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Original Report |
1 Boston IVF, Mind/Body Center for Women's Health, 40 Second Ave., Ste. 300,
Waltham, MA 02451.
2 Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center,
Boston, MA.
3 Mind/Body Medical Institute, Waltham, MA.
4 Department of General Medicine, Brigham and Women's Hospital, Boston,
MA.
5 Advanced Medical Research Foundation, Chestnut Hill, MA.
6 Department of Radiology, Beth Israel Deaconess Medical Center, Boston,
MA.
Received March 18, 2004;
accepted after revision June 1, 2004.
Address correspondence to A. D. Domar.
Abstract
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CONCLUSION. Listening to a relaxation or music audiotape before and during mammography does not reduce subjective reports of anxiety or pain. Women undergoing screening mammography report minimal levels of distress.
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Relaxation techniques have been used successfully in the treatment of numerous physical and psychologic disorders. Several studies support the efficacy of relaxation techniques in reducing pain and anxiety during radiologic procedures, including endoscopy, arteriography, and MRI [2–4]. If a simple, inexpensive, noninvasive intervention could decrease distress during mammography, not only would it benefit patients immediately, but also it is hypothesized that compliance with screening guidelines would increase if distress can be decreased. The goal of this study was to determine whether relaxation techniques reduce subjective distress during screening mammography.
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Materials
The measures included one demographic form, two self-report questionnaires,
and a Likert scale. On the basis of the data provided by subjects on the
demographic form, we assessed age, education, ethnic background, mammography
history, family history of breast cancer, the reason for undergoing screening
mammography, and experience with relaxation techniques. Information was not
collected about a history of being recalled because of mammographic findings,
a history of breast biopsy, or whether the subject had any friends with breast
cancer.
The two self-report questionnaires were the Spielberger State Trait Anxiety Inventory (STAI) [5] and the McGill Pain Questionnaire (MPQ) [6]. Both of these questionnaires have been used extensively in intervention research, are easily completed in a few minutes, are reliable in an acute setting, and have been used in previous radiologic intervention research [3]. Subjects also completed a Likert scale to rate pain and anxiety. For each Likert scale, subjects were asked to mark the level of pain or anxiety they experienced during their mammography examination on a scale of 1 (no pain) to 10 (very painful) and 1 (not anxious) to 10 (very anxious), respectively.
Methods
Women were approached by one of the research assistants after they had
changed into a gown and were sitting in the waiting room provided for
screening mammography patients only. During the recruiting phase, each
potential subject was asked if she would be interested in participating in a
brief study to determine the effects of listening to an audiotape before and
during mammography. Of the 280 women approached for potential recruitment, 88
declined to participate. Of the 192 who agreed to be screened for inclusion,
42 were found not to meet the eligibility criteria. Women who met the
eligibility criteria had the purpose and procedures of the study explained to
them and were asked to read and sign an informed consent form. They then
completed the demographic form and the STAI. Six subjects withdrew consent
before randomization for the following reasons: one was late for a meeting,
one did not want to be in a control group, one stated that reading the
questions made her "feel depressed," one changed her mind, one did
not have enough time before being called in for the mammography examination,
and one did not like the wording of the consent form. A seventh subject was
not included in the data analysis because she later reported that she did
indeed have a current psychiatric illness, thus making her ineligible.
Subjects were then randomized, according to a computer-generated random-numbers table, into one of three groups: relaxation, music, or control. All subjects were informed of their group assignment and were provided with an audiotape player and the appropriate audiotape. The relaxation audiotape contained information that led the subject through breath focus, body scan, and meditation. Breath focus involves focusing on the rhythm of the breath, body scan means to focus on different body parts as one inhales and to relax that body part as one exhales, and meditation means to focus on a neutral word or phrase in rhythm with one's breath. The music subjects had a choice of classical music, jazz, or soft rock. Control subjects listened to a blank tape.
Subjects were instructed to listen to their tape while sitting in the waiting room before and again during examination. They were asked to turn the volume lower during mammography so that they could hear the instructions of the technologist. All subjects were asked to not let the radiologic technologist know their group assignment. All subjects were told after imaging that they would not be receiving their mammography results that day. This change of hospital procedure within the past 1–2 years was based purely on staffing issues. Many of the patients would have been accustomed to receiving results immediately after mammography.
After undergoing mammography, each subject was met by the research assistant in the waiting room. They were asked to complete the STAI (State only), the MPQ, and the Likert scale. The STAI has two separate components: one is for trait anxiety and one is for state anxiety. They returned the audiotape player and tape and were thanked for participating in the study.
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A total of 50 subjects were in the relaxation group, 47 in the music group, and 46 in the control group. As can be seen in Table 1, the groups were equivalent before randomization in terms of age, education, race, mammography history, and STAI scores.
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No significant differences among the groups on any of the assessed measures were noted (Table 2). However, the mean scores of both groups for all scores were surprisingly low. For example, the STAI scores before mammography did not differ from national norms of baseline anxiety. The Likert scores for both anxiety and pain during mammography were extremely low.
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A multiple regression analysis using group, ethnicity, education, age, and mammography history showed few significant relationships. White women reported higher anxiety scores after mammography than women of other races, and older women had lower anxiety scores after mammography than younger women.
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The study may have included a biased sample. Approximately one half of approached potential subjects refused participation. It is possible that the more anxious and distressed women excluded themselves and that the calmer women felt more able to listen to the purpose and procedures of the study. However, the opposite could have been true as well, and it would make sense for the most anxious women to seize the opportunity to participate in a "relaxation study."
Perhaps patients undergoing screening mammography actually experience low levels of pain and anxiety. Pain has been cited as the most commonly reported reason why women fail to return for repeat mammography screening [1]. However, the fear of pain, rather than the experience of pain, may be decreasing compliance with mammography screening. Recent research indicates that the mammography population frequently report anxiety and pain but that only a minority (10–15%) actually experience moderate or severe distress [7]. In a review of 10 studies about psychologic distress associated with organized breast cancer screening [8], researchers determined that anxiety is the most common issue, with the highest levels found in women with abnormal results. Indeed, much of the literature about distress associated with mammography has focused on women recalled because of abnormal findings on initial mammograms [9–11].
In this study, the mean levels of anxiety and pain reported by the subjects were very low—so low, in fact, that it would be difficult for any intervention to show an effect. The results of this study led to three future steps.
The first step was to design a similar study but one that evaluates a more distressed population, such as women who have been recalled for a repeat examination after having abnormal findings on a screening mammogram. Because this population has documented levels of distress, an intervention such as relaxation may have an effect on subjective reports of pain and anxiety and, as a result, on compliance with screening guidelines. The second step is to disseminate the information from this study. Perhaps if women learned that routine screening mammography is associated with low levels of anxiety and pain, their fear may subside enough to decide to comply with the screening guidelines. Finally, the subjects in this study are being followed up for 15 months after their screening mammography examinations to determine which factors, if any, determine their decision to undergo rescreening a year later. The results should be available in a year.
Acknowledgments
We thank the following individuals for their support of this study: Herbert
Benson, Sara Orozco, Michael Otto, and the mammography radiologic
technologists at Beth Israel Deaconess Medical Center.
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