0160-7715/98/1200-0565$15.00/0Ó 1998 Plenum Publishing Corporation 565
A Descriptive Study of Breast Cancer Worry
Kevin D. McCaul,1,2 Ann D. Branstetter,1 Susan M. O’Donnell,1 Kimberly Jacobson,1 and Kathryn B. Quinlan1
Accepted for publication: March13,1998
Women with (n = 65) and without (n = 70) a family history of breast cancer re- ported on their thoughts and concern about the disease. Measures were taken across a 1-month interval and at a 1-year follow-up. Reported screening be- haviors were also measured at baseline and the 1-year follow-up. Worry dis- sipated over time, suggesting that worry levels are affected by the measurement context. However, women with a family history of the disease maintained greater worry than those without such a history, suggesting that they may be chronically worried about the disease. Thinking and worrying about breast cancer were both modestly and positively related to the frequency of screening behaviors, suggesting that some kinds of worry can motivate self-protective be- havior.
KEY WORDS: worry, breast cancer, screening.
INTRODUCTION
Treatment and early detection procedures have improved the progno- sis associated with many cancers, including breast cancer. However, breast cancer still kills approxim ately 46,000 women in a year’s time, andÐ not surprisinglyÐ a breast cancer diagnosis causes heightened worry for the victim, family members, and friends (Compas, Worsham, Ey, and Howell, 1996; Schag and Heinrich, 1986). Data also suggest that experiencing heightened worry about the disease does not require a diagnosis. Lerman et al. (1993), for example,
1Department of Psychology, North Dakota State University, Fargo, North Dakota 58105.
2To whom correspondence should be addressed.
reported that 30% of women with ® rst-degree relatives who had breast cancer said that they worried about breast cancer so much that it interfered with their daily functioning. Kash, Holland, Halper, and Miller (1992) observed levels of psychological distress that they described as suf® cient to merit counseling for more than 25% of women at high risk for breast cancer.
The purpose of this study was to describe the breast cancer worries experi- enced by women in their daily lives. We purposefully tested women who were not at unusually high risk for the disease. Moreover, we collected worry reports from women who self-monitored their thoughts and feelings over time and at homeÐ a decidedly different approach from measuring worry in the clinic or in a single interview.
A descriptive study of breast cancer worries should help to provide answers to several questions. First, we do not really know when or how much women think and worry about breast cancer. Researchers have typically measured worry on a single occasion in the context of breast cancer-related events, such as instruction about risk (e.g., Lerman et al., 1996), or just before or after mammog- raphy screening (Lerman et al., 1991b; Valdimarsdottir et al., 1995). These are not everyday events, and responses in such contexts may exaggerate the worry that women commonly experience. Daily self-monitoring can tell us more about the thoughts that cause women to worry and how much they worry over time. If worry is higher surrounding breast cancer-related events, then we would expect less worry over time as such events recede into the past.
Daily self-monitoring should also provide better inform ation about rela- tionships between worry and other variablesÐ relationships that may be affected by the measurement context. For example, participants in studies surrounding a breast cancer-related event can probably recognize the investigator ’ s interest in worry, and it could in¯ uence their reporting (Council, 1993). In particular, high- risk women may report extensive worry when they are aware that they have been selected for the study because they are at high risk. Do women with a family history of the disease continue to report greater worry when their history is less salient?
The measurement context may also affect the relationship between worry reports and screening behaviors. This relationship is not well circumscribed presently. Some authors believe that excessive worry inhibits screening behav- iors (Kash, Holland, Osborne, and Miller, 1995; Lerman et al., 1993), whereas others argue that worry motivates screening behaviors (McCaul, Reid, Rathge, and Martinson, 1996; McCaul, Reid, and Schroeder, 1996; Stefanek and Wilcox, 1991). However, these researchers typically collect summary judgments of worry (e.g., ª how often do you worry about breast cancerº ) at the same time that they measure screening behaviors. Measuring worry over time and outside the clinical context may provide more valid data concerning worry±behavior relationships (cf. Lerman et al., 1991a; Valdimarsdottir et al., 1995).
