Diagnosed with breast cancer while on a family historyscreen.docx

Diagnosed with breast cancer while on a family history
screening programme: an exploratory qualitative study
A. CLEMENTS, bsc, senior research nurse, Cancer Research
UK Primary Care Education Research Group,
University of Oxford, Department of Primary Health Care,
Oxford, B.J. HENDERSON, phd, research psycholo-
gist, Institute of Medical & Social Care Research, Ardudwy,
Normal Site, University of Wales, Bangor, Gwynedd,
S. TYNDEL, ba, research officer, Cancer Research UK Primary
Care Education Research Group, University of
Oxford, Department of Primary Health Care, Oxford, G.
EVANS, md frcp, consultant in medical genetics,
Department of Clinical Genetics, St Mary’s Hospital,
Manchester, K. BRAIN, phd, senior research fellow,
Institute of Medical Genetics, University of Wales College of
Medicine, Heath Park, Cardiff, J. AUSTOKER, phd,
director, Cancer Research UK Primary Care Education Research
Group, University of Oxford, Department of
Primary Health Care, Oxford, & E. WATSON, phd, deputy
director, Cancer Research UK Primary Care Educa-
tion Research Group, University of Oxford, Department of
Primary Health Care, Oxford, UK for the PIMMS Study
Management Group*
CLEMENTS A., HENDERSON B.J., TYNDEL S., EVANS G.,
BRAIN K., AUSTOKER J. & WATSON E. FOR
THE PIMMS STUDY MANAGEMENT GROUP (2008)
European Journal of Cancer Care 17, 245–252

Mammographic screening is offered to many women under 50 in
the UK who are at moderate or high risk of
developing breast cancer because of their family history of the
disease. Little is understood about the impact
of screening on the emotional well-being of women with a
family history of breast cancer. This qualitative
study explores the value that women at increased risk placed on
screening, both pre- and post-cancer diagnosis
and the impact of the diagnosis. In-depth interviews were
undertaken with 12 women, aged 35–50, diagnosed
with breast cancer while on an annual mammographic screening
programme. Women described the strong
sense of reassurance gained from screening prior to diagnosis.
This faith in screening was reinforced by early
detection of their cancer. Reactions to diagnosis ranged from
devastation to relief at having finally developed
a long-expected condition. Despite their positive attitudes about
screening, not all women wanted to continue
with surveillance. For some, prophylactic mastectomy was
preferable, to reduce future cancer risk and to
alleviate anxieties about the detection of another cancer at each
subsequent screen. This study illustrates the
positive yet diverse attitudes towards mammographic screening
in this group of women with a family history
of breast cancer.
Keywords: breast cancer, early screening programme, family
history, qualitative.
Correspondence address: Alison Clements, Cancer Research UK
Primary Care Education Research Group, University of Oxford,
Department of Primary
Health Care, Rosemary Rue Building, Old Road Campus, Old
Road, Headington, Oxford, OX3 7LF, UK (e-mail:
[email protected]).

Ethical approval: London Multi-Centre Research Ethics
Committee (MREC) 02/2/97.
*Other members of the A Psychosocial Evaluation of the Impact
of Mammographic Surveillance Services on Women under 50 at
moderate or high risk of
inherited breast cancer (PIMMS) Study Management Group:
Stephen Duffy, Cancer Research UK Department of Statistics,
London; Hilary Fielder, Screening
Services, Velindre National Health Service (NHS) Trust;
Jonathon Gray, Institute of Medical Genetics, University
Hospital of Wales; Douglas Macmillan,
Professorial Unit of Surgery, University of Nottingham; James
MacKay, North East Thames Regional Genetics Service.
Accepted 19 June 2007
DOI: 10.1111/j.1365-2354.2007.00837.x
European Journal of Cancer Care, 2008, 17, 245–252
Original article
© 2007 The Authors
Journal compilation © 2007 Blackwell Publishing Ltd
mailto:[email protected]
I N T R O D U C T I O N
Women with a family history of breast cancer are at
increased risk of developing the disease (Pharoah et al.
1997; Emery et al. 2001). In the UK the population risk is
currently between 1:9 and 1:10; this can be increased by at
least threefold for those with a strong family history.
Annual mammographic screening is one early detection

method recommended for women from the age of 40
whose family history places them at a lifetime risk of
developing breast cancer of 1:6 or greater (NICE 2004).
Surveillance from the age of 35 can be carried out as part
of a research programme.
Mammographic screening aims to detect tumours at an
early stage when the prognosis is enhanced. While the
potential clinical benefits of screening younger women at
increased risk have not been established, evidence is
emerging to suggest that screening younger women with a
family history leads to increased survival (Maurice et al.
2006), and preliminary retrospective data suggest it is pos-
sible to identify impalpable breast cancer with regular
mammography (Gui et al. 2006). Strong evidence of effec-
tiveness in reducing mortality is important to establish if
a national programme of early screening for all women at
increased risk is to be introduced. The findings from a
large prospective study evaluating the potential clinical
benefits of mammographic surveillance in women aged
40–49 with a family history of breast cancer are expected
in 2010 (The FH01 Management Committee, Steering
Committee and Collaborators 2006).
It is equally important to understand the psychological
impact of mammographic surveillance for women with a
family history of breast cancer, particularly as a number of
studies have reported increased levels of breast cancer
worry and anxiety in this group of women (Lloyd et al.
1996; Zakowski et al. 1997; McCaul et al. 1998). The
majority of women who attend screening receive an initial
all-clear/normal screening result, and a small proportion
will be recalled for further tests prior to their all-clear
result. To date, research has focused on comparing the
psychological impact of screening on women in these two
screening result groups (Watson et al. 2004, 2005). The

focus of the present paper, however, is on women who
received a screen-detected cancer diagnosis while on a
screening programme. It is estimated that of those with a
family history who are screened every year, four women
per thousand will receive a diagnosis of breast cancer (The
FH01 Management Committee, Steering Committee and
Collaborators 2006). To our knowledge, no studies have
looked at how women react to a diagnosis of breast cancer
while on a surveillance programme because of their family
history, or how they feel about the breast screening pro-
gramme that has detected their breast cancer. This paper
presents the first qualitative data on the emotional impact
of being diagnosed with breast cancer while on a screening
programme in the UK.
P A R T I C I P A N T S A N D M E T H O D S
A qualitative study was undertaken involving interviews
with 12 women aged 35–50, diagnosed with screen-
detected breast cancer while on a mammographic surveil-
lance programme. Participants were identified from two
sources: (1) a sample of 2321 women, at moderate or high
risk of developing a familial breast cancer, who had been
recruited by 21 centres in the UK to participate in a ques-
tionnaire survey (12 women) (Henderson et al. 2007); (2)
two of the clinics identified women outside the survey
who fulfilled the eligibility criteria (7 women). All women
were approached with the consent of their clinical team.
Six women were interviewed from each of the sources.
Reasons for non-participation were (1) non-response from
the women (four women) or (2) clinicians not agreeing to
the women being contacted (three women). See Table 1 for
biographies of the participating women.
Data were collected using in-depth, semi-structured

