Does Mammography Hurt?

Vol. 25 No. 1 January 2003

Journal of Pain and Symptom Management

53

Original Article

Does Mammography Hurt? Rama Sapir, BScPharm, M Med Sci, Michael Patlas, MD, Shalom David Strano, MD, Irit Hadas-Halpern, MD, and Nathan I. Cherny, MB BS, FRACP Department of Medical Oncology (R.S., N.C.) and Department of Radiology (M.P., I.H.-H.), Shaare Zedek Medical Center; and HALA: The Rachel Nash Jerusalem Comprehensive Breast Clinic (S.D.S), Jerusalem, Israel

Abstract The documented incidence of pain associated with screening mammography varies from 1% to 62%. Some researchers suggest that pain may undermine compliance with screening mammography. As a part of a quality improvement project, we have surveyed women undergoing mammography in 2 centers in Jerusalem to identify the prevalence, severity, and duration of mammography-associated pain, demographic risk factors, and the degree that this may undermine compliance with breast cancer screening. A 23-item questionnaire was administered to 399 women (32% at the Shaare Zedek Medical Center [SZMC] and 68% at the Rachel Nash Comprehensive Breast Clinic [HALA]). Of the total, 77% of the women reported that the procedure was painful. Of those reporting pain, 60% described pain intensity as moderate or severe. In 67%, the pain resolved within 10 minutes. By univariate analysis, the only significant predictor for pain during mammography was cyclic breast pain (P  0.053). No significant correlation was identified for age, breast size, pre-mammography counseling, and examination center (SZMC vs. HALA). The prevalence of pre-mammography counseling or explanation was low (51%). Despite that, 61% of the respondents expected that mammography would be painful. Indeed, most of those who anticipated pain reported that the actual severity was not greater than the anticipated severity. Even among women who reported pain of moderate or greater severity, less than 5% expressed preference to receive pre-emptive analgesia prior to their next mammogram. A substantial minority of women acknowledged that the experience of their mammography invoked reactions that may impend future compliance; 26% reported anxiety and 12% reported pain as factors that may interfere with ongoing compliance with regular mammographic screening. These data serve to emphasize the need for appropriate pre-test counseling and suggest a possible role for post-test debriefing to address those factors which may interfere with future test compliance. J Pain Symptom Manage 2003;25: 53–63. © 2003 U.S. Cancer Pain Relief Committee. Published by Elsevier. All rights reserved. Key Words Mammography, pain, discomfort

Introduction Address reprint requests to: Nathan I. Cherny, MBBS, FRACP, Director, Cancer Pain and Palliative Medicine, Department of Medical Oncology, Shaare Zedek Medical Center, Jerusalem, Israel 91031. Accepted for publication: March 8, 2002. © 2003 U.S. Cancer Pain Relief Committee Published by Elsevier. All rights reserved.

Breast cancer is the most common cancer in women and the leading cause of cancer related death among women worldwide.1 In Israel, breast cancer is the most common cancer among women and the incidence rate is higher than in most European countries, but lower 0885-3924/03/$–see front matter PII S0885-3924(02)00598-5

54

Sapir et al.

