INT’L. J. PSYCHIATRY IN MEDICINE, Vol. 9(1), 1978-79

PSYCHOSOCIAL ADJUSTMENT TO BREAST CANCER: A REVIEW OF SELECTED LITERATURE*

FRANCES M. LEWIS, PH. D. Division of Health Education School of Hygiene and Public Health The Johns Hopkins University JOAN R. BLOOM, PH. D. School of Public Health University of California, Berkeley

ABSTRACT

‘Ihe following is a review of the clinical and research literature concerning women’s emotional adjustment to the detection of breast cancer and its subsequent management. The review is organized into ten themes which focus on three general areas: 1) women’s response to the diagnosis of breast cancer; 2) involvement of spouse, family and professional providers; and 3) the patient’s milieu-how it impinges on the course of her treatment and rehabilitation. Also noted is the paucity of systematic research dealing with the effectiveness of support interventions, their content and duration, and the appropriate individual to provide such support.

Introduction The breast is the most frequent site of cancer in women. According to the Report to the Profession of the Breast Cancer Task Force [ 11, it was estimated that 90,000 new cases would be diagnosed in 1974, and about 35,000 women would die of breast cancer. Affecting one out of thirteen, breast cancer is the leading cause of death among women aged forty to forty-five. What effects do malignancy and its management have on a woman’s *This work was partially supported by the National Cancer Institute, Contract No. N01CN-55313 (DHEW). 1

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emotional adjustment? How do they affect the integrity and stability of the family unit? What psychosocial and environmental factors predispose an individual to successful adaptation and rehabilitation? An extensive review of the literature was conducted to answer these and related questions. This review differs from past literature reviews in several respects. Unlike Holland, attention is primarily given t o the breast cancer patient, rather than a broad spectrum of cancer patients [ 2 ] . All of the past reviews have had as their primary focus the individual or isolated breast cancer patient [ 3 , 4 ] . In the following review, attention is focused on both the individual patient and her broader social context. The authors have summarized the literature in terms of its salient themes in an effort to move attention toward building broad directives for clinical assessment and intervention for the breast cancer patient. By pointing to the methodological inadequacies of many of these studies, the authors provide guidelines for future clinical investigations. This review is in no way exhaustive, and neither addresses psychoemotional causation in breast cancer, nor adequately covers the topic of delay behavior. Each of these areas is worthy of special attention, and we defer to others for extensive treatment [ 2 , 5-13]. This literature review is organized around ten generalizations. Themes 2 through 5 focus on the individual as the unit of analysis. A large part of the accumulating literature has been concerned with the woman’s response to her diagnosis of breast cancer. Themes 6 , 7 and 8 focus not only on the patient but also on those significant t o her-her spouse, family, and professional providers. The review begins and ends with three themes in the literature that suggest how the patient’s milieu impinges on the course of her treatment and rehabilitation.

Themes From the Literature THEME 1: WOMEN HARBOR MANY MISCONCEPTIONS ABOUT BREAST CANCER

The word “cancer” bears a connotation of fear. Widespread public knowledge of cancer symptoms has led to a national cancer phobia [ 141. A Gallup poll of 1,007 women eighteen years old and over was conducted by the American Cancer Society in 1975 [15]. Data suggest that breast cancer is so much a medical concern of American women that most overestimate its prevalence. Misconceptions about breast cancer lead to fear, panic and avoidance. Forty-six per cent of all women sampled believe that monthly breast examination would make them worry unnecessarily. Misconceptions about the incidence of the disease are reinforced by widespread ignorance and confusion about the causes of breast cancer. A majority of the women surveyed believe that breast cancer is caused by a blow or injury t o the breast. Many do not realize that with increasing age there is an increasing chance of developing breast cancer.

