Guerrero M/ Enfermería Investiga Vol. 9 No. 2 2024 (April - June)

CHARACTERIZATION OF USERS OF SCREENING AND DIAGNOSTIC MASTOGRAPHY

María Violeta Guerrero Martínez1 https://orcid.org/0009-0007-7008-9871, Alfonso Reyes López2

https://orcid.org/0000-0002-6249-3678, Nuria Aguiñaga Chiñas3 https://orcid.org/0000-0002-3339-5809,

Guillermo Cantú Quintanilla4 https://orcid.org/0000-0002-3493-2207

1Master in Bioethics from the Faculty of Health Sciences, Universidad Panamericana, Mexico City, Mexico

2Research Professor at the “Federico Gómez” Children's Hospital of Mexico, Mexico City, Mexico

3Specialty in Clinical and Health Psychology from the Faculty of Health Sciences, Universidad Panamericana, Mexico

City, Mexico

4Research Professor at the Interdisciplinary Center of Bioethics of the Universidad Panamericana, Mexico City, Mexico

distributed under the terms of the Creative Commons License, which permits unlimited use, distribution, and reproduction in any medium,

provided the original work is properly cited.

Corresponding author: Dr. Guillermo Rafael Cantú Quintanilla. Email:gcantu@up.edu.mx

Received: December 15, 2023

Accepted: February 1, 2024

ABSTRACT

Introduction: The incidence of breast cancer has increased and there are areas aimed at timely diagnosis

and intervention, identifying the screening capacity of the Mexican healthcare system, which is the main

area of opportunity. When patients are informed, anxiety decreases and their psychological state improves.

Objective: Explore the characterization of users of screening and diagnostic mammography for breast

cancer, in the private healthcare area of Mexico. Methods: Data from 150 women were collected in a

spreadsheet and analyzed in Stata. Univariate analysis for continuous variables and relative frequencies for

qualitative variables were used. The relationship between quantitative variables was explored using scatter

plots. Results: The survey found that women scheduled for mammograms, although they have moderate

concerns. This shows a strong link between their level of knowledge about the procedure and their concern.

Personal and medical characteristics did not significantly affect this concern. Conclusions: Patients with

more information about mammography had a lower level of concern.

Keywords: breast cancer, information, mammography, autonomy

INTRODUCTION

In recent years, the incidence of breast cancer has

increased, being the most common cancer in

women according to the World Health Organization

(WHO), representing 16% of all cancers in women

(1). It is estimated that 1.38 million new cases are

detected each year and this figure continues to

increase (2). This condition occurs more frequently

in developed countries, possibly due to increased

life expectancy, urbanization and changes in

lifestyle, but it has a greater impact on the population

of developing countries such as Mexico (3). In the

country, the situation of breast cancer is not

encouraging because it represents the leading

cause of death from neoplasms in Mexican women

(4).

The WHO states that early detection is a

fundamental strategy because through timely

diagnosis and appropriate treatment it is possible to

reduce the impact of the disease (3). For this reason,

preventive campaigns should focus on performing

mammograms or, in countries with lower per capita

income, on the use of self-examination as a

technique for detecting palpable lesions (3).

Currently, there is little investment in prevention

programs in developing countries and little response

from the population due to the lack of training in

health personnel and the low awareness of the

needs of this at-risk group (5).

One of the main issues in Mexico is the improvement

and expansion of screening aimed at promoting

early detection of breast cancer. In developed

countries, screening programs are applied and have

facilitated early detection and timely treatment of

breast cancer, giving patients a better quality of life.

These campaigns have proven to be highly

effective, which is why they have also begun to be

replicated in developing countries (6). Available data

suggest that only between 5 and 10% of cases in

Mexico are detected in the initial stages of the

disease (localized in the breast) compared to 50%

in the United States (7).

According to the Pan American Health Organization,

in 2012 breast cancer was the most common type of

cancer in Latin America. By 2030, the same

Organization estimates that the prevalence will

increase by 46%. In Mexico, breast cancer in

women over 20 years of age is the second cause of

death (8) and the first cause of cancer-related

mortality (9). Most cases are detected in advanced

stages, when the probability of 5-year survival with

treatment is less than 30%. Additionally, costs to

women, their families, and the health system are

higher, and treatments are more difficult, more

invasive, and less effective (8).

It is important to highlight the role of information and

recognize that citizens need to know the risks to

which they are exposed in order to act accordingly.

Researchers must address gaps in knowledge to

generate better practices in health promotion, as

well as develop better technologies, programs, in

order to establish better policies and clinical care (8).

Access to information about breast cancer,

accompanied by better medical care, could promote

greater survival, as happens in developed countries

(10).

