Breast Compression in Mammography: Literature Review
Introduction
Breast compression is vital in mammography because it aids in the production of the desired diagnostic mammogram. Breast compression is also crucial in optimizing the image quality of a mammogram in order to obtain the best image possible. To achieve this, it is necessary to ensure that the breast has been sufficiently compressed. This ensures that the breast tissues are thinned and evenly spread. Consequently, the maximum breast tissues can be captured on x-ray. Besides, this helps to minimize the x-ray scatter towards the breast and the radiation dose (Poulos, 2004). Compression also aids in the minimization of the breast thickness so that the difference between the breast cancer, lesion, or breast tissues can be seen clearly, in addition to other pathological findings that may need to be investigated. Sufficient compression of the breast tissue ensures that even as the x-ray of the breast is being taken, it (the breast) remains still. Consequently, breast compression aids in the elimination of unnecessary blurred images and movements. About the procedure (breast compression), most women have reported that the mammogram procedure is quite painful, while others indicate that it is not (Smith, 2014). Accordingly, the premise of this literature review is to examine the position of this statement with respect to the research findings of various scholars on the subject. The various ways in which the painful experiences of this procedure can be attained, shall also be examined.
Breast Compression
Each year, millions of mammograms are conducted worldwide, and the expectation is that mammography shall remain the chief breast examination procedure for many years to come. While there has been a lot of advancement in medicine and technology over the past five decades, this has not been felt in regards to the issue of mammography. Even after the technological breakthrough witnessed in the medical field, the breast still needs to be flattened onto a detector. This is because the technique has been seen to reduce the dose and enhance diagnostic image quality de Groot et al., 2015). Compression of the breast during examination in order to minimize the absorbed dose and ascertain sufficient image quality is common with modern digital mammography (DM) and the conventional screen-film mammography.
From an imaging context, we can identify three advantages of breast compression: first, it minimizes breast thickness, thereby reducing image noise that is likely to emanate from scattered radiation. Secondly, breast compression involves the application of pressure on the breast, and this helps to separate tissue structures. This is important because it helps to minimize the impact of superimposition on the detection of lesion. Finally, breast compression immobilizes the breast, and this effectively eliminates motion blur (Dustler et al., 2012). In the past, guidelines for breast compression involved as much compression of the breast as possible, with the only limiting factors to this procedure being the maximum force setting of the mammography unit (usually in the region of 200 N), and the patient’s pain threshold (Dustler et al., 2012). Over the years, however, concerns have been raised on whether the force applied to the breast is according to a suitable compression guideline, as the breast is made up of various types of tissues with diverse mechanical properties. Therefore, the response to the force applied differs (Dustler et al., 2015). Nonetheless, the way the pressure due to the applied force is distributed is vital, because only the pressure applied on the compressed breast is significant from a diagnostic point of view. Breast compression could however be hindered by such firm structures as the anterior axillary fold and the pectoral muscle. It is also important to note that pressure on any of these two structures is vital in breast tissue compression as it hinders adequate compression of the breast (Dustler et al., 2012).
Pain during Mammography
For most women, breast compression is a very painful experience. This is especially the case with women receiving conservative treatment for breast cancer. Besides, pain during mammography can hinder asymptomatic women from continuously attending breast cancer screening. In addition, many women who have had to undergo breast-conserving surgery have limited options but to go through follow-up mammograms after treatment (de Groot et al., 2015). Morris (2014) contends that for patients, pain during mammography is both a costly and painful experience. According to Morris (2014), the discomfort/pain that patients experience during a mammography procedure is enough to discourage most of them from regularly attending breast screening. Consequently, the author notes that this could lead to loss in benefits associated with early detection of breast cancer. Various studies have explored reported experiences with discomfort/pain among patients undergoing a mammography (for example, Armstrong et al. 2007; Barter-Godfrey & Taket 2007; Brett et al. 2005).
Armstrong et al (2007) conducted a randomized controlled study to assess the benefits and risks associated with mammography screening among women aged between 40 and 49 years. From the data analysed from randomised, controlled trials, it emerged that about 7-23% of the studies suggested that women between 40 and 49 years of age have higher risks associated with mammography screening (Armstrong et al., 2007). While screening mammography is linked to an increased risk for mastectomy, on the other hand, it is associated with a reduced risk for hormone therapy and adjuvant chemotherapy. In addition, the risk for radiation is negligible. Armstrong et al (2007) report that while majority of the women report feeling pain during the mammography procedure, only a handful of them view such pain as a hindrance to future screening (Armstrong et al. 2007).
On the other hand, Barter-Godfrey and Taket (2007) found that the discomfort associated with breast mammography is a hindrance to breast screening. In a cross-sectional study aimed at understanding the underlying reasons for women’s non-attendance or attendance to breast screening, the authors found out that the decision on whether to attend screening or not is both personally justifiable and rational. In addition, such a decision encompasses factors associated with attitude and emotions. More importantly, the researchers noted that anxiety and pain usually experienced by patients during mammography act as key dissuaders against re-attending.
Elsewhere, Brett et al (2005) endeavoured to find out the psychological effects of mammographic screening. The researchers identified fifty-four research papers on mammographic screening published after 1990, from 13 countries. Their research findings revealed that mammographic screening rarely cause anxiety in those women who receive a clean bill of health after a mammogram and who are thereafter placed on routine recall. In contrast, women who have had to undergo further investigations after routine mammographic screening experience significant anxiety both in the short and long term (Brett et al., 2005).
