CALIFORNIA STATE UNIVERSITY, NORTHRIDGE
REPORTING BREAST SYMPTOMS IN
A JERUSALEM HOSPITAL
A thesis submitted in partial satisfaction of the
requirements for the degree of
Master of Public Health
by
Michal Schonbrun
May 1987
The Thesis of Michal Schonbrun is approved:
Shelia
Harbe~
H.S.D.
M. V. Kline, Dr. P.H.,
Committee Chair
California State University, Northridge
ii
"
Acknowledgments
My appreciation is extended to a number of people whom
without their support, this project might not have reached
fruition.
I am grateful to Dr. Michal Stark, Director of Misgav L'Dach
Hospital in Jerusalem, who granted me permission to interview the
women attending the breast clinic- minus the usua 1 bureaucratic
procedures.
I would like to thank my friend and colleague, Dr. Yonah
Yaphe, for his insights, support, and time with a 11 phases of
this project.
Dr. Michael Kline deserves special thanks for his guidance,
directedness, and flexibility with time as I raced to complete
this project between Jerusalem and Los Angeles. Unbeknownst to
her, Dr. She lia Harbet· has been an inspiration.
The generosity, love, and encouragement shown to me from my
families in New York and California cannot be fully acknowledged.
They have gone beyond the call of duty, supporting me through
another 1 ife crisis.
My mother, a survivor of breast cancer, is partia 11 y
responsible for both the birth of this project and my own bravery
in confronting the subject and threat of cancer.
Hy husband, Gershon, and daughter, Elisha, endured many
neglected nights (and days) while I labored through this
effort. r-ty love for them is endless.
Lastly, I am indebted to the women who shared their intimate
thoughts and fears with me; without them, this project could not
have evolved as it did.
Any errors found within this study are solely my own.
M.S.
April 26, 1987
Los Angeles
iii
'
TABLE OF CONTENTS
Page
ACKNOWLEDGMENTS
iii
LIST OF TABLES •
vii
.....
ABSTRACT
viii
Chapter
I.
INTRODUCTION
1
Statement of the Problem ••
7
Purpose of the Study
8
Assumptions
8
Exploratory Hypotheses •
9
Limitations of the Study •
9
Definition of Terms
2.
3.
10
REVIEW OF THE LITERATURE •
12
Early Detection of Breast Cancer
12
Symptom Reporting Behavior •
14
Reasons for Delay
16
Delay and Illness Behavior •
17
Influence of Lay Referral Systems
18
Psychological Aspects of Delay •
19
METHODOLOGY
21
Conceptual Framework of Study
21
Development of Survey Instrument
21
Respondent Selection C:ri teria
23
Study Site
24
Data Analysis
25
iv
Limitations of Study
4-
RESULTS
Demographic
5.
........
Information . . . . . .
28
28
Symptoms and Their Interpretation
31
Delay in Reporting Symptoms to a
Physician • • •
• • • •
32
Breast Self-Examination
35
Lay and Medical Consultation
39
Knowledge about Breast Cancer
45
Miscellaneous Issues
48
49
DISCUSSION • • •
Examination of Hypotheses
6.
26
49
Knowledge and Delay
49
Breast Self-Examination and
Reliance on Clinical Exam • •
51
The "Selling" Of Early Breast
Cancer Detection
• • • •
53
Preventive Care for Women at Risk •
56
Influence of Social Networks •
57
Health Beliefs, Behavior, and
Socio-economic Circumstance •
58
Psycho-social factors
58
CONCLUSIONS AND RECOMMENDATIONS
Recommendations and
Conclusions
60
60
REFERENCES • • • • • • • • • • • • • •
v
65
APPENDICES
A.
B.
BREAST CANCER TREATMENT
FLOW CHART • • • • • • •
72
CHRONOLOGICAL CONTINUUM
74
C.1 ENGLISH TRANSLATION OF
QUESTIONNAIRE
76
C.2 RESEARCH QUESTIONNAIRE
(HEBREW) • • • • • •
80
D.
BREAST CANCER INCIDENCE AND
MORTALITY IN ISRAEL: 1967-1985
vi
84
Tables
Page
Table
1.
2.
Frequency Distribution of
Subjects' Place of Birth
Frequency Distribution of
Age of Subjects
• 29
29
3.
Reported Years of Education
• 30
4·
Frequency Distribution of
Subjects' Social Class
According to Occupation
• 30
5.
Subjects' Marital Status
• 31
6.
Delay Period in Days from
Recognition of Symptom to
First Doctor Visit
• 32
Reported Frequency of Breast
Exam by Physician
• 34
Reported Frequency of Breast
Self Exam Instruction and
Performance of Breast
Self-Exam
• 35
Lay Sources of Information
about Breast Self-Exam
• 37
Reason Given for Not
Practicing Breast Self-Exam •
• 38
Reported Involvement of
Family Physician and
Gynecologist in Subjects'
Referral to Breast Clinic
• 39
Number of Lay and Medical
Consultations for Current
Breast Problems Preceding
Clinic Visit
• 40
Subjects' Perceived Causes
of Breast Cancer
• 47
Subjects Perceptions of
Women at Greater Risk of
Developing Breast Cancer
• 46
8.
9.
10.
11.
12.
13.
14.
vii
ABSTRACT
REPORTING OF BREAST SYMPTOMS
IN A JERUSALEM HOSPITAL
by
Michal Schonbrun
Master of Public Health
Breast cancer is currently the most common malignancy to
strike women.
Incidence of the disease is rising throughout the
western world.
Early detection of breast cancer is one of the
only strategies which
promises longer Rurvival rates and cure.
The three main detection methods (mammography, clinical exam, and
breast self-examination) are not widely employed in Israel. Since
delay is critical to outcome,
the purpose of this research
project is to examine those factors which influence women to
report
breast symptoms to their doctors.
processes
regarding interpretation of symptoms, the practice of
breast se 1 f-examina tion, and the
medical
The decision-making
sources
consulting with both lay and
were investigated.
knowledge, and levels of fear on
The roles of the physician,
delay
were also examined.
Thirty-one women who began the reporting process within the
past year and a half were interviewed in a hospital-based breast
viii
These women were either self- or physician-
check clinic.
referred to the clinic. An open-ended questionnaire was used for
data collection.
It was found that most women did not
delay significantly in
reporting, but delay was correlated with an absence of either
(personal) family physician or gynecologist.
ignorant
about
susceptibility,
treatment.
breast
cancer
risk
Women were largely
factors,
A tendency to over-rely on a
most of the 'I'TOmen interviewed.
physician's exam,
the data disclosed
Few
characterized
were ever taught self-exam,
that most general physicians and
gynecologists do not routinely perform breast exams.
lay
referra 1
personal
and about knowledge regarding its diagnosis and
together with a re 1 uctance to practice se 1 f-exam
and
a
systems
and
the
inf 1 uence
correlated with vi3its to the breast clinic
of
The use of
peer
pressure
by asymptomatic
women.
Several
factors
(both incentives and obstacles) were
identified which influence the
professionals
reporting process.
Health
may be able to use this information for improving
existing services and educational efforts so that new breast
cancer cases can be diagnosed at the earliest possible stages.
ix
Chapter 1
INTRODUCTION
This
chapter serves as an introduction to the issues and
problems which impact early breast cancer detection in Israel.
These
include a
available,
brief summary of the epidemiological data
the extent of public and medical awareness about the
problem, preventive hea 1 th services, institutional obstacles, and
the role of the Israel Cancer Association.
to the problem statement, and the
This discussion leads
hypotheses and
limitations of
the study.
Epidemiol ogica 1 Summary of Breast Cancer in Israe 1
Some 1200 new cases of breast cancer are diagnosed yearly
in Israel
(49:16).
The highest incidence is found among
Ashkenazic Jews, whose origins are middle and eastern Europe.
While North African and Asian (Sephardic) Jewish women have the
lowest incidence, their cumulative incidence, based on world
standardized rates,
group
in
developing
than
Israel
has risen more significantly than any other
(47:810).
The
risk
for
breast cancer is estimated to be
that of Sephardic women.
Ashkenazic
5-to~6
women
times higher
Case fatality rates for breast
cancer are not yet available for Israel.
Israe 1 ranks 13th for age-adjusted death rates for breast
1
2
cancer among 47 countries (75:178).
Public Awareness of Breast Cancer in Israel
In 1980, Israel's first and only public survey on breast
cancer was commissioned by the Israe 1 Cancer Association (21 ).
The report indicated that few women and men were able to identify
the symptoms of breast cancer. Most did not know of the
relationship between a woman's age and her chances of developing
the disease.
Only the higher socio-economic groups believed that
breast cancer could be cured.
More than 80 percent
believed that early detection increases
one's chance of being cured.
About one-third of the women claimed to be checked or selfchecked on some regular basis. Approximately two-thirds of the
women knew where to turn for a breast exam but didn't follow
through in seeking one.
Doctor visits
from western countries.
The
were highest among those
main reason given by women for not
being examined was lack of concern.
Although given legitimacy in
the formula ted question, fear was not mentioned as a factor for
not being examined.
One third of the women and 50 percent of the men did not
know that a vmman could check herself for signs of breast cancer;
45 percent
of
the women who did know about breast self-
examination did not know how to do it. Less
reported doing se 1 f -exam.
slightly higher among
than 5 percent
A willingness to conduct the exam vTas
husbands than among
wives.
Among women
3
with a history of breast cancer, there was little willingness to
practice self-examination.
Lack of Preventive Health Orientation
As a general rule, preventive health services aimed at the
adult population are sorely lacking
exceptions,
they are not provided
in Israel.
With 1 imi ted
or covered by the major "sick
funds," or insurance schemes of which approximate 1 y 97 percent of
the population are members.
At the present time, preventive
medicine is largely viewed by policymakers as a luxury which the
State cannot afford (22, 72).
Obstacles to Early Breast Cancer Detection in Israel
Limited Resources
With regard to breast cancer detection, economics and limited
resources play a significant role in Israel's struggle to advance
the cause of preventive medicine.
Early detection technology,
primarily mammography, is rather expensive and therefore not
routine 1 y used.
Another reason for its underuse has
been
attributed to few women radiological technicians, thus making it
more unlikely that women patients will expose their breasts to
non-medical personnel.
The degree to which doctors refer for and
utilize mammography is not known.
Low Awareness Among Professionals and the Public
While it is not known to what extent general physicians
4
perform breast exams or teach breast self examination to their
patients, it has been inferred that Israe 1 's "track record" in
early detection is poor, as evidenced by overall,
high
percentages of late-stage diagnoses, radica 1 mastectomies, and
death rates, especially among younger women (18). Where it is
common abroad for gynecologists to take responsibility for
examining breasts,
it is not the norm for Israeli gynecologists
to do so (although
Western-trained physicians are more likely to
perform breast exams).
Based on persona 1 communications with
both health professionals and women patients, routine breast
exams are not performed by most genera 1 practitioners or by a
good number of gynecologists.
An unpublished hospital-based
study has shown similar results (67:2).