Over a 10-year period and for every 1,000 women

undergoing mammographic screening, it is

observed that between 167 and 251 receive

abnormal results and are called for further testing, of

which approximately 56 to 64 undergo at least one

biopsy. Additionally, between 9 and 26 cases of

invasive cancer and three to six cases of ductal

carcinoma in situ (DCIS) are detected through

screening. Compared with women who refuse

screening, a reduction of 0.5 to 2 deaths from breast

cancer is observed during this period, depending on

the age of the women (11).

Recent increases in the use of mammography have

led to a decrease in breast cancer mortality.

Likewise, there is evidence that when patients are

informed about the diagnosis and the interventions

they will have, their feeling of control increases,

anxiety is reduced and their psychological

adjustment to the disease situation improves (12).

One research project assigned women to one of

three intervention groups: no educational materials

(usual care), standard materials, or adapted and

personalized materials. Those in the latter group

received materials based on their stage of adoption

for mammography. The primary outcome was

obtaining repeated mammograms, and women in

the group with tailored and personalized materials

were found to be more likely to obtain them

compared to those in the group without materials

(13).

This demonstrates the urgent need for health

education to promote early diagnosis of cancer and

timely treatment which the basis for improving the

quality of care for patients with breast cancer (10,

14). Furthermore, it contrasts with the findings of an

analysis of 58 pamphlets revealing that information

on mammography often focuses on incidence rather

than mortality, which is worrying given that

screening reduces mortality, but not incidence, and

can increase it by detecting harmless diseases (15).

A study of women in European and American

countries examined the understanding of the likely

benefits of mammography and found widespread

misconceptions. Most women believed that

screening prevents or reduces the risk of getting

breast cancer, or at least breast cancer mortality is

reduced by half. They also believed that 10 years of

regular screening will prevent 10 or more breast

cancer deaths per 1000 women (16). The greater

number of correct answers was positively

associated with a higher educational level and

negatively associated with having had a

mammogram in the last 2 years. The results suggest

that a high rate of women overestimate the benefits

that can be expected from mammographic

screening, raising questions about informed consent

procedures in breast cancer screening programs.

The main objective of Health Literacy is to enable

individuals to make informed and autonomous

decisions about their health. When facing health

problems, we look for answers first in those close to

us, such as family or friends. However, depending

on the topic, broader sources are also used, such as

the Internet, which offers a large amount of

information (17). The challenge lies in teaching the

population to discern between useful information

and that which is not, avoiding overinformation or

misinformation.

Research found that presenting information about

the benefits of cancer screening in different ways

affects an individual's decision to accept or reject

screening. Respondents were more likely to accept

screening when the benefits were presented as a

reduction in relative risk, and more likely to reject it

when they were presented as the number of

screenings needed to save a life (18). Healthcare

professionals face the challenge of balancing

presenting benefits in a positive way to improve

participation rates, with the need to provide

information in a balanced way to facilitate informed

choice.

There are three measures that seem essential to

extend the scope of existing programs for the

detection of breast cancer (9): 1. Raise awareness

among the population about the growing importance

of this problem, 2. Recognize early detection as the

key to control. of this disease and 3. Fight against

the cultural barriers that prevent its rational

approach.

The best practice when reporting is to individualize

the information to the patient as much as possible,

which requires great skill on the part of the

healthcare professional. It is vital that the difficulties

when communicating bad news, such as the

emotional impact, are recognized (19).

Communication and access to information for

patients is an excellent strategy to improve

promotion, prevention, diagnosis and rehabilitation.

So, it is necessary to normalize the use of

communication strategies in health environments,

considering all levels of intervention to which a

person is exposed.

Frequently, it is reported that the personnel in

charge of providing care to patients limits

themselves to informing them about the basics for

performing mammography (20). What's more,

patients begin to ask various questions, not only

related to the radiographic procedure, but also to

other aspects of mammography. They mainly

question whether mammography represents a

thyroid risk, the level of radiation to which they are

exposed, the degree of pain caused by the

procedure or if it is really the ideal time to have the

study.

Based on what was described above, the objective

is to explore the characterization of users of

screening and diagnostic mammography for breast

cancer, in the private health area of Mexico.

METHODS

The present report arises from a protocol that

explored the characterization of users of screening

and diagnostic mammography for breast cancer in

the private environment, whose results refer to the

baseline conditions of the participants regarding the

information they had before having been subjected

to the intervention. It is a controlled, randomized,

non-blinded trial.

Participants

The sample was census type, consisting of 150

women, who came to request a mammogram at a

private clinic, in the period from October 14 to

December 23, 2016, in Mexico City.

