-
phy screening, are less anxious
about their result than women
without a FHBC
Women who had undergone Cross sectional design no fol-
immediate diagnostic work-up low-up to see whether stress
experienced signicantly less levels were long lasting. No
 screening and diagnostic experi-
ences. Respondents were also
asked to indicate if their feel-
ings, attitudes, or breast health
practices had changed as a
result of their experience
Drossaert et al. Women completed a postal Level of distress related to
stress than those who had validated measures of distress.
undergone later diagnostic ima- Problems due to the study
ging evaluation. The observed being retrospective n.b. 6 weeks
dierence in mean stress levels after receiving nal result
could not be attributed to
group dierences in family
breast cancer history alone.
However, when age and family
history were examined together,
women younger than 50 years
who had a positive rst-degree
family history had signicantly
greater stress than did all other
women. To conclude, among
all respondents, stress from a
false-positive screening result
was greatest in women younger
than 50 with a FHBC
Anxiety about having a mam- Only measured anxiety about

Copyright # 2005 John Wiley & Sons, Ltd.

(2002) questionnaire 8 weeks after
they had been invited for an
initial mammogram. Follow up
questionnaires were then sent
to subgroups of the sample at
dierent times: shortly before
the second screening; shortly
after the second screening;
shortly before the third screen-
ing; shortly after the third
screening
Absetz et al. Postal questionnaire (PQ) (a) 1
(2003) month before screening invita-
tion; (b) PQ 2 months post
screening; and (c) PQ 12
mammography screening was
measured using ve items de-
signed for the study. Women
were also asked the extent to
which they had worried about
the test results
Non-specic distress}STAI,
BDI. Cancer-specic dis-
tress}single items used to mea-
sure frequency of intrusive
mogram was not associated
with having a FHBC
In the normal result group,
post-screening intrusive think-
ing of breast cancer decreased,
while among FPs it increased.
the mammogram experience
not cancer specic or non-spe-
cic distress. Retrospective nat-
ure of the baseline
questionnaire i.e. 8 weeks after
women were invited for a
mammogram
Measured breast cancer-specic
concerns with single item mea-
sures. No measure of acute
distress
PSYCHOLOGICAL IMPACT OF MAMMOGRAPHIC SCREENING

months post screening
thoughts, and current worry
about BC. Health related con-
cerns}5 subscales of the IAS.
Breast cancer-specic beliefs.
Health behaviour
The latter became more fre-
quent in BSE despite a simulta-
neous decrease in BSE self-
ecacy. Experience did not
inuence responses to dierent
screening ndings. Women with
experience of BC were no more
distressed than those without
experience before screening.
However, at post-screening
945

Psycho-Oncology 14: 939948 (2005)

946 E.K. WATSON ET AL.

levels of both non-specic and cancer specic

1982); HADS=Hospital Anxiety and Depression Scale (Zigmond and Snaith, 1983); IAS=Illness Attitude Scales (Kellner, 1987); IES=Impact of Event Scale (Horowitz
Abbreviations: FHBC=family history of breast cancer; BDI=Beck Depression Inventory (Beck et al., 1961); BSI=Brief Symptom Inventory (Derogatis and Spencer,
anxiety one month after notication of normal
screening results, although anxiety levels were
lower than they had been on the day of their
mammograms. This study was, however, severely
limited in that the comparison group were not
Limitations

undergoing mammography. In contrast, another

study found that women with a FHBC experienced
less acute distress (i.e. distress around the time of
the actual screen) than women without such a
family history (Gilbert et al., 1998). Valdimars-
dottir et al. (1995) found that compared to women
et al., 1979); POMS=Prole of Mood Scale (McNair et al., 1971); STAI=State-Trait Anxiety Inventory (Speilberger et al., 1983).
screening irrespective of screen-
they exhibited higher levels of

mammography
distress
stayed on a moderate level. To
conclude, experience of breast

related to disease-related dis-

cancer (including a FHBC) is

in the general population, women with a FHBC

had higher levels of acute anxiety when assessed
immediately before mammography but not when
Summary of ndings

assessed following notication of normal results.

although

However, as noted above, this study was limited in

that the comparison group were not undergoing
after

screening. Another study found that anxiety about

ing nding

having a mammogram was not associated with

distress,

having a FHBC, although this was measured

tress

retrospectively approximately eight weeks after

screening (Drossaert et al., 2002).