interviews. Interviews were carried out by AC; all women
chose to be interviewed in their own homes, and inter-
views lasted between 90 and 150 min. A flexible topic
guide was used to allow exploration of issues introduced
by the participants and incorporation of additional issues
that arose from the data analysis. The broad topic areas
included experiences of breast cancer within the family,
feelings of likelihood of developing breast cancer, own
screening and cancer diagnosis experiences, views of
mammography, of overall participation in the programme
and future management of cancer risk. Each interview was
audiotaped, transcribed verbatim by a specialist transcrip-
tion service, checked for accuracy and anonymized.
Analysis was undertaken by AC, BH and ST using the
framework approach (Ritchie & Spencer 1993). Analysis
began as soon as the first interview had been undertaken,
and continued concurrently with the data collection to
allow emerging findings to be included in subsequent
interviews. Through detailed reading of the texts, an
initial coding frame was developed, using both anticipated
and emergent issues. The frame was extended and refined
as new data were generated. Broad themes, such as ‘reac-
tion to diagnosis’ were subsequently subdivided into more
specific categories, for example, ‘relief’ and ‘acceptance’.
Texts were re-read and data relating to each theme were
arranged to allow consistency and variation to be identi-
CLEMENTS et al.
© 2007 The Authors
246

fied both across interviews and within each interview.
The coding framework, categories and themes were dis-
cussed between the three analysts to ensure the credibility
and trustworthiness of the interpretation and analysis
(Mays & Pope 1995). A qualitative software package
(ATLAS-ti 2007) was used to help in the management of
the data, in particular in the comparison of issues and
experiences between participants.
F I N D I N G S
The findings we describe below relate to the women’s
reactions to participating in an enhanced breast screening
programme, and the emotional impact of their cancer
diagnosis. The themes presented occurred across the range
of participants and the quotations represent the full range
of the responses given. The bracketed number is the iden-
tifier from Table 1.
Reasons for being on the early screening programme
The reason given by most women for wanting to be on the
programme of regular mammography related to early diag-
nosis: the sooner a cancer is detected, the greater they
perceived the chance of survival to be.
. . . that’s the crucial time to catch it isn’t it, is in the
early stages, which is what I was very keen on, think-
ing well you know if I’m going to get it I want to know
as soon as it’s there . . . I was highly unlikely to be
able to detect it myself, so I wanted someone else or
some other method of being able to detect it, which
was the mammograms. [2]
As can be seen from the previous quote, related to early

detection was the greater faith most women had in mam-
mograms and clinical breast examinations than in self-
examination. With the exception of one woman, there was
Table 1. Biographies of women diagnosed with breast cancer at
an annual mammographic screen
Participant
Age at
diagnosis Risk*
Time between
interview and
diagnosis Treatment
Type of cancer as
described by
the women
Number of
previous screens
1 46 High 8 months Lumpectomy
Radiotherapy
‘Small – caught early
second lumpectomy to
remove precancerous
cells’
None
2 37 High 17 months Mastectomy
Chemotherapy
Waiting for PM

‘Very small – no lymph
nodes, not palpable’
2
3 45 Moderate 5 months Mastectomy
Receiving chemotherapy
Waiting for PM
‘Grade 3 aggressive
cancer, many lymph
nodes involved’
11
Radiotherapy
‘Area of precancerous
cells, no lymph nodes’
5
Radiotherapy
nodes’
3
6 43 High 10 months PM
Chemotherapy
Waiting for
reconstruction

‘Aggressive’ 4
7 46 Moderate 12 months Lumpectomy
Radiotherapy and
chemotherapy
Waiting for PO
‘Small grade 3 –
aggressive’
4
8 47 High 5 months Receiving radiotherapy ‘Very small – no
lymph
nodes’
8
Radiotherapy
nodes’
None
10 40 High 37 months Mastectomy ‘Very mild’ None
Reconstruction
‘Preinvasive cancer’ (both
breasts)

20
12 50 Moderate 30 months PM
Chemotherapy
Reconstruction
‘Very small – early stage
1 lymph node
involved’
8
*Family history risk as provided by the screening clinic.
PM, prophylactic bilateral mastectomy; PO, prophylactic
oophorectomy.
Familial breast cancer diagnosis at an annual mammographic
screen
© 2007 The Authors
247
a tendency not to self-examine on a regular basis. The
experience was described as ‘painful’ and ‘worrying’ by
those with what they described as large, tender or lumpy
breasts. Lack of faith in their ability to differentiate a
potential cancerous lump from a harmless nodule made
some prefer not to self-examine.
. . . if I hadn’t have been screened, well I just dread to
think what would have happened, because I did breast
checks infrequently. Interviewer (I): You weren’t

checking regularly? No because it just made me feel
sick doing it. In case there was . . . and I know it’s
stupid, but in case there was anything there. [3]
What early screening gave the women – feelings before
the cancer diagnosis
The value that the women placed on being in the early
screening programme was striking. There was variety in
the understanding that women had about the effectiveness
of screening – some women felt that if a cancer was there,
it would be detected; others knew that not all cancers could
be picked up and that screening for women under 50 years
old was generally less effective than for older women.
There was, however, no difference in the reassurance
described by the women in terms of the reassurance that
screening offered. ‘Relief’, ‘peace of mind’, ‘safety net’ were
very common descriptions of the women’s feelings about
what screening meant to them. One woman reflects this in
her description that mammography gave her:
. . . the confidence and reassurance that I could just
forget about it (fear of developing breast cancer) now
until the following year. [6]
The security offered by mammography was also described
in the following way:
I don’t think the mammography so much was the
anxiety, it was the fact that you sit down in front of
the doctor and who goes through your genetic tree and
says your risk is, and that’s the frightening bit. and
the mammography was the safety aspect to it. [3]
For one woman, having regular and early screening took
away the worry of developing cancer. She felt that if

cancer was detected, the outcome would be far more posi-
tive than it had been for her relative.
We always thought if any of us had breast cancer,
because we were part of the screening programme, we
would never be in the same situation that our sister
was in, we were never going to be that bad. She was
one side and we were the other. I: In terms of the
potential outcome, do you mean? Yes, the severity
of the disease would be nothing like my sister had.
It was very aggressive. It was a very aggressive
cancer . . . I: Do you know what it was that made you
feel it would be very different for you . . . ‘Early
detection. If you’re having them every year they
would be detected at a much earlier stage’. [12]
Reaction to diagnosis
There was a marked difference in women’s reactions to
their cancer diagnosis. For several women, the diagnosis
brought with it a sense of relief. A relief that finally the
cancer had been diagnosed. As the following two quotes
show, this reaction can be understood in the context of
having for years lived with the fear of developing breast
cancer.
. . . it was like an expected, something we were
expecting, so once it had turned up it was like okay
we can deal with it now, whereas like before we were
thinking oh when’s it going to be and you know is it
going to turn up, isn’t it going to turn up, and you’re
almost living – not living on the edge but . . . you have
that, so it probably sounds really weird doesn’t it,
saying it was almost like a relief . . . [2]

