Mammography pain and discomfort: a cognitive-behavioral perspective

Puir1, 56 (lYY4) 247-260

0 1904 Elsevier Science B.V. All rights reserved 0304.39SY/94/$07.00

247

PAIN 2477

Clinical Review

Mammography pain and discomfort: a cognitive-behavioral perspective

Francis J. Keefe *, Emily R. Hauck, Jennifer Egert, Barbara Rimer and Phyllis Kornguth

Puin Mum~emenf Progrum. D&Y Uniwrsiiy Meriicul Co~cr, Durhrrm, NC 27710 C USA)

(Received 17 February 1993. revision received and accepted 20 September 1YY.i)

Summary Although some women report having little pain or discomfort during mammography, other women find mammography to be a painful and uncomfortable experience. Cognitive and behavioral factors may influence the perception of pain and discomfort during mammography. This review critically evaluates the research on mammography pain from a cognitive-behavioral perspective. The review is in three sections. The first reviews studies measuring pain and discomfort in women who have recently had mammograms and studies investigating the relative importance of pain and discomfort in influencing women’s decisions to have a mammogram. The second section presents a cognitive-behavioral model of mammography pain that is based on theories of behavior and self-regulation developed by Kanfer and Hagerman (1987). The review concludes with a discussion of the implications of the cognitive-behavioral perspective for clinical management and research on mammography pain and discomfort.

Key words: Mammogram; Cognitive-behavioral model; Pain; Cancer screening, barrier

Introduction

Mammography is the most effective method available for early detection of breast cancer. Current guidelines recommend that all women over the age of 50 have regular mammograms. For most women, a mammogram is a relatively straightforward procedure that, although somewhat uncomfortable, is relatively easy to cope with. For other women, however, mammography is a painful procedure that is a source of considerable anxiety and tension. In some of these women, the fear of pain may be so great that they avoid ever having a mammogram. Reductions in mor- tality will only be achieved when women over 50 are getting regular screening mammograms. A painful experience may deter some women from seeking subsequent mammograms and thereby detecting breast cancer early when it is still curable.

Although the cognitive-behavioral perspective has increased our understanding of many pain phenomena, relatively little has been written about cognitive and

* Corresponding ccurhor. Francis J. Keefe, Pain Management Pro-

gram. Duke University Medical Center, Box 3159, Durham. NC

27710. USA. Tel.: (919) 6X4-6212; Fax: (919) 684.8629.

SSDI 0304-3Y5’~(93)EO 192-3

behavioral aspects of pain during mammography. This review describes and critically evaluates previous research on mammography pain, and then presents a model of mammography pain that includes cognitive and behavioral factors that may influence pain. Finally, it highlights the clinical and research implications of a cognitive-behavioral perspective on mammography pain.

Research on mammography pain

A mammogram is a very low-dose X-ray of the breast. The examination requires that the breast be tightly compressed during the exposure in order to: (1) equalize breast thickness from chest wall to nipple and allows all areas of the breast to be imaged on a single exposure; (2) reduce motion artifact; (3) spread the breast tissue, allowing detection of tiny cancers; and (4) reduce the dose of radiation given to the breast. The breast is compressed by a plastic paddle which presses the breast against the film cassette. Compression is usually applied by the technologist either by manually lowering the paddle or by means of a foot pedal which applies hydraulic compression. Adequate compression is essential for a good image.

The same examination technique is used regardless of whether the woman is having a screening mammogram or a diagnostic study. A screening exam is generally done in an asymptomatic woman solely for the purpose of detecting early breast cancer. A diagnostic mammogram is a study done to evaluate a breast symptom (such as a breast lump, nipple discharge or breast pain).

How painful is mammography? Clinicians appear to disagree sharply on the answer to this question. Schecter et al. (1990) suggest advising that women that mammography is a “quick and painless procedure.” Hugh (19911, on the other hand, recently described the experiences of six women who had bruising and extreme discomfort and two post-mastectomy patients who refused to return for further mammograms because of pain and discomfort.

Recent studies that have examined the degree to which women view mammography as a painful or uncomfortable experience are of two basic types: (1) those examining pain and discomfort in women who have recently had mammograms, and (2) those investigating the relative importance of pain and discomfort in breast cancer screening.

Pain during mammography In the studies examining pain during mammography,

women are usually asked to complete a brief questionnaire shortly after they have a mammogram. The questionnaire typically includes items on pain and discomfort as well as questions about the woman’s age, menstrual status, symptomatic status, experience with mammography, and general perceptions of the mammogram. Table I provides a summary of seven recent studies examining pain during mammography. The

table gives information on sample size and age of the subjects, the percentage of patients for whom this was the first mammogram, and the percentage reporting pain and discomfort. As can be seen, the percentage ot patients reporting pain varies widely across studies (range = l-62%). A review of the studies may provide some insight into these variations in pain reports.

Typical of those studies finding a very low incidence of pain is a report by Stomper et al. (1988). This study used a large sample (n = 1847) of asymptomatic women who underwent screening mammograms performed at seven hospital- or office-based breast imaging centers in the United States. During each mammogram. a minimum of one oblique and one craniocaudal projec- tion of each breast was performed. Women were rc- ported to have been cared for “in the usual manner”, and “compression of the breast was considered suffi- cient when the skin became taut” (p. 522). Forty-nine percent of the women reported experiencing no discomfort during the procedure, 39% experienced mild discomfort, 9% reported moderate discomfort, 1% severe discomfort, and 1% moderate pain. No woman indicated that she had experienced “severe pain that would make (her) reconsider ever having a mammogram again” (p. 521).