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Over one-half of the women interviewed said breast removal would lead to a sense of loss of being a woman, and that chances for a single woman to be happily married would be reduced if she had only one breast. Counterbalancing the fear of breast cancer is the belief that progress has been made in its management. Sixty-one per cent of all sampled women believe that breast cancer patients can survive. Eight out of ten women know someone who has had breast cancer and has been “saved.” When discussing surgical intervention for breast cancer, simple mastectomy was familiar to the largest proportion of women, followed by radical mastectomy. The literature on delay behavior can be viewed in terms of societal misconceptions about cancer.’ While fear, misunderstanding or failure to recognize cancer symptoms are some of the identified reasons for delay, there is also some evidence that individuals from a higher social class hold different attitudes toward cancer from those of a lower social class. Higher socioeconomic groups seem to delay significantly less in seeking diagnosis, may more readily label their condition as “cancer,” and are not faced by access barriers to the medical care sjstem that may cause “delay” by those of lower social classes [19-211. A woman confronts the di,tgnosis and treatment of breast cancer with many societal misconceptions about her condition. These misconceptions and fears form the parameters within which her reactions to the diagnosis and her adjustment to the course of treatment must be considered. THEME 2: BREAST CANCER AND ITS TREATMENT ARE ASSOCIATED WITH MULTIPLE STRESSORS

Treatment of breast cancer is a more complicated management problem than that for surgery of comparable magnitude [22]. Psychological adjustment to breast cancer entails adjustment to many stressors during diagnosis, treatment and rehabilitation [2]. Only an occasional author claims the patient can absorb treatment effects with equanimity [23]. Breast cancer is frequently equated with death [24]. This death view is reinforced by society’s fear of cancer ‘and its involuntary association with decay [ 101. As if this were not sufficient, breast cancer is often perceived as synonymous with body disfigurement [25,26]. In addition to facing a cancer diagnosis, the woman with breast cancer may face surgical intervention. A mastectomy, in particular, is often viewed by the patient as a threat to femininity and sexual desirability [3, 271. Some evidence suggests prechildbearing and climacteric women are most threatened by breast loss [28]. The mastectomy patient faces adjustment to an altered body and an altered body image. “Healthy” women have specific notions of what they like or dislike about their bodies and tend to like their bodies more than men

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The delay literature is more commonly analyzed in terms of psychological variables in the individual that cause delay in seeking diagnosis or treatment [ 16-18].

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do [29]. Using evaluation of body parts as her measure of body image, Polivy found that mastectomy patients, compared to breast biopsy and noncancer, noncosmetic surgical controls, had lower body image scores three months aftex surgery [30]. Using a similar measure, in another study, Kurtz and Hirt found that chronically ill patients were also more likely than “normal” controls to evaluate their bodies’ external form negatively [31]. Rehabilitation from breast surgery is sometimes long and arduous and can be complicated by acute depression, pain, lymphedema, wound drainage and restricted joint motion [32, 331. When viewed within the perspective of a chronic illness, breast cancer is associated with expensive medical followup including radiotherapy and chemotherapy. Each procedure has its own sideeffects and costs [34], and concurrent problems with family interpersonal relations, debts and child care must be faced [35]. THEME 3: COPING PATTERNS AFFECT PSYCHOLOGICAL ADJUSTMENT TO BREAST CANCER

There is limited systematic evidence bearing on the importance of premorbid personality factors affecting psychological adjustment to breast cancer. Observations by clinicians seeing patients prior to diagnosis and during the course of their treatment suggest that patterns of previous coping are good predictors of adjustment. Validation of these observations comes from a twoyear longitudinal study recently completed in England. Morris and her associates followed 160 consecutive admissions for breast biopsy, 43 per cent of which proved malignant [36]. A third of the women having mastectomies sought psychiatric assistance postsurgically, twice the number of those having biopsy only. Elevated emotional lability and depression scores presurgically predicted poorer postsurgical adjustment two years later. In another study, interview data obtained from sixty married, terminally ill cancer patients and their spouses showed no significant association between previous personality instability and current emotional disturbance. “Good” copers, however, did reveal less depression, anxiety, social withdrawal and instability. The capacity to face problems, a sense of life-fulfillment, and a positive marital adjustment were also associated with an easier adjustment to dying [37]. Some evidence also suggests that individuals claiming religious affiliation cope better with their cancer [38, 391. What is a “good” coper? What is a “successful” premorbid personality? The specific literature on breast cancer only hints at the answers, and clearly more research is needed in this area. THEME 4: A CHARACTERISTIC SET OF EMOTIONAL REACTIONS IS OBSERVED IN WOMEN WITH BREAST CANCER