As demonstrated in the above-mentioned public survey,
lay
knowledge and awareness regarding breast cancer and early
detection is still low,
even though the situation is thought to
have improved in the past decade.
Women do not commonly request
a breast exam from their doctors, so the initiative lies largely
with the physician or nurse.
women seem to be uti 1 izing
While more and more asymptomatic
check stations for periodic exams,
most remain ignorant about breast cancer warning signs and risk
factors.
While there is no documented data to support these
claims,
they are based on information gathered from health
professionals and women patients alike.
Professional Training
5
With a surplus of physicians in the country, many of whom are
trained abroad, there is
a wide variation in the quality of
training and practice (35:7).
Israel
has yet to establish
licensure laws for the practice of medicine.
Routine clinical breast exams are not common practice.
A
few family physicians consulted for this research claim that
among those who do perform breast exams on their patients, the
quality of the exam is poor because most doctors lack the proper
training in breast exam as well as an awareness about its
importance.
Underutilization of Screening Services by Women at Risk
Since 1970,
the Is rae 1 Cancer Association ( ICA) has opera ted
some 13 regional early detection
settings
in
10
cities
throughout
clinics (EDP) in hospital
the
country.
Another 55
volunteer clinics at various locations are operated by volunteer
physicians and ICA volunteers (Most of these physicians are not
on co 1 ogists) (50:822).
Four
hospi ta 1-based
Jerusalem area.
detection
centers
operate
in
the
A few reports on utilization patterns in these
clinics show that it is younger women, not necessarily those at
higher risk, who are making use of these services (50:824).
Contrary to many countries,
economic factors are not
associated with low utilization behavior.
There is a
tendency
in Israel toward an inverse relationship between social class and
use of health services.
Israel maintains one of the highest
6
rates of doctor visits and hospital admissions per capita in the
world (4:33,
6:466).
There are few barriers,
technica 1 or
normative, to the utilization of health services in Israel.
Scarcity of Research
Scant research has
been
conducted
on
the
subject of
screening program participation and cancer detection in Israel.
Between 1955 and 1975, only a few studies examined delay behavior
in cancer detection among different population groups (4, 19,
40).
At a recent nursing conference, a
study was presented which
showed that of 180 women referred to a Tel Aviv area hospi ta 1 due
to lumps in their breasts, a large majority had never before been
checked
and as many as 17 percent
delayed seeking medical help
by three months to three years for fear of cancer (67:6).
The Role of the Israel Cancer Association (ICA)
It is only in the past few years
that any attempt to educate
health professionals in the area of breast self-exam has been
carried out in Israe 1 (47).
Without any financia 1 backing from
either the government-based ministries or the sick funds, the
Association has embarked on a few programs aimed to train nurses
and family physicians in disseminating
breast cancer detection information.
se 1 f-exam
The programs
and early
largely
resemble that of the American Cancer Society.
The
ICA
has
begun organizing breast self examination
7
trainings
in a
number
of
industria 1
settings,
government
agencies, rural kibbutzim (communal settlements), and in the
Israe 1 Defense Forces (IDF).
Beginning in 1985, the ICA
produced
a sixty second public
service announcement for television, which stressed the benefits
of early detection.
In 1986, a number of television (talk)
consumer shows covered the subject of breast cancer,
on both the
Hebrew and Arabic-speaking programs.
As of mid-1987, there is one sick fund neighborhood clinic in
Jerusalem which
teaches breast self-exam.
Registration for this
program is limited to women residing within the clinic's district
area.
Statement of the Problem
Many problems and obstacles relating to the early detection
of breast cancer have been discussed.
In Israel,
the three
primary detection methods are not widely utilized and there
exists a definite lack of knowledge, awareness, and attitudes
among both professionals and the lay public which might
detection capabilities at earlier stages.
The economic
limitations which prevent both screening programs and the
use of preventive
services in general,
improve
all
wider
serve
as
justification for focusing on an area which may yield valuable
information for health
the
planners.
There is a need to investigate
factors which influence women to report breast symptoms
their doc tors.
to
8
Purpose of Study
The purpose of this study is:
1. To determine if there are any identifiable, repeatable
patterns of behavior among women who report breast symptoms
to their doctors;
2.
To
identify
and
determine
the
role
of
lay
consultation/ so cia 1 networks and lay referra 1 systems on
symptom reporting for breast problems; and
3.
To ascertain the roles of the physician, fear,
and
levels of knowledge on symptom reporting, and on delay with
breast symptoms.
Assumptions
1.
Based on the fact that Israelis have an extraordinary rate
of over-utilization of hea 1 th services, and that few barriers
exist in using these services,
it was assumed that delay in
reporting would be minimal.
2.
Whether the result of a constant threat of war or a history
of communal oppression,
Israeli Jewish society is characterized
by stress and close social ties between people.
It was assumed
that so cia 1 supports and influences, necessary for every day
living,
would provide women with valuable information and
motivation to seek care for breast problems.
3.
Because the State of Israe 1 possesses so few resources for
advancing the cause of preventive medicine,
it was assumed that
9
knowledge levels about breast cancer would be minimal.
Exploratory Hypotheses
It is expected that:
1.
Women will not have accurate information with regard to
treatment modalities for breast cancer: they will possess
little
information about diagnostic procedures and the
benefits of early detection;
lack of information will have
little impact on delay behavior.
2.
Women will not be familiar with, or inclined to practice
breast self-examination.
Few women will have been taught the
technique by a physician.
3.
Low levels of knowledge will not positively correlate
with longer delays in reporting.
4.
The availability of social networks will positively
correlate with the utilization of
breast
check stations.
Limitation of Study
The small
study population represents
the Jerusalem area.
one small clinic in
Conclusions drawn from this sample cannot
be generalized for other demographic areas of the country.
10
Definition of Terms
1.
Social supports, as defined by McKinlay, refer to all forms
of family, kinship, and friendship contacts or networks which
influence the "way individuals define and act (or fail to act)
upon symptoms of life crises" (57:275).
These supports serve as
"buffers" against stress, help shape indi v idua 1 responses to
illness by defining the latter's physical condition (through
approval or disapproval of a sick role), provide information
about health matters, and contribute to the decision of whether
or not to seek professional care.
Social supports also promote
morale and can encourage preventive health behaviors.
2.
Lay consultation/lay referral systems,
refer to the process
of face-to-face consultation with a member/s of one's social
network for the purpose of seeking advice and referra 1 before,
during, and after the recognition of a h3a 1 th problem.
Lay
referral systems are defined by 1) their particular culture or
knowledge people have about hea 1 th and hea 1 th agents, and 2) the
interrelationships of lay people from whom advice and referral
are sought (34:290).
Lay
consultations
were
counted
as
the
number
of
separate/specific consultations mentioned by the interviewee.
3.
Medical consultation, refers to the face-to-face consultation
with a member of a
licensed health professional (usually a
physician) by a lay individual for the purpose of diagnosing a
given symptom.
Medical consultations were counted as the number of separate
11
consultations or meetings with a physician that were mentioned by
the interviewee.
4.
"Other" influences, refer to any other experience which
influenced the woman to take action regarding her symptom.
These
would include such things as observing a television program about
breast cancer or some other media presentation, and any first- or
second-hand knowledge about/experience of breast cancer in
another woman.
"Other" influences were counted by number,
according to the
frequency of report by the interviewee.
5.
Delay period is defined as the
time
elapsing from
recognition of symptom to the first visit to a physician for
the
purpose
of consu 1 ta tion about the
condition.
This is
measured in days.
6.
Symptorr.-reporting is
any face-to-face meeting between the
physician and woman patient for reasons of presenting the given
symptom.
7.
Age is defined according to year of birth of the subject.
8.
Ethnic group is defined according to country of birth of the
subject.
9.
10.
Marital status is
defined according to legal status.
Education is defined according
to number
of years
of
completed education.
11.
Socia 1 class is based_ on a classification of occupation
only, as used by the British Registrar-General (1:74).
Chapter 2
REVIEW OF THE LITERATURE
The literature review focuses on a number of areas re levent
to the early detection of breast cancer. The first section
presents a critique of the primary early detection methods of
breast cancer.
The second section is concerned with a review of
why women delay with breast symptoms.
The third section explores
the role of lay referral, and the last portion involves a review
of some psychological aspects of delay behavior.
The Early Detection of Breast Cancer
While the value of primary breast cancer detection methods
remains unchallenged,
and their use recommended in most
instances, there are, however,
a number of drawbacks to their
utilization.
The first method, clinical breast exam, is flawed by low
sensitivity rates, and is
all by physicians.
training,
often performed inadequetly or not at
This may be the result of poor medical
lov1 priority, or apathy (32, 62, 64).
about the practice of
breast exam by physicians.
Little is known
In the case of
fast-growing tumors, a yearly clinical exam may be too late to be
of benefit to the patient.
For menopausal women no longer in
need of regular gynecological care, yet who are at greatest risk
12
13
of developing the disease, a breast exam by a qualified physician
may not ever be performed. It should be remembered that
approximately 90 percent of all palpable breast tumors are found
by women themselves, usually by accident (2:110).
The second method, mammography, is an X-ray used to visualize
the internal structure of the breast. It is still a controversial
method of de te c ti on for many physicians.
compliance with American Cancer Society
are very low (15).
Gyneco 1 ogists'
Guidelines for its use
It is expensive, involves radiation exposure
of varying amounts, depending on the age of the machinery, and it
is not recommended for screening women under 35 years of age.
It
produces high false positive rates in women under 50 because of
benign conditions found in this group.
It also requires expert
radiological skill and experience to be of maximum benefit to the
patient. One radiologist consul ted for this report claims there
are only 40 such individuals in the United States (10).
Breast self-examination, the subject of numerous research
and health education efforts, is the third primary detection
method.
It holds the greatest potential for reducing morbidity
and mortality from breast cancer (59, 60). Unfortunately, studies
have shown that few women perform it, either adequately or
regularly enough to make it advantageous (46, 58). Most women
associate the practice with finding potentia 1 cancer rather than
checking for normalcy in the breast.
incentive to perform it (20).
Thus, there is little
Calnan suggests that many women
tend to over-rely on clinical exams and on sophisticated
14
(l
technology and are therefore more reluctant and less
motivated
to take personal responsibility for checking their own breasts
( 12).
To summarize, no method of breast cancer detection is ideal.
In the cases of clinical exam and self-exam, competency and
adequacy are
indi vidua 1.
dependent upon the
The third method,
variable behavior of the
mammography,
is only beneficial
for select groups of women and is viewed with caution by many
physicians.
There is a need, therefore to study other aspects of
the detection process.
Symptom-reporting Behavior
The following section will discuss the relationship between
symptom-reporting and early detection.
Whether a woman practices breast self-exam with any
,/
regularity or not, her role is clearly not diagnostic.
However,
it will be argued that the woman's role in symptom-reporting at
an early stage is critical to
outcome.
Much remains to be
learned about those factors which impact the reporting of breast
symptoms (73:129).
Little research has been devoted to the
actual process or time continuum in which women decide to act on
their "discoveries,"
action" (26:256).
or as Eardley ca 11 s, "the triggers to
Among medica 1 professiona 1 s,
there is a
preoccupation with the post-diagnosis stage (see Appendix A).