Although the incidence of pain was low, Stomper et al. found that women who had undergone prior mammography were more likely to report breast discomfort than women who had not. In addition, women who expected to experience more discomfort did, in fact, report greater discomfort. Interestingly, women who had undergone prior mammography expected more, not less, discomfort. The source of information regarding mammography pain and discomfort also appeared to be important. Women who developed expectations

TABLE 1

SUMMARY OF STUDIES EXAMINING PAIN AND DISCOMFORT DURING MAMMOGRAPHY

Study n Age First-time Reporting Reporting Assessment

mammography discomfort pain instrument

(%) (%) (%I

Stomper et al. (1988) 1847 25-86 37 49 1 6-point scale combining pain

and discomfort descriptors

Jackson et al. (1988) 356 23-84 NI a 81 NI ’ 6-point scale of discomfort Wolosin (1989) 985 21-87 55 NI ’ 56 = less checklist

15 = more than expected

Brew et al. (1989) 203 NI a NI a 49 4.4 4-point scale combining pain

and discomfort descriptors

Fallowfield et al. (1990) 113 NI a 89 91 62 two 3-point scales of pain

and discomfort

Nielsen et al. (1991) 272 x = 53.6 78 36 36 unspecified descriptive

rating scales

Leaney and Martin (1992) 374 NI = NI a NI a 40% 4-point scale of pain

Kornguth et al. (1993) 109 46 32 Pain and discomfort lower 6-point scale combining pain with self-compression and discomfort descriptors

a NI = not indicated.

about pain from either friends or newspaper and maga- zine articles indicated that they experienced less pain

than they expected, in contrast, those who developed expectations based on their contacts with physicians indicated that their experience matched their expecta-

tions. Although the findings of Stomper et al. are interest-

ing, the study has several limitations. First, the 6-point scale used to assess discomfort and pain provided women with only two alternatives for rating pain: ei-

ther “moderate pain” or “severe pain that would make me reconsider ever having a mammogram again.” With such a limited set of response options, it is not likely that the scale was sensitive enough to detect important aspects of the pain experience. Even more problematic. the authors combined descriptors measuring pain and discomfort into one scale. Current conceptualizations view the pain experience as multidimensional and a

number of studies have demonstrated the utility of analyzing its separate dimensions, e.g., the perceived unpleasantness and perceived sensory intensity. In- deed, medications designed to reduce pain may have differential effects on the intensity and unpleasantness of the pain (Gracely et al. 1978, 1979). By combining affective descriptors and sensory descriptors into one scale, Stomper et al. made it impossible to assess the multidimensional aspects of pain. Unfortunately their scale, being one of the first in the radiologic literature on mammography, has come to be rather widely used.

A further limitation is that the Stomper et al. data on patient expectations were collected after, rather than before mammography. Subjects’ recollections of their initial expectations may have been biased by their

experience during mammography. Despite its limitations, however, the study by Stomper et al. is notable in underscoring the influence that both learning factors (past experience with mammography) and cognitive factors (expectations) have on the perception of pain during mammography. Moreover, this study is one of the few that have assessed pain close to the time of the actual mammogram.

Wolosin (1989) also examined the influence of women’s expectations on their experience of pain during mammography. This study recruited women undergoing screening mammograms from a mobile mammography unit, radiology outpatient offices, and a hospital-based practice in the Midwestern United States, Of the women approached to participate, 72%

agreed to do so, yielding a relatively large sample (n = 985). All subjects completed an 11-item questionnaire measuring attitudes towards mammography immediately after the procedure but before test results were provided. One variable assessed was whether the pain that patients experienced was greater or less than what they had expected. Fifteen percent of first-mammogram patients and 15% of repeat mammogram pa-

tients reported having found the mammogram more painful than they had expected. Sixty-five percent of

first-mammogram patients reported that the procedure was less painful than expected and 45% of repeat mammogram patients reported less pain than ex-

pected. The results of Wolosin (1989), like those of Stomper

et al. (19881, suggest that pain may not be a major

problem during mammography. However, it should be noted that Wolosin (1989) failed to assess the subjects’ actual pain. Instead, the study simply measured whether subjects had more or less pain than they expected. Thus, patients who had moderate to severe pain but who expected to have this amount of pain were not identified. This study, like that of Stomper et al., also assessed expectations retrospectively, leading to the possibility of recall bias.

The lowest incidence of pain during mammography was reported in a study conducted in New Zealand by Brew et al. (1989). Their sample of 303 women who had undergone mammography either at a public hospital or private radiology facility completed a questionnaire on the experience immediately after having their mammograms. Ninety-five percent of the women reported that the mammogram was either painless or “uncomfortable but not too bad.” This study, unlike the Stomper et al. (1988) and Wolosin (1989) studies,

included both asymptomatic women undergoing screening mammograms (n = 95) and symptomatic women undergoing diagnostic mammograms (n = 108). Women who have fibrocystic changes and painful lumps undergo regular mammograms and may, because of preexisting pain, be more likely to perceive mammography as painful. However, despite the fact that this study included symptomatic patients, only nine women reported that the procedure was either painful or very

painful. Interestingly, seven of the nine women indicated that their breasts had been painful immediately prior to the evaluation. This study found no relationship between mammography pain and age, breast size, previous biopsy, texture of breasts to palpation, amount of residual breast tissue, or “technically difficult mammograms.”

One factor in the low rate of pain and discomfort in this study may be the rate and degree of breast compression during mammography. The authors provided no information on the parameters of breast compression, however, they noted that “Radiographers were aware that graded compression with careful “peeling” of the breast from the chest wall was important in minimizing discomfort” (p. 335). When breast compression is increased in a careful manner, patients may experience less pain. Alternatively. it is possible that the overall level of compression was lower in this study than in reports of other investigators.

Jackson ct al. (1988) note that vigorous compression

‘50

of the breast is required to attain the highest quality film screen mammograms. These authors report that “the degree of compression was as much as the consis- tency of the breast would allow” (p. 421), and the results of their study suggest that high levels of breast compression may be associated with reports of more pain and discomfort. Jackson et al.‘s subjects were undergoing mammography at an Indiana Hospital: 57%~ of the women approached to participate agreed to do so. The women were instructed as to the necessity of high levels of breast compression and then asked to rate their level of comfort after the procedure using six verbal descriptors ranging from “very comfortable” to “intolerable.” Twenty-nine percent rated the procedure “mildly uncomfortable”; 38% rated it “uncomfortable, but tolerable”; 11% rated it “very uncomfortable”: and 3% rated it as “intolerable.”

This study included a large sample of asymptomatic women having screening mammograms (n = 429) and a large sample of symptomatic women who were undergoing mammography because of a palpable mass, breast pain, or other problems (n = 219). The incidence of pain, however, was not found to vary as a function of symptomatic status. Forty percent of the women reporting intolerable pain had had their menstrual period within the past week, and 60% drank more than five caffeinated beverages per day. Taken together, the findings suggest that vigorous or high levels of breast compression may be associated with increased reports of discomfort and that menstrual status may be an important factor in particularly high levels of pain or discomfort. It should be noted, however, that the findings regarding caffeine intake have not been replicated by other investigators.