than in the US.2 Early detection of breast cancer is a major public health priority. Mammography is, at the present time, the most effective method for the early detection of breast cancer. In most published studies, it had been demonstrated that screening mammography can significantly reduce mortality attributable to breast cancer among women older than 50 years of age.3–8 The efficacy of this approach remains controversial, however, and a recent study demonstrated that the addition of annual mammographic screening to a physical examination showed no impact on breast cancer mortality among women aged 50–59 years.9 In particular, public health policy regarding mass screening with mammography for women younger than 50 remains controversial, as the data for women of this age group is inconclusive.3,8 To achieve maximum public health benefit from community-based mammography programs, it is essential that eligible women in the community attend initial baseline mammograms and annual or biennial re-screening mammography at least until age 70.1 Surveys evaluating the rate of adherence to mammographic screening in western countries show that in countries with social health systems the rate of performance of screening mammography among women older then 50 is 70–90%.10,11 In the US, 33–63% of women over the age of 40 had undergone at least one mammographic examination.12 In Israel, mammographic screening for early detection of breast cancer among women over 50 years of age is included in the basket of services provided under the Israeli National Health Insurance Law since 1995.13 Despite this, compliance with screening mammography is relatively low.14 Bentur et al., from the JDC-Brookdale Institute of Gerontology and Human Development in Jerusalem, reported that only 56% of women between the ages 50– 74 underwent at least one mammographic examination during their lives and only 49% of them had undergone a test in the past 2 years. It is important to identify barriers to compliance with screening mammography. Some researchers suggest that pain associated with the procedure may, for some women, undermine compliance with screening mammography.15–17 It had been suggested that a painful mammography may undermine personal compliance and discourage the participation of peers.

Vol. 25 No. 1 January 2003

To date, controversy continues to cloud the issue of mammography-associated pain. There remains no consensus as to the prevalence of the problem, its severity, its duration, risk factors for the development of pain, or the impact on future compliance. We have attempted to address these issues in a survey of women undergoing mammography in 2 centers in Jerusalem.

Methods Women undergoing bilateral mammography at the Department of Radiology at the Shaare Zedek Medical Center (SZMC) and the Rachel Nash Comprehensive Breast Clinic (HALA) in Jerusalem during December 2000 and January 2001 were asked to participate in a prospective study of pain related to mammography. The participants were given a brief explanation on the survey by the mammography technician. The survey questionnaire was administered to women after the procedure was completed, while waiting to be discharged. Completed questionnaires were referred to the radiologist who indicated the reason for performing the test: screening or diagnostic. All mammograms were carried out using standard institutional procedures. At neither center was the level of compression recorded. The survey tool was a structured self-completed 23-item questionnaire. It recorded patient demographics, and evaluation of patient’s experience with regards to physical pain, premammogram counseling, and general satisfaction. Pain severity was assessed using a 5-point verbal descriptive scale. The questionnaire was available in Hebrew and in English. Response frequencies for each of the demographic, pain descriptive, and analytical items were analyzed by actual percentage responses to each of the multiple-choice options. The influence of site of examination on patient attitudes and preferences was evaluated by chisquare test.

Results Demographics A total of 399 women completed the survey, 128 (32%) at SZMC and 272 (68%) at HALA. A total of 84% of women were referred for screening mammography and 16% for diagnostic investigation of suspicious lesions. The

Vol. 25 No. 1 January 2003

Does Mammography Hurt?

major reason for not completing the survey questionnaire was language barrier. The majority of women completed the questionnaire within 5 minutes of finishing the mammogram (73%) and the rest within 5–10 minutes (25%). The demographic characteristics of women from both centers were similar and are presented in Table 1. Twenty percent of women reported breast tenderness prior to the mammography; 15% reported mild tenderness, and 5% reported moderate tenderness.

Pain Experience Seventy-seven percent of the women reported that the procedure was painful. Of those reporting pain, 31% described pain intensity as moderate, and 34% described pain as severe. In 67% of respondents, the pain resolved within 10 minutes. The majority of women reported pain as symmetric (60%). The expectation of 61% percent of women that the procedure would be painful matched the actual pain.

55

Predictors for Pain Experience By univariate analysis, the only predictor for pain during mammography trending toward significance was the prior existence of cyclic breast pain (P  0.053). No significant correlation was identified for age, breast size, premammography counseling, and examination site (SZMC vs. HALA).

Future Care Issues Even among women who reported pain of moderate or greater severity, fewer than 5% expressed a preference to receive pre-emptive analgesia prior to their next mammogram. A substantial minority of women acknowledged that the experience of their mammography invoked reactions that may impede future compliance; 26% reported anxiety regarding the test and its outcome and 12% reported pain as factors that may interfere with ongoing compliance with regular mammographic screening.

