Table 1.

Studies examining the role of anxiety, fear, and worry as related to breast cancer screening behavior

Author(s)YearOperationalization of anxiety, fear, or worrySample characteristicsMajor findings/conclusion regarding anxiety/fear
Andersen et al.2003Worry about breast cancer risk (assessed using five questions): (1) During the past month, how often you thought about your risk of developing breast cancer? (2) How often do these thoughts affect your mood? (3) How often do they affect your ability to perform daily activities? (4) How often do you worry about your risk of developing breast cancer? (5) A general question asking women to describe their feelings of distress regarding their risk of breast cancer. All questions employed a four-point ordinal scale. No reliability analysis provided.N = 6685 (97% Caucasian; 50–80 yr)Quadratic or inverted-U relationship between worry and screening among women with and without family history (i.e., screening greatest at intermediate levels of worry)
Aro et al.2001Illness worry: measured by an ad hoc list (27 items) of statements relating to screening behavior (e.g., pain at mammography). Each rated on a four-point scale (1 = agree fully, 2 = agree partially, 3 = does not agree, 4 = cannot tell). An option for other reasons was provided.436 Finnish nonattenders (50–59 yr)Nonattenders of a screening invitation reported more trait anxiety as well as state anxiety than attenders.
Reasons such concern about pain and radiation hazard at mammography were the most frequently reported reasons for nonattending screening.
Austin et al.2002Not applicable: review studyLiterature review of Hispanic studiesFear of finding something wrong inhibits Hispanic women mammography use.
Bloom et al.1987Fear of cancer: assessed by survey, called a preintervention survey of Oakland (no details). Questions included general knowledge about the disease as well as beliefs regarding cancer curability and treatment. No reliability analysis provided.317 African American women, 251 men (300 were between 20 and 39 yr)Greater fear of cancer was associated with lower likelihood/frequency of screening.
Beliefs that medical treatment for cancer do “more harm than good” and “cancer viewed as a death sentence” are noted.
Caplan et al.1996Lack of fear of cancer (as a reason for delay): defined as patient belief that problem is not important or urgent (included a lack of concern, feeling that symptoms will disappear, misdiagnosing oneself, and uncertainty about symptoms)367 breast cancer patients (161 Caucasian and 206 Black)Lack of fear is a larger barrier to an efficient diagnosis than the fear of cancer.
Fear (as a reason for delay): Incorporated fear of disease, fear of hospitalizations and fear of surgery.
Chaitchik and Kreitler1991Trait anxiety/fear: measured as part of a 39-item emotion adjective checklist assessing 10 basic emotions. Items “never,” “sometimes,” and “often.” Number of items assessing anxiety not clear; no reliability analysis provided.466 women (210 nonattenders, 210 self-referred screeners, 46 in experimental/induced sample)No differences in fear or anxiety between attenders and nonattenders
Consedine et al.2004Breast cancer worry: measured with Cancer Attitude Inventory, a four-item scale tapping four domains of cancer concern. Scores on each item range from 1 to 6. Items added to form aggregate (α = .73)1364 women from six ethnic groups (mean age, 53.9 yr)Greater worry predicts greater screening even where background characteristics are controlled.
Diefenbach et al.1999Breast cancer worry: assessed with single item, “During the past month, how often have you worried about your own chances of developing breast cancer?” Scored 1 (not at all) to 4 (almost all of the time). No reliability analysis possible.213 women with family history of breast cancerCancer worry is a better prospective predictor than generalized anxiety.
Suggests that there may be a curvilinear relationship between worry and screening.
Edwards and Jones2000State anxiety: assessed via Symptoms of Anxiety and Depression Scale. No scale details or psychometrics given.1604 women over 65 yr (51% between 70 and 79 yr)Greater anxiety associated with greater indicated willingness to attend a future screening.
Friedman et al.1995Cancer-related fears and anxieties: assessed as a part of a seven-item “barriers” checklist and comprised an aggregate measure including included fear of radiation, unnecessary worry, and fear of finding something rather not think about it. Factor analytic, but no reliability analysis.259 women (50+ yr)Cancer fears/worries are major barriers to mammography for African Americans.
Kreitler et al.1990Trait anxiety and trait fear: measured as part of a 39-item emotion checklist assessing 10 basic emotions. Scored “never,” “sometimes,” and “often.” Number of items assessing anxiety not clear; no reliability analysis provided.420 women (control: mean age, 40.5 yr; experimental: mean age, 40.9 yr; 63–65.7% Israeli, 20.5–22.4% Middle Eastern or North African)Attenders higher than nonattenders on anxiety and fear.