Leaney and Martin (1992) recently presented data on women whose mammograms were conducted using maximal permissible compression. They administered a questionnaire on mammography pain to 470 consecu- tive patients who had mammograms at a large subur- ban radiology center, 374 completed all questionnaire items and were included in data analyses. No information was provided on the numbers of women having a mammogram for screening or diagnostic purposes, however, the investigators noted that 18% of the women had a prior history of breast disease. Although the authors indicate they used the “maximal permissible compression” during each mammogram, they did not report the actual compression force that was applied to the breast. Women rated their perception of mammography pain using a 4-point scale (none, mild, moderate, severe). Forty percent reported having pain. The pain was rated as mild by 31% of the women, moderate by 8%, and severe by 1%. Pain was not found to be influenced by menopausal status, menstrual cycle, or coffee drinking. One of the most noteworthy findings of this study was the importance of a history of breast

disease in explaining pain reports: women with prcvr- ous breast disease were more than twice as likely as

other women to report moderate to severe pain (3Xc’; vs. 18%). Unfortunately, since the questionnaire was quite brief and completed anonymously. the investigators were unable to determine whether the nature OI- severity of prior breast disease had an impact on mammography pain.

One of the most important reasons to study pain and discomfort during mammography is that it might affect women’s decisions to have subsequent mammograms. In Jackson et al.‘s study 14 patients reported that they would not return for future mammograms. Discomfort appeared to affect this decision in that 77% of the women who indicated they would not have a future mammogram rated their discomfort during the procedure as “very uncomfortable” or “intolerable.”

Fallowfield et al. (1990) conducted one of the few studies that have assessed not only pain and discomfort, but also psychological variables (e.g., anxiety, embarrassment) in women undergoing mammography. Subjects were 113 asymptomatic women who had accepted an invitation to attend a breast cancer screening clinic in a London shopping mall. After the mammogram, each subject was given a set of questionnaires and asked to return them by mail, before receiving their mammogram results. Subjects rated their pain, discomfort, embarrassment, and anxiety on a 3-point scale (“not at all”, “a little”, and “very”). Twenty-one percent of the women reported that the mammogram was “very painful” and 41% reported it was “a little painful”. Analysis of discomfort ratings indicated that 27% found mammography “very uncomfortable” and 64% found it “a little uncomfortable”. Nine percent of the patients rated the procedure “very embarrassing” and 19% rated it “a little embarrassing.” Sixteen percent reported that they were “very anxious”, 38% reported they were “fairly anxious”, and 45% reported they were “not at all anxious.”

The Fallowfield et al. study is noteworthy in that it asked subjects to rate their subjective responses to mammography on different dimensions (e.g., pain, discomfort, and anxiety). A relatively high proportion of patients had some amount of pain, discomfort, or anxiety. The study had two major problems, however. First, the range of the rating scales was quite restricted, making it difficult for subjects to indicate gradations in their subjective experience between, for example, “a little” and “very.” Second, the study failed to analyze how pain or discomfort ratings were related to psychological factors such as anxiety or embarrassment.

Most studies of mammography pain have relied on white women recruited from middle class or affluent communities. The degree to which findings from these studies can be generalized to other racial or socioeco- nomic groups is not known. A recent study by Nielsen

et al. (1991) is noteworthy in that it examined mam-

mography pain in a sample that included a high proportion of African American women (78.2%) living in an economically disadvantaged area. Each woman was asked to rate her perceived pain, discomfort, and anxiety after the niammogram using a series of descriptive rating scales, A relatively high number of the women (128 of 208) reported pain and/or discomfort during the mammography procedure. Within this subgroup of women, 24.2%, reported only pain, 23.4% reported only discomfort, and 52.4% reported both pain and discomfort.

Nielsen et al. found that demographic and physicai differences were important in explaining mammography pain and discomfort. Race and age were significant factors: African Americans were much less likely to report pain than other women from the same low-in-

come community, and younger women less likely to report pain. Finally, a larger chest size was associated with a lower likelihood of discomfort.

The Nielsen et al. study is also important because it is one of the few to have analyzed the relation of nlammography pain and anxiety. Chi-square analysis indicated that women who said they were anxious about the mammography experience were much more likely than other women (P < 0.00001) to report pain

and discomfort during mammography. Nielsen et al. reported that they “quantified the

amount of pain, discomf~~rt and anxiety associated with mammography” using descriptive rating scales, which

presumably included multiple adjective descriptors. Unfortunately. the results they presented are limited to

dichotomous (yes or no) responses. Taken together, the findings of the studies reviewed

above suggest that women vary widely in the degree to

which they experience mammography as a painful procedure. Although these studies suggest that most women report little or no pain, each study found that a percentage of women had more severe pain or discomfort. Factors influencing the report of pain or discomfort appear to include demographic variables (age. race), physical factors (breast size, caffeine intake).

medical status variables (pre-existing breast pain), patient history variables (prior experience with mammography), procedural variabIes (rate or degree of compression), and psych~~logicai variables (anxiety, expecta-

tions). Methodological limitations determine in part the

variability in findings regarding mammography pain and discomfort. All the studies reviewed had a number of methodological problems. First, they relied only on volunteer subjects, who may be biased towards minimizing their reports of pain. Second, most failed to analyze the effects of variables such as patient cxperi- ence with mammography, diagnostic status (symptomatic vs. asymptomatic). and referral source. Each of

these factors could have a major impact on anxiety level and, in turn, affect the perception of pain. Fur-

ther, though several authors (Jackson et al. 19)xX; Stom- per 198X; Baines et al. 1990) noted the critical importance of technician variables such as communicati~~n skills, ability to relieve anxiety and technical skill. to date, no systematic investigations of these variables have been carried out.

Existing research has also been limited by inadequate pain assessment methods. Two problems arc noted. First, the pain assessment instruments used have often combined pain and discomfort ratings in one scale. They also failed to provide descriptive information on the location of the pain and do not diffcren- tiate between different dimensions of pain such as intensity and affective quality. Second, the timing of pain assessments has varied across studies. with some studies assessing pain immediately after mammogr~lphy while others asked women to provide retrospective assessments hours or days after mammography. Finally, no studies have cxamincd the course of pain following mammography. As a result, nothing is known about how long pain persists in w~~rnen who have moderate or severe pain during mammography.

