Does Mammography Hurt?

Demographics 

A total of 399 women completed the survey, 128 (32%) at SZMC and 272 (68%) at HALA. A total of 84% of women were referred for screening mammography and 16% for diagnostic investigation of suspicious lesions. The major reason for not completing the survey questionnaire was language barrier. The majority of women completed the questionnaire within 5 minutes of finishing the mammogram (73%) and the rest within 5–10 minutes (25%). The demographic characteristics of women from both centers were similar and are presented in Table 1. Twenty percent of women reported breast tenderness prior to the mammography; 15% reported mild tenderness, and 5% reported moderate tenderness.

Table 1. Patient Demographics

	Age group
	26–45	22%
	46–55	44%
	56–65	19%
	66–75	9%
	Center performed	SZ = 128 (32%) HALA = 271 (68%)
	Reason	85% screening, 15% diagnostic
	Country of origin
	Israel	42%
	West & Central Europe	13%
	East Europe	8%
	North America	16%
	Middle East	6%
	Other	15%
	Number of prior mammograms
	First mammogram	15%
	2–5	54%
	>5	25%
	Suffer from chronic pain	10%
	Suffer from cyclic pain	23%
	Size of bra
	A	4%
	B	39%
	C	36%
	D	18%
	DD	3%

Pain Experience 

Seventy-seven percent of the women reported that the procedure was painful. Of those reporting pain, 31% described pain intensity as moderate, and 34% described pain as severe. In 67% of respondents, the pain resolved within 10 minutes. The majority of women reported pain as symmetric (>60%). The expectation of 61% percent of women that the procedure would be painful matched the actual pain.

Information 

Only half of the respondents reported that they received any explanation regarding the mammography they were to undergo. Of those who received prior counseling, 66% were told that the procedure would be painful.

Predictors for Pain Experience 

By univariate analysis, the only predictor for pain during mammography trending toward significance was the prior existence of cyclic breast pain (P = 0.053). No significant correlation was identified for age, breast size, pre-mammography counseling, and examination site (SZMC vs. HALA).

Future Care Issues 

Even among women who reported pain of moderate or greater severity, fewer than 5% expressed a preference to receive pre-emptive analgesia prior to their next mammogram. A substantial minority of women acknowledged that the experience of their mammography invoked reactions that may impede future compliance; 26% reported anxiety regarding the test and its outcome and 12% reported pain as factors that may interfere with ongoing compliance with regular mammographic screening.

Frequency and Degree of Reported Pain 

There is wide discrepancy in the reported rate of mammography-associated pain. The reported incidence ranges from 1% in Stomper et al.28 to 85% in the study conducted by Kornguth et al.29, 30 The documented incidence of pain associated with screening mammography varies from 1% to 62%.21, 28, 30, 31, 32, 33, 34 Methodological problems appear to contribute to the variation in results. There is clear lack of consistency relating to the use of pain scales in these surveys.

In the studies summarized in Table 2, the pain assessment instruments varied from a simple 4-point verbal rating scale to the use of multiple assessment measures including Visual Analog Scale, the Brief Pain Inventory, and the McGill Pain Questionnaire.35, 36 Several studies used an idiosyncratic univariate 6-point scale that sought to evaluate both discomfort and pain, and in some studies, the pain assessment instrument is not described at all.28, 37, 38, 39

Table 2. Summary of Studies Examining Pain and Discomfort During Mammography, 1988–2001

