Original Article

Influence of Discomfort Tolerance of Women who Undergo Mammography on the Perceived Pain Intensity Due to the Procedure

10.4274/ejbh.2020.6068

  • Neriman Akansel
  • Muaz Gülşen
  • Muhammed Gültaş

Received Date: 28.08.2020 Accepted Date: 11.12.2020 Eur J Breast Health 2021;17(1):68-75

Objective:

This study aims to determine the capacity to tolerate discomfort by women who undergo mammography.

Materials and Methods:

The data were obtained using the face-to-face interview method immediately after the procedure with women who undergo mammography (n=132). Demographic data collection form and the Discomfort Intolerance Scale was used for data collection.

Results:

Among the women, 78.8% experienced pain during mammography and the pain intensity was determined as 3.55 (standard deviation=3.00) on the 0-10 Visual Analogue Scale. Women who were not on pain relievers and nonsmokers have high discomfort tolerance. Women who were consuming substances containing methylxanthine (eg. chocolate) tend to avoid discomfort. Women with a history of breast mass and abnormal test results did not avoid discomfort as much as women who undergo regular checkup mammograms. Most of the women experience pain during mammography, and avoidance from discomfort increases as the perceived pain during the procedure increases.

Conclusion:

Conducting different studies using the same scale can be useful in evaluating the discomfort experienced during mammography and its contribution to reducing pain.

Keywords: Pain, Discomfort Intolerance Scale, mammography

Introduction

Cancer is the most frightening disease that causes mortality worldwide (1, 2). The most effective way to decrease the mortality rate is early diagnosis and treatment. American Cancer Society estimates 279,100 new breast cancer cases in 2020, and 42,690 of them are predicted to die due to breast cancer. Diagnosis of breast cancer includes a physical exam done by a physician as well as mammography (3, 4), and it is a reliable diagnosis method used all over the world (5, 6, 7). In mammography, breast radiography is obtained using a low dose of radioactive rays. With this procedure, early diagnosis and treatment are possible by detecting the structures that can turn into breast cancer years later (3). Recently, 3-dimensional (3D) mammography has become more popular in achieving better results. In medical imaging methods, the ability to detect pathological conditions depends on the image quality. Compression (pressure) is applied to the breast tissue in mammography to achieve this quality. This compression causes both pain and discomfort in the individuals (5, 8). Additionally, reasons such as the compressor material’s being cold, claustrophobia in those who undergo mammography, lack of empathy of healthcare staff, not giving information about the procedure, prolongation of the reporting process cause patients to postpone having a mammography. Negative experiences encountered during mammography affect the patients’ compliance, satisfaction, and comfort levels (9). Even the possibility of negative outcomes of mammography impress women's pain and satisfaction from mammography. Feeling of embarrassment and discomfort during the procedure could result in unpleasant perceptions toward this procedure (10). Whelehan et al. (11) reported that 3%-46% of British women did not comply with control mammography, due to previous pain and discomfort they experienced. Pain felt during a mammography is not only limited to the breast, it also could extend to the axilla as well (12). The women's ethnicity, breast density, previous biopsy experience, and psychological factors are causative factors of discomfort during mammography (9). Breast implants also trigger the pain and anxiety of women during the procedure (13).

A study published in the Cochrane database revealed that education is given to patients before mammography may decrease discomfort and pain felt during the procedure. Although using a breast pad decreases discomfort and paracetamol application is not effective (14). Freitas-Junior et al. (5) found that a capsule form of paracetamol given before the mammography procedure is effective in reducing moderate pain. Various studies have examined the effects of administering lidocaine (15), using Mammopad, Bedford, and mattresses (7, 10, 14, 16, 17), and reducing the compression force applied during mammography on reducing pain and discomfort due to mammography (7, 17, 18, 19, 20, 21). This study aims to assess the effect of the capacity to tolerate discomfort on the pain felt by women undergo mammography.


Materials and Methods


Design

This study was conducted with 132 women who had mammography at the Radiology Department of a University Hospital between February and April 2017 (for three months).


Participants and settings

A total of 225 patients were registered to have mammography for 3 months. Raousoft sample size calculator was used to calculate the sample size. With 90% reliability and 5%, the error margin sample size was calculated as 124 patients.