Most studies also have failed to provide information on the compression used during mammography. C’om- pression is the major stimulus likely to elicit pain and

the lack of information on this variable is unfortunate. Until recently, objective measures of degree of com-

pression were not easily obtained, new mammography machines, however, are capable of providing digital readouts of compression force (in kg of force) and

information on the resulting thickness of the compressed breast (in mm). The avaii~~biiity of this information may prove quite imp~~rtant for future research

on mammography pain. Although some authors (Gold I%X; Fallowfield et

al. 1990) recommend that women be forewarned about the need for breast compression, only one study has experimentaIIy tested the effects of giving women direct control over breast compression during mammography (Kornguth et al. 1992). This study used a crossover design in which for each woman one breast was compressed by a technologist and the other breast was compressed by the patient using a handheld hut- ton. The study found that 44% of the women noted a difference in the pain produced with the two compression techniques; 71% of these women rated self-compression as less painful than technologist compression (I” 2 0.001). One potential drawback of self-compression is that women may not expose themselves to high enough levels of compression to cnsurc an adequate image. In this study, however, the majority of women did apply enough compression, depending on the order of compression. Self-compression was as effective in producing an adequate image as technologist compres-

sion only when the technologist compression was done first. This suggests that the women learned from the technologist how much compression was necessary.

The Kornguth et al. (1993) study had several other noteworthy findings. First, this was the first study to evaluate medication intake on the day of mammography. A total of 22% of the patients studied had taken either pain medications or tranquilizers on the day of mammography. Although the use of medication did not appear to influence pain ratings, analyses of medication effects did not take into account the type and

actual intake of medication. Second, this study found a relationship between breast size and pain: women having a smaller bra cup size reported more pain. Third, the density of the breast tissue, as determined by mammography, was found to be important in terms of both adequacy of compression and pain. A total of 14 breasts were judged by a radiologist on a blinded basis to be inadequately compressed. All of these breasts were moderately dense or dense. Women having denser breasts also reported higher levels of pain and discomfort. (It should be noted that women with dense breast tissue may be more likely to have fibrocystic changes and, because of this, may be more prone to pre-mammogram cyclic breast pain.) Finally, the study did not find race to be related to pain although adequate

numbers of minority women were included. The Kornguth et al. (1993) study is important be-

cause it suggests that, for some women, self-compression may be an effective means of reducing mammography pain. The study has a number of positive design features such as adequate subject sampling, assessment of patient characteristics across a range of relevant variables, and a within-subject crossover design that enabled the investigators to rigorously test their hy- pothesis. Finally, the study also provides the first ex- perimental test of a cognitive behavioral intervention designed to reduce mammography pain. Although the

study had some limitations (e.g., order effects influencing adequacy of compression, use of a pain scale combining pain and discomfort ratings), its results should stimulate future research on the control of mammogra-

phy pain.

Pain as a factor in the decision to undergo mammography screening

Many large scale studies have examined factors that may influence a woman’s decision to participate in mammography screening. The studies typically con- tacted women either before or after mammography and assessed their attitudes towards mammography using a telephone interview or mailed questionnaire. Most studies have been cross-sectional with no attempt

to standardize the length of time from a woman‘\ previous mammogram. Most have assessed sociodemir-- graphic, health-related factors, or cognitions or belief’s that might be related to the decision to have a mammogram, but only a few have directly addressed pain or the fear of pain as a potential barrier to mammography screening.

Slenker and Grant (1989) conducted one of the first studies to assess the relative importance of pain as an influence on the decision to have a mammogram. Sub- jects in the study were 201 women recruited from shopping malls who were asked to complete a questionnaire measuring the relative importance of variables that might affect their decision to have a mammogram. The variables included perceived susceptibil- ity to breast cancer, perceived barriers to mammography (e.g., pain) and perceived benefits of mammography (e.g., knowing that one is free of cancer). Respon- dents rated the relative importance of each item using a S-point scale.

Slenker and Grant found that the most important factor in the decision to have a mammogram was the recommendation of a physician to undergo mammography. After controlling for the influence of physician recommendation, the next most important factors were the perceived benefits of mammography and the per-

ceived barriers to mammography. These findings suggest that pain and other perceived barriers to mammography are much less important than a physician’s recommendation or perceived benefits in the decision to have a mammogram. Unfortunately, however, items measuring fear of pain were combined with other items in such a way that the importance of pain as a specific barrier to mammography could not be determined.

A recent study by Glockner et al. (1992) produced findings similar to those of Slenker and Grant. In this

study, women who were waiting for a mammogram at a university affiliated hospital were asked to complete a questionnaire on their mammography screening bc- liefs. Of the 469 women surveyed, only 381 who had a normal breast exam by their doctors and had no history of breast cancer and no abnormal mammograms in the previous 6 months were included in the study. The questionnaire asked respondents to rate the relative importance of 15 incentives for having a mammogram (e.g., a physician’s recommendation, etc.) and 14 deterrents (e.g., fear of pain, fear of radiation) by using a 4-point response scale.

These women rated the incentives for having a mammogram as much more important than the deterrents. Again, the single most important factor intluenc- ing the decision to have a mammogram was a physician’s recommendation to undergo the procedure. Among deterrents to mammography, “fear of medical intervention” was second only to “costs” in importance. The fear of medical intervention was a compos-

ite variable which included the item measuring fear of pain.

Although the Glockner et al. (1992) study addressed the perception of mammography as being painful, like the earlier study by Slenker and Grant (1989), it failed

to analyze data in such a way that the unique impact of pain could be examined. Another major limitation of this study is that its results were based solely on information collected from women who had already decided to have a mammogram. The fact that the incentives for mammography outweigh deterrents in such a sample is not surprising.

A recent breast cancer screening study by Polednak et al. (1991) suggests the importance in mammography screening decisions may vary depending on how women are asked about pain. In this study, information on barriers to mammography was collected from women who had never had a mammogram either by means of a mailed questionnaire (n = 1164) or a telephone interview (n = 475). The mailed questionnaire asked women to check off all the items that applied to them from a list of potential barriers to mammography, including pain. The telephone interview used open ended ques-

tions asking respondents why they had not had a mammogram.

Fear of pain was reported as a disincentive to mam-

mography by 6.1% of the women completing the questionnaire. but by only 2.1% of the women interviewed by telephone. Although the difference in fear of pain

between these two assessment formats was not statisti- cally analyzed, it is quite interesting that almost three times as many women reported a fear of mammography pain on a self-report measure as when questioned by an interviewer. This suggests that the method by which women are asked about barriers to mammography may affect their responses. It is also evident from this study that regardless of the assessment format. a subgroup of women perceive mammography to be a painful procedure and, as a result, may decide not to undergo the procedure.