Kushner (52) has raised the issue that eight out of ten
breast rna sses are benign, meaning that 80 percent of a 11 women
'
15
(1
with initial symptoms will suffer various levels of anxiety
and/ or fear, before and after submitting themse 1 ves to one or
more diagnostic procedures.
In the United States a 1 one, this
means that almost a million women each year must endure some exam
or test- in order to find the approximately 120,000 new cases who
will actually be diagnosed with breast cancer.
diagnosis in symptomatic women,
therefore,
The pre-cancer
has far more reaching
consequences in terms of early detection behavior than is usually
credited.
Polls have verified the fact that fear of disease is a major
preoccupation among women. Many studies claim that women over-.
estimate their risk of getting cancer, and that "unfamiliar,
unpredictable, and threatening symptoms lead more to stress than
to action" (38).
Existing support programs, as well as research
by leading hea 1 th agencies,
patient;
are designed for the post-operative
the pre-diagnostic traumas of women facing biopsies are
given little attention (52).
A.C.S. and N.C.I. polls have shown
that women's terror of breast cancer starts long before the
surgeon's scalpel approaches their breasts (38).
In addition to
the women/patients themselves, it should be noted that countless
numbers of women friends, re la ti ves and co-workers a 1 so 1 i ve
through this "pre-diagnosis" experience, albeit vicariously.
In summary, the "pre-clinical" anxiety of women reporting
breast symptoms
has
described by Kushner.
yet
to
be
measured
or documented,
as
Understanding more about this "before"
period may yield valuable information for educators, health
'
16
professionals, and health policymakers.
Earlier detection of the
disease would inevitably lower health care costs.
Reasons for Delay
Green and Roberts surveyed the literature on why women delay
in seeking medical care for breast symptoms (37).
was divided among
seven
variables: 1) ignorance, 2) fear, 3)
the interaction between knowledge and fear,
cancer,
Their analysis
4)
beliefs about
5) individual medical and health practices,
personality factors,
and 7) physician delay.
6)
As aresult of
contradictory studies and methodological problems, the authors
were reluctant to verify most of the relationships discussed in
the 1 i tera ture which they
ana 1 yzed.
Some arguments, though,
appear to be consistent.
1. Delayers are less likely to have thought of the possibility of
cancer, or to have seen their symptoms as a cause for concern.
2.
Fear, and a fear of disease and disfiguration, is the most
commonly cited reason for delay.
individuals,
Among worrier-types of
knowledge of cancer may increase delay whereas for
non-worriers, it may reduce it.
3.
While there is no clear, one-to-one relationship between
having knowledge about cancer and action to seek care,
factors
seem
to
interact with
this awareness.
several
Knowledge
pertaining to the significance of specific symptoms have been
shown to be associated with delay (37:166).
4.
Personality traits which interact with the potential or real
17
threat of cancer, and one's coping resources to dea 1 with that
threat may be of some value in understanding delay behavior.
5.
There is sufficient evidence which point to inappropriate,
inadequate, or delayed medical procedures as a cause for delay in
treatment.
Delayand Ilness Behavior
Whereas disease refers to an objective physica 1 or menta 1
condition with tangible signs or symptoms, illness relates to
the individual's subjective interpretation and perception of that
illness or event.
Illness does not always include the presence
of identifiable
symptoms of disease.
Understanding this
distinction is crucial to understanding how, when, and why people
seek medical care.
They will do so when they "feel" ill.
In the process of ascribing meaning to one's distress or
pain,
the individual consults his social environment.
He must
acquire the approval of those around him, and this is only likely
to happen if there is evidence, i.e. symptoms present, which can
be labelled "disease" or "illness."
In sociological terms,
cancer is an unconditionally legitimate deviance (34:241).
What criteria will a woman use to define illness in order to
seek medical care for a breast symptom?
Colette and Baum, citing
Herzlich and Zola, claim that illness as a subjective state is
related to functional incapacity (20:70).
This, they claim, is
not an issue for most breast patients because
the pain or
discomfort they initially feel does not interfere with everyday
18
activities. Because a lump may be minimal at the onset and only
increasing in size over time, "a breast symptom is likely to give
rise to concern only on the basis of a woman's belief about its
possible implica tions ••• It is then, primarily the suspicion of
cancer
that
motivates
and
provides
an
incentive
for
consultation" (20:71 ).
To cone l ude, numerous research has been conducted on de lay
behavior with cancer symptoms.
Since human behaviour is often
irrational and unpredictable,
it remains difficult,
impossible,
to validate specific correlations which will apply
to all people.
delay,
if not
While fear is the most commonly cited reason for
i t encompasses many dimensions. As it interacts with
knowledge and other factors,
it does not necessarily lead us any
closer to understanding the process of delay.
Use and Influence of Lay Referral Systems
An important determinant of whether a person consults a
medical source or not is one's social network (34, 51, 57, 73).
A lay referral system is defined by 1) the particular culture
or knowledge people have about health and health agents, and by
2) the interrelationships of the lay person from whom advice and
referral are sought (34:290).
The organization of lay referrals
can enforce a particular orientation toward illness, or it can be
so loose as to leave the individual free of others' influences
(34:282).
Contact with a professional is most likely when the
culture of the person seeking help is similar to that of the
19
professional and when the referral structure comprises many
people (34:73).
In relation to breast problems,
Eardley and Wakefield
examined the role of lay consultation by women reporting breast
1 umps to their doctors (27).
They found that "lay consultants"
encouraged patients to visit a doctor in a mean lapse-time of
three months.
Seventy-two of the 100 women spoke to one or more
lay consultants before deciding to see a physician.
did not lead to delay.
Lay referral
One in five, though, did wait three
months or longer before seeking
care.
Only one in twelve of
those interviewed claimed that she recieved negative advice, and
the most frequent reason given by the 28 women who consulted with
no one was, "I didn't want to worry anyone."
As shown in other
studies, those women suspecting cancer from the outset were those
exhibiting the least de lay.
"Information acquired from friends
and relatives who form part of the woman's social network is more
likely to be fully comprehendible and understood than that gained
from family doctors" (27:39).
To cone 1 ude, the use of lay consu 1 tan ts
has been shown to
influence the process of symptom-reporting and is often the
trigger to act, once a symptom is discovered.
Psychological Aspects
Focusing on the past decade, Colette and Baum reviewed the
psychological literature on delay with breast symptoms during the
last decade (20).
Their review appeared five to fifteen years
20
following the reviews by Green, and Antonovsky and Hartman.
maintain that, overall,
delayers
They
exhibit little fear or anxiety
about their symptoms because they see them as less serious than
non-delayers. They are also more likely to avoid the term,
"cancer."
Knowledge levels are
low among delayers.
Eardley found that the most common reaction among the women
she studied was to seek care fairly quickly in order to resolve
the fear of not knowing (26).
Also reiterated is the finding
that women who de lay are more often unconvinced and/ or ignorant
about the value of early detection.
Person-to-person methods of
acquiring information are often what spurs a woman to action
(26:264).
In Hagarey's
study of 90 women interviewed before undergoing
biopsies, 25 percent delayed more than four months and half of
them had never examined their own breasts.
Delay was related to
unconscious psychological processes- denial, suppression, and
intellectualization-isolation (55).
To summarize,
for delay.
there are essentially three principal reasons
Lack of awareness regarding the implications of
cancer and of early treatment is the first reason.
Delayers are
less likely to equate a symptom with cancer and/or to view a
specific
symptom with concern.
Unconscious denia 1
implications of the symptom is the second reason.
defense behavior,
cancer.
of
the
This involves
and a denial of emotions associated with
The conscious fear and avoidance of a cancer "diagnosis"
make up the third category of reasons for delay.
Q
Chapter 3
METHODOLOGY
This chapter describes the methodological
research study.
foundation of the
This includes the conceptual framework,
the
research instrument, respondent selection criteria, the study
site, and data ana lysis.
Conceptual Framework of Study
The model conceptualized for understanding the reporting
process for breast problems is based on a continuum of six stages
(see Appendix B - Chronological Continuum):
recognition
of a
sign/ symptom,
2)
the
1) The initial
interpretation
and
evaluation of the symptom, 3) the decision-making process, 4) all
action taken (or not taken) based on
eva 1 ua tion of phase 4,
if action was
stage
taken~
3,
5)
the
re-
If advice was
sought, the women either accepts, rejects, or modifies what she
received.
The sixth stage invo 1 ves a 11 subsequent behavior,
which caul d, the ore tica 11 y, involve passing through a 11 five
phases again at a later stage.
This study is only concerned with
the first five phases.
Development of the Survey Instrument
An open and loosely structured questionnaire was chosen (see
21
'
22
Q
Appendix C.1,
C.2).
The questionnaire was designed to elicit the
most natura 1 responses, and to faci 1 ita te discussion in a way
that the women could pinpoint and raise whatever issues were
relevant to them.
It was influenced by Blaxter's "ethnomedical"
model on women's beliefs about disease causation
(9).
Instead
of collecting data based on answers to predetermined questions,
content analysis is performed on the conversation initiated by
the interviewees.
Because health and illness behavior are
influenced by cultural and social forces, especially in a multicultural state like Israel, i t \-las thought that information
gained in this fashion would yield data about lay behavior
patterns and their effect, if any, on de lay.
For those who had
difficulty expressing themse 1 ves freely, the questionnaire was
more rigidly adhered to.
Only two women refused to be interviewed and many more women
were interviewed (N=52) than are actually included in this sample
(N=31 ).
This
occurred
because
some
women
did not fit
the
established criteria in terms of the one and one-half year cutoff point (beginning from the time their symptom first appeared),
and this was not always known to the interviewer until
discussion
was well underway.
the
In a few cases, it was not known
until the end of the interviewing session, or until the women
finished seeing the surgeon, that her breast problem had, in
fact,
begun years prior to the current visit.
The questionnaire was pretested for validity among 10 women
between May and June 1986.
During this
phase of testing, it was
'
23
necessary to define the scope of the problem and to pinpoint
specific areas from which to concentrate.
It
was then reviewed
for criticism and refinement by a doctoral student in medical
sociology at the Hadassah Hospital School of Public Health, and
by a family physician, who is a lecturer in the family medicine
training program at Hada ssah Hosptia 1.
pretesting,
As a result of the
the questionnaire was expanded to inc 1 ude more
questions dealing with the timing and types of consultations
sought.
It also included more refined questions dealing with the
practice of breast self-examination and physician examination of
the
breast.
All
confidentiality.
questionnaires
were
completed
They were administered by this author.
in
The
actual interviews took place between June 1986 and January 1987.
Respondent Selection Criteria
Three different categories of women were included in this
study group.
1.
Women self-referred for a first time visit following an
initial, first-time discovery of a breast problem.
2.
Women first seen by their own physician or gynecologist, and
upon confirmation of a suspicious finding, referred to the Misgav
L'Dach breast clinic.
3.
Women previous 1 y diagnosed and treated for some specific
problem, who are now in a stage/s of follow-up, observation or
further treatment.
