Risk,anxiety and defensive action: general practitioner's referral decisions for women presenting with breast problems

Women visiting their general practitioners with breast problems are a common occurrence in the United Kingdom (UK). General practitioners can expect to see around 30 new presentations per 1000 women each year. Although routine, this aspect of their work is characterized by a considerable degree of uncertainty. Differential diagnosis is difficult and the most important problem facing the general practitioner is how to distinguish between symptoms that require immediate referral and those which can be managed in primary care. If they refer women inappropriately, specialist services will be overloaded resulting in delay in treatment for those who may have breast cancer. The paper draws on data from a study of a systematic sample of 85 women newly referred to four main specialist breast clinics and their referring general practitioners. In-depth, semi-structured interviews were conducted with the referring general practitioners. Examination of respondents' discourses revealed that in providing justification for their referral behaviour they invoked a number of arguments that served to present their referral decisions as ‘apparently’ logical and defensible. They achieved this by locating the source of risk with the ‘disease’ (breast cancer) on the one hand and the ‘litigious woman’ on the other. These became the sites of risk rather than the objective nature of individual patient's signs, symptoms and personal characteristics. Two broad defensive stances emerged in their discourses: (1) women were ‘at risk’ from a malevolent disease, the vagaries of clinical judgement and anxiety; (2) doctors were ‘at risk’ with their clinical and professional autonomy threatened by women who, in the context of breast cancer, become litigious. This has important implications for those wishing to modify general practitioners behaviour to reduce inappropriate referrals.     

Gaining control over breast cancer risk: Transforming vulnerability,uncertainty, and the future through clinical trial participation – a qualitative study

Concepts of disease risk and its management are central to processes of medicalisation and pharmaceuticalisation. Through a narrative perspective, this paper aims to understand how such macro‐level developments may (or may not) be experienced individually, and how an algorithm that is used for recruitment into a clinical trial may structure individual notions of being ‘at risk’ and ‘in need of treatment’. We interviewed 31 women participating in the Study of Tamoxifen and Raloxifene (STAR), a chemoprevention trial conducted in the US between 1999 and 2006. Interviews were thematically analysed. Women in the study had experienced the threat of breast cancer and felt vulnerable to developing the disease prior to STAR participation. The diagnosis of ‘being at risk’ for cancer through an algorithm that determined risk‐eligibility for STAR, opened up the possibility for the women to heal. The trial became a means to recognise and collectivise the women's experiences of vulnerability. Through medication intake, being cared for by study coordinators, and the sense of community with other STAR participants, trial participation worked to transform women's lives. Such transformative experiences may nevertheless have been temporary, enduring only as long as the close links to the medical institution through trial participation lasted.     

Dangerous knowledge vs. dangerous ignorance: Risk narratives on sex education in the Russian press

The paper is devoted to analysis of the debates on sex education in the Russian press. ‘Risk narrative structure’ of media articles on sex education was determined. This structure represents a system of mutually constituting elements, which include object of risk, risks themselves, solutions to their prevention, solutions opponents, and type of society these solutions presuppose. It is argued that analysis of risks with the aid of ‘risk narrative structures’ can be a useful development of sociocultural theory of risk, as competing risk narratives can be fully grasped only when considered not as discrete claims about different ‘risks’ but as coherent systems of interrelated meanings. On the basis of this structure, competent risk media narratives of proponents and opponents of sex education were reconstructed. In these narratives different definitions of ‘children’ as objects of risk were constructed, and so were types of risks, and types of society. It would be oversimplifying to consider debates on sex education as a battle of ‘enlightened rationality’ against ‘dark irrationality.’ In each risk narrative the solution (introduction or ban of sex education) is a logically following element in the respective risk narrative. While sex education advocates were concerned about negative consequences of children's sexual behaviour and defence of the ‘civilised society's moral boundaries, the opposite side was concerned about retaining children's moral purity and defence of ‘traditional’ moral boundaries.     