Initially it was quite a shock. I felt quite shocked by it.
and I have to say, it was a really strange feeling, and it
probably sounds horrible, but I was almost relieved
when I was diagnosed. Because I thought this dark
cloud, that I’ve always been waiting for, is finally here.
I don’t have to wait for it any longer. I can deal with it
now and get it over and done with. I know it sounds
really strange but there was almost a feeling of relief. I
mean obviously initially not, I was shocked. [11]
For some, there was nothing positive about the diagnosis.
One woman described herself as being absolutely devas-
tated when she developed breast cancer; for her, the diag-
nosis was completely traumatic. Having been told she had
a one-in-four chance of developing breast cancer, she had
interpreted this as:
. . . my stakes were pretty high really on not getting it,
and it never really affected my life . . . I managed to
get through life thinking I was never going to get it
and that’s how I coped with it. [6]
While some women did not describe a sense of relief, they
did describe resignation, an acceptance of the diagnosis,
and a feeling of knowing that what they had felt was
inevitable had finally happened and they would now deal
with it.
CLEMENTS et al.
© 2007 The Authors
248

. . . no, I certainly wouldn’t have liked to have
thought right I want to have it just so that then I can
move on. No, not at all . . . when you were younger
and . . . more at risk? No. No. My anxieties were
please don’t let me get it, not right just give it to me
and I can move on. No not at all. Yeah. You’re not
shock, shocked when you get the phone call, because
you know you’re at risk, but you are instead shocked
that well this is it, it’s happened now . . . [3]
Feelings about mammography after the detection
of cancer
Perhaps not surprisingly, all the women were overwhelm-
ingly positive in their attitudes to having had a mammo-
gram. Their diagnosis had come early enough for
treatment to be beneficial. This was most noticeable for
women whose cancers could not be felt even when seen
on the mammogram, although women whose cancers
were at a more advanced stage still felt mammography had
given them the opportunity for curative treatment.
I: How do you feel about accepting the offer that they
made of being on the screening programme? Elated!
(laughs) Because as I say the way I look at it, if I hadn’t
been on that screening I’d be dead, because it being a
grade three, I wouldn’t have found that lump possibly
for a couple of years, by which time it would be too
late for treatment basically because by that time, with
it being a grade three, it would have gone through my
body and it would have been elsewhere and that
would have been a horrible prognosis I think, defi-
nitely. So I’m eternally grateful for being on it. [7]
Anticipated reactions to future screening

Despite the overwhelmingly positive reaction to mam-
mography, there were differences between the women’s
reactions to the ongoing management of their cancer risk.
Not all women wanted to continue with surveillance by
yearly mammography. Some described wanting to rid
themselves of the anxiety that they felt regular screening
would provoke, and in preference selected bilateral mas-
tectomy as their treatment of choice.
I don’t want to have any more screening done,
because you’re looking for something again aren’t
you, you know. So if I’ve had my breasts removed
there’s nothing left for anybody to screen . . . I just
want to get rid of the anxiety now, of having to go
back for regular . . . it was like a reassurance before,
whereas like now I’m thinking I don’t want you to
look, just remove whatever you need to remove . . . [2]
. . . if I hadn’t have had my other breast off, I think I
would have had fear then, every time I had a mam-
mogram I would have been more fearful . . . So I had
bilateral mastectomy which, I had no difficulty
making that decision at all. I just didn’t want to live
under the cloud every year of having mammograms
on the other breast. [12]
Another woman who no longer wanted to continue
with screening also selected bilateral mastectomy as
her treatment of choice, as she wanted a minimal
chance of the cancer returning. Her mother had
experienced two recurrences following her initial
breast cancer, and she herself had suffered a very
powerful emotional reaction to her chemotherapy
regime. [6]

Those who felt that they would carry on with screening
described an anticipation of feeling more anxious at the
time of the next mammogram, fearful that a second diag-
nosis might be made. Despite this, the first diagnosis was
translated into a positive reason to maintain screening. If
a further cancer did develop, the women had faith that it
would again be detected by mammography.
I think if I got called up again, and they found another
one I’d be fed-up obviously, you know if they said
“Sorry Mrs xxx we’ve found another one in here”, I’d
just say ‘Right well take it out.’ You know what else
can you do? [5]
Women had not always anticipated their reactions to
future management. One woman, who had felt a strong
sense of relief at the point of diagnosis, had initially
decided to undergo bilateral mastectomy. This was based
on her feeling ‘. . . how much of my life do I want to spend
thinking I’m going to get cancer?’. She subsequently
changed her mind about treatment and decided to con-
tinue with screening, having become aware that her
worries about dealing with cancer were now less than they
had been prior to her diagnosis.
I hope I’m right in thinking this, but in another year
or two if they tell me they’ve found something else I
do feel as though I’ll probably be a lot more sort of oh
okay, right what happens next? I think I’ll deal with it
better than I thought I would in the first place you
know. As I say I’ve dealt with it all right actually this
time . . . much better than I thought I would . . . [8]
D I S C U S S I O N
This study has highlighted both commonalities and diver-

sities in the women’s reactions to mammographic surveil-
screen
© 2007 The Authors
249
lance and to a cancer diagnosis. The perceived value of
early detection gave women a strong sense of reassurance
during the time they were receiving screening, and the
detection of their cancer at a sufficiently early stage to
warrant potentially curative treatments confirmed their
faith in the screening programme. Specific reactions to the
diagnosis varied, from a sense of relief that finally the wait
was over, to intense shock. Despite the positive attitudes
towards mammography, both pre- and post-diagnosis, not
all women wanted to continue mammographic screening,
preferring bilateral mastectomy both to reduce risk and to
alleviate continuing concerns.
When asked to reflect back on their feelings about the
screening programme before their diagnosis of breast
cancer, most women described the security afforded by
the screening programme and their belief that any cancers
would be detected at an early stage. While some women
highlighted issues to do with effectiveness of screening for
younger women, this seemed not to influence the relief
they obtained from receiving an all-clear result. The faith
in mammography held by women has been highlighted in
another qualitative study exploring beliefs and expecta-
tions of women under 50 years old regarding screening

mammography in the general population (Nekhlyudov
et al. 2003). In both this and our study, all women had
positive attitudes towards screening mammography; the
perceived risks of mammograms were seen to be minimal,
and the women’s feelings did not reflect the current con-
troversy about the value of screening in women under 50
(Moss 2004).
While repeated regular self-examination is not currently
advocated, breast awareness involves being responsive to
potential changes, which may be seen or felt (‘Be Breast
Aware’ leaflet 2006). A number of women in our study
voiced concerns about examining their own breasts, a
finding which has also been reported in other qualitative
studies (Salazar & Carter 1994; Persson et al. 1997). Some
questioned how reliable self-examination is as a means of
detecting breast symptoms, and also described being
inhibited from touching their breasts through fear of
detecting a symptom. It may be that these apprehensions
increased the trust placed in early screening. This finding
is slightly at odds with a study of adherence to self-
examination in women with a family history of breast
cancer (Brain et al. 1999) in which an association between
increased general anxiety and cancer worries, and hyper-
vigilant self-examination was seen. It may be beneficial
for women to have detailed discussions with their care
teams to ensure that any concerns they have are under-
stood, and where possible barriers to maintaining breast
awareness are diminished.
One of the unexpected findings from this study was the
positive reaction by some women to their cancer diagnosis,
describing feelings of relief, while other women seemed
accepting of their situation, and only one woman described
the emotional devastation the cancer diagnosis had
brought to her. One suggestion for these findings is the