Lagerlund et al.2000Breast cancer worry: 36 items assessing 17 subscales including emotional barriers (α = .58) and worry (α = .79). Up to one-third of data missing.949 women (mean age, 55.5 yr for attenders and 56.1 yr for nonattenders)Women who worry most about breast cancer more likely to screen than women who worry least.
Lauver and Chang1991Anxiety: measured by Spielberger State-Trait Anxiety Inventory (STAI), a 20 item, four-point scale. Participants were asked to imagine that they had just found a small lump and then respond to the STAI in terms of how they would feel about seeing a doctor for this breast change. Reliability unclear.99 women aged 21–82 yr with no history of breast cancerAnxiety positively related to intention to screen
Anxiety positively related to family history of breast cancer
Lerman et al.1991Anxiety about breast cancer: assessed with structured questions, including level of anxiety about the results of future mammograms, current tendency to worry about developing breast cancer, current impairment in mood and in daily activities because of worrying about breast cancer; effects of having mammography on concerns about breast cancer. No reliability analysis provided.308 women aged 50–74 yr (women with breast cancer were excluded)Women with normal mammograms reported low anxiety about mammograms and less breast cancer worry and reported worry interfering less with mood or functioning.
Mammography increased anxiety for high suspicion results.
Lindberg and Wellisch2001State and trait anxiety: STAI. 40-items, four-point Likert (1 = almost never to 4 = almost always); α for state scale = .80430 women from high-risk clinic aged 15–78 yr (84.4% White)Anxiety regarding Pap smear less than that for either mammogram or breast self-examination
Anxiety regarding Pap smear, mammography, and breast self-examination: single item for each, “How anxious about x?”; four-point scale, 1 = min to 4 = max. No reliability analysis provided.Significant positive correlations between breast self-examination and mammogram worry and STAI trait anxiety
McCaul et al.1998Worry about breast cancer: measured using four items from Lerman et al. (1991): “How often do you worry about breast cancer?” “How many days out of last 7 did you worry about breast cancer?” “Does breast cancer worry affect your mood?” “Does breast cancer worry affect your performance or daily activities?” (α = .85), test-retest r = .61 across 1 month, and .58 across 1 yr135 women with and without family history of breast cancer aged 18–77 yrThinking and worrying about breast cancer were modestly and positively related to the frequency of breast self-examination behavior and intentions toward mammography.
Trait anxiety: STAI (Spielberger et al., 1970). 20-items, four-point Likert (1 = almost never to 4 = almost always); α = .92Trait anxiety not related to breast self-examination behavior or intentions.
McCaul, Reid et al.1996Fear/worry about breast cancer: three items measuring frequency of worry, extent of worry, and extent to which women were upset/frightened. Frequency and worry measured on a five-point scale; upset/frightened measured on a four-point scale. Combined to a single scale (α = .71).838 women aged 40–75 yrGreater fear associated with more frequent breast self-examination and mammography and greater intention to continue performing screening behaviors.
McCaul, Schroeder et al.1996Breast cancer worry: three items measuring frequency of worry, extent of worry, and degree of upset/frightened. Frequency and worry measured on a five-point scale; upset/frightened measured on a four-point scale. Combined to a single scale (α = .71)353 women aged 40–75 yr taken from McCaul et al. (1996)Greater concern about breast cancer was related to greater likelihood that women performed breast self-examination, went for a mammogram, and had clinical breast examination (controlled for susceptibility).
Miller and Hailey1994Anxiety about cancer: unspecified number of items (out of possible 40 items) extracted from Berrenberg's Cancer Attitude Inventory on the basis of a face validity assessment. No psychometrics provided.32 African American women aged 35–73 yrHigher levels of cancer anxiety with women who never had a mammogram, but no difference between women who did and did not complete regular breast self-examination.
Royak-Schaler et al.1995Breast cancer worry: four items taken from Lerman et al. (1991) measuring how often a women thought and worried about developing breast cancer. No psychometrics provided.Telephone interview of 60 African American women with first-degree relatives with breast cancerMajority felt that cancer worry did not affect their mood (70%) or daily activities (87%).
Relation between worry and screening behavior not reported.
Schwartz et al.2003Breast cancer worry: two of three items from Lerman et al. (1993). No reliability analysis provided.159 women with at least one first-degree relative with breast cancer who completing both baseline and follow-up (83% White, 50% college)Prospective odds of obtaining mammogram 70% less among women with high levels of worry.
Breast cancer distress: seven intrusion items from the Impact of Event Scale. α = .85, but skewed.
Styra et al.1993State and trait anxiety: measured by Spielberg State Anxiety Scale, a 20-item measure. No psychometrics provided.100 women (mean age, 40.7 yr)Symptomatic women who identified their lump as a concern had significantly more anxiety than women who did not.