Measurements

The data were obtained using the demographic data form developed by researchers according to relevant literature and the Discomfort Intolerance Scale (7 items) which was adapted to Turkish by Özdel et al. (22). The Discomfort Intolerance Scale (DIS) was originally developed by Schmidt et al. (23) to measure the personal differences to tolerate discomforting sensations. This scale has two dimensions named discomfort intolerance (DI-DI) and discomfort avoidance (DI-DA). Split-half test reliability was 0.710 in the Turkish form of scale (DI-DI measures the capacity to tolerate physical sensations while DI-DA measures the level of avoidance from physical sensations). Each item of the scale includes Likert type options numbered from 0 to 6 defined as; 0= not at all like me to 6= extremely like me (22, 23). The total score that can be obtained from the scale ranges from 0 to 42. The lower scores describe a decline in the person’s capacity to tolerate discomforting bodily sensations (22).


Data collection procedure

Data were collected by the researchers using face-to-face interview methods with patients who volunteered to participate in the study after mammography. Each interview took 10-15 minutes.


Ethical consideration

Ethical committee approval was obtained from the Bursa Uludağ University (decision no: 2016-19/6) and institutional approval was obtained from the hospital where the study was going to be conducted The patients were informed that participation is voluntary, and they can leave the study whenever they want, then their verbal and written approvals were obtained.


Data analysis

Data analysis was done by SPSS. Normality analysis was done using the Shapiro-Wilk test. Data were presented in numbers, percentages, means, and SD. T-test, One-Way ANOVA, and Pearson correlation was used for statistical analysis.


Results

Table 1 shows the descriptive characteristics of patients who undergo mammography. The mean age of the patients was 55.62 [standard deviation (SD) =9.83] and their Body Mass Index (BMI) was calculated as 29.62 (SD=6.05). More than half of the participants (52.2%) were primary school graduates. The rate of undergoing mammography annually was 57.6%, and 75.8% of women reported having control mammography (Table 1).

Table 2 shows the effect of patients' demographic characteristics on their DIS scores. As the BMI and weight increase, women tend to have more discomfort, and their score increase (p<0.05). Nonsmoking women had more discomfort tolerance power than smokers (p<0.05). The chocolate-eating routine had significantly increased DI-DA scores of women (p<0.05), and women who custom to take analgesics for their pain regularly were more intolerant to discomfort (p<0.05). The patients' other demographic variables did not have any influence on their discomfort (p>0.05) (Table 2).

Table 3 shows the influence of women's mammography-related characteristics on their DIS scores. Characteristics of pain felt during mammography did not influence discomfort intolerance scale scores and DI (p>0.05). The discomfort avoidance was high among women who reported crushing and stinging pain during mammography (p<0.01) (Table 3).


Discussion and Conclusion

Not having breast tenderness is associated with feeling less pain during mammography (24). The majority of the patients (75%) who underwent mammography did not report any breast tenderness and most of them were not used to take pain relievers. This study did not assess whether the analgesics that the patients used were prescribed. The majority of the patients (78.8%) reported having pain during mammography, and the pain intensity was calculated as 3.55 (SD=3.00) on Visual Analogue Scale 0-10 (VAS 0-10); (0= no pain, 10= intense pain), the pain characteristics were mostly crushing/stinging (Table 1). The presence of a mass in the breast and abnormal findings on physical examination are associated with extreme pain during the mammography (24). Yılmaz and Kıymaz (25) emphasized that patients may experience anxiety due to the possibility of being diagnosed with cancer. The burden of having a mammography, feeling discomfort, and being anxious resulted in dissatisfaction with mammography (26). Sufficient knowledge of the procedure tend to decrease the anxiety among women (25), and pain perception is usually associated with personal sensitivity rather than the pressure itself (12). The presence of a breast mass and previous abnormal tests may have influenced the majority of the women's pain perception. Therefore, not starting the mammography procedure with the tender breast may decrease the unpleasant outcomes of the procedure (12). Pain and discomfort are subjective concepts that vary among people. While a study revealed that the explanatory information given to patients decreased pain sensation due to procedure (24), another study emphasizes that written information provided did not influence susceptibility to procedural pain (25). Additionally, applying standardized pressure results in less pain, less discomfort, and prevents excessive compression especially in small-breasted women (8). Pain felt during mammography with flexible and standard compression did not differ between groups, and 34% of them experienced moderate or severe discomfort (20). A study conducted with experimental and control groups showed that the severity of pain during the mammography was 3.5 in the experimental group that took paracetamol, while it was 2.9 in the placebo group (5).