reduction of uncertainty in the threatening situation of
being at risk of developing breast cancer. Individuals vary
in their need for certainty (Frenkel-Brunswick 1949;
Kruglanski 1989), and this has been shown to be related to
motivations to undergo genetic testing (Croyle et al. 1995;
Henderson et al. 2006). It could be that the women who
describe feeling relieved at their diagnosis prefer the cer-
tainty of the situation compared to the ambiguous one of
being at risk. A further potential explanation is that the
years during which the women have been at risk have
enabled them to prepare psychologically for their diagnosis
of breast cancer. The diagnosis is therefore not as shocking
or devastating as it may be for women without a family
history because their expectations have been confirmed.
The highly positive views that women held of mam-
mography after their diagnosis of cancer are comparable to
those of other women diagnosed with screen-detected
cancers (Farmer 2000; Miles et al. 2003), who seem to
have lower levels of psychological morbidity compared
with women with symptomatically detected cancer.
Farmer demonstrated that women with screen-detected
breast cancer received more reassurance by doctors that
their cancer had been caught at an early stage, which in
turn led to a minimization of the significance of screen-
detected cancer.
While all women described their full appreciation of the
screening programme, prior to and following the detection
of their cancer, not all wanted to continue with annual
mammography, with some preferring bilateral mastec-
tomy as their management choice. It is possible that the
surveillance and care offered by the programme conferred a
high level of psychological protection as long as no cancer
was detected. For some women, once the diagnosis was
made, and regardless of their reaction to it, surveillance

was no longer sufficient. Greater security could be gained
from reducing the risk of recurrence as far as was possible,
even if this meant undergoing more radical surgery than
was clinically warranted. It may also be that for some of
these women, their diagnosis would have confirmed they
were likely high-risk gene mutation carriers, and their risk
of a contralateral breast cancer may have exceeded their
previous counselled risk of breast cancer. Previous work
has shown that many women in this situation who have
been properly counselled about this future risk have opted
for risk-reducing surgery (Evans et al. 2005).
CLEMENTS et al.
© 2007 The Authors
250
The value of qualitative research lies in the depth of
understanding gained from detailed descriptions of spe-
cific experiences. For this reason, the number of partici-
pants in a qualitative study is necessarily small. Although
it was the restricted number of women available to us,
rather than data saturation that determined our sample
size, the views of the 12 women included in this study are
a valuable addition to the scarcity of literature regarding
women who are diagnosed with breast cancer while on a
family history screening programme. One limitation to
the study is that the views of the women who declined, or
were not approached to participate, may have added even
more to our understanding, particularly as they may have
been more adversely affected by their diagnosis and their
cancers may have been diagnosed at a more advanced

stage. It may be useful in future work to attempt to deter-
mine specific reasons for non-participation, to estimate
how far the findings from this study can be translated to
other women in the same situation.
Several clinical implications arise from this study. Not
all women diagnosed with breast cancer while on a family
history screening programme will have a pronounced
negative reaction to their diagnosis; indeed a number may
feel relieved that they have finally developed the condi-
tion that has been long expected. The period while they
are under threat of developing the condition may be a time
of psychological preparation for the women, which helps
them adjust more readily to their diagnosis. We have also
identified that women may select bilateral mastectomy as
their treatment of choice, although clinically, their cancer
may warrant a less radical approach. Surgeons need to be
aware that women may have a need to reduce, as far as is
possible, the risk of a future cancer, or alleviate totally the
fears associated with future screening. Although women
place significant emphasis on the early detection of
cancer, self-examination, as part of maintaining breast
awareness between annual mammograms, is often not
practised. It may help to identify women who may be
averse to self-examination, to see if the reasons for avoid-
ance can be overcome. We have shown that being diag-
nosed with cancer for the women in this study has not
been solely a negative experience. It may therefore benefit
asymptomatic women, who are particularly distressed
about their likelihood of developing breast cancer, to be
involved in a mentoring system with those who have
experienced the process of diagnosis and treatment in
order to improve their perceptions of their ability to cope
with a potential diagnosis of cancer.
Extending this work with a larger number of women

could enable an exploration for patterns within psycho-
logical reactions to screening and diagnosis, and pragmatic
reactions to risk management. Future work also needs to
explore the experiences of women who have put their
faith in a screening programme but whose cancers have
not been detected by an annual mammogram, or whose
cancers are at a much more advanced stage at the point of
diagnosis.
A C K N O W L E D G E M E N T S
We would like to thank those at the following centres who
helped in the recruitment of patients to this study: Breast
Test Wales – North, South East and South West Wales;
Royal Cornwall Hospital; Withington Hospital, Manches-
ter; Nottingham City Hospital and in particular Dinah
Winstone and Sue Thomas who facilitated this process.
We are indebted to the women who gave their time and
shared their experiences.
This work was supported by Cancer Research UK, grant
number C73/A2916.
R E F E R E N C E S
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© 2007 The Authors

252
http://www.nice.org.uk/pdf/CG014quickrefguide.pdf
One strong direction will be to bring in an outside and
contemporary artwork or works that would make a great
comparative study and help to progress your narrative and
connections between the past and the present.
Or, you could further discuss the elements and principles of art
focusing on a particular element or principle.
Or, possibly talk about the iconography more extensively.
Deliverables:
· 2 Page commentary focused on one work of art in proper MLA
forma by February 18.
My chosen artwork is The Louvre Museum in comparison to
pyramids, particularly to the Great Pyramid of Giza.
Research Evaluation Checklist
Complete the checklist below for the study/article you are to
evaluate.
Define topic and need.
· What phenomenon does the study investigate?

· Is the phenomenon a problem, an opportunity, or a dilemma?
· What symptoms (easily observable signs) indicate that it is a
problem, opportunity or a dilemma?
· How do people who know this organization explain these
symptoms? What do administrators want to know about the
phenomenon?
· How can it be expressed in manageable terms?
Assess relevant knowledge.
· How much is already known?
· Is additional background information necessary? Should this
research be conducted?
· Is the topic a special case of a broader, more fundamental and
important problem?
Identify variables and measures, and research questions and
hypotheses.
· What variables associated with the phenomenon are
investigated? How are the variables measured?
· What are the research questions?
· What specific hypotheses are formulated?
Identify and analyze the research design.
· What is the research design—exploratory, descriptive, or
causal research? Is this non-experimental, quasi-experimental,
or experimental research? What is the nature of data—primary

or secondary?
· What is the source of data—interviews, questionnaires,
existing databases? Are answers obtained through interviews
and questionnaires objective?
Analyze the sample.
· What is the population from which the respondents have been
selected? How large is the sample?
· Is it random, stratified, or other sample?
Gather data.
· How are data gathered?
· Does the procedure of gathering data ensure objectivity?
Analyze data.
· Are the data words (qualitative data) or numbers
(quantitative)? How are qualitative data analyzed?
· How are quantitative data recorded and checked for accuracy?
What statistical methods are used to analyze data?
Assess results.
· What are the answers to research questions? Are hypotheses
supported?
· What evidence did the study produce that helps answer
research questions or support/refute hypotheses?
Evaluate recommendations.