In an attempt to more definitively assess the profile of women who did and did not comply with a mam-

mography screening program, Rimer et al. (1989) interviewed 600 randomly sampled women (> 40 years old) who were offered a free mammographic examination. Telephone interviews were completed with 95% of the women; 484 were asymptomatic and were included in the study sample. The interview covered: personal experience with mammography, reaction to health education materials on mammography, factors facilitating the decision to undergo mammography, and perceived barriers (including pain).

Rimer et al. (1989) found that the perception of mammography as painful was not a significant predictor of the decision to have a mammogram. Women who failed to comply with mammography recommen-

dations were more likely never to have undergone mammography and less likely to remember receiving

health education materials. The noncompliers also had significantly higher barrier scores. agreeing more fre- quently with the statements: that mammography is

unnecessary in the absence of symptoms. doctors told them not to have one, mammography is too much trouble, time consuming and inconvenient, and they would rather not think about it. Women who complied with mammography screening were less likely to believe that getting a mammogram would be inconvenient, and more likely to be white, to remember getting an information packet, to believe that their doctors felt that they should have regular mammograms, to bc

married and to have a family history of breast cancer. Rimer et al. found that compliance with mammography screening was more accurately predicted than noncom- pliance: they were able to accurately predict behavior 73% of the time for compliers and 63% for noncompliers.

One of the best ways to assess the relation of pain and discomfort to mammography screening behavior is to study a sample of women over the course of several years. This approach was used in a study by Baincs et al. (1990) whose research relied on a sample of women who had participated in the Canadian National Breast Screening Study (NBSS). All NBSS participants had been assigned to one of two conditions: (I) annual mammography and physical examination, or (2) physi-

cal examination alone. Women who discontinued participation after one visit were categorized as “dropouts”, while women who attended 2-5 of five possible screens or 2-4 of four possible screens over a 3-4 year period were categorized as “active respondents.” Over the course of the NBSS, women who received abnormal screens were referred to a clinic for possible diagnostic intervention. Women known to have breast cancer were excluded from the questionnaire on pain and

discomfort. Among women allocated to the mammography and

physical examination group. 37.79: reported mild discomfort, 36.2% reported moderate discomfort. and 8.7% reported extreme discomfort during mammograms. An additional 7.8% reported “variable degrees of discomfort” which were not further defined by the authors. Although many women reported experiencing discomfort, the study failed to provide information on factors found in other studies to be important in ex-

plaining this (e.g., prior experience with mammography, expectations about pain. menstrual status, degree or rate of breast compression). This study also failed to indicate whether subjects’ reports of discomfort were related to their status as “active respondents” ot “dropouts.”

One of the major limitations of the Baines ct al. study is that subjects’ ratings of discomfort were made

retrospectively. Given the longitudinal nature of the NBSS, the length of time from mammography to questionnaire completion and the total number of mammo-

grams may have varied greatly. Time may play a significant role in biases associated with retrospective reports of pain. For example, examination of responses by a

subsample of 68 women who completed two questionnaires at a mean interval of 8.6 months (range 1.7- 16.5 months), indicated that while there was an overall

85.3% test-retest rate of agreement on items measuring attitudes towards mammography, the lowest level of agreement (59%) was found on a question assessing the degree to which mammography was uncomfortable.

One of the most important findings of the NBSS

study was that pain appeared to play a role in screening schedule compliance. Women who dropped out of the NBSS but who later completed questionnaires cited multiple disincentives for screening. Over 22%, however, indicated that mammography was “too painful.”

Taken together, the studies reviewed suggest that

pain and discomfort, as well as other deterrents. may play a role in a woman’s decision to avoid undergoing regular mammograms. However, these studies have not adequately addressed the issue of pain. None of the studies, for example, examined important characteristics of the pain (duration, quality) that women expect to have as a result of mammography. Furthermore, most of the studies that have assessed fear of pain have failed to analyze and present data on this variable. The studies have also failed to take advantage of standardized psychological tests that can be used to document factors such as anxiety, though Henrich et al. (1992) demonstrated that one can successfully incorpo- rate brief versions of a standardized anxiety scale (Taylor Manifest Anxiety Scale) (Bendig 1956) and a defensiveness scale (Marlowe-Crowne Social Desirabil- ity Scale) (Crowne and Marlowe 1960) into a large

STIMULUS

Technician Behavior

Socio-Environmental

ORGANISMIC

Biological

Race

Symptomatic Status

Menstrual Status

Drug Intake

Emotional Arousal

Psychological

Expectations

Information Deficits

Self-Monitoring

Self-Evaluation

scale screening study examining psychosocial factors and mammography use. Finally, because pain was not always measured in proximity to the actual mammography experience, memory bias may be a problem. Fur- ther research is needed to definitively test the importance of pain as a factor influencing decisions about having a mammogram.

Mammogruphy pain: u cognitive-hehuliorul model To date, pain during a mammogram has been viewed

as a sensory phenomenon largely related to mechanical factors such as the level of breast compression. Pain

researchers, however, have found that pain is a multidimensional phenomenon that is often influenced by sensory, emotional, and behavioral factors (Keefe ct al. 1992). Research findings have led to the development of new models of the pain experience that highlight the role of cognitive and behavioral factors (Keefe and Gil

1986). These cognitive-behavioral models are important not only because they can help us better under- stand mammography pain, but also because they can

lead to new treatment methods designed to prevent and reduce pain during mammography.

Fig. 1 presents the basic elements of a cognitive-behavioral model of mammography pain which is based on theories of behavior and self-regulation developed by Kanfer (Kanfer and Phillips 1970; Kanfer and Hagerman 1987; Kanfer and Schefft 1988). The model views pain during mammography as the result of a continuous set of interactions between behavior, biological and social-environmental influences. A systems perspective is inherent in the model, with changes in one part of the system influencing other parts of the system. Thus, the report of pain during mammography can feed forward and affect the perception and impact of events happening during and after mammography, and the social and environmental consequences of re-

RESPONSE

555J

Non-Verbal Pain Behaviors

Psychological

CONSEQUENCES

Socio-Envirollmental

Psychological

I$lie~;~Diagnost~ ”

Anxiety ah0111 Diagnostic Outcome

Feedforward Feedback

Fig. I. A cognitive-behavioral model of mammography pain.

porting pain (attention and support from the technician) can feed back and affect psychological variables

such as anxiety. The model also highlights the important role that the patient’s own efforts in self-regulation (e.g., use of pain coping strategies) play in determining the report of pain.