If the women in question did not begin the
initial reporting process within the past one and one-half years,
24
then she is considered outside the range chosen for this study.
A significant amount of time may have passed since the .ini tia 1
reporting process and memory is likely to be faulty.
Potentially, a fourth category could include all women first
seen by another physician, without a confirmed finding,
but
referred to the breast clinic for the woman's "peace of mind."
No such woman visited the clinic.
Only women falling within the first three categories and who
began the reporting process within the past one and one-half
years were included in the sample.
Thirty-one women were interviewed,
social class, and ethnicity.
who ranged in age,
The women are mostly residents of
Jerusalem, but some come to the clinic from bordering towns.
women were either self-referred or referred by a
The
genera 1
physician or gynecologist.
Study Site
Misga v L'Dach, the hospi ta 1 where this study was carried out,
is a small, maternity hospital which has, in recent years, tried
to promote a
concern for women's hea 1 th issues.
evidenced by its active promotion of natura 1
This is
childbirth,
breastfeeding and pre-nata 1 education courses. Because of its
small size, the atmosphere is intimate and informal.
Permission
to interview women attending the breast clinic was granted by the
director of the hospital.
The cost of the exam is a bout $7.
One male surgeon is responsible for operating the weekly
25
clinic.
He is on staff at a larger, nearby hospital.
Many of
the women reporting to Misgav L'Dach will be treated by the
surgeon at this other hopsi ta 1 during subsequent follow-up (Two
other hospitals offer weekly or bi-weekly breast exam clinics for
the public at large.
In one, the waiting time is two-to-three
months; in the other, about one-to-two weeks).
(With one notable exception in Jerusalem,
it should be
pointed out that none of the sick fund clinics provide screening
exams.
This means that a woman coming to a hospital-based clinic
must have the fee waived by obtaining a voucher which almost
always requires a referral letter from the woman's sick fund
physician.
If not, she must bear the expense herself).
Data Analysis
A total of 31 questionnaires were collected.
the
questionnaires was
summarized
frequencies and, when appropriate,
in
table
The data from
form,
showing
mean scores.
Responses to the first eleven questions pertain to:
symptom discovery,
b) interpretation of symptom,
of decision-making,
a)
c) the process
and d) consultations with both lay and
medical sources, prior to this current visit to the hospital
clinic. The second group of questions concern knowledge about the
cause, prevention, diagnosis, and treatment of breast cancer.
The last four questions in the second section pertain to breast
self-examination and physician exam.
The third and final section
of the questionnaire elicits demographic data about the
26
respondents.
Data Analysis
Data was
transferred from
tabulation sheets.
the questionnaire
sheets
to
Frequency and percent distributions, as well
as mean scores for numerical variables \-Iere calculated.
Knowledge scores of breast cancer (causes, risk factors,
diagnosis and treatment) were determined by points, one for
every correct factor mentioned.
Limitations of Study
1.
A se 1 f -referred sample may comprise a specia 1 population.
The women in this sample cannot be said to represent the larger
Israeli population.
educated,
extent, and
Women who are self-referred may
be more
utilize preventive health services to a greater
generally may differ in other ways when compared to
a non-referred group.
2.
A possible
bias of the questionnaire relates to the method
of collecting information based on self-report.
3.
The investigator's lack
of objectivity and her interpre-
tations of the responses may introduce bias to the analysis.
4·
The size of the sample presents a serious 1 imitation of the
study.
5.
With the use of a loosely-structured, largely-open question-
naire, the reliability (reproducibility) of the findings are
obviously jeopardized.
This type of structure is useful, though
27
r ,
in preliminary surveys, whose purpose is to obtain information
for the subsequent planning of health education programs, or
future research design.
I'
Chapter 4
RESULTS
This chapter highlights the findings of the research.
demographic data will be presented in the first section,
The
and is
followed by a discussion about breast symptoms and how they were
interpreted by the women interviewed.
De lay in reporting
symptoms to a physician comprises the third category of variables
examined, and this is followed by discussion concerning physician
performance of breast exam and breast self-examination by the
women. The role of lay and medical consultation is the subject of
the fifth section, followed by knowledge leve 1 s about breast
cancer causation, symptomvl ogy, diagnosis, and treatment. The
last
section briefly describes a few miscellaneous issues which
arose during the interviews.
Demographic Information
Tables 1-5 summarize the relevant demographic data.
Table 1 shows that half the women interviewed were born in Israel
and the United States.
The remainder represent a cross-section
of the Is rae 1 i population, with women from western Europe, the
USSR, Asia, and the Middle East.
The ages
of
the women
reporting to
the
breast clinic
Most of the women are young
are presented in Table 2.
28
.
29
(Twenty-six are under the age of 50 and five women are between
the ages
of 50-69).
frequently represented.
The
30-39 age
group was
the most
The average age was 38.5;
a 11 ages
ranged between 25-68 years.
Table 1
Frequency Distribution
of Subjects• Place
of Birth
PLACE OF BIRTH
NUMBER
Israel
United States
u .. s.s.R ..
Germany
England
Algeria
Australia
France
Iraq
Morocco
New Zealand
Poland
South Africa
Syria
10
1
1
l
1
l
Total
31
100
5
3
2
2
1
1
1
1
1
1
l
PERCENT
32
16
10
6
6
3
3
1
1
1
1
Table 2
Frequency Distribution of
Age of Subjects
Age of Woman
Number
Percent
20 - 29
5
16
30 - 39
16
51
40 - 49
5
16
50 - 59
3
9 ... 6
69
2
6.4
31
100 .• 0
60 'Eotl\l
30
Table 3 shows the completed years of education among the
women.
The overall level achieved was almost 15 years (x=l4.93)
(Almost a fifth of the total number of women interviewed at
Misgav L'Dach were asymptomatic).
Four women had not completed
high school but nineteen of the 31 (61%) had at least a
degree;
college
educational levels ranged between 8-23 years.
Table 3
Reported Years of Education
Years of Education
Number
Percent
8 -12
9
29.0
- 16
12
38 •. 7
17 - 20
9
29.0
More than 20
1
3.2
31
99.9
13
Total
Table 4 exhibits the marital status of the women.
Sixty-five
percent are married, 16 percent divorced, 13 percent single, and
6 percent widowed.
Table 4
Frequency Distribution of Subjects•
Social Class according to Occupation
Social Class
Number
II
III
1
13
9
IV
2
I
v
Not known
Total
Percent
J .•. z
4
41.9
29.0
6.4
12.9
2
6 .• 4
31
99.8
31
5 shows the socio-economic status of the
Table
women a c cording
to
o c cup a t ion
Genera 1 Registry ( 1 :7 4).
b a sed
on
the
B r i tis h
It can be seen that 75 percent of the
women are represented in classes
II and III..
Table 5
Subjects' Marital Status
Marital Status
Number
Percent
Married
Divorced
Single
Widowed
20
5
4
2
64.5
16.1
12.9
6.5
Total
31
100.0
Symptoms and Their Interpretation
As
categorized,
pain,
1 umps,
and
pain
and
1 umps
together, accounted for 88 percent of a 11 reported symptoms at
the breast check clinic. (One women interviewed was not aware
of the symptom for which her gynecologist had referred her to the
clinic ).
Seventy-five percent of the symptoms were found by the
women themselves; the remaining 25 percent were discovered by the
woman's gynecologist.
Sixty-four percent (N= 20) of the women immediately thought
of breast cancer as a real or potential cause of their symptoms,
yet only 50 percent (16) of the women were of the opinion that
their symptom warranted immediate medical care.
Many women,
associating their symptom with cancer, had information which did
32
not lead to either panic (e.g., "cancer symptoms are usually not
painful") or delay.
A few women claimed that they were too
frightened by the prospect of breast cancer to really think or
act at all.
For another five
women,
panic and fear were
specifica 11 y mentioned as an ini tia 1
reaction.
Six women
expressed "concern" about their symptom, but had no immediate
plans to visit a doctor.
How was delay influenced by these
initial interpretations?
Delay In Reporting Symptoms to a Physician
Table 6 shows the time period marking the moment the woman
first discovered her symptom to her first reporting it to a
physician.
This time, expressed in days, is referred to as the
de lay period.
Table 6
Delay Period in Days from
Recognition of Symptom
to First Doctor Visit
Delay Period (Days)
Number
Percent
Less than 8 days
Less than 15 days
Less than 30 days
Less than 60 days
180 Days or more
21
3
1
3
3
6 7 •. 7
9.6
3 •. 2
9.6
9.6
Total
31
100 .• 0
Sixty-seven percent
within 15 days.
(21)
of the women reported their symptoms
Three women reported
between 30 and 60 days
following discovery, and three women delayed between six and
33
seven months (180-210 days).
Of these last three
delayers, the
following initial interpretations of symptoms were given:
In the
first case, the woman thought she had a heart problem which a
physician should check, yet it took her six months before she
recognized the symptom as "serious."
In the second case, faced
with a small lump and an inverted nipple, the woman did not
perceive her problem as an "emergency" and decided to proceed
with "self follow-up."
(This woman has two family members who
worked at the Misgav L'Dach Hospital and it was they who finally
referred and accompanied her for
the
check-up.
mentioned panic or fear as a reason for delay).
She never
In the last
case, involving a seven month delay, the woman also took a "wait
and see" attitude.
The longest delayer in this sample, this
woman was being followed monthly for another problem by her
gynecologist, but since the onset of the breast problem (seven
months prior),
she had been "too preoccupied" to see him.
(Note:
This gynecologist had never checked her breasts).
In
three
other instances,
the
women were
very
prompt
in initially reporting their symptoms to their doctors,
but delayed between 45-180 days in the follow-up period, or
after a duration in which there was a recurrence of symptoms.
In one case,
the
the severity
family doctor
of
her
reassured the woman about
symptom
(a
lump),
and
she
subsequently delayed four months before seeing the recommended
surgeon (In the meantime her lump doubled in size).
Of
the
women who reported fear or panic as their initial reaction, none
34
delayed significantly.
see,"
It was rather those with a "wait and
"concerned" or "self care" attitude who reported late.
Of the six delayers, three had achieved at least a masters
leve 1 education.
Only one woman in this group was not a high
schoo 1 graduate.
Breast Exams by Physicians
Table
7
shows
the
breakdown
of
responses
to
the
question, "Have your breasts ever been checked by a doctor and if
so, under what circumstances?"
Table 7
Reported Frequency of Breast
Exam by a Physician
Breasts ever checked?
Number
1. Never checked
2~ Yes, a few times
3. Only when I requested it
4. Once only
s. Not until this episode
6~ Not in Israel
Total
8
6
2
2
6
7
Percent
25 •. 8
19.3
6 ... 4
6.4
19.3
22 .•. 5
31
Only six women
reported being checked "more than a few times" by
their doctors.
Twenty-five percent of the women (8) had never
been checked by any physician.
Only two women reported that
their breasts were periodically checked by a gynecologist.
Physicians other than gynecologists were never mentioned as
examining breasts.
Very few women claimed that a breast exam was any different
35
from an ordinary gynecological exam,
and only three women
expressed a preference for a woman physician.