What recommendations can be made on the basis of results?
What recommendations are made that cannot be supported with
results?
Evaluate the study.
· What limitations does the study have?
· What improvements in research design can be recommended?
Page 1 of 3
Research Methods in Health Administration
A. CLEMENTS, bsc, senior research nurse, Cancer Research
UK Primary Care Education Research Group,
University of Oxford, Department of Primary Health Care,
Oxford, B.J. HENDERSON, phd, research psycholo-
gist, Institute of Medical & Social Care Research, Ardudwy,
Normal Site, University of Wales, Bangor, Gwynedd,
S. TYNDEL, ba, research officer, Cancer Research UK Primary
Care Education Research Group, University of
Oxford, Department of Primary Health Care, Oxford, G.
EVANS, md frcp, consultant in medical genetics,
Department of Clinical Genetics, St Mary’s Hospital,
Manchester, K. BRAIN, phd, senior research fellow,

Institute of Medical Genetics, University of Wales College of
Medicine, Heath Park, Cardiff, J. AUSTOKER, phd,
director, Cancer Research UK Primary Care Education Research
Group, University of Oxford, Department of
Primary Health Care, Oxford, & E. WATSON, phd, deputy
director, Cancer Research UK Primary Care Educa-
tion Research Group, University of Oxford, Department of
Primary Health Care, Oxford, UK for the PIMMS Study
Management Group*
CLEMENTS A., HENDERSON B.J., TYNDEL S., EVANS G.,
BRAIN K., AUSTOKER J. & WATSON E. FOR
THE PIMMS STUDY MANAGEMENT GROUP (2008)
European Journal of Cancer Care 17, 245–252
Mammographic screening is offered to many women under 50 in
the UK who are at moderate or high risk of
developing breast cancer because of their family history of the
disease. Little is understood about the impact
of screening on the emotional well-being of women with a
family history of breast cancer. This qualitative
study explores the value that women at increased risk placed on
screening, both pre- and post-cancer diagnosis
and the impact of the diagnosis. In-depth interviews were
undertaken with 12 women, aged 35–50, diagnosed
with breast cancer while on an annual mammographic screening
programme. Women described the strong
sense of reassurance gained from screening prior to diagnosis.
This faith in screening was reinforced by early
detection of their cancer. Reactions to diagnosis ranged from
devastation to relief at having finally developed
a long-expected condition. Despite their positive attitudes about
screening, not all women wanted to continue
with surveillance. For some, prophylactic mastectomy was

preferable, to reduce future cancer risk and to
alleviate anxieties about the detection of another cancer at each
subsequent screen. This study illustrates the
positive yet diverse attitudes towards mammographic screening
in this group of women with a family history
of breast cancer.
Keywords: breast cancer, early screening programme, family
history, qualitative.
Correspondence address: Alison Clements, Cancer Research UK
Primary Care Education Research Group, University of Oxford,
Department of Primary
Health Care, Rosemary Rue Building, Old Road Campus, Old
Road, Headington, Oxford, OX3 7LF, UK (e-mail:
[email protected]).
Ethical approval: London Multi-Centre Research Ethics
Committee (MREC) 02/2/97.
*Other members of the A Psychosocial Evaluation of the Impact
of Mammographic Surveillance Services on Women under 50 at
moderate or high risk of
inherited breast cancer (PIMMS) Study Management Group:
Stephen Duffy, Cancer Research UK Department of Statistics,
London; Hilary Fielder, Screening
Services, Velindre National Health Service (NHS) Trust;
Jonathon Gray, Institute of Medical Genetics, University
Hospital of Wales; Douglas Macmillan,
Professorial Unit of Surgery, University of Nottingham; James
MacKay, North East Thames Regional Genetics Service.
Accepted 19 June 2007
DOI: 10.1111/j.1365-2354.2007.00837.x
European Journal of Cancer Care, 2008, 17, 245–252

Original article
© 2007 The Authors
mailto:[email protected]
I N T R O D U C T I O N
Women with a family history of breast cancer are at
increased risk of developing the disease (Pharoah et al.
1997; Emery et al. 2001). In the UK the population risk is
currently between 1:9 and 1:10; this can be increased by at
least threefold for those with a strong family history.
Annual mammographic screening is one early detection
method recommended for women from the age of 40
whose family history places them at a lifetime risk of
developing breast cancer of 1:6 or greater (NICE 2004).
Surveillance from the age of 35 can be carried out as part
of a research programme.
Mammographic screening aims to detect tumours at an
early stage when the prognosis is enhanced. While the
potential clinical benefits of screening younger women at
increased risk have not been established, evidence is
emerging to suggest that screening younger women with a
family history leads to increased survival (Maurice et al.
2006), and preliminary retrospective data suggest it is pos-
sible to identify impalpable breast cancer with regular
mammography (Gui et al. 2006). Strong evidence of effec-
tiveness in reducing mortality is important to establish if
a national programme of early screening for all women at
increased risk is to be introduced. The findings from a
large prospective study evaluating the potential clinical

benefits of mammographic surveillance in women aged
40–49 with a family history of breast cancer are expected
in 2010 (The FH01 Management Committee, Steering
Committee and Collaborators 2006).
It is equally important to understand the psychological
impact of mammographic surveillance for women with a
family history of breast cancer, particularly as a number of
studies have reported increased levels of breast cancer
worry and anxiety in this group of women (Lloyd et al.
1996; Zakowski et al. 1997; McCaul et al. 1998). The
majority of women who attend screening receive an initial
all-clear/normal screening result, and a small proportion
will be recalled for further tests prior to their all-clear
result. To date, research has focused on comparing the
psychological impact of screening on women in these two
screening result groups (Watson et al. 2004, 2005). The
focus of the present paper, however, is on women who
received a screen-detected cancer diagnosis while on a
screening programme. It is estimated that of those with a
family history who are screened every year, four women
per thousand will receive a diagnosis of breast cancer (The
FH01 Management Committee, Steering Committee and
Collaborators 2006). To our knowledge, no studies have
looked at how women react to a diagnosis of breast cancer
while on a surveillance programme because of their family
history, or how they feel about the breast screening pro-
gramme that has detected their breast cancer. This paper
presents the first qualitative data on the emotional impact
of being diagnosed with breast cancer while on a screening
programme in the UK.
P A R T I C I P A N T S A N D M E T H O D S
A qualitative study was undertaken involving interviews