	Reference/Year	No. Patients	Objectives	% Discomfort	% Pain	% Severe Pain	Assessment Instrument	Interference with Screening
	Stomper et al. (28) 1988	1847	To determine what women actually experience during mammography To foster the development of reasonable patient expectations of the procedure	10	1	none	Univariate scale combining discomfort and pain	No women stated that they had such severe pain that it would make them reconsider ever having a mammogram again
	Jackson (39) 1988	356	To determined the magnitude of discomfort associated with mammography.	81	Not assessed	Not assessed	Univariate scale of discomfort	94% said that they would re-attend
	Brew (49) 1989	203	To determine magnitude of pain associated with mammography	49	4	0.5	4-point scale	Not reported
	Wolosin (50) 1989	985	To examine the influence of expectations on the experience of pain during mammography	Not assessed	15 more than expected 56 less than expected		Check list	Not reported
	Fallowfield et al. (44) 1990	242	To examine the psychological factors influencing attendance non-attendance and re-attendance at a breast- screening center	90	62	21	3-point verbal scales	88% of women intend to come again
	Sullivan(37) 1991	560	To examine correlation between pressure applied to the breasts during mammography with the patient's subjective impression of the examination	76	8	1	Univariate scale of discomfort (Painful response was defined as a response to very uncomfort- able)	Not assessed
	Nielsen et al. (51) 1991	272	To quantify the amount of pain, discomfort and anxiety associated with mammography	62% reported pain/or discomfort. Of that 62%, 24.2% reported only pain, 23.4% reported only discomfort, and 52.4% reported both.			VAS scale 5-point verbal scale portion of the McGill	Not reported
	Cockburn (38) 1992	95	To describe levels of discomfort experienced by women undergoing screening mammography To examine whether the degree of discomfort experienced was perceived as a deterrent for re-screening	63	6	1	Univariate scale combining discomfort and pain	Three per cent said that it might stop them, while 97% of women said that it would not stop them at all
	Leaney BJ, Martin M. (52) 1992	470	To determine magnitude of pain associated with mammography	Not assessed	40	1	4-point verbal scale	Only one patient stated that the pain from the procedure would prevent her from having a further mammogram
	Rutter (42) 1994	597	To identify the nature of pain and discomfort How can the pain be ameliorated	35	6	Not assessed	Not reported	Only 3.5% did not intend to return next time.
	Fine et al. (53) 1991	255	To evaluate subjective experience of mammography	Not assessed	38- in current 56- in last	3- in current 7- in last	5-point verbal scale	More than one- third (34 percent) of women having a first mammogram stated that their mammogram experience affected their future plans for having another.
	Baskin-Smith et al. (54) 1995	272	To assess the mammography experience and the sensation experience in women undergoing mammography	11.4	28.4	5.7	2 open ended questions	Not assessed
	Aro et al. (55) 1993	883	To investigate associations of mammography pain and discomfort with sociodemo- graphics, personal history, psychological factors	59	61	4	4-point verbal scale	No one reported no intention to re-attend screening
	Kornguth et al. (30) 1996	119	To examine the incidence, quality and intensity of mammography pain using a variety of pain measures	Not assessed	75–85	5–10	VAS, BPI, McGill	Not assessed
	Kashikar-Zuck et al. (32) 1977	125	To evaluate how pain coping efficacy and pain coping strategies were related to reports of pain during mammography	Not assessed	35	5	VAS, BPI, McGill, 6- points univariate scale combining discomfort and pain	Not assessed
	Poulos et al. (46) 1997	200	To assess factors related to the degree of discomfort experienced by women attending for first-time mammography	82.7	Not assessed	Not assessed	5-points scale of discomfort	Not assessed
	Hafslund (34) 1998	170	To estimate the pain and anxiety by women in relation to mammography Quality improvement	Not assessed	66.5	8.3	McGill, STAI	Not perceived as a great problem by most of the women
	Elwood et al. (23) 1998	200	To assess the reasons why many women who have been screened once in a breast screening programmed decline an invitation for further screening	Not assessed	Of 200 women who had received and declined an invitation for re-screening (n = 81), the major reason (46%) was their previous mammogram being painful.
	Bakker et al. (56) 1998;	315	To determine women's satisfaction and experience with breast cancer screening and associated factors	Not assessed	40	Not assessed	5-points scale of agreement: from “strongly disagree” to “strongly agree”	89% strong intention to return for screening in the future
	Bruyninckx et al. (20) 1999	247	To evaluate experience of pain during and after mammography To identify the factors that determine the risk of a painful experience	Not assessed	73	Not reported	10-point numeric scale	Not assessed
	Keemers-Gels et al. (19) 2000	945	To evaluate experience of pain during and after mammography To evaluate associations with personal and medical history, sociodemo- graphics and/ or situational factors To evaluate impact of pain on intention to return for future breast cancer screening	Not assessed	72.9	Not reported	5-point verbal scale	3.3% indicated that they would not attend further screening
	Sapir R. et al.	399	To identify the prevalence, severity and duration of mammography associated pain, demographic risk factors, the degree that this may undermine compliance.	Not assessed	77	34 (of those reporting pain)= 26%	5-point verbal scale	12% reported pain as factor that may interfere with ongoing compliance with regular mammo- graphic screening

N = not indicated; VAS = Visual Analog Scale; BPI = Brief Pain Inventory; McGill = The McGill Pain Questionnaire; STAI = State-Trait and Anxiety Inventory.

In an analysis of these data, Kornguth et al. found that when well validated measured of pain like the Visual Analog Scale (VAS) or the McGill pain questionnaire (MPQ) are used, a large proportion of women report having pain during mammography.30 The results of their study strongly suggest that the method used to report pain can influence the proportion of women reporting pain. In studies using unidimensional 6-point pain/discomfort scale, a much lower rate of pain report has been found.30 The 6-point unidimensional scale incorporates unpleasantness and the perceived sensory intensity in a single item question. This scale allows a limited set of response options regarding pain and it may not be sensitive enough to measure the incidence of pain. Indeed, Keefe et al. suggest that this approach is invalid.40 In the current study, the 5-point verbal rating scale was selected because it is a validated scale and was appropriate for a large study of a heterogeneous population of women involving a self-administrated questionnaire.41

The current study adds to the evolving picture of mammography-related pain. Pain is common and it is reported by up to 77% of women. Pain is usually mild to moderate in severity (66%), and is severe in about a one-third of women. The frequency of pain in this study is similar to that reported by previous researchers who used a validated pain measure.19, 20, 30, 34