Most were more
concerned with a doctor's expertise than with his/her gender.
Breast Self-Examination
Table 8 presents responses regarding the frequency of selfexam instruction and actual self-exam performance.
Table 8
Reported Frequency of Breast Self-Exam
Instruction and Performance of Breast
Self-Examination
Doesn't
Do BSE
Total
%
4
5
9
( 2 o.• 9)
9
13
22
(10.9)
18
31
Does BSE
Learned BSE
%
Did not learn
BSE
Total
13
Almost 50 percent
their breasts.
examine themselves
(41.9)
(14) claimed they had never checked
Another
on
32
percent
occasion.
(10)
Most of
claimed
these
to
"seldom
checkers" said that they periodically "felt themselves," but this
was not viewed by the women as any proper kind of exam.
or almost 20 percent of the women,
Six,
reported checking their
breasts "frequently," but the extent or exact meaning of this was
not
ascertained. (This finding should be viewed in light of the
fact that the majority of the women interviewed have never been
36
taught self-exam formally or been examined by their physicians
(see Table 8).
to
practice
Of the 13 women (approx. 40 percent) who claimed
self-exam
in
some
form,
confidence in their ability to do so.
only five
expressed
Of the five who said they
performed self-exam frequently, three said they did not feel
confident enough.
Given the hypo the tica 1 situation in which the
woman was
taught breast self-examination by a qualified
physician,
80 percent said they would probably still feel
inadequate,
lack confidence, and would prefer to rely on a
doctor's exam.
Table 8 shows that 70 percent of the women were never formally
taught breast self-exam, yet approximately 40 percent do check
themselves in some fashion.
Interestingly, women v1ho were never
officia 11 y instructed in se 1 f-exam claimed to perform the
technique more than those who did learn formally.
A few women said they were afraid or reluctant to ask their
doctors for information or instruction because:
l. "They're ( the doctors) too rushed"
2.
"They don't have the patience for such things."
3.
"They don't
touch
breasts unless they have to,
unless
a woman asks for an exam."
4·
"Why would they spend the time teaching me when they can send
me to a surgeon
instead?"
Where have women learned about breast self-examination (not
including medical sources)?
responses to
Not presented in table form were
questions pertaining to
sources of instruction
37
about self-exam.
Nine women reported being taught the technique.
Two were taught by gynecologists in Israel (trained abroad), five
by gynecologists abroad, one by a nurse (trained by the Israel
Cancer Association), and one received instruction in
hea 1 th conference
workshop.
a women's
Of these nine women who were
taught, five do not practice it currently and four do.
who claimed they were never taught, (N=22),
Of those
nine claimed to do
it currently and 13 said they did not practice it.
Of the five
women who claimed they were taught self-exam by gynecologists
abroad, four maintain they are still practicing it today.
Table 9
Lay Sources of Information
about Breast Self-Exam
Source
Television
Pamphlets
Newspapers
Women~s magazines
Media advertisements
Self-help books
Women friends
Not known
Total
Number
Percent
9
5
4
2
2
1
1
7
29 .•. 0
16 .• 1
12,. 9
31
99.7
6.4
6 .• 4
3.2
J .• 2
22 ... 5
Table 9 shows that a third of the women mentioned television
as a source of learning about self-exam, and another third of the
sample mentioned newspapers and pamphlets as being their
source of information about self-exam.
were mentioned by only a few.
major
Women's self-care books
38
Amongst all
women who
who were
most stated their preference for a
also expressed a
self-exam,
desire
to
fibrocystic
receive
changes,
physician's exam.
more
Many
information a bout
breast structure,
physiological changes during menopause.
to receive such information
interviewed (N=52),
They
and
expressed a desire
from their doctors.
A few
explicitly stated their need to be "pushed" and "encouraged" by
their doctors to practice self-exam more regularly.
Table 10 shows the reasons stated for not performing regular
self-examination.
Table 10
Reasons given for not Practicing
Breast Self-Examination
Reasons
Number
Percent
1. "I'm not qualified
Better if expert does it"
2~ Lack of confidence/aelfdoubta "I!ll mise something"
3~ Too frightening
4. Too painful
S~ Low perception of
auaceptibllitya "I won't
get lt"
6. Too many lumps to know
what is normal
1r Laziness
8~ Not known
11
Total
31
35 •. s
7
2
2
2
2
2
3
99.6
One-third of the women felt they were not capable enough to check
themse 1 ves, possibly another way of saying that they prefer a
"safer and better" exam
by an "expert."
Almost 25 percent of
the women claimed that lack of confidence or self-doubt was the
39
major barrier to practicing self-examination.
Like the I.C.A.
survey in 1980, few women in this study cited fear as a reason
for not performing self-exam.
Most women were anxious to receive the
I.C.A.
pamphlet
on breast self-examination instruction which was distributed
after each interview.
Most said they would be interested in
receiving more information about the practice from their doctors.
A few women said they would prefer reading materials or a
support-group framework for learning more about self-exam.
Many
expressed anger and frustration about there not being a place for
women to go who want to learn self-exam.
Of
the
women
who
claimed
to
practice
self-exam,
few
felt confident in their abilities.
Role of Lay and Medical Consultation
Table
11
shows
the
extent
of
involvement
of
family physicians and gynecologists in reported breast symptoms.
Table ll
Reported Involvement of Family Physician
and Gynecologist in Subjects'
Referral to Breast Clinic
Family
Dr~
Gynecologist
Yes
10
(32%)
14
(45%)
No
16
(Sl%)
12
(39%)
5
{16%)
N .A •.
Both
Neither
4 {13%)
4 ( 13%)
40
It can be seen from the table that family physicians were
involved in
about one third of the cases. Gynecologists were
involved in
about 45 percent of the cases.
In
four instances,
neither (family physician or gynecologist) was consulted
(even though three of these women had such doctors).
In three
of the four cases where neither physician was involved, delay was
relatively excessive
(60,
42, and 210 days respectively).
No
additional information was obtained in order to further
understand what happened amongst these women. In only four other
cases were family physician and gynecologist
both involved.
Table 12 presents the number of lay and medical consultations
and influences that occurred during the current episode, and
which lead up to, but not including,
the present exam at Misgav
L'Dach Hospi ta 1.
Table 12
Number of Lay and Medical Consultatlona
for Current Breast Problem
Preceding Clinic Vlslt
Type of
Consultatlon
Number of Consultations
0
1
2
3
4
5
6
7
8
Lay
1
12
8
4
4
2
0
0
0
31
Medical
7
7
3
4
4
0
4
0
z
31
Other
5
13
8
3
2
0
0
0
0
31
Total
13
32
19
11
10
2
4
0
2
All but one woman discussed
or mo r e
(1ay)
Total
her problem with at least one
i n d i v i d ua 1 s •
The
average
number
of
41
lay consultations
was
2.12
A third
per woman.
of
the
women interviewed consul ted with three-to-five lay sources
before turning to their doctors.
There were "other" factors which the women discussed that
had some bearing on the present problem.
These are ca tagorized
as "other" influences, e.g. first- or second-hand knowledge of
women who had/have breast cancer, as well as the effects of
various media messages, etc.
The use of "lay referral systems," as previously defined, was
most often mentioned for the following reasons:
moral support and reassurance,
1) to receive
2) to receive advice about where
to turn for further help, and 3) for gaining knowledge about the
"experiences" of others (with similar problems), for purposes of
coping, assessing the severity of the problem,
and deciding how
and when to act.
When asked about the type of people sought, about 80 percent
(25) of the women claimed they consul ted with "women friends,"
many being work colleagues.
Husbands or
boyfriends were also
mentioned in about 60 percent (19) of the cases.
Three women
consulted with their sisters and one with her daughter.
A fourth
woman discussed her problem with her teenage children.
Four other women consulted with or notified their mothers about
their problem. (A few mentioned that they did not want to cause
unnecessary worry to their mothers).
In one case, it was the husband who forced his wife to see a
doctor, and it was he who got the
woman to make and keep the
42
scheduled appointment (She cancelled once and procrastinated
before making a second appointment).
In two other cases,
it was
the partner's interpretation of the woman's symptom as "serious"
which led the woman to seek care sooner than she waul d have had
she acted alone.
In only one case was the male partner (a former
medical student) the one who found the initial symptom (lump),
and only after the women found it a week later did he confess
that he had been too scared to say anything to her about
i~
Women v10rk colleagues were especially influential in getting
their friends to come to the breast
claimed that it was
c 1 inic.
A number of women
their women friends from work who had
increased their awareness about the importance of periodic
exam and about the common frequency of breast problems.
three cases, the
"woman friend"
In
made the appointment for the
woman involved and in three other cases, the women came to the
c 1 inic as a group to be examined on the same day.
When asked,
these particular three women all said they would not have come to
the c 1 inic without the
support of the others.
These findings
confirm the strength of socia 1 networks and lay support systems
(see exploratory hypothesis 4).
Other influences, while not of a consultative nature, were
identified by
the
respondents.
Twelve
women (38
percent)
reported previous experience with cancer among immediate family
members,
e.g.
parents and siblings.
Six
previous cancer experience involving
women reported a
distant relatives.
Combined (N=l8), this characterized 58 percent of the sample.
43
Eleven women reported no previous experience with family-related
cancer.
Having either first- or second-hand knowledge of a woman
who has/had breast cancer was an important and, usually, positive
motivator to report early, or to get a preventive check-up.
than half the women had either persona 1 friends,
More
acquaintances,
or knowledge of individuals within their own social networks, who
had died from or survived breast cancer (Mentioned more often
were those in the former group).
These included women friends,
family friends, neighbors, the employer's
wife, and co-workers.
Sometimes the awareness and knowledge of these "others" was
perceived as helping the women cope better with her own symptoms.
In only a few instances did these influences add to or exacerbate
the woman's already-fatalistic outcome that she too might die.
This was especially true when the knowledge involved a young
woman (under 40) dying of breast cancer.
Among this group, it seems that the majority of women were
no doubt anxious about the prospects of breast cancer, but that
this anxiety almost always led to consulting others, confronting
the situation, and seeking medica 1 care.
How was de lay affected by these lay consultations? There was
basically no correlation between the two.
The six women who
delayed longest, between 35-210 days, consulted with two or less
lay individuals about their problem; this was within the average
for the sample as a whole (X=2.12).
44
Role of Medical Consultations
Table 12 also shows the number of medical consultations by
the women in this study.
The average number of medical
consultations was 2.65 per women,
average number of lay consultations.
slightly
higher than the
Twelve women (38 percent)
consu 1 ted with three-to-six medical sources before arriving at
Misga v L'Dach Hospi ta 1.
Six women ( 19 percent) reported to six-
to-eight physicians before turning to the hospital.
referred women
Some
women
physician.
reported to the
reported
clinic for the first time.
to
their genera 1
or family
Some of these doctors then chose to follow-up with
these women themselves,
surgeon.
first
Five self-
or to refer directly to a hospital
Some women reported to their gynecologists initially,
or for second opinions following the visit with the family
doctor.