with 12 women aged 35–50, diagnosed with screen-
detected breast cancer while on a mammographic surveil-
lance programme. Participants were identified from two
sources: (1) a sample of 2321 women, at moderate or high
risk of developing a familial breast cancer, who had been
recruited by 21 centres in the UK to participate in a ques-
tionnaire survey (12 women) (Henderson et al. 2007); (2)
two of the clinics identified women outside the survey
who fulfilled the eligibility criteria (7 women). All women
were approached with the consent of their clinical team.
Six women were interviewed from each of the sources.
Reasons for non-participation were (1) non-response from
the women (four women) or (2) clinicians not agreeing to
the women being contacted (three women). See Table 1 for
biographies of the participating women.
Data were collected using in-depth, semi-structured
interviews. Interviews were carried out by AC; all women
chose to be interviewed in their own homes, and inter-
views lasted between 90 and 150 min. A flexible topic
guide was used to allow exploration of issues introduced
by the participants and incorporation of additional issues
that arose from the data analysis. The broad topic areas
included experiences of breast cancer within the family,
feelings of likelihood of developing breast cancer, own
screening and cancer diagnosis experiences, views of
mammography, of overall participation in the programme
and future management of cancer risk. Each interview was
audiotaped, transcribed verbatim by a specialist transcrip-
tion service, checked for accuracy and anonymized.
Analysis was undertaken by AC, BH and ST using the
framework approach (Ritchie & Spencer 1993). Analysis
began as soon as the first interview had been undertaken,
and continued concurrently with the data collection to
allow emerging findings to be included in subsequent

interviews. Through detailed reading of the texts, an
initial coding frame was developed, using both anticipated
and emergent issues. The frame was extended and refined
as new data were generated. Broad themes, such as ‘reac-
tion to diagnosis’ were subsequently subdivided into more
specific categories, for example, ‘relief’ and ‘acceptance’.
Texts were re-read and data relating to each theme were
arranged to allow consistency and variation to be identi-
CLEMENTS et al.
© 2007 The Authors
246
fied both across interviews and within each interview.
The coding framework, categories and themes were dis-
cussed between the three analysts to ensure the credibility
and trustworthiness of the interpretation and analysis
(Mays & Pope 1995). A qualitative software package
(ATLAS-ti 2007) was used to help in the management of
the data, in particular in the comparison of issues and
experiences between participants.
F I N D I N G S
The findings we describe below relate to the women’s
reactions to participating in an enhanced breast screening
programme, and the emotional impact of their cancer
diagnosis. The themes presented occurred across the range
of participants and the quotations represent the full range
of the responses given. The bracketed number is the iden-
tifier from Table 1.

Reasons for being on the early screening programme
The reason given by most women for wanting to be on the
programme of regular mammography related to early diag-
nosis: the sooner a cancer is detected, the greater they
perceived the chance of survival to be.
. . . that’s the crucial time to catch it isn’t it, is in the
early stages, which is what I was very keen on, think-
ing well you know if I’m going to get it I want to know
as soon as it’s there . . . I was highly unlikely to be
able to detect it myself, so I wanted someone else or
some other method of being able to detect it, which
was the mammograms. [2]
As can be seen from the previous quote, related to early
detection was the greater faith most women had in mam-
mograms and clinical breast examinations than in self-
examination. With the exception of one woman, there was
Table 1. Biographies of women diagnosed with breast cancer at
an annual mammographic screen
Participant
Age at
diagnosis Risk*
Time between
interview and
diagnosis Treatment
Type of cancer as
described by
the women

Number of
previous screens
Radiotherapy
‘Small – caught early
second lumpectomy to
remove precancerous
cells’
None
2 37 High 17 months Mastectomy
Chemotherapy
Waiting for PM
nodes, not palpable’
2
3 45 Moderate 5 months Mastectomy
Receiving chemotherapy
Waiting for PM
‘Grade 3 aggressive
cancer, many lymph
nodes involved’
11
Radiotherapy
‘Area of precancerous

cells, no lymph nodes’
5
Radiotherapy
nodes’
3
Chemotherapy
Waiting for
reconstruction
‘Aggressive’ 4
7 46 Moderate 12 months Lumpectomy
Radiotherapy and
chemotherapy
Waiting for PO
‘Small grade 3 –
aggressive’
4
8 47 High 5 months Receiving radiotherapy ‘Very small – no
lymph
nodes’
8

Radiotherapy
nodes’
None
10 40 High 37 months Mastectomy ‘Very mild’ None
Reconstruction
‘Preinvasive cancer’ (both
breasts)
20
12 50 Moderate 30 months PM
Chemotherapy
Reconstruction
‘Very small – early stage
1 lymph node
involved’
8
*Family history risk as provided by the screening clinic.
PM, prophylactic bilateral mastectomy; PO, prophylactic
oophorectomy.
screen

© 2007 The Authors
247
a tendency not to self-examine on a regular basis. The
experience was described as ‘painful’ and ‘worrying’ by
those with what they described as large, tender or lumpy
breasts. Lack of faith in their ability to differentiate a
potential cancerous lump from a harmless nodule made
some prefer not to self-examine.
. . . if I hadn’t have been screened, well I just dread to
think what would have happened, because I did breast
checks infrequently. Interviewer (I): You weren’t
checking regularly? No because it just made me feel
sick doing it. In case there was . . . and I know it’s
stupid, but in case there was anything there. [3]
What early screening gave the women – feelings before
the cancer diagnosis
The value that the women placed on being in the early
screening programme was striking. There was variety in
the understanding that women had about the effectiveness
of screening – some women felt that if a cancer was there,
it would be detected; others knew that not all cancers could
be picked up and that screening for women under 50 years
old was generally less effective than for older women.
There was, however, no difference in the reassurance
described by the women in terms of the reassurance that
screening offered. ‘Relief’, ‘peace of mind’, ‘safety net’ were
very common descriptions of the women’s feelings about
what screening meant to them. One woman reflects this in

her description that mammography gave her:
. . . the confidence and reassurance that I could just
forget about it (fear of developing breast cancer) now
until the following year. [6]
The security offered by mammography was also described
in the following way:
I don’t think the mammography so much was the
anxiety, it was the fact that you sit down in front of
the doctor and who goes through your genetic tree and
says your risk is, and that’s the frightening bit. and
the mammography was the safety aspect to it. [3]
For one woman, having regular and early screening took
away the worry of developing cancer. She felt that if
cancer was detected, the outcome would be far more posi-
tive than it had been for her relative.
We always thought if any of us had breast cancer,
because we were part of the screening programme, we
would never be in the same situation that our sister
was in, we were never going to be that bad. She was
one side and we were the other. I: In terms of the
potential outcome, do you mean? Yes, the severity
of the disease would be nothing like my sister had.
It was very aggressive. It was a very aggressive
cancer . . . I: Do you know what it was that made you
feel it would be very different for you . . . ‘Early
detection. If you’re having them every year they
would be detected at a much earlier stage’. [12]
Reaction to diagnosis