The cognitive-behavioral model of mammography pain groups the sources of control over pain report into four major categories: ( 1) stimulus variables, (2) organ-

ismic variables. (3) response variables, and (4) response consequences.

Stimulus variables include those environmental and social events that bear a functional relationship to pain report. The physical stimuli involved in mammography, e.g., actual compression of the breast tissue, play an obvious role in determining pain. When high rates of breast compression are utilized. the incidence of pain appears to increase. The rate of compression may also bc important. If compression is increased in a slow and graded fashion, women may report less pain.

One important stimulus variable that has been men- tioned in previous research reports but has rarely been studied systematically is the behavior of the technician, which can vary widely. A technician who appears inter- ested in the patient, who carefully prepares the patient

for the procedure, provides support, and is experienced can provide an environment that is conducive to coping with any pain or discomfort. On the other hand, a technician who fails to take time to establish a relationship with the patient, provides an inadequate explana- tion of the procedure, or appears to lack familiarity with the procedure, is more likely to elicit complaints of pain and discomfort.

The physical environment in which mammography is conducted is another important stimulus. Women who. in the past, have experienced repeated painful mammograms may be particularly responsive to cnviron- mental stimuli that have been associated with mammography pain. In these women the sight of the mam-

mography equipment or technician may serve as a

conditioned stimulus signalling the onset of yet another painful experience. Pain-related emotional and bchav- ioral responses elicited by such stimuli may serve to heighten the severity and impact of any pain that is experienced.

The social milieu of mammography may also be important. Patients undergoing mammography have the opportunity in waiting areas to meet with, observe, and talk to other women before and after they have undergone this procedure. These women may serve as models of how one might respond to mammography. The potential for modeling of negative, pain-related behaviors is always present. Some women, for example, may be quite anxious about the procedure and describe in

detail the pain and discomfort they cxpcrienced. The

effects of this may be particularly potent for women who have limited experience with mammography.

Organismic variables include biological and psychological factors inherent in the individual organism that can influence pain report. Studies of cxperimcntal pain (Tursky and Sternbach 1067: Woodrow et al. 1972) and clinical pain (Winsberg and Greenlick 1067) suggest that ethnic or racial differences may influence pain report. To date, only one study (Niclscn ct al. IWI)

has found the incidence of mammography pain to be related to race. This study. which relied mainly on subjects recruited from an economically disadvantaged community, found that pain levels wcrc higher in white as opposed to African American women. Symptomatic status is also likely to bc important. Women who have mammography for diagnostic purposes, i.c.. who have fibrocystic changes or who have had recent hrcast radiation or breast surgery. may have structural changes in the breast that cause them to experience more pain.

Menstrual status is also important. During certain

phases of the menstrual cycle women art‘ much more

likely to report breast sensitivity and to find mammog-

raphy painful. Also, breast size appears to bc impor-

tant; women who have smaller breasts tend to pcrccive

more pain during mammography. Medication intake is a biological variable that can

have a profound intlucncc on mammography. Because

of concerns about pain, some women may take anal-

gesic medications prior to mammography. Other women may be on antiintlammatory agents. antihypcr-

tensivc drugs. or psychotropic medications that can

influence pain perception. Kornguth et al. ( IW2) found

that 227; of the women in their study had taken some

medication on the day of the mammogram. Unfortu- nately, the study failed to identify whether women took medication for pain rclicf or as part of their rcgulaI

medical treatment.

Negative emotional arousal is an important biologic

variable that can affect the report of pain. Women who arc highly anxious, upset, or embarrassed about mam-

mography may perceive mammography as more painful

than those who arc rclaxcd and confident. One of the most powerful sources of anxiety during mammography

is the fear of cancer. This fear may bc particularly pronounced in women who arc undergoing a mammo-

gram for diagnostic purposes. Biological changes ;ISSO-

ciated with scvcrc depression may also heighten the

perceived severity of mammography pain and discon-

fort (Cain et al. IOXX).

Organismic variables also include psychological fac-

tors such as expectations and information deficits. As noted earlier, Stomper ct al. found that women who

cxpccted to experience more breast discomfort did, in

fact, report more pain. Women may have little information about the procedure, and, as a result, be unsure of what to expect. Women who rely on friends or on

the media for information may expect more pain than those who get their information on mammography from a physician (Stomper et al. 1988). A woman’s personal experience with mammography is obviously a very important source of information about pain and discomfort. Stomper et al. (19881, for example, found that women who had prior mammograms tended to report more pain. Women who have a history of negative

experiences with painful mammograms or other inva- sive medical procedures may enter mammography with the conviction that the procedure will be painful.

Self-regulation processes are known to influence the pain experience (Keefe et al. 19921, and may play an important role in mammography pain. Kanfer and Hagerman (1985) have proposed that self-regulation occurs when an individual is uncertain about a new situation or the usual ways of responding fail to be effective. Thus, self-regulation is quite likely to occur if a patient is going through her first mammogram or if she experiences an unusual amount of discomfort. Self-regulation involves several components. One component, self-monitoring, occurs when an individual de- liberately focuses more attention on her behavior. General perceptions of ability to control pain are a crucial part of self-monitoring. If a woman views mam-

mography pain as largely controlled by environmental (excessive breast compression) or biological factors (increased breast sensitivity), she is likely to make few attempts at self-control. In this case, behavior will proceed according to previous experiences of what one does in an uncontrollably aversive situation. On the other hand, if a woman views herself as an important source of control over mammography pain, she is more likely to make efforts on her own to cope and deal with the situation (Kornguth et al. 1993).

Self-monitoring can bc problematic when it is excessive or deficient (Kanfer and Hagerman 198.5). For example, a woman who is preoccupied with each physical sensation during mammography may be prone to incorrectly label internal cues as painful. On the other hand, a woman who ignores or fails to make efforts to respond to potentially painful stimuli may find that she has more pain and discomfort.