Finally, a descriptive study is important because it can address method- ological questions. Investigators have used different measures of worry, includ- ing scales formed from a few investigator-invented items and scales with better- known psychom etric properties (see Lerman et al., 1993; Lerman, Kash, and Stefanek, 1994). In addition, researchers have used measures that emphasize thought (e.g., the Revised Intrusive Events Scale; the REIS, Horowitz, Wilner, and Alverez, 1979) but also measures that focus on affect (e.g., anxiety). It would be important to know how these scales relate to each other, their stability over time, whether they predict day-to-day worries, and how they relate to screening behaviors.
In summary, we need to know more about the day-to-day thoughts and wor- ries that women have about breast cancer. To that end, we selected women with and without a family history of breast cancer and collected baseline measures before teaching the women about breast self-exam (BSE). Then, participants self- monitored their worries for 1 week, and we interviewed them for 3 additional weeks, and at 1-month and 1-year follow-up sessions. The data provided infor- mation about the following questions: (a) what thoughts prompt worry about breast cancer?, (b) how much do women report worrying about breast cancer?, (c) does worry decline over time as women are removed psychologically from the breast cancer context?, (d) do women with a family history worry more than those without such a history?, (e) how do different thought and worry measures interrelate?, and (f ) how do thinking about and worrying about breast cancer relate to screening behavior?
METHOD Participants
The total sample included 135 women. Approxim ately half were recruited from undergraduate psychology classes at North Dakota State University (n
=
68). These women, who ranged in age from 18 to 27 (M
=
20), volunteered to participate for extra class credit. The other half of the sample was recruited through churches (n=
27), advertising in the campus newsletter (n=
20), and advertising in the community newspaper (n=
20). These women, who ranged in age from 34 to 77 (M=
52), were paid either $15 (church women) or $25 (advertising women) for taking part in the study.All women were recruited to participate in a study of breast cancer worry, and requests were explicitly made for women with a family history of breast cancer.
For analysis, we divided the total sample according to whether women had a self- de® ned family history of breast cancer. Sixty-® ve women reported having some family history. Nineteen of the 65 (29%) reported having a ® rst degree relative with
breast cancer. The ages of women in the family history group did not differ from those in the no history group (M s
=
35.3 and 36.6, respectively, t<1). These groups were also similar in terms of marital status. In the family history group, 46% were married and 43% were single. In the no family history group, 36% were married and 54% were single (chi-square p=
.35). Finally, the groups did not differ for years of education completed ( p=
.59).Procedure
Women took part in groups at the university or the church. After sign- ing a consent form, participants completed baseline measures and then viewed an educational videotape (American Cancer Society, 1994) showing BSE tech- niques. The experimenter asked participants to do BSE once during the next month and then gave self-monitoring instructions for a daily worry journal and a nightly questionnaire. Finally, participants were randomly assigned to read and take home one of two pamphlets. One presented information about the value of BSE as a screening technique, whereas the second contained 12 arguments about the consequences of failing to do BSE.3The ® rst meeting with participants then ended.
Four weeks after the baseline session, participants returned, and some mea- sures were repeated. Ten participants (7%) missed this session. We were then able to recontact 100 (80%) of the remaining 125 participants for a phone inter- view approximately 11±12 months following the ® rst session.4 We compared the 35 participants who did not participate at every measurement interval to the 100 who did, using baseline measures. No reliable differences appeared on any measure.
Measures Worry
On the baseline and follow-up questionnaires, we gathered measures of worry. Four questions, borrowed from Lerman et al. (1991b) and McCaul, Reid, Rathge, and Martinson (1996), addressed worry: (a) ª How often do you worry
3This manipulation was intended to replicate part of an experiment in which a negatively framed message caused increased BSE performance compared to a positively or no framed message (Meyerowitz and Chaiken,1987). We thought that the framing effect might have been mediated by worry. However, the manipulation produced absolutely no differences on any outcome measure, including worry or reported BSE. Thus, we have simply collapsed across this manipulation for the present paper.