Information

Discussion

Only half of the respondents reported that they received any explanation regarding the mammography they were to undergo. Of those who received prior counseling, 66% were told that the procedure would be painful.

In prior studies, predictors of adherence with screening mammography have included demographic factors: younger age, higher level of income, ownership of health insurance, higher level of education, and Caucasian ethnicity.

Table 1 Patient Demographics Age group 26–45 46–55 56–65 66–75 Center performed Reason Country of origin Israel West & Central Europe East Europe North America Middle East Other Number of prior mammograms First mammogram 2–5 5 Suffer from chronic pain Suffer from cyclic pain Size of bra A B C D DD

22% 44% 19% 9% SZ  128 (32%) HALA  271 (68%) 85% screening, 15% diagnostic 42% 13% 8% 16% 6% 15% 15% 54% 25% 10% 23% 4% 39% 36% 18% 3%

56

Sapir et al.

Documented barriers to compliance include women’s beliefs and attitudes with respect to screening mammography, a family history of breast cancer and prior mammography experience associated with embarrassment and unpleasant interactions with the screening staff.18–24 There are a few published studies addressing the issue of barriers to compliance with screening mammography that relate to health behaviors in Israeli women.25–27 None of these studies addressed the issue of pain associated with mammography.

Vol. 25 No. 1 January 2003

invalid.40 In the current study, the 5-point verbal rating scale was selected because it is a validated scale and was appropriate for a large study of a heterogeneous population of women involving a self-administrated questionnaire.41 The current study adds to the evolving picture of mammography-related pain. Pain is common and it is reported by up to 77% of women. Pain is usually mild to moderate in severity (66%), and is severe in about a one-third of women. The frequency of pain in this study is similar to that reported by previous researchers who used a validated pain measure.19,20,30,34

Frequency and Degree of Reported Pain There is wide discrepancy in the reported rate of mammography-associated pain. The reported incidence ranges from 1% in Stomper et al.28 to 85% in the study conducted by Kornguth et al.29,30 The documented incidence of pain associated with screening mammography varies from 1% to 62%.21,28,30–34 Methodological problems appear to contribute to the variation in results. There is clear lack of consistency relating to the use of pain scales in these surveys. In the studies summarized in Table 2, the pain assessment instruments varied from a simple 4-point verbal rating scale to the use of multiple assessment measures including Visual Analog Scale, the Brief Pain Inventory, and the McGill Pain Questionnaire.35,36 Several studies used an idiosyncratic univariate 6-point scale that sought to evaluate both discomfort and pain, and in some studies, the pain assessment instrument is not described at all.28,37–39 In an analysis of these data, Kornguth et al. found that when well validated measured of pain like the Visual Analog Scale (VAS) or the McGill pain questionnaire (MPQ) are used, a large proportion of women report having pain during mammography.30 The results of their study strongly suggest that the method used to report pain can influence the proportion of women reporting pain. In studies using unidimensional 6-point pain/discomfort scale, a much lower rate of pain report has been found.30 The 6-point unidimensional scale incorporates unpleasantness and the perceived sensory intensity in a single item question. This scale allows a limited set of response options regarding pain and it may not be sensitive enough to measure the incidence of pain. Indeed, Keefe et al. suggest that this approach is

Timing of Pain Assessment In studies to date, there has been no consistency in the timing of pain assessment with relation to the mammogram. In some studies, pain assessment took place immediately after mammography, whereas in others women were asked to provide retrospective assessment, hours or days after mammography. Keefe et al. suggest that time may play a significant role in biases associated with retrospective reports of pain.40 In the current study, pain assessment was performed soon after examination. In this way, the actual experience of pain was assessed in real time rather than a recall of the event. By administrating the survey questionnaire soon after the examination, we were also able to assess the duration of mammography associated pain. This is important information that is not provided by many of the previous studies. Our data confirm that pain caused by mammography is an acute, transient, self-limiting pain that usually resolves within 10 minutes. Similar findings were reported by Rutter et al.42