In the 25 percent of cases where the gynecologist found
the symptom,
surgeon.
the patient was either followed or referred on to a
At Misgav L'Dach it was almost always the case that
gynecologists connected to the hospital referred directly to
the
surgeon responsible for operating the weekly breast check clinic.
In a
handful
of cases,
i t was
the woman who asked her
gynecologist for the referral to Misgav L'Dach, even though a
written referral is not required (The woman pays the equivalent
of $7 regardless of how she arrives at the clinic).
And as
stated previously, in a few cases, it was the gynecologist who
incidenta 11 y discovered the woman's breast symptom,
treating the patient for another problem.
while
In most cases where a
45
family physician was first consulted, the patient was referred to
another hospital clinic (where there exists a two-to-three month
waiting period).
In 29 percent (N=9) of the cases, a woman's
general or family physician was first consulted, and in another
29 percent (N=9),
contacted.
i t was the gynecologist who was first
The surgeon at Misgav L'Dach was consul ted first by
10 women (32 percent), and in two other cases, a pediatrician and
another hospital surgeon were the initial advisors.
In only two instances was there a clear case of "doctor
shopping," which was
the
result of
the
patient
receiving
contradictory information from different doctors, or the woman
trying to find a doctor whose "prescription" fit her own.
of these episodes,
aspiration
In one
fear about repeating a second fine-needle
led the woman
to pursue other physicians.
In the
second example, a number of bureaucratic problems led to the
"shopping," as did the refusa 1 of the woman to undergo a biopsy
(after three different doctors suggested she do it) because of
the hospital's consent form policy.
Knowledge About Breast Cancer
Table 13 lists the "perceived causes" of breast cancer
as reported
by the women in the sample.
One-third
of
the
women
questioned
apparently knew
nothing about any of the theories/suspected factors which may
cause breast cancer.
are
(as
yet)
A few women cited suspected causes which
unfounded:
caffeine,
a 1 cohol,
gynecol ogica 1
46
problems,
and various psychosomatic causes.
Four women thought
that cigarette smoking caused breast cancer and two mentioned the
use
of birth contra 1 pi 11 s.
Only six women in the sample
mentioned heredity as playing a role in increased risk of breast
cancer.
Table 14
Subjects' Perceptions of Women at Greater Riak
of Developing Breast Cancer
Woman at greater risk
1.
2 ...
3 ...
4.
s.•
6 .•
7.
8 •.
9 ..
10 •.
11 ...
12 ...
13 ..
Number
Doesn•.t kno'll
Women over 40
Woman 'llith family history
High fat diets
Women smokers
Use of birth control pills
High stress
Every woman at equal risk
Never breaatfeeding
Unhealthy lifestyles
Nulliparous \lOman
Late childbearing
Excessive alcohol consumption
Percent
11
6
5
4
35 .• 4
19 ... 3
16.1
12 .. 9
12.9
4
3
3
9 ... 6
9 •. 6
3
9.6
1
3 .. 2
1
1
1
3 .. 2
3 .• 2
3 .• 2
3 .•. 2
1
Table 14 provides answers regarding what women, if any, are
at a higher risk of getting breast cancer.
Again, about one-
third did not mention at least one factor associated with higher
risk.
Not one woman mentioned the fact that Jewish women are
estimated to be at a higher risk than other, caucasian women.
Few women were able to identify more than one-to-two factors
commonly associated with higher breast cancer risk.
Only one
woman was able to state that breast cancer affects 1:13 women
(1:11 would have been more accurate); only one woman knew that
47
eight out of ten breast lumps are benign.
Table 13
Subjecta' Perceived Cauaea of Breaat Cancer
Cauaea
Number
1 .. Doean't know
2., Genetic/hereditary
3 .. Cigarette amoking
4. Streaa and lnab!.lity to
cope with atreae
s~ Overweight/high fat cllet
6. Birth control pills
7.w Alcohol
s. "Contemporary llfeM
9, Damage to breast
10 .. Negative aelf-image
11. Caffe1.ne
12 •. Hiatory of gynecological
problema
13. Envt.ronmental pollution
14~ Paychoaomat1c factor a
Percent
10
6
4
32 .. 2
19.3
12 ... 9
3
3
2
9.6
9.6
6.4
3.2
3 .. 2
3,.2
3,2
3 •. 2
1
1
1
1
1
1
3.2
3.2
3.2
1
1
In reference to other "knowledge" questions,
less than half
( 14) of the women mentioned early detection as the (only) "cure"
for breast cancer.
Four women thought that low-fat diets might
prevent breast cancer and one believed that lengthy breastfeeding
would have a preventive effect.
Only one woman in the entire
sample was able to quote a statistic about cure rates with early
detection.
Regarding knowledge about diagnostic tools for breast cancer,
more than 50 percent of the women mentioned biopsy (18) and
twelve women mentioned X-ray (four of these said "mammography" by
name).
Six women
diagnosed.
had no
idea
about how
breast cancer
Four women cited fine needle aspiration,
cited physician exam and two cited blood tests.
is
four women
One women
believed that breast self-examination practice and the subsequent
48
finding of a lump was, in itself, a cancer diagnosis.
Twenty-two
(70
percent)
women
mentioned
mastectomy
(three used the word "surgery") as the primary treatment for
breast cancer.
Sixteen women (50 percent) mentioned radiation.
Eight cited chemotherapy and·three mentioned lumpectomy.
One
woman spoke of hormone therapy and another of nutrition therapy.
Only one woman was unable to provide any answer to this question.
Other Issues
There was some discussion among the women that bureaucratic
factors played a certain role in the reporting or treatment of
breast problems.
A few women cited difficulties in obtaining the
necessary waiver forms from their sick funds a 11 owing them to
undergo the necessary tests such as fine needle aspiration or
biopsy (which requires hospi ta 1 iza tion in many cases).
Two women discussed the problem of hopsital consent forms as
being a barrier
to
following through with the necessary care.
Many hospitals do not follow the two-stage procedure which gives
a woman time and further options in the event that cancer is
diagnosed and where immediate mastectomy is not
performed.
For
one woman in this sample, this problem led to significant "doctor
shopping," which
ended when the woman in question found another
surgeon in another hopsital willing to perform a less invasive
test.
Q
Chapter 5
DISCUSSON
This chapter presents a
discussion about the initial
hypotheses. The primary areas to be examined are:
knowledge and
delay, breast self-examination, and reliance on clinical exam.
The "selling" of early detection,
preventive care for women at risk,
physician behavior,
the influence of social
networks, and the role of the media in promoting early breast
cancer detection are also analyzed.
Many more women than are actually included in this sample
were interviewed for this project (N=52).
When appropriate,
discussion will include the total group and not just the 31 women
who comprise the analyzed sample.
Many women not included in the
analyzed group provided valuable information about their own, as
well as their doctors' attitudes and behaviors regarding breast
exams, etc.
Within the tota 1 group, there was a high percentage
of asymptomatic women (N=l4) who were also interviewed; they were
visiting the clinic for "preventive" check-ups.
Examination of Hypotheses
Knowledge and Delay
The responses
information
indicate a serious lack of knowledge and
with regard
to
49
risk
factors,
diagnosis,
and
'
50
treatment options of breast cancer.
proven,
While it is true that no
definitive causes of breast cancer have been isola ted,
evidence supporting a number of theories and related factors have
accumulated in recent years.
Environmental, hereditary, and
dietary factors are suspected of playing a role in either its
development or proliferation and have been featured in the
popular press and on te lev is ion.
have also been implicated.
Estrogen and chronic stress
The low knowledge scores
women questioned in this study become
when considering their
among the
all the more significant
high educational levels.
One
can only
speculate as to what a more "average" woman might know about the
disease. Much
remains to be done in terms of pub 1 ic education
about breast cancer, especially in the area of risk factors.
Similar to
other studies, it was shown in this population
that knowledge and educatational level were not
associated with
delay. This may be explained by the fact that Israelis are
accustomed to utilizing the health services.
actually play a role in reducing delay.
This norm may
Israel maintains the
distinction of having one of the highest
doctor visits per
capita rates in the world.
Related to knowledge in another sense, there may be barriers
which prevent women from becoming more knowledgable and
responsible for their personal health. Israel has
influenced by the
yet to be
changes (at least on the awareness level) in
patient-physician relationships which have occurred
United States as a result of the Women's Liberation
in the
~'!ovement.
51
Compounding the typica 1 rna le physician-female patient dyad, in
which the physician is typically authoritative and active,
and
the patient ignorant and passive, the task of requesting a breast
exam (which involves
body),
exposing
an intimate, private part of the
may be difficult for a
perceived to be
physician.
non-assertive woman,
who is
apathetic or indifferent in the eyes of the
Furthermore, many physicians are not up to date
about breast cancer risk,
diagnosis and treatment. Many doctors,
as pointed out in the interviews, are also reluctant or unwilling
to examine breasts.
Those that do perform it may be doing it
inadequately.
Women are in an ideal position to become familiar with
monitoring changes in
breast structure, rather than rely on
their doctors who see them on an annual basis or even less.
Unfortunately, one of the more serious obstacles facing both
women and their physicians is that many women
the idea of self-exam, even though
are resistant to
they are equally if not more
capable of self examination than their own doctors.
Breast Self-Examination and Reliance on Clinical Exam
Emigration from a western country was a good predictor of
self-examination practice.
Women in this category had learned
the technique from their gynecologist abroad and seemed to have
internalized the value and importance of both self-exam
clinical exam.
and
Surveys previously cited have shown that public
awareness about the technique and its practice are higher in
52
these countries than in Israel (21, 58).
While it was true that
the overwhelming majority of women questioned had never been
formally instructed in breast self-examination,
many women did
claim to feel and/or check themselves, although not in any
systematic fashion. The majority of women preferred a clinical
exam by a doctor, while at the same time expressing reluctance
about assuming more responsibility for this aspect of their
health care.
The extent to which a woman's preference for a
physician's exam correlated with a lack of forma 1 instruction
could not be ascertained.
The tendency to rely, or over-rely,
on a physician's care and competence
were, in this researcher's
eyes, both exaggerated and unfortunate.
As expected,
women did desire more information about breast
disease and breast changes during the life cycle. Many expressed
anger over the fact that there is no place in the city which
offers women the opportunity to learn the technique from a health
professional
(Towards the end of this project, it waslearned
that one sick fund clinic in Jerusalem offers such a class twice
a month, but that registration is limited to those women residing
in the clinic's service area) (76).
An important point reinforced by this study is that it is not
enough to teach women the technique of self exam.
One reason
compliance is not very high with self-exam is that women do not
know enough about their breast structure - what is normal, or
what is and is not supposed to be part of the breast.
feel little, if any confidence in what they are doing,
Thus, they
which in
53
turn,
reduces the degree of self-efficacy and motivation to
perform it.
It is likely that physicians suffer from similar problems
relating to confidence and motivation.
expertise,
as
it is doubtful whether
Until they
achieve this
they will be· able to succeed
role mode 1 s, while educating their patients.
The "Selling" of Early Breast Cancer Detection
Regarding knowledge about early detection,
less than half the
women questioned mentioned it as influencing either outcome of
treatment or survival.