4For simplicity, we will refer to this interval throughout the rest of the paper as ª1year.º
about breast cancer?º (1
=
ª not at allº ; 5=
ª almost all the timeº ), (b) How many days out of the last 7 did you worry about breast cancer?º , (c) ª Does breast can- cer worry affect your mood?º (1=
ª not at allº ; 5=
ª almost all the timeº ), and (d) ª Does breast cancer worry affect your performance of daily activities?º (1=
ª not at allº ; 5=
ª almost all the timeº ). For the analyses reported below, we standardized and averaged these four items to form a worry scale (Cronbach’ s alpha=
.85). In addition, we report some data for the individual items to make comparisons with previous research. Test±retest values for the worry scale were r=
.61 across the 1-month interval and .58 across 1 year.5At baseline, we administered the trait subscale of the State-Trait Anxiety Inventory (Spielberger, Gorsuch, and Lushene, 1970). This 20-item scale, which measures general anxiety apart from any speci® c content such as breast cancer, showed internal consistency of .92.
Intrusive Thoughts
On the baseline and follow-up questionnaires, we included a standardized measure, the intrusion subscale of the RIES (Horowitz et al., 1979). Partici- pants completed the scale for intrusive thoughts about breast cancer (e.g., ª I thought about it when I didn’ t mean toº ). Internal consistency for the seven items comprising this scale was good (alpha
=
.84). Horowitz et al. reported 1-week, test±retest reliability for the intrusion subscale of r=
.89. We obtained an r of .48 for the 1-year interval.Behavioral Reports
At baseline and the 1-year follow-up, we measured prior BSE performance with two questions: (a) ª How often do you typically perform breast self-exami- nation?º (1
=
ª neverº ; 4=
ª once a month or moreº ) and (b) ª During the last year, how many months did you perform a breast self-exam?º These two items were standardized and averaged (baseline alpha=
.92). BSE intentions were measured at baseline and the 1-month follow-up with two questions: (a) ª In the next year, how many times do you intend to perform breast self-exams?º and (b) ª How many months out of twelve do you intend to perform breast self-exams?º These items were averaged (baseline alpha=
.86).5Because the1-year follow-up was a phone interview, we shortened the questionnaire as much as possible. Thus, only the ® rst three worry items listed above were included at the1-year follow-up, and the test±retest estimate of r=.58was based on a three-, rather than four-item scale.
Self-Monitoring
The day after the initial meeting, participants began a week of diary record- ing. Each time they thought about breast cancer, they recorded information in a small 3 ´ 5 inch self-monitoring journal, including when the thought occurred, what triggered it, and how bothersome it was (1
=
ª not at allº ; 5=
ª extremelyº ).At the end of each day, participants answered three questions when they went to bed. The questions included: (a) ª Did you feel any distress today because of thoughts about breast cancer?º (yes
/
no), (b) ª How much did worry about breast cancer affect your mood?º (1=
ª not at allº ; 5=
ª almost all the timeº ), and (c) ª How much did worry about breast cancer interfere with your ability to perform your daily activities?º (1=
ª not at allº ; 5=
ª almost all the timeº ). We averaged the latter two items for each day and for the week as a whole (alpha=
.90 forthe weekly averages).
Phone Interviews
Once a week during each of weeks 2±4, trained interviewers called partic- ipants. We conducted phone interviews rather than continuing self-monitoring because of concern about adherence to the self-monitoring regimen. Most phone calls were made at night on a randomly selected week day. We failed to contact 21% of the participants in week 2, 19% during week 3, and 7% during week 4. For weeks 2 and 3, we averaged the data, using one or the other value when participants were missing only one of those weeks.
The interview was designed to simplify the diary questions. The interviewer
® rst asked whether the participant had any of ® ve thoughts during the day: (a) ª what it would be like to have breast cancer,º (b) ª BSE,º (c) ª your risk of hav- ing breast cancer,º (d) ª what it would be like if someone you know developed breast cancer,º and (e) ª this experiment.º6For any reported thought, participants said how many times the thought occurred to them that day, the time of day, whether something reminded them of it, or if it just ª popped into their mind,º and how much the thought bothered them (ª 1
=
ª not at allº ; 5=
ª extremelyº ).Finally, participants estimated the extent to which worry about breast cancer affected their performance of daily activities and their mood (1
=
ª not at allº ; 5=
ª extremelyº ). Across all phone interviews, the latter two items were highly related (alpha=
.73), so they were averaged to create an overall measure of worry impact.6We selected these ® ve categories based on a quick survey of the self-monitor ing records, which revealed participants’ most common thoughts.