Rate of breast cancer diagnoses among postmenopausal women with self-reported breast symptoms

BACKGROUND: Breast cancer rates in women with multiple breast symptoms have not been well described. METHODS: We examined the association between self-reported symptoms (lump, nipple discharge, pain, other) and breast cancer risk for screening and diagnostic mammograms in 57,681 women. Subanalyses evaluated risk among women with no prior mammograms, new symptoms, and repeated symptoms. One thousand, three hundred and eighty-nine women were diagnosed with cancer within 12 months of their mammograms. We calculated the breast cancer rate for each symptom and odds ratios (OR) with 95% confidence intervals (CI) for breast cancer among symptomatic women compared with asymptomatic women. RESULTS: Women reporting a lump had an increased odds of breast cancer compared with asymptomatic women (OR for diagnostic examination = 2.8, 95% CI = 2.3 to 3.4; OR for screening examination = 3.6, 95% CI = 2.6 to 5.0). No other symptoms were associated with breast cancer after controlling for a reported lump. A new lump at a diagnostic examination was significantly predictive of cancer among women with no prior mammograms (OR = 12.2, 95% CI = 2.8 to 53.5); reporting symptoms at 2 successive exams had little effect on breast cancer risk (OR for lump = 1.2, 95% CI = 0.6 to 2.5). CONCLUSIONS: Having a lump is the most predictive symptom of breast cancer whether it is reported at a screening or diagnostic examination or in conjunction with other symptoms.     

‘Fiona Farewells Her Breasts’: A popular magazine account of breast cancer prevention

In this paper, the authors examine a popular media account of prophylactic mastectomy—the surgical removal of ‘healthy’ breasts for preventive purposes—focusing on the ways in which the account works to normalize what might alternatively be considered extreme preventive health behaviour. Although the procedure remains controversial, prophylactic mastectomy is increasingly presented as a treatment option for women considered to be at high risk of developing breast cancer. A discursive analysis focuses on how one woman's ‘decision’ to undergo prophylactic surgery of this type was accounted for in terms of two broad identity constructions or positionings: as ‘mother’, and as ‘certain to die of breast cancer’ in the absence of such surgery. It is argued that constructions of prophylactic mastectomy, such as that depicted in this account from a popular women's magazine, can be seen to draw on traditional gendered discourses, and on notions of responsibility central to the new public health. Such media accounts thus promote general acceptance of the procedure, and risk management more generally, as enterprising actions that reasonable, morally responsible, ‘at-risk’ women should undertake to maintain their own health and to care for their families.     

Constructing classification boundaries in the memory clinic: negotiating risk and uncertainty in constituting mild cognitive impairment

Determining the boundaries around processes of ‘normal’ ageing and pathological cognitive deterioration associated with Alzheimer's disease (AD) is a difficult process, complicated further by the expansion of the disease category to include mild cognitive impairment (MCI). MCI is a label used to identify individuals with the symptoms of cognitive deterioration not attributable to ‘normal ageing’ but deemed to be ‘at risk’ of developing AD despite clinical uncertainty around whether individuals will go on to develop the condition in the future. Drawing on qualitative data gathered across an out-patient memory service, this article examines practitioners’ accounts of the complexity associated with constructing the boundaries around MCI, AD and age in the clinic. Practitioners utilise uncertainty by classifying patients with MCI to keep them on for review to account for the possibility that patients may go on to develop AD but they also recognise the difficulty in predicting future progression to AD. Negotiating classification boundaries in the clinic is, however, not only about managing uncertainty regarding potential future risk but also about navigating the wider social and political context in which ageing and cognitive deterioration intersect, and are constructed and managed.     

‘M‐apping’ sleep? Trends and transformations in the digital age

This article critically explores recent trends and transformations in the monitoring and management of sleep in the digital age, taking as its focus the advent of new digital technologies to trace and track the ‘sleep of ourselves’ far away from the conventional sleep laboratory or clinic. Our argument is situated dually in the history of sleep science and medicine on the one hand, and the rise of new digital forms of so‐called self‐tracking and mobile health (m‐Health) on the other hand. While the recent history of sleep science and medicine may rightly we suggest, in Kroker's terms, be characterised as a concern with the ‘sleep of others’, a new chapter in this story may well be dawning through the advent of these smart new mobile tools and technologies for mapping, or ‘m‐apping’ as we term it, the ‘sleep of ourselves’ in the digital age. The problems and prospects this holds are then critically considered – through the interrelated themes of selfhood, sociality and governance – and some preliminary conclusions ventured in this new digital domain.     