Some of the demographic characteristics (age, breast size, marital status, education, income level, place of residence, profession, breast cancer history in first degree relatives, being in menopause, presence of breast tenderness, tea-drinking routine) of the patients in this study did not have any influence on DIS and sub-dimension scores (Table 2). Another study found that age, education level, breast size, breast cancer history in first degree relatives, being in menopause, and drinking coffee did not influence the pain experience and discomfort due to mammography (5). Chan et al. (7) reported that the age and breast size of women were not related to the discomfort felt during mammography. They also found that Mamopad application significantly decreased the discomfort experienced during mammography, and women with low breast density experienced less discomfort. On the contrary, there is also a study showing that smaller breasts are more sensitive to the compression that occurs during mammography (12, 18). Thus mammography procedure applied with the pressure standardization method in women with small breast decreased the pain and discomfort felt during the procedure (8, 21). Moreover, it provided better results on the image quality, and eased the diagnosis process (8). A study conducted with technicians who take mammography revealed that small breast size increased discomfort during mammography and the discomfort levels of women with high breast density during mammography were similar to that of women who had a previous lumpectomy or biopsy experience (9).

In this study patients' power to tolerate discomfort decreased as their weight increased. Similarly, the negative correlation between BMI and DIS score was evaluated that as the BMI increases, the patients' tolerance towards the disturbing stimulus decreases. Apart from the results of this study, Moshina et al. (27) found that BMI did not interfere with pain experienced due to compression paddle during mammography.

Women who did not use to taking pain relievers had significantly high  DI. Not being able to tolerate discomfort is among the important risk factors on the emergence, development, and continuity of anxiety (28). In some studies, smoking is presented as an excuse to cope with stress, and individuals continue smoking when they feel stressed (29). This study revealed that nonsmokers were more resistant to disturbing stimuli.

The craving to eat chocolate was determined to be triggered through stress or important events in North American women (30). This study found that the DI-DA scores of women who consume chocolate were significantly higher than those who did not (p=0.036). DI-DA scores of women with no mammography experience (p=0.020), and were unable to define the pain experienced during mammography (p=0.000) were low (Table 3). Based on these results, women with previous mammography experience display more discomfort avoidance behaviors. Similarly, the severity of pain sensation due to the procedure increases discomfort avoidance (p<0.001). The DIS total score and DI sub-dimension scores of women with previous mammography experiences were higher but statistically insignificant.

The burden of having mammography was found to increase dissatisfaction (26). DA scores of women undergone mammography due to the presence of mass or abnormal test results were lower (p=0.041) than those who had control mammography in this study. Having mammography for checkup purposes resulted in more discomfort in women than the women who had a mass in the breast, and or abnormal test results. The reason for this outcome could be due to women's anxiety related to pending results.


Limitations of the study

The limitations of the study are that the study data were collected in one center and a specific time frame. The study data were written by discussing with other studies on mammography since there is no scientific study using the discomfort scale in this subject.

In conclusion, most of the women experience pain during mammography. The ability to tolerate discomfort shows how well people can tolerate conditions that disrupt comfort. Women who were not on pain relievers and non-smokers have high discomfort tolerance. Women who were consuming substances containing methylxanthine (eg. chocolate) tend to avoid discomfort. Women with a history of breast mass and abnormal test results did not avoid discomfort as much as women who undergo regular checkup mammograms.

Conducting different studies using the same scale can be useful in evaluating the discomfort experienced during mammography and its contribution to reducing pain.


Acknowledgements: We would like to thank all the patients who volunteered to contribute to this study.

Ethics Committee Approval: Approval was obtained from the Bursa Uludağ University Ethics Committee (approval number: 2016-19/6; December 16th,2016) and institutional approval was obtained from the Bursa Uludağ University Medical Hospital where the study was conducted.

Informed Consent: The patients were informed that participation is voluntary, and they can leave the study whenever they want, then their verbal and written approvals were obtained.

Peer-review: Externally peer-reviewed.

Authorship Contributions

Conception: N.A., M.G., Mu.G.; Design: N.A., M.G., Mu.G.; Supervision: N.A., M.G., Mu.G.; Fundings: M.G.; Materials: N.A., M.G., Mu.G.; Data Collection and/or Processing: M.G., Mu.G.; Analysis and/or Interpretation: N.A.; Literature Review: M.G., Mu.G.; Writing: N.A., M.G.; Critical Review: N.A., M.G.

Conflict of Interest: The authors declare no conflict of interest.

Financial Disclosure: No financial support was received from any company to complete this study.

Images

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