Predictors and Risk Factors for Pain Demographic and technical factors predictive of worse pain with mammography are complex and the data are characterized by many contradictory findings (Table 3). In the current study, the only significant predictor of pain was breast tenderness. This is consistent with the findings of a number of other researchers.16,28,39 Facility-specific features and staff attitude may be a risk factor for pain prevalence. Dullum et al. found that more women experienced pain in certain mammography centers than others and that a belief that the technologist was too rough was a significant predictor of

Vol. 25 No. 1 January 2003

Does Mammography Hurt?

57

Table 2 Summary of Studies Examining Pain and Discomfort During Mammography, 1988–2001 No. Reference/Year Patients Stomper et al. (28) 1988

1847

Jackson (39) 1988

356

Brew (49) 1989

203

Wolosin (50) 1989

985

Fallowfield et al. (44) 1990

242

Sullivan(37) 1991

560

Nielsen et al. (51) 1991

272

Objectives To determine what women actually experience during mammography To foster the development of reasonable patient expectations of the procedure To determined the magnitude of discomfort associated with mammography. To determine magnitude of pain associated with mammography To examine the influence of expectations on the experience of pain during mammography To examine the psychological factors influencing attendance non-attendance and re-attendance at a breastscreening center To examine correlation between pressure applied to the breasts during mammography with the patient’s subjective impression of the examination To quantify the amount of pain, discomfort and anxiety associated with mammography

% Discomfort

% Pain

10

1

81

49

Not assessed

Not assessed

4

% Severe Pain

Assessment Instrument

Interference with Screening

none

Univariate scale combining discomfort and pain

No women stated that they had such severe pain that it would make them reconsider ever having a mammogram again

Not assessed

Univariate scale of discomfort

94% said that they would re-attend

4-point scale

Not reported

Check list

Not reported

3-point verbal scales

88% of women intend to come again

0.5

15 more than expected 56 less than expected

90

62

21

76

8

1

62% reported pain/or discomfort. Of that 62%, 24.2% reported only pain, 23.4% reported only discomfort, and 52.4% reported both.

Univariate Not assessed scale of discomfort (Painful response was defined as a response to very uncomfortable)

VAS scale 5-point verbal scale portion of the McGill

Not reported

(continued)

58

Sapir et al.

Vol. 25 No. 1 January 2003

Table 2 Continued No. Reference/Year Patients Cockburn (38) 1992

95

Leaney BJ, Martin M. (52) 1992

470

Rutter (42) 1994

597

Fine et al. (53) 1991

255

Baskin-Smith et al. (54) 1995

272

Aro et al. (55) 1993

883

Objectives

% Discomfort

To describe levels 63 of discomfort experienced by women undergoing screening mammography To examine whether the degree of discomfort experienced was perceived as a deterrent for re-screening To determine Not magnitude of assessed pain associated with mammography

To identify the 35 nature of pain and discomfort How can the pain be ameliorated To evaluate Not subjective assessed experience of mammography

To assess the mammography experience and the sensation experience in women undergoing mammography To investigate associations of mammography pain and discomfort with sociodemographics, personal history, psychological factors

11.4

59

% Pain

% Severe Pain

Assessment Instrument

6

1

Univariate scale Three per cent combining said that discomfort it might and pain stop them, while 97% of women said that it would not stop them at all

40

1

4-point verbal scale

6

Not assessed

Not reported

38- in current 56- in last

3- in current 7- in last

5-point verbal scale

28.4

61

5.7

2 open ended questions

4

4-point verbal scale

Interference with Screening

Only one patient stated that the pain from the procedure would prevent her from having a further mammogram Only 3.5% did not intend to return next time. More than onethird (34 percent) of women having a first mammogram stated that their mammogram experience affected their future plans for having another. Not assessed

No one reported no intention to re-attend screening

(continued)

Vol. 25 No. 1 January 2003

Does Mammography Hurt?