Infant feeding in risk society

A large percentage of British women, in common with women in other Western countries, feed their young babies formula milk. The paper reports some findings of a study of infant feeding that focussed on women's experiences of feeding their babies this way. Data about this issue were collected through detailed, qualitative face to face interviews with 33 mothers and through telephone interviews using a structured questionnaire with 503 mothers. The study found overall that mother's accounts of feeding babies formula milk draw attention to contradictions and tensions in motherhood and mothering. Formula feeding is predominantly experienced by mothers as ‘easy,’ enabling them to address a wide range of demands and difficulties that mothering a small baby poses for them. At the same time, mothers demonstrate awareness of the socio-cultural construction of the ‘moral mother’ as the mother who minimizes and avoids risk, and so does not use formula milk for infant feeding. How women react to this tension between ‘real life’ and ‘doing what is healthy’ varies, but the study reported here found a large minority of women experience manifestly difficult and debilitating feelings as they attempt to reconcile a pragmatic wish or need to formula feed with dominant constructions of the ‘moral mother.’ By detailing women's accounts of this aspect of motherhood, the paper contributes to sociological investigation of everyday experiences of risk society. To contextualize this discussion, a brief account of the relationship between eating, feeding babies and risk society is also offered.     

The search for wellbeing in alternative and complementary health practices

This article is premised on a need to understand and analyse how those turning to alternative and complementary medicines conceptualise the role of these practices; to ask what kind of ‘health’ is produced through alternative and complementary medicines and how might the help provided by these practices relate to questions of identity, self and subjectivity? Even though alternative and complementary medicines can be utilised in the face of serious illness, the healing produced through these practices is here argued to transcend physiological health and relate rather to a subjectively assessed sense of ‘wellbeing’. In this article, I analyse what this wellbeing entails, in particular, in terms of contemporary understandings of selfhood as well as in relation to the production of appropriate emotions through ‘emotion management’. I argue that the wellbeing produced through alternative and complementary health practices can be conceptualised as a means of asserting a particular kind of self as well as a means of negotiating identities offered to people in wider societal discourses and institutions. This article is based on qualitative interviews with both practitioners and users of varied alternative and complementary medicines. The focus is on women's experiences.     

‘It's their blood not mine’: Who's responsible for (not) telling relatives about genetic risk?

With advances in the ‘new genetics’, an increasing number of people will have access to genetic information and predictive or susceptibility testing. Genetic knowledge has implications for individuals themselves, as well as other family members. In general, health professionals encourage people to pass on genetic risk information to their relatives. However, the disclosure of such information is not always straightforward and, consequently, some people may not be aware of their risk. If risk information is actively withheld, genetic counsellors may need to determine whether they have a duty to pass this on, particularly when preventive action can be taken. To date, little research has explored the barriers and facilitators in family communication about genetic risk. This paper draws on empirical data from a qualitative study exploring communication in families with late-onset familial disease. Interviews were conducted with participants who received genetic counselling for risk of Huntington's disease and hereditary breast or ovarian cancer. Participants' experiences of who was responsible for (not) telling relatives in their families is studied. A number of themes were identified. These were: (1) ‘whose place is it to tell’, (2) the gendering of disclosure, and (3) who is ‘family’. The implications of these findings are considered.     