There was a marked difference in women’s reactions to
their cancer diagnosis. For several women, the diagnosis
brought with it a sense of relief. A relief that finally the
cancer had been diagnosed. As the following two quotes
show, this reaction can be understood in the context of
having for years lived with the fear of developing breast
cancer.
. . . it was like an expected, something we were
expecting, so once it had turned up it was like okay
we can deal with it now, whereas like before we were
thinking oh when’s it going to be and you know is it
going to turn up, isn’t it going to turn up, and you’re
almost living – not living on the edge but . . . you have
that, so it probably sounds really weird doesn’t it,
saying it was almost like a relief . . . [2]
Initially it was quite a shock. I felt quite shocked by it.
and I have to say, it was a really strange feeling, and it
probably sounds horrible, but I was almost relieved
when I was diagnosed. Because I thought this dark
cloud, that I’ve always been waiting for, is finally here.
I don’t have to wait for it any longer. I can deal with it
now and get it over and done with. I know it sounds
really strange but there was almost a feeling of relief. I
mean obviously initially not, I was shocked. [11]
For some, there was nothing positive about the diagnosis.
One woman described herself as being absolutely devas-
tated when she developed breast cancer; for her, the diag-
nosis was completely traumatic. Having been told she had
a one-in-four chance of developing breast cancer, she had
interpreted this as:
. . . my stakes were pretty high really on not getting it,
and it never really affected my life . . . I managed to

get through life thinking I was never going to get it
and that’s how I coped with it. [6]
While some women did not describe a sense of relief, they
did describe resignation, an acceptance of the diagnosis,
and a feeling of knowing that what they had felt was
inevitable had finally happened and they would now deal
with it.
CLEMENTS et al.
© 2007 The Authors
248
. . . no, I certainly wouldn’t have liked to have
thought right I want to have it just so that then I can
move on. No, not at all . . . when you were younger
and . . . more at risk? No. No. My anxieties were
please don’t let me get it, not right just give it to me
and I can move on. No not at all. Yeah. You’re not
shock, shocked when you get the phone call, because
you know you’re at risk, but you are instead shocked
that well this is it, it’s happened now . . . [3]
Feelings about mammography after the detection
of cancer
Perhaps not surprisingly, all the women were overwhelm-
ingly positive in their attitudes to having had a mammo-
gram. Their diagnosis had come early enough for
treatment to be beneficial. This was most noticeable for
women whose cancers could not be felt even when seen

on the mammogram, although women whose cancers
were at a more advanced stage still felt mammography had
given them the opportunity for curative treatment.
I: How do you feel about accepting the offer that they
made of being on the screening programme? Elated!
(laughs) Because as I say the way I look at it, if I hadn’t
been on that screening I’d be dead, because it being a
grade three, I wouldn’t have found that lump possibly
for a couple of years, by which time it would be too
late for treatment basically because by that time, with
it being a grade three, it would have gone through my
body and it would have been elsewhere and that
would have been a horrible prognosis I think, defi-
nitely. So I’m eternally grateful for being on it. [7]
Anticipated reactions to future screening
Despite the overwhelmingly positive reaction to mam-
mography, there were differences between the women’s
reactions to the ongoing management of their cancer risk.
Not all women wanted to continue with surveillance by
yearly mammography. Some described wanting to rid
themselves of the anxiety that they felt regular screening
would provoke, and in preference selected bilateral mas-
tectomy as their treatment of choice.
I don’t want to have any more screening done,
because you’re looking for something again aren’t
you, you know. So if I’ve had my breasts removed
there’s nothing left for anybody to screen . . . I just
want to get rid of the anxiety now, of having to go
back for regular . . . it was like a reassurance before,
whereas like now I’m thinking I don’t want you to
look, just remove whatever you need to remove . . . [2]

. . . if I hadn’t have had my other breast off, I think I
would have had fear then, every time I had a mam-
mogram I would have been more fearful . . . So I had
bilateral mastectomy which, I had no difficulty
making that decision at all. I just didn’t want to live
under the cloud every year of having mammograms
on the other breast. [12]
Another woman who no longer wanted to continue
with screening also selected bilateral mastectomy as
her treatment of choice, as she wanted a minimal
chance of the cancer returning. Her mother had
experienced two recurrences following her initial
breast cancer, and she herself had suffered a very
powerful emotional reaction to her chemotherapy
regime. [6]
Those who felt that they would carry on with screening
described an anticipation of feeling more anxious at the
time of the next mammogram, fearful that a second diag-
nosis might be made. Despite this, the first diagnosis was
translated into a positive reason to maintain screening. If
a further cancer did develop, the women had faith that it
would again be detected by mammography.
I think if I got called up again, and they found another
one I’d be fed-up obviously, you know if they said
“Sorry Mrs xxx we’ve found another one in here”, I’d
just say ‘Right well take it out.’ You know what else
can you do? [5]
Women had not always anticipated their reactions to
future management. One woman, who had felt a strong
sense of relief at the point of diagnosis, had initially
decided to undergo bilateral mastectomy. This was based
on her feeling ‘. . . how much of my life do I want to spend

thinking I’m going to get cancer?’. She subsequently
changed her mind about treatment and decided to con-
tinue with screening, having become aware that her
worries about dealing with cancer were now less than they
had been prior to her diagnosis.
I hope I’m right in thinking this, but in another year
or two if they tell me they’ve found something else I
do feel as though I’ll probably be a lot more sort of oh
okay, right what happens next? I think I’ll deal with it
better than I thought I would in the first place you
know. As I say I’ve dealt with it all right actually this
time . . . much better than I thought I would . . . [8]
D I S C U S S I O N
This study has highlighted both commonalities and diver-
sities in the women’s reactions to mammographic surveil-
screen
© 2007 The Authors
249
lance and to a cancer diagnosis. The perceived value of
early detection gave women a strong sense of reassurance
during the time they were receiving screening, and the
detection of their cancer at a sufficiently early stage to
warrant potentially curative treatments confirmed their
faith in the screening programme. Specific reactions to the
diagnosis varied, from a sense of relief that finally the wait

was over, to intense shock. Despite the positive attitudes
towards mammography, both pre- and post-diagnosis, not
all women wanted to continue mammographic screening,
preferring bilateral mastectomy both to reduce risk and to
alleviate continuing concerns.
When asked to reflect back on their feelings about the
screening programme before their diagnosis of breast
cancer, most women described the security afforded by
the screening programme and their belief that any cancers
would be detected at an early stage. While some women
highlighted issues to do with effectiveness of screening for
younger women, this seemed not to influence the relief
they obtained from receiving an all-clear result. The faith
in mammography held by women has been highlighted in
another qualitative study exploring beliefs and expecta-
tions of women under 50 years old regarding screening
mammography in the general population (Nekhlyudov
et al. 2003). In both this and our study, all women had
positive attitudes towards screening mammography; the
perceived risks of mammograms were seen to be minimal,
and the women’s feelings did not reflect the current con-
troversy about the value of screening in women under 50
(Moss 2004).
While repeated regular self-examination is not currently
advocated, breast awareness involves being responsive to
potential changes, which may be seen or felt (‘Be Breast
Aware’ leaflet 2006). A number of women in our study
voiced concerns about examining their own breasts, a
finding which has also been reported in other qualitative
studies (Salazar & Carter 1994; Persson et al. 1997). Some
questioned how reliable self-examination is as a means of
detecting breast symptoms, and also described being
inhibited from touching their breasts through fear of
detecting a symptom. It may be that these apprehensions