Interestingly, it was learned during the
course of this project that
a highly conservative attitude
exists among Israeli surgeons regarding the treatment of breast
cancer (18).
It was not surprising that so few women knew about
the lumpectomy procedure, as it is performed in very few cases in
Israe 1 ( 18). Modified radica 1 mastectomies are the most common
procedures performed.
there may be
In
"publicity" terms, this means that
little, if any incentive for a woman to value early
detection if she is guaranteed to lose her breast- regardless of
stage of disease at presentation (The possibility of this outcome
may be more powerful in influencing a woman to not take action
than the threat of possible death from extensive delay).
United States,
an emphasis
on early detection
has
In the
become
increasingly associated with the slogan that "breasts can be
saved through early detection, not only lives."
Israel may be
decades away from accepting this philosophy, at least on the
54
medical front.
As long as conservative attitudes and radical
surgery remain "standard procedure,"
an early detection motto
may never be accepted by the public as offering women any
benefit.
It could be hypothesized further that unti 1 Is rae 1 i
women become informed about their rights as patients, and until
these rights become protected by law, no immediate changes in
this situation can be expected. Adding to this conservatism is
the
fact
that there
are
relatively
few
cases
of
breast
reconstruction in Israel. This may also point to conservative
attitudes among the nation's surgeons.
Together, these
factors
may play a role in either creating or strengthening an already
fatalistic attitude about breast cancer as well as contributing
to delay in reporting.
Medical Consultations Patterns
Contrary to the pattern of lay consultations described, no
repeatable,
similar behavior patterns were identified among the
women reporting breast problems to their doctors.
The "doctor-
shopping" phenomena, although present in only a few of the cases,
should be investigated further.
Physician Behavior
Because Israeli doctors receive such a wide range of training
backgrounds with varying professional standards,
that many have not had proper
exam,
it is
likely
instruction in cl inica 1 breast
and that their knowledge and awareness levels
regarding
55
the va 1 ue of the exam are low.
It is a 1 so the case that almost
all oncological surgeons in Jerusalem are male,
gynecologists are also male,
thus
re 1 uctance of women to "seek out"
"expert."
motivated
that most
possibly explaining the
a breast exam by aso-ca lled
When combined with the prevalence of religiouslymodesty (a trait valued by a large percentage of
observant Jerusalemites) barriers may indeed be present,
physicians
(though not women patients)
investigator.
This would be
pointed
as many
out to
the
a 11 the more reason to increase
efforts in teaching self-exam skills to women.
In terms of doctors' behavior,
this study disclosed that few
genera 1 physicians/family physicians a;d gynecologists
breast exams.
those
perform
The reasons for this are likely to be similar to
usually associated with women's low performance of the
technique.
First,
there is a
low level of knowledge and
awareness about the importance of early detection.
Am tti tude
which doubts the value of the exam may also play a role in
physicians' low compliance with the procedure.
There are no
institutional incentives for doctors to perform "preventive
behaviors,"
and many physicians would claim that present work
conditions are not conducive to conducting such an exam.
There may exist role conflicts concerning the responsibilty
of performing breast exams.
Should it be the task of the family
physician? gynecologist? or surgeon?
(among these,
females)
they themselves are
Secondly,
some doctors
interviewed for this study claimed that
as uncomfortable and embarrassed by touching
56
a woman's breasts as are their patients.
deserves further investigation.
This problem certainly
Many women who were interviewed
claimed their doctors were opposed to checking their breasts and
preferred to refer them directly to a hospital-based surgeon.
Role of Family Physician
Because Israelis
tend to over-utilize the health services,
the physician's influence in modifying individual behavior toward
cancer is potentially
great.
Despite the drawbacks mentioned,
the family doctor is in the best position to communicate relative
risk to a patient, to encourage the practice of se 1 f-exam, and
recommend appropriate interventions for women in high risk
categories.
Preventive Care for Women at Risk
This
study revealed a serious ommission of
gynecological
health services for women.
For
preventive,
those women who
no longer require the services of a gynecologist (and these
women, over 40,
are at increasingly higher risks ofdeveloping
breast cancer), this problem was clearly illustrated.
There
appears to be no normative expectation that a woman should be
periodically examined.
Pap smears and breast exams are not
routine practices in Israel.
A number of younger as well as
older women in the sample confessed they did not even have a
gynecologist to visit.
A common remark from the women
interviewed was: "I only need my gynecologist from birth to
57
birth."
The Influence of Social Networks
The last exploratory hypothesis, regarding the influence of
social networks on the utilization of breast-check clinics,
received much support.
The
strongest predictor for an
asymptomatic woman visiting the clinic was the availability and
inf 1 uence of socia 1 supports and lay
they provided a
woman with more
referra 1 s; In manycases,
relevant information and
emotiona 1 support than she might receive from a physician.
Eardley and
Antonovsky cited similar evidence
(4,
26).
Women's
social networks provided morale, encouraged preventive health
behavior, and helped shape a
response to the (potential) threat
of breast cancer.
As Calnan
suggests,
the ir.fluence of lay supports and
referra 1 systems may be quite significant in that they
create
and exert a kind of normative pressure to attend a breast clinic,
especially among asymptomatic women (14).
From
this
study it was
true
that direct and indirect
experience of breast cancer was associated with a
feeling of vulnerability or susceptibility.
stronger
This perception was
associated with many asymptomatic women visiting the breast
clinic.
A previous experience with cancer was also linked to
more anxiety and feelings of fatalism.
Siero probed this
relationship and found that manipulation of seriousness and
susceptibility in various media messages, caused no difference in
58
,,
fear leve 1 s.
Yet fear
was found to correlate with a woman's
intention to seek care and/or practice self exam(69).
This
reinforces the importance of educating women about the re la ti ve
risksof developing breast cancer.
Women should have realistic
information for assessing personal risk.
That so few women
mentioned heredity as a risk factor reinforces the necessity of
including these facts in media messages or health education
campaigns.
Health Beliefs, Behavior and Socio-economic Circumstance
Another area worthy of further investigation is the
relationship between health beliefs, behavior, and socio-economic
circumstances.
As Calnan suggests, a socially disadvantaged
woman may be characterized by i 11 hea 1 th,
which in turn may
influence the: way she defines normal health (13).
Chronic or ill
health may also contribute to a woman's sense of lowered/reduced
health norms and a tendency toward non-utilization of preventive
services.
Psycho-social Factors
Some studies have examined the role of
psycho-social factors
in influencing both delay and breast self-exam practice in
symptomatic women.
by factors beyond
These behaviors
though,
conscious awareness and
may be influenced
control.
efforts may need to consider the irra tiona 1,
Educational
unconscious fears
which form a woman's ini tia 1 reaction to a breast symptom.
This
'
59
would also mean stressing the benefits of early detection.
Effective communication must
reduce anxiety while tak.ing into
account individual differences in styles of coping against
perceived threat of the disease.
More subtle messages, for
example, may be needed for women with a tendency toward avoidance
through denial and repression.
Utilization and Influence of the Media
Communicating the risk of personal susceptibility to breast
cancer while assuring that fear is not increased in the process
should be the focus of future public education campaigns.
Stressing the positive benefits of breast self-examination as
well as the necessary self-exam skills, should
be introduced via
television and the printed media.
Recommended interventions for promoting the early detection
of breast cancer in Israel will be the focus of the sixthand
final chapter.
Chapter 6
CONCLUSIONS AND RECOMMENDATIONS
This research has described some behavioral aspects of
symptom reporting for breast problems in a small Jerusalem
hospital.
The three primary methods of early breast cancer
detection are not widely employed in Is rae 1.
Little is known
about the pre-diagnostic stages of breast cancer or symptoms of
breast cancer in women.
The
study attempted
to obtain
information about women's knowledge and attitudes about breast
cancer,
breast self-examination,
perceptions
physicians' behavior in the same regard.
of
their
Factors which
may
contribute to delay in reporting were a 1 so examined.
A number of significant findings have been presented which
demonstrate a need for further investigation.
Major conclusions
and recommendations for improving early detection efforts in
Israel will be presented.
Recommendations
Outreach in the Clinic Setting
Since Israelis tend to over-utilize the health services
provided by the major sick funds, it would be both reasonable and
appropriate for the funds to initiate
programming aimed at
educating the female adult population about:
60
1) risk factors for
61
breast cancer, 2) the importance of yearly physican exam, and 3)
breast self-examination. The neighborhood clinic is the most
appropriate place for posting literature, for conducting periodic
screenings at low cost, (A modest beginning such as offering an
annual or bi-annual screening program would also constitute a
major step toward strengthening preventive health in Israel), and
for instructing women in self-examination on some periodic basis.
Since a large percentage of adult women in Jerusalem are
religiously observant and modest, and because most surgeons who
examine breasts are male, it becomes increasingly important for
women to learn self-exam skills, not as a replacement for a
physician's
exam, but as a supplement to it.
Again, the clinic
becomes the logical target for such activities.
There is a critical need to investigate breast self-exam
attitudes and behaviors among religious and non-religious women,
together with their respective physicians, in order to verify the
extent of the "modesty" problem.
Clinical exam by trained nurses should also become an active
component of early detection programs. In Israel, the nurses'
role at the present time in conducting breast exams is minimal,
and this situation should be reversed.
Continuing Education for Physicians
There is a need to educate medical students and practicing
physicians about the prevalence of breast cancer.
Doctors must
become more aware of the importance of competent clinical exam
62
together with instruction in self-exam techniques.
The Ministry
of Health should coordinate mandatory in-service trainings for
physicians in all areas of cancer risk and prevention.
It is
suggested that a few high-status, hospital-based surgeons be
selected for
their potential ability to influence colleagues in
this regard.
They should
conduct "internal campaigns" within
the profession, with a primary focus on changing the attitudes
and behavior of physicians.
The Israel Cancer Association could
act as a consultant for such efforts.
It is this researcher's opinion that economic limitations are
not the most crucial problems facing the fight against late stage
diagnoses of breast cancer.
and apathy are
Low awareness, outmoded attitudes,
probably more
responsible
situation than many would like to believe.
for
the
current
The fact that only
one Kupat Holim (Sick Fund) clinic to date has initiated a
program in self-exam instruction (a revolutionary step in
Israel), supports the slowness of the needed changes.
There appears to be little ideological fervor or motivation
among Israeli physicians to get involved in the "preventive
health" movement.
There are no incentives for such involvement
and this is precisely what the Ministry of Health and Kupat Holim
should be striving to create.
even lowering health
gain by such activity.
In the interest of maintaining or
care costs,
these bodies have the most to
These two agencies are responsible for
the public health, and should find the resources to
cancer screenings in all areas,
especially
provide
for high-risk
63
populations.
There is a critical need to investigate the attitudes and
behaviors of physicians with regard to breast examination.
The Role of the Media
It is in the realm
of "public relations" that early breast
cancer detection stands much to gain.
Television is probably the most influential medium in
Israel, and more public service announcements should be produced
with the aim of educating the public about the relative risks of
developing the disease, and about the importance of confident
self-exam practice.