Engagement: an indicator of difference in the perceptions of antenatal care for pregnant women from diverse socioeconomic backgrounds

Background Socioeconomically deprived women are at greater risk of adverse pregnancy outcomes. Research tends to focus on access of services. Yet access may not equate with the equity of services for women from different socioeconomic backgrounds. Objectives To determine whether pregnant women’s perceptions of antenatal provision differed in relation to their socioeconomic deprivation ranking (determined by the Scottish Index of Multiple Deprivation 2006). Design A longitudinal, qualitative study with comparative antenatal case studies between January 2007 and April 2009. Setting/Participants Cases were primigravida women from ‘least deprived’ (n = 9) and ‘most deprived’ (n = 12) geographical areas within one local authority in Scotland. Analysis Data were analysed using case study replication analysis. Results There was little difference in access to antenatal services between the ‘least’ and ‘most’ deprived groups. Perception of care differed in relation to the level of ‘engagement’ (defined using constructs of: language and personalization of care; power and relationships; and health literacy). Engagement was evidenced in most of the ‘least deprived’ cases and almost none of the ‘most deprived’ cases. Specifically, socioeconomically deprived women described less evidence of personal connection to their own care, effective communication and the opportunity for shared decision making. Conclusion In women from socioeconomically deprived areas, access may be a less useful indicator than engagement when assessing antenatal service quality. As engagement levels may be one method by which to predict and improve health outcomes, a more equitable antenatal service may need to be developed through the early identification of those women at risk of non‐engagement.     

Evaluating the impact of a promotional campaign for screening mammography: women's knowledge and sources of awareness

Abstract: The Breast X-Ray Programme of the Central Sydney Health Service was advertised by generalised strategies aimed at the total community, including poster and pamphlet distribution, and strategies aimed at general practitioners, supplemented by written invitations and recommendation from the general practitioner, invitations for friends, and invitations from the service using the electoral listing. In order to evaluate the reach or impact of the promotional campaign in the Drummoyne local government area, telephone interviews were conducted with women aged 45 to 70 randomly selected from the community. Women's knowledge about breast cancer, screening and the Breast X-Ray Programme, plus sociodemographic characteristics, were obtained before screening (n = 628), 10 months (n = 93) and 2 years after screening started (n = 206). While knowledge about risk did not change, significant increases were found in the proportion of women who had heard of mammography, screening mammography specifically and the screening van. In addition there were significant increases in the proportion of women exposed to information about screening mammograms. The campaign generally had an equal effect on different sociodemographic but managed to achieve greater effects in women of non-English-speaking backgrounds and lower occupational status. A random sample of program attenders aged 45 to 70 (n = 763) were asked how they found out about the van. ‘Seeing the van’ was the most consistently reported source of awareness. Others included ‘GPs’, ‘newspapers’, ‘other print media’ and ‘personal networks’. Women with additional qualifications since leaving school were more likely to state ‘newspaper’ and ‘other print media’ as a source.     

‘Crack down on the celebrity junkies’: Does media coverage of celebrity drug use pose a risk to young people?

This study analysed news media content to examine the role played by celebrity drug use in young people's perceptions of drug use. We know that young people have access to discourses of drug use through music and other media which may emphasise short term gains (of pleasure or sexual success) over longer term health and social problems. This study goes beyond a simple modelling approach by using Media Framing Analysis (MFA) to take an in-depth look at the messages themselves and how they are ‘framed’. New stories about Amy Winehouse's drug use were used and we conducted focus groups with young people asking them questions about drugs, celebrity and the media. Frames identified include: ‘troubled genius’, ‘losing patience’ and ‘glamorization or gritty realism’. Initially, the press championed Winehouse's musical talent but soon began to tire of her recklessness; the participants tended to be unimpressed with Winehouse's drug use, characterising her as a promising artist who had ‘gone off the rails’. Young people were far more critical of Winehouse than might be expected, demonstrating that concerns about the influence of celebrity drug use and its impact on future health risk behaviour among young people may have been over-simplified and exaggerated. This study illustrates the need to understand young people and their frames of reference within popular culture when designing drug awareness information relevant to them. Furthermore, it indicates that critical media skills analysis may contribute to health risk education programmes related to drug use.     