59

Table 2 Continued No. Reference/Year Patients Kornguth et al. (30) 1996

119

Kashikar-Zuck et al. (32) 1977

125

Poulos et al. (46) 1997

200

Hafslund (34) 1998

170

Elwood et al. (23) 1998

200

Bakker et al. (56) 1998;

315

Objectives To examine the incidence, quality and intensity of mammography pain using a variety of pain measures To evaluate how pain coping efficacy and pain coping strategies were related to reports of pain during mammography To assess factors related to the degree of discomfort experienced by women attending for first-time mammography To estimate the pain and anxiety by women in relation to mammography Quality improvement

% Discomfort Not assessed

Not assessed

82.7

Not assessed

Not To assess the assessed reasons why many women who have been screened once in a breast screening programmed decline an invitation for further screening To determine Not women’s assessed satisfaction and experience with breast cancer screening and associated factors

% Pain

% Severe Pain

75–85

5–10

35

5

Not assessed

Not assessed

66.5

8.3

Assessment Instrument

Interference with Screening

VAS, BPI, McGill

Not assessed

VAS, BPI, McGill, 6points univariate scale combining discomfort and pain

Not assessed

5-points scale of Not discomfort assessed

McGill, STAI

Not perceived as a great problem by most of the women

Of 200 women who had received and declined an invitation for re-screening (n  81), the major reason (46%) was their previous mammogram being painful.

40

Not assessed

5-points scale of 89% strong agreement: intention to from return for “strongly screening in disagree” to the future “strongly agree” (continued)

pain.43 In our study, no difference in pain frequency was found between the two mammography centers. Mammography pain is generated by the compression of the breast, which is a crucial

component of a successful mammogram examination. Compression is necessary to separate overlapping structures, to improve detection accurately and to reduce the amount of radiation absorbed by the breast tissue. There is no

60

Sapir et al.

Vol. 25 No. 1 January 2003

Table 2 Continued No. Reference/Year Patients Bruyninckx et al. (20) 1999

247

Keemers-Gels et al. (19) 2000

945

Sapir R. et al.

399

Objectives To evaluate experience of pain during and after mammography To identify the factors that determine the risk of a painful experience To evaluate experience of pain during and after mammography To evaluate associations with personal and medical history, sociodemographics and/ or situational factors To evaluate impact of pain on intention to return for future breast cancer screening To identify the prevalence, severity and duration of mammography associated pain, demographic risk factors, the degree that this may undermine compliance.

% Discomfort

% Pain

% Severe Pain

Assessment Instrument

Interference with Screening

Not assessed

73

Not reported 10-point numeric scale

Not assessed

Not assessed

72.9

Not reported 5-point verbal scale

3.3% indicated that they would not attend further screening

Not assessed

77

34 (of those reporting pain) 26%

12% reported pain as factor that may interfere with ongoing compliance with regular mammographic screening

5-point verbal scale

N  not indicated; VAS  Visual Analog Scale; BPI  Brief Pain Inventory; McGill  The McGill Pain Questionnaire; STAI  State-Trait and Anxiety Inventory.

quantitative guideline to indicate the optimum amount of force to use37,44 The suggested actual amount of appropriate pressure force needed to obtain film quality and reduced radiation is probably in the range of 25–40 lbs.21 Only 3 studies have addressed the issue of correlation between level of compression and pain during mammography. In 2 studies, Sullivan et al.37,44 and Kimme-Smith et al.,45 a relationship between compression and pain severity was observed. However, the results of the study reported by Poulus and Rickard46 regarding the correlation between the level of com-

pression and pain were inconclusive. With regards to the image quality, the majority of radiologists involved in this study perceived that the lower-compression view does not diminish image quality. Their results suggest that the experience of discomfort in mammography may not be simply due to the level of breast compression and that there may be other variables that interact with this variable.46

Intervention Strategies to Prevent/Manage Pain Strategies to address the issue of compression and pain and discomfort during mam-

Vol. 25 No. 1 January 2003

Does Mammography Hurt?