Many women in this study claimed to be
influenced by both the
I.C.A.'s
advertisementand by a
popular which featured different aspects of breast cancer.
so many women remembered so
programs,
1 i ttle
information from
only days after they were viewed,
importance of repeating media messages on a
few
That
these
reinforces the
regular basis and
keeping them in constant view of the public eye.
The movie theater also has great potential for promoting
early detection messages.
These settings would have a tremendous
impact since Israelis frequent them so often.
Anumber of
successful female media personalities should be solicited to
"star" in such advertisements.
Health Education in the Workplace
The role of social pressure and lay influence was shown to
64
have a positive impact on women reporting
breast symptoms in
this study.
The workplace, whether it be an office, factory, or army
base, can easily be targetted for on-going educational programs.
Businesses and industry should finance such efforts, as they have
the most to gain in terms of
reducing employee illness and delay
in diagnosis and treatment.
Unfortunately, Israel
still seems
to be a few decades away from recognizing the relationship
between employee wellness, worker productivity, and profit
margins. The workplace is a unique framework
for another reason.
It can promote not only sharing and information exchange, but can
create peer pressure and new normative
preventive behaviors, in
a way more likely to influence the average individual than say, a
television program being viewed alone at home.
The establishment of a joint United States-Israel task
force,
supported by the Israeli Government,
should study these
issues, draw up recommendations, and implement programs •
Such a
project could do much to foster professional and educational
links between the two Jewish communi ties.
Statistically, Jewish
women in both countries are at high risk of deve 1 oping breast
cancer.
Israeli health policy planners and administrators have
much to learn and gain from American trends in promoting
healthier lifestyle behaviors.
The contribution of this research lies in its identification
of issues which, if better understood, may lead to improved early
detection efforts in breast cancer control in Israel.
p •
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APPENDICES
71
APPENDIX A
BREAST CANCER TREATMENT FLOW CHART
72
Diagnosis and Treatment of Breast Cancer
H
BREAST
EVALUATION
BIOPSY
Asymptomatic
Biopsy
Woman-Screening
!NoCanc.,.J
..
IV
v
VI
vu
VUI
PRlMAIIY
TREATMENT
ADJUVANT
THERAPY
BREAST
RECONSTRUCTION
FOLLOWUP
CARE
RECURRENT
ADVANCED
DISEASE
DISEASE
------
------
• Physician Exams
• Mammogram. if
app<opnate
• BSE
j
Biopsy and Immediate Mastectomy-Breast
rhe~herapHwoman·~\
Rad1at~
Option
Therapy
/
Evaluation
• Palpat~
Symptom - - • Asptrarton
Woman with
Continuing care:
• Mammogram
_ _ _ _:;.
---~--
·rh~herapJ-twoman·J- • sSE
Rad~ation
~-
T•dapy
.
0 pt~
Dbe:ase Control:
• surgery
• Phy>k:al exams - - - • Radiation - - - Palliative
the a
Carr
• Mammograms
• Other t~su
r PY
• Chemcxhrt'apy
----
• Hormone
therapy
• Of:ty.r
methods
Biopsy - - Mastectomy - - - - : wnh
tm111rd1atr
breast
recorurruction
Biopsy- RadlatTherapy
[opt~na]
l
hemcxheraw
Rad~IOll
Therapy
.,.,
>
""
2!
....
t:l
><
>
L
chemotherapy 1-------
National Cancer Institute
Aprill'l&l
-...]
w
74
APPENDIX B
CHRONOLOGICAL CONTINUUM
QIRONOL(X;ICAL CONriNUUM OF STAGES IMPACTING TilE REPORTING/'ffiEATMENT OF SYM!"''C.t-S FUR BREAST PROBLEMS
I
RECCX;NITION OF
SYMP'J'(}1/S
II
I7
III
v
IV
II
fNTERPRETATION/DIAllJATION
DECISION-MAKING I~ :ACTION Tt¥EN/
OF SYMP'J'(}1/S
~
PROCESS
NUr/TI>¥Dl
VI
POST-DECISION-MAH[NG
f-7 D/AllJATION/ACTION
FOIJ.()..1-UP
BEHAVICR
---~
BSE/Jtl BSE
A. Woo.an feels/
observes sarething
Meaning attrib.Jted to
symptom
lA. Symptan within a
nonnal range
B. \l'o!llan' s partner
B. Sy111ptan within an
feels/observes
abnonnal range
C. Physician " .,
A. Do nothi.ng/
ignore
B. Wait amt. of
time
A. Action taken
B. Action not
taken
A. Acception
B. Rejection
C. Modification
C:. Seek medical
D. Other/trigger
2. Reason/basis for
to self-exarr. or
physician exam
interpretation
E.Change/
Re-evaluation/interpretation following action
taken
advise/consult.
D. Seek non-medi-
cal advise
of
medical or
non-medical
advise
recurrence/
persistance of
symptan
What was
symptan?
a. breast paintenderness
b. discharge
c. lU!p/thickeni.ng
d. change in size/
color I shape
e. other sensory
disturbance
...,
...,
>
1'1
:z:
t:l
H
><
...
f. nipple inversion
g. puckering
h. inflamation
i. dinple
j. llDle change
-.)
Ul
APPENDIX C.1
ENGLISH TRANSLATION OF QUESTIONNAIRE
76
77
APPENDIX C.l
Eqgltsh
A.
~~~lation
of Hebrew Questionaire
t}.Jestions on S)'IIJltom discovery, interpretation, reporting process
1.
Can you recall when your breast problem first appeared?_ _ _ _ _ _ _ _ _ __
1-ho discovered it?
2.
1-bw was it discovered?
\-hat was/were the syrrptom/s exactly?_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
3. v.hat went through your mind at that tirre? How did yru feel? Did you think what
you fourrl was nonnal? abnonnal? What did you first think of doing?_ _ _ _ _ _ __
4. v.hat happened next? What did you decide to do, if anything? (Consult with
spruse/friend/other? )_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Did you tum to any other source (book, magazine •.• )_ _ _ _ _ _ _ _ _ _ _ _ __
5. 1-.ho or whatever you did consult with: \-hat did you want to know? How did yru
expect this person/source of infonnation to help yru?_ _ _ _ _ _ _ _ _ _ _ __
1-hy did you tum to the person/thing that you did? _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
6. Do you remember how Jll..lch tirre passed from the norrent yrur syrrptom was four.::!
to the tirre you ~nt for the first physical exam?_ _ _ _ _ _ _ _ _ _ _ _ _ _ __
7.
\-hat brought yru/led yru to go to the doctor (and lo.hich doctor) at the tirre that
you ~nt? - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 8. How did you doctor react to your problem?_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
9.
Did you discuss the doctor's visit with anyone afterwards? _ _ _ _ _ _ _ _ __
10.
\-hat happened next? (follow-up visit to sarre doctor/referral to hospital clinic/
discussion with other/s)
11.
(If appropriate)
---------------------------
1-bw Jll..lch tirre passed from day you saw your G.P. or GYN. to today
(or whenever yru see the hospital surgeon for the first t i r r e ? ) - - - - - - - -
78
12.
was/is there a difference to you between going to a gynacologist for a regular
check-up exam and going to a doctor or surgeon with a breast problem?
13.
B.
If yes, how so?
lbes the sex of the doctor make a difference to you in this case?_ _ _ _ _ _ __
Q..testions on knowledge
14. (If not already discussed) Did it ever occur to you that your problem was
related to cancer? Why or why not?_______________________________
15.
As far as you know, what causes breast cancer?
16.
In your opinion, can breast cancer be prevented or cured?_____________
17.
As far as you know, how is breast cancer diagnosed and treated? _____________
18.
Have you ever heard of or learned breast self exam?
Have you ever tried to examine yourself?
1-bw often?
Who's at risk for cancer?_ _ __
If yes, fran who?_______
W:ly/..tly not?____________
If yes, did you feel confident in your ability to check your breasts?_________
If no, from who !.Ullld you like to learn rrore about BSE? .ffcm \IJ~OI\\?
19.
c.
If there any infotmation that is important for you to have now?
DerrograEhic data
21.
age
22.
marital status
23.
Place of birth
24.
Years of education
25.
Occupation
26.
No. of births
27.
Previous history of breast probleras____________ exper. w/ cancer______
Father's {place of birth.._)_ __
Ages of children - - - - - - - - - - - - - -
79
lAY a>NSULTATIOOS
MEDICAL COOSULTATIONS
lilte:
Person(relationl:
Sought for:
futcane/recomn:
Date:
Person( relation)•
Swght for:
futcane:
lilte:
Person(relationl:
Sought for:
futcane/recomn:
Date:
Person:
Swght for:
futcane:
lilte:
Person(relation):
Sought for:
futcane/recomn:
Date:
Person:
Sought for:
futcane:
IAlte:
Person(relationl:
Sought for:
futcane/recomn:
Date:.
lilte:
Person(relation)·
Sought for:
futcane/recoorn:
Date:
Person:
Sought for:
futcane:
Person:
Sought for:
futcane:
·--
APPENDIX C.2
RESEARCH QUESTIONNAIRE (HEBREW)
80
81
APPENDIX C.2
(Hebrew ver11on of queat1ona1re)
---------------------------------- ?n~Anl Nln 1'N
?D''lDD Y1'D
nn1
.1~
11TY' NlnD
n•~1/n•o•~/nlDn
nnl
n~o•n
?DlUDD>Dn nN n~>A >n
DNn
?NVlll 011DD
-------------- 'U1D
ND11 \N nnDVD
ND\1~ nlJD~
1nY1
~y n~y
DNn
1
J\VN1n
l~~l ND\1~
nNDiD/ND\1~
nyAnV 1Y DlUDD'On
n~AnJv
n>JD
Y\1D/Yl1D
N~
ON
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- - - - - - - - - - D•1'1•i1 •N'I•A
APPENDIX D
BREAST CANCER INCIDENCE AND MORTALITY
IN ISRAEL:
84
1967 - 1985
Jewish, Female Breast Cancer Incidence and Mortality1 Israel 1967-1985
1967-1971
In cide11ce
p ar 100,000
1972-1976
a
1977
1978
1979
1980
a
1981
a
700
906
1017
300
392
512
1069
1060 1146
396
332
1982
a
1146
c
b
b
--
------
-
528
----~--
528
461
l_____ ·----l____
575
-
1984
1985
c
c
c
1200 ~200 ~200
1200
De ath Rates
pe r 100,000
-
1983
-
---------
c
511
--
c
488
------
a
column figure refers to yearly average based on 5-year total rate, or
on 2-year rate (1981-1982). Unlettered columns refer to Source A~.
b
refers to Source B~
c
refers to Source c~ These are estimated rates~
Source of Information
a
Israel Cancer Registry, Cancer Incidence and Mortality, Ministry of Health
b
World Health Organization, Statistics Annual,
c
Israel Central Bureau of Statistics, (unpublished, 1987) and Israel Cancer
Association, 1984 Annual Report, Tel Aviv~.
W.H~o~,
Geneva, 1985
~
H
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t:l
co
U1
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