Between blame and care: women's ‘needs talk’ about obesity interventions in prenatal care

Pregnant women's weight is no longer a private life situation, but a public health issue. In western prenatal care policies, pregnant women with a high body mass index (BMI) are targeted as a high-risk group in need of extra prenatal care to prevent pregnancy complications and childhood obesity. Recent studies argue that such targeting leads to a number of unintended negative consequences for women such as stigmatisation and mother blame. While targeting based on BMI increases the surveillance of women's weight and behaviour in pregnancy, it might also provide extra care and services for women. This article draws on Nancy Fraser's concept of ‘needs talk’ to investigate how women interpret Danish prenatal care services provided to meet the ‘obese’ pregnant women's needs. The analysis shows that women engage ambivalently with claims about their needs and who they ‘are’ as these are formulated by health authorities. Some claims and assumptions about the ‘obese’ pregnant woman are accepted. Others are rejected or redefined. The article concludes by discussing maternal ambivalence about the obesity discourse in relation to the ‘obese’ pregnant woman as a category that positions women between being blamed and receiving extra prenatal care.     

Understanding processes of risk and protection that shape the sexual and reproductive health of young women affected by conflict: the price of protection

Background

It is assumed that knowing what puts young women at risk of poor sexual health outcomes and, in turn, what protects them against these outcomes, will enable greater targeted protection as well as help in designing more effective programmes. Accordingly, efforts have been directed towards mapping risk and protective factors onto general ecological frameworks, but these currently do not take into account the context of modern armed conflict. A literature overview approach was used to identify SRH related risk and protective factors specifically for young women affected by modern armed conflict.

Processes of risk and protection

A range of keywords were used to identify academic articles which explored the sexual and reproductive health needs of young women affected by modern armed conflict. Selected articles were read to identify risk and protective factors in relation to sexual and reproductive health. While no articles explicitly identified ‘risk’ or ‘protective’ factors, we were able to extrapolate these through a thorough engagement with the text. However, we found that it was difficult to identify factors as either ‘risky’ or ‘protective’, with many having the capacity to be both risky and protective (i.e. refugee camps or family). Therefore, using an ecological model, six environments that impact upon young women’s lives in contexts of modern armed conflict are used to illustrate the dynamic and complex operation of risk and protection – highlighting processes of protection and the ‘trade-offs’ between risks.

Conclusion

We conclude that there are no simple formulaic risk/protection patterns to be applied in every conflict and post-conflict context. Instead, there needs to be greater recognition of the ‘processes’ of protection, including the role of ‘trade-offs’ (what we term as ‘protection at a price’), in order to further effective policy and practical responses to improve sexual and reproductive health outcomes during or following armed conflict. Focus on specific ‘factors’ (such as ‘female headed household’) takes attention away from the processes through which factors manifest themselves and which often determine whether the factor will later be considered ‘risk inducing’ or protective.

     

‘Men are leavers alone and women are worriers’: Gender differences in discourses of health

This paper explores gender differences in health talk, how such talk is informed by discourses at a societal level and the extent to which talking about health is a way of ‘doing gender.’ It draws on in-depth interviews with 48 women and men in their twenties and thirties showing that gender influences both the way people talk about health and their willingness to engage in health talk. It explores the way cultural constructions of gender influence the propensity to take risks with particular reference to HIV/AIDs and recreational drug use and the extent to which discourses of risk inform health talk. We discuss how changes in the occupational structure and the associated influx of men into ‘women's’ work are associated with more ‘feminized’ masculinities and a recognition among some men of the male body's vulnerability. They are also associated with men's health talk becoming more like women's. We conclude that cultural constructions of gender not only have an impact on health talk but also on the regulatory power of discourses of risk and risk management.     