61

Table 3 Risk Factors Associated or Not Associated with Pain During Mammography Factor Pre-existing breast pain/tenderness Experience of moderate to severe pain Caffeine intake Menstrual status Increasing force during examination Young age Anxiety Non–African-American Menopausal state Underlying breast disease (usually fibrocystic disease) Previous mammographic experience High education Average pain at the last mammogram Breast density Less ability to decrease general pain Prior expectations Breast weight Staff-related Family history of breast diseases Breast size

mography have been investigated by other researchers. Kornguth et al. tested the hypothesis that giving women control over the compression portion of the mammography examination results in the perception of less painful experience. The results of the study supported the hypothesis. Patient-controlled compression resulted in less painful experience without detracting from the quality of the image produced. Nielsen et al. suggested that patient education by trained nursing counselors may reduce mammography-related pain and discomfort.47 Another strategy to reduce pain associated with breast cancer screening has been the development of new imaging techniques that do not require breast compression. At a recent conference of the Radiology Society of North America, Rosenthal et al. reported a study evaluating Diffraction Enhanced Imaging (DEI) as an alternative to standard mammography with improved patient comfort and enhanced diagnostic performance.48 The authors of this study conclude that DEI may allow breast imaging without breast compression, but these are preliminary results of a small study performed on human specimens and further research on this subject is warranted. In recent years, attention has been focused on procedural pain and its pharmacological prevention. There is only one published study that evaluated medication intake on the day of

Supporting Studies [19, 20, 28, 49] [28] [39] [39] [37] [51] [19, 39, 51] [51, 53] [52] [19] [28, 30] [30, 37] [32] [19, 20, 28, 38, 42, 46] [46] [19, 20, 39] [19]

Non-Supporting Studies [46] [52] [37, 46, 52] [19, 28, 37, 38, 52] [19, 28, 37, 52] [46] [19, 38] [38] [32, 38]

[19, 46, 53]

mammography. The Kornguth et al. study reports that a total of 22% of women had taken either pain medication or a tranquilizer on the day of mammography.30 This study found that the use of medication did not appear to influence pain rating. In the current study, only 3% of the participants responded positively to the question regarding their desire to receive a painkiller prior to their next mammography. The currently available data regarding the issue of pre-emptive analgesia for mammographyassociated pain is not sufficient to indicate the value of pre-medication as a preventive measure.

Conclusions The results of this study add to the evidence that mammography is commonly associated with a transient pain experience of moderate severity. Our data confirm that pain caused by mammography is acute, short-lasting pain that resolves in most cases within not more than 10 minutes. In our study, the only significant predictor of pain was breast tenderness. Despite the frequency of pain experienced by the respondents, a substantial minority of women acknowledged that the pain experience during their mammography invoked reactions that may impede future compliance (12%). The data collected in this study serve to emphasize the need for appropriate pre-test counseling and suggest a possible role for post-test debriefing

62

Sapir et al.

Vol. 25 No. 1 January 2003

to address those factors which may interfere with future test compliance.

Screening Study. A questionnaire survey. Cancer 1990; 65:1663–1669.

References

18. Thomas LR, Fox SA, Leake BG, et al. The effects of health beliefs on screening mammography utilization among a diverse sample of older women. Women Health 1996;24:77–94.

1. Parkin DM, Pisani P, Ferlay J, et al. Global cancer statistics. CA Cancer J Clin 1999;49:33–64. 2. Health Status in Israel. Israel Center for Disease Control;1999. 3. Shapiro S. Screening: assessment of current studies. Cancer 1994;74(Suppl):231–238. 4. Shapiro S. Periodic screening for breast cancer: the HIP Randomized Controlled Trial. Health Insurance Plan. J Natl Cancer Inst Monogr 1997;22:27–30. 5. Shapiro S, Venet W, Strax P, et al. Ten to fourteen-year effect of screening on breast cancer mortality. J Natl Cancer Inst 1982;69:349–355. 6. Verbeek AL, Hendricks JH, Holland R, et al. Reduction of breast cancer mortality through mass screening with modern mammography. First results of the Nijmegen project, 1975–1981. Lancet 1984;1: 1222–1224. 7. Shapiro S. The status of breast cancer screening: a quarter of a century of research. World J Surg 1989;13:9–18.

