Patients Perception Of Pain And Understanding Of Procedure

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Mammography is totally no doubt that it creates anxiety amongst women and is a risk factor for pain. The fear women have when they attend for mammography is not only rooted in the prospect of a painful examination but also in the fear of breast cancer itself, (Drossaert et al.,2002; Mainiero et al., 2001), the possibility of further medical examinations and the associated embarrassment of exposing their breasts (Doyle and Stanton, 2002). The challenge is to relieve anxiety amongst women experiencing mammography for the first time. Since anxiety and pain are linked, reducing anxiety at this stage should reduce pain which in turn could reduce the risk of pain at subsequent mammography (Davey, 2006).

Studies on pain and discomfort during mammography have revealed that many women experience pain during breast compression (Asghari and Nicholas, 2004; Andrew, 2001). However, only a very limited number reports high levels of pain (Stomper et al., 1988).

According to Davey (2006), there are risk factors that have been associated with pain during mammography where there is no conflicting evidence and these can be divided into three main areas: (1) Biological - breast tenderness, thickness, (2) Psychological - pain expectation, previous painful mammogram, anxiety level, and (3) Staff-related - attitude, communication problems. Furthermore, tense and worried women experience higher pain levels than calmer women (Myklebust et al., 2009). The more worry the women experienced, the more level of pain they perceived.

Furthermore, Lupton (1993) identified the relationship between feelings of vulnerability, anxiety and perception of risk. As Poulos and Llewellyn (2004) have succinctly put it;

" the discourse of risk is weighted toward disaster and anxiety rather than peace of mind." (in Lupton, 1993 : p.433)

Women also experience anxieties over other risks when they have their mammogram. These include concern over the competence of the radiographer and the potential for damage to the breasts. These concerns appear exaggerated when perception of personal risk is heightened. For example, participant who had a lump in the breast questioned the competence of the radiographer because the radiographer was not a doctor or she also feared that the compression would damage her breasts. (Poulos and Llewellyn, 2004). Nearly all physicians agreed that patients' anxiety (87%) or expressed expectations of being tested (88%) influence their decision to order a test that they would not usually recommend (Haggerty et al., 2005)

In addition, differences in physicians' clinical judgment about recommended practice are consistent with differences in their clinical decisions and test ordering is influenced according to the patients' anxiety and expectations (Wenberg et al., 1982; Haggerty et al., 2005). Physicians' clinical judgment influenced test ordering differed according to patients' anxiety or expectations. When patients have no anxiety about cancer or expectation of being tested, physicians' perception of recommended practice is the main driver of screening decisions for which guidelines are equivocal. Patients' anxiety or expectations not only increased the likelihood of getting the screening test, but acted most powerfully on the screening decisions of physicians whose clinical judgment would otherwise make them least inclined to order the test (Haggerty et al., 2005).

As patients increasingly form their perceptions of risk of disease and efficacy of tests from information in the media, on the Internet, and in direct-to-consumer advertising, physicians need to be trained to respond to their patients' expectations. One strategy might be to elicit explicitly patients' expectations rather than inferring them. Often what is perceived to be a treatment expectation is, in fact, an expectation of information, reassurance, or symptom management. (Butler et al., 1998; Pshetizky et al., 2003).

According to Miller, Livingstone and Herbison (2008), sufficient information provided to the women regarding the procedure prior to the mammogram may reduce pain and discomfort and at the same time, patient-controlled breast compression has also been shown to significantly reduce discomfort. Women should also be informed of the benefits of early detection from a 'preventive medicine' approach rather than a 'perception of risk' perspective. This may facilitate reducing anxiety on the day. Women who attend for 'preventive medicine' reasons are potentially more confident that nothing is wrong and they merely attend to check this. Women who attend because they feel at risk of developing breast cancer are more likely to experience anxiety and hence discomfort (Poulos and Llewellyn, 2004).

Understanding the procedure is crucial in mammography as it will decrease the level of anxiety and pain in the patient. The patient individual experience is related to physiological and situational factors. Sufficient information given to the patient concerning the procedure due to mammography may reduce pain and discomfort. The pain during breast compression may reduce by sufficient information prior to and during mammogram (Myklebust et al., 2009).

A study by Poulos and Llewellyn (2005), women who live according to the philosophy of preventive medicine and healthy lifestyle were keen to be reassured that they were free from breast cancer. They are highly motivated and believe that mammography were done for security and they need evidence that they are healthy. As stated by some patient ;

''I'm confident there are no problems so I go. It's not like I don't want to go

I don't want to find out anything. I think I'll go because I don't believe there

are any problems. But if there was something well it would be very much

at its early stages. I'm a pragmatist''(in Poulos and Llewellyn, 2000: p.20)

Some women may also bring along their understandings concerning the role of mammography in breast cancer. Participant also will be well informed of the benefits of mammography screening in finding breast cancer early. However, poorer woman are less likely to get mammogram as are women with low level of education (Engelman et al., 2010).