A second component of self-reguiation is self- evaluation (Kanfer and Schefft 1988) in which the individual compares current behavior to previous standards. The standards women use in the situation of mammography may be based on their own experiences or on prevailing social norms. Thus, women who have never had a painful mammogram or who have been informed by others that mammography is painless may have difficulty if they begin to experience pain or discomfort. A critical determinant of how women re-

spond emotionally to mammography is whether the standard they use is a short-term, situation speciiic standard or a more long-term standard related to the

maintenance of enduring personal goals. Many women view the way they cope with mammography as a tcm- porary issue and, as a result. their efforts arc largely focused on coping and adjusting to the situation. Other women, however, may view their behavior in this situation as highly important to their goals and self-image. For these women, successfully coping becomes an important challenge and any pain or discomfort may be perceived as a sign that they are failing to cope effec- tivcly. The result may he overly negative self-evaluations and intrusive negative thoughts (e.g.. -‘I can’t stand this pain,” “ There is nothing 1 can do to cope with this pain”) during and after mammography. Ke- search suggests that such negative thinking and catastrophizing heighten the severity and emotional impact of pain (Keefe et al. lY8Y: Gil et al. 1YYO).

Response Lsariables Mammography can produce pain-related behavioral,

biological, and psychological responses. Probably the most common behavioral response is verbal report of pain. During mammography, some women readily describe the intensity and quality of the pain they experience. Other women may be reluctant or embarrassed to report pain. Still others may have difficulty reporting pain to a technician because of deficits in social skills or language abilities. The absence of a verbal report of pain, therefore, should not be taken as evidence that a woman is not experiencing discomfort or pain. Careful measurement of pain through the use of well validated rating scales (e.g., numeric or visual analogue scales) or verbal descriptor scales (e.g., the McGill Pain Ques- tionnaire) may reveal that a higher proportion of women have pain than would be expected on the basis of spontaneous verbal reports alone.

During mammography, pain also may be evident in non-verbal pain behaviors such as grimacing or pain- avoidant posturing. Although careful behavioral observations have proven quite useful in documenting pain behaviors in other clinical populations (Keefe and Dunsmore 1992), these methods have not yet been applied to the analysis of pain during mammography.

Biological responses to mammography include local tissue and systemic reactions to mechanical stimulation involved when the skin is stretched and placed under pressure. Biologically based differences in sensory thresholds may be important in determining whether the stimulation is perceived as pressure or pain.

Psychological responses to mammography include the use of self-regulatory and self-control skills. A variety of pain coping strategies may be used to reduce and control pain. For example, some women may use cognitive coping strategies such as distraction, imagery,

or imaginative reinterpretation to reduce their pain. Other women may use behavioral strategies such as talking or listening to music to control pain. Although pain researchers have found that the use and perceived effectiveness of such coping strategies is important in understanding pain (Keefe et al. 1987), the degree to which coping responses relate to mammography pain and discomfort is unknown.

Mammography pain can influence and be influenced by its social consequences. In some patients, the atten-

tion paid to pain complaints may be rewarding and may increase the likelihood that pain will be reported during future mammograms. For example, an overly solicitous friend may prompt and unwittingly reinforce reports of mammography pain.

Over the course of several mammograms, a patient may learn which individuals are likely to attend to complaints of mammography pain. As a result, she may fail to mention having pain to the radiology technician who tends to minimize her complaints, while at the same time talking extensively about mammography pain with close friends. One reason for the relatively low

incidence of reports of mammography pain may be that women have learned that health care professionals arc not very responsive to their pain complaints. Some women may respond to this by avoiding further mammograms.

The diagnostic outcome of a mammogram can also influence pain responses. Women who are emotionally upset because they fear they may have cancer may experience more pain during mammography but tend to minimize this pain once they learn that the mammogram was negative. The reduction of emotional arousal that occurs following a negative mammogram can sell/c

as an important feedback function and may act as a reference standard for future self-evaluations of the experience.

Implications of the cognitive-behavioral perspective for assessment and treatment of mammography pain

The cognitive-behavioral model described above has important implications for the assessment and treatment of mammography pain. In this section we con- sidcr implications both for clinical practice and for research in this area.

Clinicul itnplica tions The cognitive-behavioral model maintains that pain

can be better understood and managed if clinicians attend to a broader range of variables. To clinically manage mammography pain, one needs to go beyond viewing the pain as simply a sensory phenomenon and

consider its antecedents, behavioral responses. and

consequences. Antecedetzts of pain. As noted carlicr, cnvironmcntal

stimuli and organismic responses that precede an actual mammogram can have an important influence on whether or not pain is experienced or reported. By modifying these antecedents. one can pntcntially reduce pain.

Instructions can play an important role. As part ot the preparation for a mammogram. women can he given written material on the procedure that includes information relevant to pain. Specific topics that need to bc addressed openly include: (1) the fact that a proportion of women experience pain, (2) the fact that although someone may feel inhibited about complain- ing. it is acceptable to report pain during the pt-oce- dure. and (3) mammography pain can be potentially

controlled. Ideally, the technician performing the procedure should supplement written materials with an opportunity for questions and answers before the procedure.

Carefully prepared videotaped materials can also he quite useful in managing mammography pain. A video- tape might include interviews with women who have gone through the procedure for the first time. (‘om- mon concerns and fears as well ah barriers to the control of pain could be addrcsscd.

Effective pain management can bc achieved only it women report their pain. For this reason, the possibility of pain should be directly addressed prior to a mammogram and women should be strongly cncour- aged to report any pain that they cxpericnce during mammography. Systematic assessments of pain using standard numeric or adjective pain descriptors could be easily integrated into clinical practice. These pain asscssmcnt tools provide information on the intensity and duration of pain that is useful in planning pain management.

The setting in which mammography is carricti out can also be engineered to enhance pain control. 13~ providing an environment rich in distractions such as pleasant music, enjoyable paintings/posters. or rcad- ing material one may enable women to divert theil attention from pain and achieve improved pain control.

Another way to control the antcccdcnts of mammography pain is to provide women with more accw

rate sensory and procedural information prior to each step in the mammography process. Women arc often better able to marshal1 their coping resources when they know what they can expect to face at each stage of the mammogram.

Hehrrr~iotul r-esponscs. During mammography the rate and level of compression are often determined by ;I technician-controlled foot switch. Recent rcscarch hy Kornguth ct al. (1993) suggests that women who arc given control of compression using a hand switch arc

much less likely to report mammography pain. ‘I’his finding agrees with other pain studies showing that ;I heightened sense of control over pain is related to decreased pain (Vallis and Bucher 1086; Litt 1988; Rokkc and La11 1992). The results of the Kornguth ct

al. study have very important clinical implications since they suggest that providing women with options such as direct control through self-compression or verbal control over the timing of compression can significantly reduce pain.