19. Keemers-Gels ME, Groenendijk RP, et al. Pain experienced by women attending breast cancer screening. Breast Cancer Res Treat 2000;60:235– 240. 20. Bruyninckx E, Mortelmans D, Van Goethem M, et al. Risk factors of pain in mammographic screening. Soc Sci Med 1999;49:933–941. 21. Loken K, Steine S, Laerum E, et al, Mammography: influence of departmental practice and women’s characteristics on patient satisfaction: comparison of six departments in Norway. Qual Health Care 1998;7:136–141. 22. Sutton S, Saidi G, Bickler G, Hunter J. Does routine screening for breast cancer raise anxiety? Results from a three wave prospective study in England. J Epidemiol Community Health 1995;49:413–418. 23. Elwood M, McNoe B, Smith T, et al. Once is enough—why some women do not continue to participate in a breast cancer screening programme. NZ Med J 1998;111:180–183.

8. Peer PG, Werre JM, Mravunac M, et al. Effect on breast cancer mortality of biennial mammographic screening of women under age 50. Int J Cancer 1995;60:808–811.

24. Bobo JK, Dean D, Stovall C, et al. Factors that may discourage annual mammography among lowincome women with access to free mammograms: a study using multi-ethnic, multiracial focus groups. Psychol Rep 1999;85:405–416.

9. Miller AB, To T, Baines CJ, et al. Canadian National Breast Screening Study-2: 13-year results of a randomized trial in women aged 50-59 years. J Natl Cancer Inst 2000;92:1490–1499.

25. Hagoel L, Ore L, Neter E, et al. The gradient in mammography screening behavior: a lifestyle marker. Soc Sci Med 1999;48:1281–1290.

10. de Waard F, Kirkpatrick A, Perry NM, et al. Breast cancer screening in the framework of the Europe against cancer programme. Eur J Cancer Prev 1994;3(Suppl 1):3–5. 11. Basinski AS. The Canadian National Breast Screening Study: opportunity for a rethink. Cmaj 1992;147:1431–1434. 12. Rimer B. Mammography use in the US: trends and impact of interventions. Ann Behav Med 1994; 16:317–326. 13. National Health Insurance Law 1995. 14. Bentur N, Gross R, Berg A, et al. Screening tests for early detecting breast cancer in women in Israel—performance rates and patient characteristics. Harefuah 1998;134:425–428, 504. 15. Owen P, Long P. Facilitating adherence to ACS and NCI guidelines for breast cancer screening. Aaohn J 1989;37:153–157. 16. Gold RH. Painless mammography. Arch Intern Med 1988;148:517. 17. Baines CJ, To T, Wall C, et al. Women’s attitudes to screening after participation in the National Breast

26. Ore L, Hagoel L, Shifroni G, et al. Compliance with mammography screening in Israeli women: the impact of a pre-scheduled appointment and of the letter-style. Isr J Med Sci 1997;33:103–111. 27. Remennick L. Breast screening practices among Russian immigrant women in Israel. Women Health 1999;28:29–51. 28. Stomper PC, Kopans DB, Sadowsky NLM, et al. Is mammography painful? A multicenter patient survey. Arch Intern Med 1988;148:521–524. 29. Kornguth PJ, Rimer BK, Conaway MRM, et al. Impact of patient-controlled compression on the mammography experience. Radiology 1993;186:99–102. 30. Kornguth PJ, Keefe FJ, Conaway MR, et al. Pain during mammography: characteristics and relationship to demographic and medical variables. Pain 1996;66:187–194. 31. Scaf-Klomp W, van Sonderen FL, Stewart R, et al. Compliance after 17 years of breast cancer screening. J Med Screen 1995;2:195–199. 32. Kashikar-Zuck S, Keefe FJ, Kornguth P, et al. Pain coping and the pain experience during mammography: a preliminary study. Pain1997;73:165–172.