Timing of Pain Assessment 

In studies to date, there has been no consistency in the timing of pain assessment with relation to the mammogram. In some studies, pain assessment took place immediately after mammography, whereas in others women were asked to provide retrospective assessment, hours or days after mammography. Keefe et al. suggest that time may play a significant role in biases associated with retrospective reports of pain.40 In the current study, pain assessment was performed soon after examination. In this way, the actual experience of pain was assessed in real time rather than a recall of the event. By administrating the survey questionnaire soon after the examination, we were also able to assess the duration of mammography associated pain. This is important information that is not provided by many of the previous studies. Our data confirm that pain caused by mammography is an acute, transient, self-limiting pain that usually resolves within 10 minutes. Similar findings were reported by Rutter et al.42

Predictors and Risk Factors for Pain 

Demographic and technical factors predictive of worse pain with mammography are complex and the data are characterized by many contradictory findings (Table 3). In the current study, the only significant predictor of pain was breast tenderness. This is consistent with the findings of a number of other researchers.16, 28, 39

Table 3. Risk Factors Associated or Not Associated with Pain During Mammography

	Factor	Supporting Studies	Non-Supporting Studies
	Pre-existing breast pain/tenderness	[19, 20, 28, 49]	[46]
	Experience of moderate to severe pain	[28]
	Caffeine intake	[39]	[52]
	Menstrual status	[39]	[37, 46, 52]
	Increasing force during examination	[37]
	Young age	[51]	[19, 28, 37, 38, 52]
	Anxiety	[19, 39, 51]
	Non–African-American	[51, 53]
	Menopausal state		[19, 28, 37, 52]
	Underlying breast disease (usually fibrocystic disease)	[52]	[46]
	Previous mammographic experience		[19, 38]
	High education	[19]
	Average pain at the last mammogram	[28, 30]	[38]
	Breast density	[30, 37]	[32, 38]
	Less ability to decrease general pain	[32]
	Prior expectations	[19, 20, 28, 38, 42, 46]
	Breast weight	[46]
	Staff-related	[19, 20, 39]
	Family history of breast diseases	[19]
	Breast size		[19, 46, 53]

Facility-specific features and staff attitude may be a risk factor for pain prevalence. Dullum et al. found that more women experienced pain in certain mammography centers than others and that a belief that the technologist was too rough was a significant predictor of pain.43 In our study, no difference in pain frequency was found between the two mammography centers.

Mammography pain is generated by the compression of the breast, which is a crucial component of a successful mammogram examination. Compression is necessary to separate overlapping structures, to improve detection accurately and to reduce the amount of radiation absorbed by the breast tissue. There is no quantitative guideline to indicate the optimum amount of force to use37, 44 The suggested actual amount of appropriate pressure force needed to obtain film quality and reduced radiation is probably in the range of 25–40 lbs.21 Only 3 studies have addressed the issue of correlation between level of compression and pain during mammography. In 2 studies, Sullivan et al.37, 44 and Kimme-Smith et al.,45 a relationship between compression and pain severity was observed. However, the results of the study reported by Poulus and Rickard46 regarding the correlation between the level of compression and pain were inconclusive. With regards to the image quality, the majority of radiologists involved in this study perceived that the lower-compression view does not diminish image quality. Their results suggest that the experience of discomfort in mammography may not be simply due to the level of breast compression and that there may be other variables that interact with this variable.46

Intervention Strategies to Prevent/Manage Pain 

Strategies to address the issue of compression and pain and discomfort during mammography have been investigated by other researchers. Kornguth et al. tested the hypothesis that giving women control over the compression portion of the mammography examination results in the perception of less painful experience.

The results of the study supported the hypothesis. Patient-controlled compression resulted in less painful experience without detracting from the quality of the image produced.

Nielsen et al. suggested that patient education by trained nursing counselors may reduce mammography-related pain and discomfort.47 Another strategy to reduce pain associated with breast cancer screening has been the development of new imaging techniques that do not require breast compression. At a recent conference of the Radiology Society of North America, Rosenthal et al. reported a study evaluating Diffraction Enhanced Imaging (DEI) as an alternative to standard mammography with improved patient comfort and enhanced diagnostic performance.48 The authors of this study conclude that DEI may allow breast imaging without breast compression, but these are preliminary results of a small study performed on human specimens and further research on this subject is warranted.

In recent years, attention has been focused on procedural pain and its pharmacological prevention. There is only one published study that evaluated medication intake on the day of mammography. The Kornguth et al. study reports that a total of 22% of women had taken either pain medication or a tranquilizer on the day of mammography.30 This study found that the use of medication did not appear to influence pain rating. In the current study, only 3% of the participants responded positively to the question regarding their desire to receive a painkiller prior to their next mammography. The currently available data regarding the issue of pre-emptive analgesia for mammography-associated pain is not sufficient to indicate the value of pre-medication as a preventive measure.