Although cognitive-behavioral strategies for coping with painful medical procedures have been developed, these methods have not been widely used to control mammography pain. The level of coping skills training required varies with the patient. Women who have never had a mammogram, or who have had little pain during prior mammograms, could simply be encour- aged to use coping methods they generally find useful. More intensive training in pain coping skills is likely to be needed for patients who are at high risk for pain, e.g., those who have had severe pain during previous

mammograms or those who are especially anxious. Relaxation training might be especially beneficial for patients who are anxious or tend to tense up during the procedure. Training in attention diversion methods

such as imagery. focal point, and slow and rhythmic counting is likely to help patients who tend to be preoccupied with the physical sensations of mammography. Patients who are prone to negative thinking and catastrophizing might respond well to self-instructional training in which they learn to use calming self state-

ments and maintain a more rational outlook when dealing with pain. An understanding of a patient’s information coping style may help in matching patients to treatments (Miller 1987).

Corzseqllences @‘pain. The control of mammography pain can also be enhanced if clinicians attend to the consequences of pain and pain management. Medical personnel need to frankly acknowledge the report of pain when it occurs, rather than dismissing it as abnormal. Responses to the report of pain should not only focus on the fact that pain has been experienced but also on encouraging the patient to use pain coping strategies. Attending to and discussing coping strategies can often enhance the use and perceived effectiveness of these strategies.

One of the most important consequences of a mammogram is the diagnostic outcome. Providing women with information on diagnosis as soon as it is available can decrease the anxiety about mammography.

Research implications A central weakness in the existing research is a lack

of clarity regarding subject characteristics such as race, familiarity and/ or experience with mammography, perception of breast cancer risk, and symptom status.

In most studies, either these factors have been ignored or heterogeneous subject samples have been utilized. Usually, there have been insufficient numbers 01’ minority women to draw conclusions about their rcaz- tions. According to the cognitive-behavioral model presented above. prior experience with mammography may sensitize women to environmental stimuli and influ-

ence their USC of self-monitoring, self-regulation and self-evaluation before, during, and after the procedure. Furthermore, the context of the testing procedure (i.c.. diagnostic evaluation or asymptomatic screening) may significantly influence the level of anxiety experienced by women both before and during a mammogram, as well as their interpretation of sensations associated with the procedure. Similarly, organismic variables such as the presence of symptoms (e.g.. lump or discharge). pre-existing breast tenderness, breast size, menstrual status, fatigue, emotional arousal, and medication rn- take are also potentially important factors. Re- searchers need to document these patient characteristics and employ larger subject samples which will enable them to use more sophisticated analyses, controlling for both known and suspected moderating variables. Larger samples would also allow researchers to make comparative analyses of truly homogeneous subject groups.

The cognitive-behavioral model of mammography pain suggests that stimulus variables play an essential role in the continuous interplay between behavior. biological, and social-environmental influences. There- fore, environmental factors such as amount of compression, provision of verbal or written information, modeling by other patients or staff, patients’ degree of control over the rate and extent of compression, and technician variables such as interpersonal communica- tion, technical skills, and gender warrant additional attention. To date, it is unclear whether manipulation of these variables could significantly influence women’s perceptions and reports of pain. It may be useful to conduct studies in which these variables arc carefully documented and either controlled 01 systematically varied. Intervention studies in which high-risk patients were trained in various adaptive strategies such as physical relaxation, imagery. and distraction would also be invaluable.

Researchers also need to broaden the range 01 variables considered in future functional analyses of mammography pain. Chronic pain literature researchers have examined patients’ beliefs, appraisals and expectancies regarding the utility of coping efforts (Jensen et al. 1991) and their data suggest that beliefs (especially negative thoughts) may directiy affect mood. In addition, patients’ appraisal of their situations may influence their coping efforts and adjustment in multiple areas of psychological, physical, and psychosocial functioning. For example, a general external or chance

locus of control among pain patients has been associ-

atcd with depression (Skevington, 1083) and decreased life satisfaction (Laborde and Powers 1985). Locus of control has also been linked to the type of pain coping strategies employed by chronic pain patients (Buckelew et al. IYYO). Furthermore, research suggests that perceptions of control over pain are related to pain coping strategies and psychological distress among chronic pain patients (Crisson and Keefe 198X).

In addition to locus of control, researchers have investigated the role of numerous other pain beliefs (e.g., attributional style. cognitive distortions, self-ef-

ficacy, and outcome expectancies) as both direct correlates and mediating factors between pain coping strategies and various dimensions of adjustment to chronic pain (for a brief review, see Jensen et al. lY91). Re- starch is needed to determine whether findings related to chronic pain can be cxtrapolatcd to the more acute pain associated with mammography.

A broader range of measurements must be employed in future research. Most new mammography machines arc capable of providing a direct measure of the amount of compression applied to the breast. This objective measure means that it will be much easier for researchers to analyze the relation between compression and pain perception. It will also enable re- scarchcra to study how variations in perceived pain

occurring over the course of the mammogram relate to both the rate and level of compression. Although a discussion of available pain instruments is beyond the scope of this article (for a more complete review. see Karoly and Jcnscn 1987) it is recommended that rc- scarchera use instruments that will allow them to assess multidimensional aspects of pain (e.g., McGill Pain Questionnaire) (Melzack lY6S). In particular, there is a need for more information comparing the perceived intensity and unpleasantness of mammography pain. Observations of non-verbal pain behaviors would also be useful in more fully characterizing how women respond to mammography. In addition, future studies should also include assessments of psychological functioning, such as measures of depression (e.g.. Beck Depression Inventory) (Beck et al. 1961), anxiety (e.g.. State-Trait Anxiety Inventory) (Spiclberger 107(l), and personality factors such as locus of control (e.g., Multi- dimensional Health Locus of Control) (Wallston et al. lY78). Finally, assessments of pain expectations should bc prospective rather than part of a retrospective assessment of pain.

Conclusions

Based on the studies reviewed in this paper, it scums reasonable to draw three major conclusions. First, some women perceive mammography as a painful

and uncomfortable experience. Second, there is reason to believe that pain is a factor that prevents at least some women from participating in regular breast cancer screening. Finally, it is clear that the problem of mammography pain has not received adequate research or clinical attention.

It is our hope that this paper will stimulate interest in research on mammography pain. New approaches and new studies are needed if we are to improve our understanding of this clinical problem. Researchers and clinicians working in this area need to give consid-

eration to the cognitive-behavioral perspective since it may lead to innovative methods of assessing and treat- ing the pain and discomfort occurring during mammography.

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Mammography pain and discomfort: a cognitive-behavioral perspective

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