Having ascertained that pain/discomfort is not uncommon during mammography, and that it could cause anxiety among patients in subsequent screenings, there is need to understand women’s responses to this procedure. In her study titled, “Having a Mammogram: How does it feel?” Poulos (2004) sought to examine the various aspects of this descriptor by asking women to identify possible perceived differences between pain and discomfort in relation to the mammography procedure. The differences as described by the women enabled the researcher to construct an accurate description of the experiences of women who have to undergo a mammogram. The study involved a sample population of thirty women. All the women who took part in the study were undergoing routine breast screening procedures at BreastScreen Eastern Sydney and NSW Central. To these women, the researcher administered a questionnaire whose focus was on their perceptions of the discomfort/pain while undergoing the mammography procedure. According to the study’s research findings, discomfort acts as a more suitable descriptor of the mammography experience.
At the same time, classifying the perceived differences between pain and discomfort also helped to shed more light on novel information for use in mammographic practice (Poulos, 2004). An understanding of how women respond to the mammography procedure is crucial for several reasons. To begin with, there is need for radiographers and other health professionals to understand how such patients feel so that they can offer suitable and informed explanations of this procedure to their patients. In addition, the mammography experience needs to be accurately described in order to determine the extent of the discomfort/pain experienced, in addition to facilitating the comparison of the various research studies that have examined the impact of the various variables on the patient experiences of mammography discomfort/pain (Paulos, 2004).
Acceptability of the mammography procedure is vital for women who might be deliberating on partaking in breast screening. However, the discomfort and pain often associated with the mammography procedure means that this practice remains unacceptable to a number of women. Various studies reported on the varying nature of the frequency of pain during the mammography procedure. For example, Lee and Tsai (2011) report that discomfort and pain during mammography can also significantly reduce compliance with this procedure. Lee and Tsai (2011) report a prevalence of pain during mammography varies between 28 and 77 per cent. A further 9.4 % of women report severe pain during the mammography procedure.
Anxiety is quite common among women undergoing mammography, and is mainly attributed to lack of knowledge regarding the examination, and the fear of the outcome of the procedure. This aspect has been examined extensively by existing literature. For example, Chojniak et al. (2012) endeavoured to assess the frequency of anxiety in women undergoing the mammography procedure. In this study, more than half of the participants (52.2%) reported experiencing self-perception of anxiety. On the other hand, anxiety in majority of the patients (35.5%) was attributed to worry over results, while a further 26.6% reported anxiety over possible discomfort or pain during the mammography procedure. While a certain level of anxiety ought to be expected on account of the acknowledgement of the ability and significance of mammography in breast cancer diagnosis at its early stage, there is need to recognize patient experiencing high levels of anxiety and provide suitable psychological support to them.
Coping Strategies
While compression of the breast has been reported as a leading source of pain during the mammography procedure, majority of the studies do not show any correlation between the level of pain and compression pressure (Lee & Tsai, 2011). Nevertheless, technician’s behaviour and attitude plays a crucial role in reducing the anxiety experienced by patients and possibly, the perceived pain during the mammography procedure. Giving verbal information prior to the mammography procedure has also been reported to be an effective means of reducing discomfort of a mammogram (Lee & Tsai 2011). Verbal information involves explaining the procedure to the patient, and its importance. The use of a cushion pad has also been reported to reduce discomfort by as much as 33%, (Chida et al., 2009), without compromising images of the mammogram. When breast compression is under the control of the patient, such patients have been noted to experience less discomfort. However, patient-controlled compromise significantly reduces the image quality of mammograms. Pre-medication prior to the mammography procedure does not also have a significant influence on minimising pain (deGroot et al., 2015). Chida et al (2009) carried out a study in which they endevoured to determine if reduced compression mammography helps to relieve breast tenderness. The study’s research findings revealed that reducing the compression force of the mammogram has no significant effect in reducing discomfort. The study findings further revealed that a compression force of 90 N was better tolerated by women undergoing mammography. Majority of the patients are often seen to experience breast pain when the compression force is at 120 N.
Thus far, a number of pain-preventing strategies during mammography have been proposed; however, most of them are not ready for implementation due to several reasons (Miller, Livingstone & Herbison, 2008). There is a need therefore to undertake further research into this area. It is interesting to note that nearly all studies on mammography pain and the associated pain prevention strategies seem to have only evaluated pain levels as reported by patients following breast compression, as opposed to the whole compression process (deGroot et al., 2015). According to deGroot et al (2015), one of the most widely accepted and effective pain preventing strategy during a mammography is one in which the patient asks the radiographer to cease the compression at a point where they regard the procedure as being too painful. An alternative pain-preventing strategy involves the implementation of a feature that “stops the compression when the breast’s ability to be flattened reaches a point where applying extra force does not result in ‘sufficient’ extra breast flattening” (deGroot et al., 2015, p. 2).
Conclusion
Despite the reported pain/discomfort that accompanies breast compression during the mammographic procedure, it is a necessary step in that it facilitates in the attainment of the desired diagnostic mammogram. Despite the many benefits of breast compression, including breast immobilization and the consequent elimination of motion blur, thereby improving the quality of the mammogram image, the procedure has received its fair share of criticism. This has been the case due to the pain/discomfort associated with it, as the procedure has been reported to be very painful. The anxiety and fear over possible pain/discomfort while undergoing the procedure has discouraged many women from undergoing the process. This is in spite of the method having been found suitable in aiding the detection of early stage cancer. However, there are several strategies that have been implemented to alleviate and/or minimize such fears, including giving verbal information to the patient before commencing with the procedure. Other coping strategies include patient-controlled compression, and the patient informing them when to stop compression when the procedure becomes too painful.
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