Instrument and procedure

A 14-question questionnaire was designed to

evaluate patients' knowledge and doubts about

mammography, as well as their main source of

information. The first two questions cover

sociodemographic aspects such as sex, age,

occupation and education, while the remaining 12

cover aspects related to the mammography

procedure with multiple choice answers (e.g. yes/no,

not at all/a little/regular/a lot, etc.). The variables it

measures are: the reason for the procedure, the

number of times the procedure has been performed

previously, the degree of concern about the

procedure, the level of knowledge about the

procedure, the main source of information, the

number of doubts about the procedure and the type

of doubts they had.

The instrument was applied prior to the procedure in

the same place where the mammography was

performed. The informed consent was read to them

and the conditions of privacy, trust and comfort were

guaranteed, emphasizing that their participation was

voluntary and could be terminated at any time, and

would not affect their medical care. In accordance

with the guidelines and ethical principles for medical

research on human beings recommended by the

Declaration of Helsinki (21), they were provided with

all the necessary instructions for the proper conduct

of the survey and informed that the use of the

information collected would be with caution,

exclusively for scientific purposes.

Analysis strategies

All data were collected in a spreadsheet for

validation and were subsequently exported to the

Stata program for statistical analysis. A univariate

analysis was carried out by calculating measures of

central tendency and dispersion for the variables on

a continuous scale, while relative frequencies were

obtained for the qualitative variables. The

relationship between quantitative variables was

carried out using scatter graphs.

RESULTS

150 women participated with an average age of 53.9

years (SD ± 9.1 years). Regarding education, those

with a bachelor's degree predominated (37%), with

high school in second place (34%) and postgraduate

in third place (15%). A small percentage of patients

only had secondary education (7%), or primary

education (6%). Regarding occupation, the majority

said they were housewives (53%), while 29% said

they were employees and 10% worked as

independent professionals. The rest mentioned

some commercial or business activity.

Although the percentage of women who came to

request mammography due to medical indication

predominated (59%), the percentage of women who

came by their own decision (41%) is noteworthy. Of

the total sample, only 11 women came to request a

mammogram for the first time (7.3%). However, in

the rest of the participants, the heterogeneity in the

number of subsequent occasions when they had

taken the test was notable. In this sense, 20 of them

reported having had 10 previous mammograms

13.3%, but a small group of women mentioned

having had 30 mammograms (2.7%). In fact, a

moderate positive correlation (r=0.58) was evident

between the number of previous mammograms and

the age of the participants. The summary of the

sociodemographic data is evident in Table 1 below.

The prevalence of nervousness reported by the women prior to undergoing the mammogram was

characterized as not at all according to the 58.67% obtained, followed by a little level at 22%, which is

interpreted as absence of nervousness, as observed in the table 2 presented below.

Guerrero M/ Enfermería Investiga Vol. 9 No. 2 2024 (April - June)

Most women have fair knowledge prior to performing

the mammography according to the 50.67%

obtained, followed by 27.33% with little knowledge

and only 4% did not know anything about the

procedure, as seen in the table 3. On the other hand,

69.99% had no doubts about the procedure, while

15.33% claimed to have some or very few doubts

about it.

When evaluating the relationship between the level

of nervousness of women and the knowledge about

the procedure they have regarding mammography,

a highly significant association was found (p =

0.009) between knowing or not, what

mammography is and the level of nervousness that

generates them. That is to say, the less knowledge

of the procedure the degree of concern increases

and vice versa.

Table 4 shows the results of the last part of the

questionnaire regarding knowledge about the

benefits and risks of mammography, as well as the

information needs expressed by the participants. Of

those interviewed, 83.5% received the information

from their treating doctor, 8.25% referred to

television, and 4.25% mentioned clinics or hospitals

or conversations about the topic with other people.

Regarding the amount of information, they reported

knowing about the benefits of the intervention,

46.7% mentioned having a lot, 38.7% having regular

information, 13.3% having little and 1.3% having

little information about the benefits. In contrast,

38.7% mentioned not having any information about

the risks of the procedure and only 18.7% indicated

having a lot of information about it. Finally, 81.4%

requested more information about the benefits and

risks of the study without a statistically significant

association between the interest in receiving more

information and the level of concern.

Guerrero M/ Enfermería Investiga Vol. 9 No. 2 2024 (April - June)

DISCUSSION

The results of this survey allow us to recognize a

moderate prevalence of nervousness in women who

are going to undergo a mammogram in a private

setting. From the sociodemographic perspective,

the high educational level predominates. However,

the majority of women are dedicated to the work of

housewives, a reflection of a socioeconomic status

that would favor not only the care of their own health,

but also the concern for having information related

to health and interventions aimed at disease

prevention. An investigation in 2007 found that

women who do not undergo regular mammograms

show a greater perception of health and a lower

feeling of vulnerability to breast cancer, which

influences their decision not to comply with the

recommended mammographic screening guidelines

(22).