The impact of receiving a false positive result

Several studies have explored the impact of false

positive screening ndings on women with a
FHBC. Absetz et al. (2003) and Lindfors et al.
(2001) found that whilst women who underwent
Measures

further tests before receiving a clear result did

experience increased anxiety, having a family
history did not inuence womens responses. Haas
et al. (2001) found that women with a family
history felt less anxious about their abnormal
screening result than women without a family
Methods of data collection

history of breast cancer. On the other hand,

Gilbert et al. (1998) reported that women with a
family history experienced more non-specic
anxiety four months after recall than women
without a family history, although their anxiety
scores at four months tended to be lower than at
baseline making this nding dicult to interpret.
Furthermore, half of the women with a FHBC
who were recalled, were recalled solely on account
Table 2. (Continued).

of their family history.

Longer term anxiety

Authors

Irrespective of screening result, however, Absetz

et al. (2003) found that in a group of women aged

Copyright # 2005 John Wiley & Sons, Ltd. Psycho-Oncology 14: 939948 (2005)
 PSYCHOLOGICAL IMPACT OF MAMMOGRAPHIC SCREENING
50 undergoing screening for the rst time, experi-
ence of breast cancer at close range (including a
FHBC) was related to moderate cancer specic
anxiety, and that this persisted for up to 12 months
after screening, despite a normal screening result.
Predictors of response to screening
Lindfors et al. (2001) reported that anxiety levels
in response to mammographic screening could not
be attributed to group dierences in family breast
cancer history alone. However, when age and
family history were examined together, women
younger than 50 years who had a positive rst-
degree family history had signicantly greater
stress than did all other women, although this
may have simply been an age eect. Similarly, as
described above, Valdimarsdottir et al. (1995)
examined anxiety in a group of women with a
FHBC aged between 21 and 50 years, and reported
a higher level of non-specic anxiety and intrusive
thoughts of breast cancer in this group of women
than women in the general population. One
explanation for this might be that they explored
anxiety in a younger group of women than other
studies in the review}the majority of which
investigated the impact of mammography screen-
ing in women aged 50 or above. No study reported
other potential predictors of emotional responses
to screening, such as sociodemographic factors
other than age, aspects of the screening process,
and individual dierence variables including per-
sonality, coping, and social support.
DISCUSSION
From the few studies reported to date, women
with a FHBC do not appear to experience high
levels of anxiety associated with mammographic
screening, although some women who receive a
clear result may experience slight increases in
anxiety in the short-term. Women who are recalled
for further tests do experience increased anxie-
ty}however, the levels appear to be no greater
than those for women without a FHBC. Inter-
pretation of the studies in this review was
hampered by the heterogeneous nature of the
studies}with dierences in populations, study
designs, sample sizes and outcome measures as
well as diering degrees of family history. In
Copyright # 2005 John Wiley & Sons, Ltd.
947
addition, a number of the studies had methodolo-
gical limitations using, for example, small sample
sizes, non-validated measures of anxiety and/or
inadequate study designs. Only one study in this
review presented a comparison of baseline levels of
anxiety between the two groups (Absetz et al.,
2003). Although this study did not nd any
dierences between the two groups, it is important
that future studies measure and report baseline
anxiety levels so that comparisons of the magni-
tude of changes pre-screening and post-normal
result or false positive result can be made. Further
prospective studies which are designed specically
to consider both the positive and negative impact
of screening on women with a FHBC are required
to denitively determine the psychological impact
of mammographic screening for this group of
women. Women with a family history may gain
considerable reassurance from participating in a
screening programme. It is recommended that, in
combination with qualitative approaches, future
studies should use validated measures of anxiety
and worry, and should include a baseline, pre-
screening measure of anxiety. Measures of indivi-
dual dierence variables, such as personality,
coping and appraisal, should also be included in
order to identify sub-groups of women who may
be most vulnerable to adverse emotional conse-
quences of breast screening.
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