Cervical cancer narratives: invoking ‘God's will’ to re-appropriate reproductive rights in present-day Romania

Drawing from ethnographic fieldwork in contemporary Southern Romania, this paper scrutinises local moralities governing some women's refusal to enrol in free reproductive healthcare initiatives targeting cervical cancer through primary and secondary prevention (human papillomavirus [HPV] vaccination and Papanicolaou [Pap] testing, respectively). Women backed up their rejection of participation in official reproductive care programmes by mentioning ‘God's will’ as the ultimate trigger of cervical cancer. They withheld their own and their daughters' bodies from biomedical intervention and used discursive references to divine logic to imbue their refusal with moral legitimacy. However, ‘God's will’ is not a mere rhetorical device, since it has a correlate in many of these women's embodied reproductive experiences. As this paper argues, religious narratives, far from stripping ordinary citizens of their reproductive choices, constitute the medium through which they display individual agency. In fact, invoking ‘God's will’ empowers Romanian women to challenge state control and it enables them to re-appropriate their bodies by making a counter-intuitive, yet bold, choice.     

Non-normal Screening Mammography Results,Lumpectomies, and Breast Cancer Reported by California Women, 2001–2009

BackgroundAlthough screening mammography may contribute to decreases in breast cancer mortality in a population, it may also increase the risk of false positives, anxiety, and unnecessary and costly medical procedures in individuals. We report trends in self-reported non-normal screening mammography results, lumpectomies, and breast cancer in a representative sample of California women.MethodsData were obtained from the 2001, 2005, and 2009 cross-sectional California Health Interview Surveys (CHIS) and weighted to the California population. CHIS employed a multistage sampling design to administer telephone surveys in 6 languages. Our study sample was restricted to women 40 years and older who reported a screening mammogram in the past 2 years. Sample sizes were 13,974 in 2001, 12,069 in 2005, and 15,552 in 2009. Women reporting non-normal results were asked whether they had an operation to remove the lump and, if so, whether the lump was confirmed as malignant.FindingsBetween 2001 and 2009, the percent of California women who reported having been diagnosed with breast cancer was relatively stable. For each of the three age groups studied, the percentage of non-normal mammography results increased and the percentages of lumpectomies decreased and, for every woman reporting a diagnosis of breast cancer, three women reported a lumpectomy that turned out not to be cancer. This ratio was greater for younger women and less for older women.ConclusionsDespite relatively constant rates of breast cancer diagnosis from 2001 to 2009, the percentage of non-normal mammography results increased and lumpectomies declined.     

No one scans you and says ‘you’re alright now’: the experience of embodied risk for young women living with a history of breast cancer

The concept of ‘embodied’ risk has been used to understand the experience of being at risk of cancer, yet there has been less engagement of the concept in relation to those who have been diagnosed and treated for the disease. In this paper, I draw on young women’s accounts of living with breast cancer with the aim of developing analyses of embodied risk and expanding our understanding of the concept. Twenty women diagnosed with breast cancer while they were aged 18–44 took part in semi-structured interviews in the UK, and I analysed these interview data using social constructionist grounded theory. The findings illustrate how a sense of risk from within the body shaped the young women’s experiences and perceptions of their bodies, and how their body as risky was relational, becoming salient in interactions with others. I also explore new dimensions of embodied risk related to the age and social circumstances of the young women. Although the fear of cancer recurrence is well documented, this paper explores it as an embodied experience.     

The relationship of symptoms and psychological factors to delay in seeking medical care for breast symptoms

BACKGROUND: The psychological processes involved in the delay between noticing breast symptoms and seeking medical care are not well understood. METHODS: We evaluated 85 women referred to a specialist breast clinic prior to their clinic appointment. We assessed the relationship between delay and the type of breast symptom, immediate emotional response to the symptom, perceived risk of breast cancer, fear of breast cancer treatment, and disclosure of the breast symptom to others. RESULTS: Delay was unrelated to demographic factors but was related to the type of breast symptom; women who had a breast lump waited a significantly shorter time period before visiting the doctor than those without a breast lump. Initial symptom distress on the discovery of the breast symptom was also significantly related to delay. Knowledge of a friend or family member with breast cancer, perceived risk of breast cancer and fear of breast cancer treatment, and disclosure of the symptom to a partner or other person were all unrelated to delay. CONCLUSIONS: The results show the importance of the type of symptom and initial emotional distress in delay and highlight the importance of widening public perceptions of breast symptoms other than breast lumps in order to reduce delay times.