increased the trust placed in early screening. This finding
is slightly at odds with a study of adherence to self-
examination in women with a family history of breast
cancer (Brain et al. 1999) in which an association between
increased general anxiety and cancer worries, and hyper-
vigilant self-examination was seen. It may be beneficial
for women to have detailed discussions with their care
teams to ensure that any concerns they have are under-
stood, and where possible barriers to maintaining breast
awareness are diminished.
One of the unexpected findings from this study was the
positive reaction by some women to their cancer diagnosis,
describing feelings of relief, while other women seemed
accepting of their situation, and only one woman described
the emotional devastation the cancer diagnosis had
brought to her. One suggestion for these findings is the
reduction of uncertainty in the threatening situation of
being at risk of developing breast cancer. Individuals vary
in their need for certainty (Frenkel-Brunswick 1949;
Kruglanski 1989), and this has been shown to be related to
motivations to undergo genetic testing (Croyle et al. 1995;
Henderson et al. 2006). It could be that the women who
describe feeling relieved at their diagnosis prefer the cer-
tainty of the situation compared to the ambiguous one of
being at risk. A further potential explanation is that the
years during which the women have been at risk have
enabled them to prepare psychologically for their diagnosis
of breast cancer. The diagnosis is therefore not as shocking
or devastating as it may be for women without a family
history because their expectations have been confirmed.
The highly positive views that women held of mam-
mography after their diagnosis of cancer are comparable to
those of other women diagnosed with screen-detected
cancers (Farmer 2000; Miles et al. 2003), who seem to

have lower levels of psychological morbidity compared
with women with symptomatically detected cancer.
Farmer demonstrated that women with screen-detected
breast cancer received more reassurance by doctors that
their cancer had been caught at an early stage, which in
turn led to a minimization of the significance of screen-
detected cancer.
While all women described their full appreciation of the
screening programme, prior to and following the detection
of their cancer, not all wanted to continue with annual
mammography, with some preferring bilateral mastec-
tomy as their management choice. It is possible that the
surveillance and care offered by the programme conferred a
high level of psychological protection as long as no cancer
was detected. For some women, once the diagnosis was
made, and regardless of their reaction to it, surveillance
was no longer sufficient. Greater security could be gained
from reducing the risk of recurrence as far as was possible,
even if this meant undergoing more radical surgery than
was clinically warranted. It may also be that for some of
these women, their diagnosis would have confirmed they
were likely high-risk gene mutation carriers, and their risk
of a contralateral breast cancer may have exceeded their
previous counselled risk of breast cancer. Previous work
has shown that many women in this situation who have
been properly counselled about this future risk have opted
for risk-reducing surgery (Evans et al. 2005).
CLEMENTS et al.
© 2007 The Authors
250

The value of qualitative research lies in the depth of
understanding gained from detailed descriptions of spe-
cific experiences. For this reason, the number of partici-
pants in a qualitative study is necessarily small. Although
it was the restricted number of women available to us,
rather than data saturation that determined our sample
size, the views of the 12 women included in this study are
a valuable addition to the scarcity of literature regarding
women who are diagnosed with breast cancer while on a
family history screening programme. One limitation to
the study is that the views of the women who declined, or
were not approached to participate, may have added even
more to our understanding, particularly as they may have
been more adversely affected by their diagnosis and their
cancers may have been diagnosed at a more advanced
stage. It may be useful in future work to attempt to deter-
mine specific reasons for non-participation, to estimate
how far the findings from this study can be translated to
other women in the same situation.
Several clinical implications arise from this study. Not
all women diagnosed with breast cancer while on a family
history screening programme will have a pronounced
negative reaction to their diagnosis; indeed a number may
feel relieved that they have finally developed the condi-
tion that has been long expected. The period while they
are under threat of developing the condition may be a time
of psychological preparation for the women, which helps
them adjust more readily to their diagnosis. We have also
identified that women may select bilateral mastectomy as
their treatment of choice, although clinically, their cancer
may warrant a less radical approach. Surgeons need to be
aware that women may have a need to reduce, as far as is
possible, the risk of a future cancer, or alleviate totally the

fears associated with future screening. Although women
place significant emphasis on the early detection of
cancer, self-examination, as part of maintaining breast
awareness between annual mammograms, is often not
practised. It may help to identify women who may be
averse to self-examination, to see if the reasons for avoid-
ance can be overcome. We have shown that being diag-
nosed with cancer for the women in this study has not
been solely a negative experience. It may therefore benefit
asymptomatic women, who are particularly distressed
about their likelihood of developing breast cancer, to be
involved in a mentoring system with those who have
experienced the process of diagnosis and treatment in
order to improve their perceptions of their ability to cope
with a potential diagnosis of cancer.
Extending this work with a larger number of women
could enable an exploration for patterns within psycho-
logical reactions to screening and diagnosis, and pragmatic
reactions to risk management. Future work also needs to
explore the experiences of women who have put their
faith in a screening programme but whose cancers have
not been detected by an annual mammogram, or whose
cancers are at a much more advanced stage at the point of
diagnosis.
A C K N O W L E D G E M E N T S
We would like to thank those at the following centres who
helped in the recruitment of patients to this study: Breast
Test Wales – North, South East and South West Wales;
Royal Cornwall Hospital; Withington Hospital, Manches-
ter; Nottingham City Hospital and in particular Dinah
Winstone and Sue Thomas who facilitated this process.
We are indebted to the women who gave their time and

shared their experiences.
This work was supported by Cancer Research UK, grant
number C73/A2916.
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Assignment 2: Final Project Part III: Designing a Study
You are the hospital administrator in a medium-sized, urban,
for-profit hospital that caters to middle-income groups. You
wonder if patients' satisfaction with the hospital stay will
increase significantly if they are given better and more flexible
meal options. You decide to conduct a research study to find the
answer. The first step is to design the study.
Design a descriptive study to investigate if better meal options
will increase patient satisfaction. Include the following
elements of design:
1. Develop a research question or purpose of the study
2. Selection of subjects for study (what is the sample)

3. Assignment of subjects to experimental or control groups
4. Study time period
5. Type of data to be gathered
6. Measures of meal options and of patient satisfaction
7. Method of data collection
8. Guidelines for data interpretation
After you complete building the study design, list three design
elements you considered in your study that were not readily
obvious in the one you read last week “Diagnosed with Breast
Cancer While on a Family History Screening Programme: An
Exploratory Qualitative Study.”

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