RESULTS Baseline Data
Table I shows values for the baseline measures categorized separately for women without (negative) and with (positive) a reported family history of breast cancer. The ® rst three measures are individual worry items that allow for com- parisons with previous data. For the item ª How often do you worry about breast cancer?º , 45% of our participants reported worrying ª sometimesº to ª almost all of the timeº (3±5 on the 5-point scale). Lerman et al. (1991b) reported that 35%
of their sample of women who had recently received a mammogram worried ª somewhatº to ª a lot.º As Table I shows, women with a family history reported more frequent worrying than those without such a history (F(1, 133)
=
14.52,p< .01).
The second item in Table I is whether worry affects mood. Ten percent of our sample reported that their mood was affected at least some (3±5 on the 5-point scale). Lerman et al. (1991b) reported that 17% of their sample believed that worry affected their mood ª somewhatº or ª a lot.º Again, women in the present study with a family history reported more distress than those without (F(1, 131)
=
9.45, p=
.003).The ® nal comparable worry item was whether breast cancer worry affected daily activities. No one in our sample reported that their daily activities were affected more than a little (i.e., as high as 3 on the 5-point scale). These data are not too dissimilar from those obtained by Lerman et al. (1991b)Ð only 6% of their sample said that their activities were affected more than a little. However, in a different study, 30% of the sample reported that worry affected their daily
Table I. Baseline Means and Standard Deviations for Family History Groupsa
Family history
Negative Positive
Measures (n=70) (n=65)
How often worry?* 2.18(.71) 2.65(.69)
Worry and mood* 1.31(.60) 1.67(.72)
Worry and daily activities 1.07(.26) 1.17(.38) Trait anxiety (STAI) 37.90(8.8) 38.30(10.2) Intrusive thoughts (REIS)* 1.09(2.0) 2.88(3.3) Past Breast Self-Exam (BS) ± .09(.97) .08(.94)
BSE Intentions* 7.03(4.9) 8.87(5.1)
aThe means for past BSE are averages of standardized variables. Standard deviations are in parentheses. Measures followed by an asterisk (* ) showed signi® cant family history differences ( p< .05).
activities (Lerman et al., 1993). The sample in the latter case was ® rst-degree relatives of breast cancer patients. In our sample, the means for worry affecting daily activities were higher for women with a family history but not signi® cantly so (F(1, 131)
=
3.37, p=
.07).Table I includes several other baseline measures. No family history differ- ences appeared on the trait anxiety scale (F < 1), but strong differences were obtained for intrusive thoughts (F(1, 131)
=
14.45, p< .01). The family history groups did not differ signi® cantly in reports of prior BSE behavior (F<1), but women with a family history had stronger intentions of doing BSE in the next year (F(1, 126)=
4.32, p=
.04).Describing Worry
Table II summarizes the thoughts that women recorded in their 1-week diaries. Participants described 795 thoughts across the week, an average of one thought (M
=
1.00) each day. As Table II reveals, many recorded thoughts were about the study itself, and the study was the most frequent cue to think about breast cancer. However, the table also shows that thoughts about the study were not very bothersom e (M=
1.4). Personal risk was the next most frequent thought, and participants who reported thinking about their risk also said that those thoughts were bothersome (M=
2.5). The other most bothersom e thoughts concerned thinking about family or friend risk, fear of or death from breast can- cer, and the high prevalence of the disease. Thoughts about BSE were frequent, perhaps because we had asked participants to do one self-exam during the month.Most thoughts characterized as ª otherº were stated too im precisely to categorize.