Despite this approach, the most important finding

was the highly significant association between the

degree of knowledge and information about

mammography and the level of perceived

nervousness. The socioeconomic and demographic

characteristics of the patients were not statistically

associated with concern, nor was the history of

previous mammograms or the reason for requesting

the study. The literature indicates that women who

do not seriously consider performing

mammography, as well as those who meet risk

criteria, but do not undergo frequent check-ups, are

characterized by having less knowledge about the

benefits of mammography and reduced access. to

relevant information about breast cancer and early

detection (23). This increases when they are older

women or from a vulnerable group, and the

perceived barriers tend to be higher, they tend to

experience more concerns related to pain, cost,

logistics or the time required to undergo the test (24).

These results have several implications for

healthcare providers. First of all, from an ethical

point of view, in any contact of people with health

establishments for diagnostic, preventive or

therapeutic purposes, dignified treatment must

prevail. This must include the provision of all the

necessary information to promote joint decision-

making for the benefit of the patient, respecting their

freedom and idiosyncrasies. This is mainly due to

the percentage, although small, of women who

receive their information from television according to

the data of the present study.

Secondly, insufficient information or misinformation

can cause delays in seeking care with undesirable

consequences for the health of patients, with

negative impacts for health systems, as proposed in

the conceptual model of Unger-Saldaña et al ( 9).

Unfortunately, in health systems, both public and

private, a “medicalized” paradigm has prevailed

where the opinion of the health professional is

privileged over the expectations and demands of

patients. According to the findings presented, it can

be seen that there is a high percentage of women

who still want to receive more information about the

procedure, which contrasts with the 7.3% who came

for the first time. There is talk of a change from the

anthropocentric approach to a technocentric one,

where pure scientific knowledge has increased, but

humanitarian care for the patient has been lost (25).

Along these lines, various studies have investigated

different communication strategies. One study

reported that telephone counseling may be more

effective than tailored print communications in

promoting change among nonadherent women,

possibly being the preferred intervention for placing

these women in the mammography screening

program (26). Another study found similar results,

although they conclude that women who received

adapted printed materials in addition to telephone

counseling had greater knowledge and perception of

breast cancer risk, and were more likely to undergo

mammograms compared to those who received

usual care ( 27). Furthermore, the literature also

reports that if the interventions are adapted to the

stage where the participant is, the rate of performing

mammograms increases (28).

The work of Philip Musgrave brings to the table an

interesting reflection contrasting the ideas of

“demand” versus “need for health care” (29).

“Demand” is what a patient wants and is willing to

pay, if there is a price to pay. While the “need” is

what the doctor thinks the patient should have. This

paradigm can be observed in the participants'

reasons for taking the study, with more than half

attending on their own initiative and 41% due to

medical indication. Logically, doctors can disagree

when it comes to diagnoses and treatments,

considering that for some conditions there is no

effective treatment, so a need for help does not

clearly translate into a need for particular medical

care. Even so, “need” remains a more objective

notion than demand because it is less dependent on

the patient's beliefs and tastes.

The literature converges that the “total quality”

approach should be implemented from the

beginning, ensuring that clear objectives and

standards are established (30). Unique national

protocols should be established to facilitate

comparison of results and identification of trends.

Having a clear benchmark, such as a randomized

controlled trial, improves the effectiveness of

programs.

Therefore, it is not surprising that when planning

public health supply, the idea of need is addressed,

with little or no attention to demand. However, when

hiring standards do not take into account the

characteristics of the population and diseases, they

cease to have any relationship with need. In

addition, the focus on the “need” loses sight of the

“demand” and we begin to hear expressions

referring to the fact that patients should not know

more about mammography, when the important

thing is to obtain a diagnosis to save their lives. .

Which brings back the importance of patient-

centered care, returning to the “demand”

perspective and considering non-medical factors

that have an impact on prevention, adherence and

even treatment results. Factors such as level of

knowledge and degree of concern about the

procedure.

CONCLUSIONS

The principle of patient autonomy would be fully

exercised only in moments when they could make a

real decision. To do this, they would have to have

the elements to do so. Otherwise, the patient's

decision would never be theirs but the health

professional’s, who tells them what to do. It is a fact

that healthcare agents will always seek treatments

or courses of action for the benefit of the patient and

never to their detriment, but this does not detract

from the fact that the decision belongs to the patient

and/or her family. Therefore, it is the duty of the staff

to share the necessary information so that the

patient and/or their family can recognize the benefits

of the plan proposed by their medical team, as well

as encourage prevention with clear indications of

how it can be achieved so that the patient counts.

with the tools that make you an agent of change

within your community.

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