Vol. 25 No. 1 January 2003

Does Mammography Hurt?

63

33. Andrews FJ. Pain during mammography: implications for breast screening programmes. Australas Radiol 2001;45:113–117.

45. Kimme-Smith CM. N.W.G. Patient Comfort level vs. full breast compression required by mammography. RNSA. 2000.

34. Hafslund B. Mammography and the experience of pain and anxiety. Radiography 2000;6:269–272.

46. Poulos A, Rickard M, et al. Compression in mammography and the perception of discomfort. Australas Radiol 1997;41:247–252.

35. Melzack R, et al. The McGill Pain Questionnaire: major properties and scoring methods. Pain 1975;1: 277–299. 36. Cleeland C. Measurement of pain by subjective report. In: Chapman CR, Loeser JD, eds. Issues in pain measurement. 1989 New York: Raven. 37. Sullivan DC, Beam CA, Goodman SM, et al. Measurement of force applied during mammography. Radiology 1991;181:355–357. 38. Cockburn J, Cawson J, Hill D, et al. An analysis of reported discomfort caused by mammographic X-ray amongst attenders at an Australian pilot breast screening program. Australas Radiol 1992;36:115–119. 39. Jackson VP, Lex AM, Smith DJM, et al. Patient discomfort during screen-film mammography. Radiology 1988;168:421–423. 40. Keefe FJ, Hauck ER, Egert J, et al. Mammography pain and discomfort: a cognitive-behavioral perspective. Pain 1994;56:247–260. 41. Jensen MP, Turner LR, Turner JA, et al. The use of multiple-item scales for pain intensity measurement in chronic pain patients. Pain 1996;67:35–40.

47. Nielsen B, et al. Pain with mammography: fact or fiction? Oncol Nurs Forum 1993;20:639–642. 48. Rosenthal MH, Jhonston RE. Effect of tissue compression and image processing on fearure visible in Diffraction Enhanced Imaging. RNSA. 2000. 49. Brew MD, Billings JD, Chisolm RJ, et al. Mammography and breast pain. Australas Radiol 1989;33: 335–336. 50. Wolosin RJ. The experience of screening mammography. J Fam Pract 1989;29:499–502. 51. Nielsen BB, Miaskowski C, Dibble SL, et al. Pain and discomfort associated with film-screen mammography. J Natl Cancer Inst 1991;83:1754–1756. 52. Leaney BJ, Martin M. Breast pain associated with mammographic compression. Australas Radiol 1992; 36:120–123. 53. Fine MK, Rimer BK, Watts P, et al. Women’s responses to the mammography experience. J Am Board Fam Pract 1993;6:546–555.

42. Rutter DR, Calnan M, Vaile MS, et al. Discomfort and pain during mammography: description, prediction, and prevention. BMJ 1992;305:443–445.

54. Baskin-Smith J, Miaskowski C, Dibble SL, et al. Perceptions of the mammography experience. Cancer Nurs 1995;18:47–52.

43. Dullum JR, et al. Rates and correlates of discomfort associated with mammography. Radiology 2000; 214:547–552.

55. Aro AR, Absetz-Ylostalo P, Eerola T, et al. Pain and discomfort during mammography. Eur J Cancer 1996;32A:1674–1679.

44. Fallowfield LJ, et al. What are the psychological factors influencing attendance, non- attendance and re-attendance at a breast screening centre? J R Soc Med 1990;83:547–551.

56. Bakker DA, Lightfoot NE, Steggles S, et al. The experience and satisfaction of women attending breast cancer screening. Oncol Nurs Forum 1998; 25:115–121.