Table II. Frequencies for Breast Cancer Thoughts and Cues that Prompted the Thoughtsa
Thoughts % (number) Bothersome Cues % (number)
This study 22% (173) 1.4 Study 32% (256)
Personal risk 21% (167) 2.5 Media 19% (157)
BSE 13% (100) 1.8 Talking with someone 14% (113)
Family
/
friend risk 11% (91) 2.9 Someone with cancer 6% (45)Media 3% (25) 2.2 BSE brochure 4% (29)
Mammograph y 3% (23) 2.0 Nothing 3% (27)
Fear of cancer 2% (18) 3.1 Shower 3% (25)
Death from cancer 2% (17) 2.7 Literature 2% (13)
Prevalence of BC 2% (16) 3.0 Breast problem 1% (12)
Doctor ’ s appointment 1% (7) 1.9 Shopping 1% (3)
Research 1% (6) 2.0 Other 16% (129)
Other 19% (152) 1.1
aThe bothersome scores are averages derived from ratings made on a1(not at all) to4(extremely) scale.
For example, when women wrote they thought about ª breast cancer,º without additional elaboration, we included it in the ª otherº category.
The cues to breast cancer thoughts show how often the topic appears in the media, as participants reported 157 thoughts during the week that were prompted by the media (newspaper, magazines, radio, television). Talking with someone also frequently prompted thoughts of breast cancer, as did noticing someone with cancer. The BSE brochure that we sent home with participants caused about 4%
of the thoughts that they reported.
Of course, thinking about breast cancer does not necessarily prompt wor- rying about breast cancer. Table III summarizes data over time on how many thoughts participants reported, how much those thoughts bothered them, and the impact of worry on mood and daily functioning. Because there was little dif- ference between weeks 2 and 3, we averaged across them for data presenta- tion.
The number of thoughts increased from the journal recording to the tele- phone interviews in weeks 2±4. This increase is best attributed to differences in recording methods; in weeks 2±4, participants did not have to write down their thoughts but just reported them to an interviewer. It is also important to see that women without a family history decreased their reported number of thoughts
Table III. Means and Standard Deviations of Breast Cancer Thoughts and Worries Across Timea
Family history
Negative Positive
(n=70) (n=65)
Thoughts per day
Week1( journal) .90(.62) 1.11(.68)
Weeks2±3 1.56(1.71) 1.68(1.57)
Week4* .62(1.21) 1.44(1.65)
Bothersomeness of thoughts
Week1( journal)* 1.26(.83) 1.76(.99)
Weeks2±3 1.69(.56) 1.88(.68)
Week4 1.44(.71) 1.63(.75)
Worry impact
Baseline 1.20(.39) 1.40(.46)
Week1(nightly) 1.20(.31) 1.23(.31)
Weeks2±3 1.15(.30) 1.13(.32)
Week4 1.03(.15) 1.09(.31)
aStandard deviations are in parentheses. Measures that are followed by an asterisk (* ) showed signi® cant family history differences ( p < .05). ª Journalº refers to daily self-monitorin g; ª nightlyº refers to the record keeping that participants did each night during week1. Weeks2±4data all come from phone surveys.
in week 4Ð much more so than women who were positive for a family history.
Women with a positive family history reported signi® cantly more thoughts dur- ing the week 4 interviews (F(1, 123)
=
10.28, p=
.02).Table III also shows the average bothersome ratings for the thoughts that participants experienced. Bothersome ratings did not decline over time. The strongest difference between women with and without a family history was observed during the week of journal recording, with family history women reporting being more bothered (F(1, 129)
=
10.03, p=
.002).The last measure shown in Table III is ª worry impactº Ð the extent to which participants felt that worry affected their mood or activities. Overall, the means for these items are low; more interesting, however, is the consistent decline in the means over time. By week 4, for example, women with a family history were reporting less impact than women without a family history had reported in earlier weeks. We conducted a repeated measures analysis of variance on these items, with weeks serving as the repeated measure. The time effect was signi® - cant (F(3, 107)
=
12.42, p< .01), the between groups effect was not (F(1, 109)=
2.50, p=
.12), and the interaction was not signi® cant (F(3, 107)=
2.27, p=
.09). Although the interaction was not signi® cant, the means in Table III show the pattern of data. The interaction pattern was that women with a family his- tory showed nonsigni® cantly higher worry impact at baseline and at week 4 but clearly equivalent worry impact during weeks 1±3.
Predicting Worry
Table IV presents correlations between baseline measures and the self-mon- itoring journal data. Except for the association between trait anxiety and the number of thoughts per day, all of the correlations were reliable. The best pre- dictor of the frequency of reported diary thoughts was the baseline intrusive thoughts measure, which provides support for the validity of the RIES. On the other hand, the baseline worry judgment was the best predictor of how bother- some the thoughts were rated. We were curious about whether the worry- and thought-bothe rsomeness relationships could be explained by participants’ lev- els of trait anxiety. Perhaps those persons who are routinely more anxious also report more breast cancer worry and say that their breast cancer thoughts bother them more. To test this idea, we computed partial correlations for the bother- someness ratings, correlating worry and intrusive thoughts with those ratings after partialing out variance associated with trait anxiety. In both cases, the par- tial correlations were signi® cant, although they were slightly reduced in size (.39 for bothersome-worry and .32 for bothersom e-intrusive thoughts). Overall, these data suggest that baseline worry judgments are modest predictors of daily
Table IV. Correlations Within and Between Baseline Worry Measures and Self-Monitor ing Measuresa
Baseline Journal
Worry
judgment STAI-Trait RIES Thoughts
/
Day Bothersomene ss BaselineWorry judgment Ð
STAI-Trait .37* Ð
RIES .75* .24* Ð
Journal
Thoughts
/
day .28* .08 .30* ÐBothersomenes s .44* .23* .36* .46* Ð
aThe STAI measures trait anxiety and the RIES measures intrusive thoughts.
*p< .05.
thoughts and worries, and individual differences in trait anxiety do not explain those relationships.
Worry and Screening
Table V presents relationships between the baseline and self-monitoring worry measures and reported BSE behavior and intentions. The baseline worry judgm ents and intrusive thoughts both showed modest but signi® cant, positive relationships with reported BSE behavior and intentions. Trait anxiety measured at baseline was not related to BSE behavior and was (nonsigni® cantly) negatively related to BSE intentions. As the table also shows, the summary judgments were more strongly related to reported behavior at 1 year than the measures derived from self-monitoring.
Table V. Correlations Between Worry Measures and Follow-up BSE Measuresa
Baseline Follow-up
Behavior Intentions Behavior Intentions Worry measures
Baseline worry judgment .37* .32* .31* .22*
Baseline trait anxiety .00 ± .09 .05 ± .09
Baseline intrusive thoughts .28* .25* .24* .21*
Journal thoughts per day .24* .32* .17 .26*
Journal thoughts bothersome .19* .18* .10 .16
aCorrelations marked by an asterisk are reliable at p< .05, two-tailed.
Other Analyses
We divided the family history women into two groups, depending on whether they had at least one ® rst-degree relative (mother, sister, daughter) with breast cancer or not. We then compared these groups on all of our measures.
The means typically showed differences that one might expect between these groups. For example, the ® rst-degree group reported more intrusive thoughts at baseline (M
=
3.11) than the second-degree group (M=
2.74). However, none of these differences was signi® cant (all ps> .07). The presence of some kind of a family history was more important than the closeness of the relationship.DISCUSSION
Before addressing what we can learn from this study, we should note sev- eral limitations of the methodology. First, generalizations must be limited to the particular group of women recruited for the studyÐ college students and a non- random collection of community women. The sample as a whole was highly educated and not very diverse. It is thus unclear whether the observed levels of worry would be similar to those exhibited by different groups of women. Sec- ond, we noted earlier that the results of other studies might be due to the context in which the data were collected; that criticism also holds to some extent for the present study. It is possible that discussing BSE as a screening tool for breast cancer, for example, could have affected the worry that our participants ª natu- rallyº reported, at least early in the self-monitoring phase.
Reservations noted, what can we learn from this study? At the outset, recall that this is the ® rst study to assess breast cancer worries intensively over time and partially removed from signi® cant breast-cancer related events (e.g., mam- mography screening). From a purely descriptive perspective, the study provides data about the content of thoughts about breast cancer and what prompts those thoughts. Most thoughts about breast cancer center on risk, both one’ s own and the risk of family members and friends. Those thoughts about risk, which women reported to be somewhat bothersom e, extend less frequently to even more emo- tionally compelling thoughts about fear of cancer, death from cancer, and the prevalence of breast cancer.
The frequency of reported thoughts (on average, participants recorded seven thoughts during the week of self-monitoring) was probably overstated, because the study itself made up 22% of the ª breast cancerº thoughts. Moreover, the study served as a frequent prompt of breast cancer thoughts. Still, participants noted many other potent cues, including the media, just talking with others, or observing others with cancer. We suspect that the high frequency of thinking about breast cancer, though exaggerated by the study itself, probably re¯ ects
the daily experience of many women confronted with many triggers to thinking about the disease.
As noted earlier, however, thoughts may differ from worryÐ the latter idea carries affected connotations not necessarily associated with thinking by itself.
How much did the women in this study report worrying about breast cancer?
The data do not allow us to answer this question simply. First, the levels of worry reported at baseline were fairly high and comparable to levels observed in other investigations (e.g., Lerman et al., 1991). Second, worry levels declined over time, suggesting the possibility of context effects. These data suggest that ª normal,º day-to-day worries, are not as frequent or as bothersom e as one might suspect from studies that measure worry on a single occasion. However, even this latter conclusion must be tempered by the ® nding that women with a fam- ily history were less likely to report a decline in worry. Thinking about and worrying less about breast cancer during the 1-month monitoring interval best characterized those women without a family history of the disease.
Indeed, the family history differences observed in this study suggest that women with a family history may be chronically more worried about breast can- cer than women without such a history. These data ® t the ® ndings of Valdimars- dottir et al. (1995), who studied 26 women with two or more ® rst-degree relatives with breast cancer. Valdimarsdottir et al. discovered that these high-risk women were more worried both before and 1 month following a scheduled mammo- gram than a comparison group of 27 women recruited using advertisements in the community. Valdimarsdottir et al. wondered whether their data would gen- eralize to women with a less extreme family history. The present data suggest that they do.
This study also sheds light on some measurement questions. Speci® cally, baseline summary judgm ent measures of worry were signi® cantly related to the self-monitoring and phone interview measures. This was true for both items that Lerman et al. (1991) used as brief measures of worry. The data also highlight a distinction between worry as affect and intrusive thoughts. It was the speci® c worry items that best predicted the bothersomeness of thoughts; the intrusive thoughts questionnaire was the best predictor of the number of thoughts. Finally, worry reporting was not highly related to trait anxiety. We would suggest that the worry judgm ent measures represent fair measures of the worry that women experience daily about breast cancer per se.
Does worry have any value? The present study suggests that thinking and worrying about breast cancer may motivate self-protective behavior in the form of BSE. The baseline summary worry judgments, the baseline intrusive thoughts scale, and the daily self-monitoring thoughts all related positively to measures of reported BSE and intentions. Trait anxiety, on the other hand, did not predict self- protective behavior. These data converge with ® ndings concerning worry in other domains as well as some other studies in the breast cancer screening literature.
Davey (1993), in a methodological study of worry questionnaires, concluded that content-based worry (i.e., worry about a particular worry domain such as breast cancer) predicts problem solvingÐ it is ª constructive worrying.º General worry, in contrast, is more highly related to general anxiety and more predictive of avoidant coping. In the breast cancer screening literature, anxiety appears to inhibit mammography screening (Kash et al., 1992), whereas worry about breast cancer is positively associated with mammography screening (McCaul, Branstetter, Schroeder, and Glasgow, 1996). Given that the worry levels in this study, even those reported by women with a family history of breast cancer, were not excessive, one might suggest that occasional bouts of breast cancer speci® c worry serve a valuable self-protective function.
ACKNOWLEDGMENTS
Thanks to Melissa Bjerke, Kit O’ Neill, David Wittrock, George O’ Neill, Sarah Jacobson, Tanna Mehlhoff, and Beth Meyerowitz for their help with this work. The research served partially to ful® ll Ann Branstetter’s requirements for the MS Degree in Psychology and was supported by an NDSU graduate research award, the National Cancer Institute (CA58659), and the U.S. Army (DAMD17- 94-4378).
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