Although any woman’s response pattern is unique and dependent on both the objective reality of her situation and the symbolic meaning she imparts to

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it, a characteristic set of reactions to breast cancer may be expected from any sampled group of women. These responses are somewhat time-bound in that the woman passes through a process that can include many different responses at different stages [40-431 . Common responses include anxiety, depression, anger, guilt, fear, regression and denial [3, 25, 40, 44-49]. In their seminal report, Renneker and Culter describe the responses to mastectomy observed in fifty women [28]. They frequently observed postmastectomy depression marked by anxiety, insomnia, depressive attitudes, occasional suicidal ideas, and feelings of worthlessness and shame. The authors hypothesize that the severest reactions to mastectomy occur in women of childbearing age, and the mildest reactions in postclimacteric women with husbands and children. Older women focus more on adjustment to cancer; younger women focus more on breast loss itself [28,47] . Friel, Nicolay and Frank emphasize the short-term nature of many postsurgical depressive reactions [50] . Of all the articles reviewed, only three focused on the emotional reactions to breast cancer from the patient’s perspective. Using participant observation techniques, Quint intensively followed twenty-one women undergoing mastectomies from hospitalization until one year after discharge [5 11. Expressed concerns included problems of adjusting to change in bodily appearance and their altered views of the future. Data from Maguire’s prospective study of 450 potential mastectomy patients suggest that most women were predominantly concerned with survival and the possible suffering involved rather than with the actual breast loss [52]. Data from nineteen intensive clinical interviews by Fitzmaurice and Ross validate Maguire’s observation that the concerns of women with breast cancer often go unnoticed by the medical and nursing staff [53]. Denial is a common response to the diagnosis of breast cancer and to the effects of surgical intervention [54]. Authors are divided into two opposing camps; one group views denial as a necessary response to breast cancer, and the other views denial as maladaptive. A central position is represented by Weisman and Worden [55], who emphasize the importance of denial initially in the coping process, and Biegler [56], who highlights the importance of supporting denial in the terminally ill breast cancer patient. There are only two systematic studies in this area. Polivy reported that women having mastectomies deny their feelings initially compared to samples of women having noncosmetic surgery or breast biopsies [30]. In followup interviews one year later, the denial had broken down. Bloom and her associates compared two samples of women having mastectomies and found that initial denial was less in the group seen by a patient counselor during hospitalization [57] . THEME 5: THE WOMAN WITH BREAST CANCER FREQUENTLY BECOMES A SOCIAL AND EMOTIONAL ISOLATE

In her longitudinal study described previously, Quint observed a lack of support from family and friends for patients faced with physical and

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emotional adjustments [51]. Interaction with the interviewers in the study proved t o be one of the few outlets these women had for their most painful fears and feelings. At a time when the woman is struggling to heal and regain her energy, family and friends often assume that she will soon “return t o normal.” They may not understand the protracted nature of the healing process. Social isolation can be aggravated by slow wound healing and drainage as well as by a poorly fitting prosthesis or a delay in obtaining one. Quint’s research team was impressed by the amount of loneliness with which the women lived. Loneliness stemmed from two sources: body disfigurement and the possibility of dying from the disease. Maguire reports that all women in her sample experienced a decline in social and leisure activities [52]. Friends may feel uncomfortable in initiating interactions. Sexual relationships are often affected. Currier claims that sexual avoidance frequently accompanies body alterations [58] , and numerous papers claim that sexual adjustment after a mastectomy is a pressing situational crisis [52, 591. The unmarried woman may have particularly severe problems in reestablishing sexual relations after breast surgery [58] . However, poor postsurgical sexual adjustment attributed to mastectomy may actually be due to chronological and biological perimenopausal status [36] . A theme of marital threat first proposed by Bard and Sutherland [40] has received substantiation from two subsequent studies that used more systematic means of data collection [53, 601. Both studies conceptualized this phenomenon as a process of mutual withdrawal. According to Grandstaff, the process is initiated by the husband’s refusal to look at the surgical scar [60]. If the patient perceives this as a threat to her femininity, the woman withdraws both emotionally and physically. Inevitably, the husband perceives her withdrawal as rejection and responds by further withdrawal. Without therapeutic intervention, the cycle of mutual withdrawal usually continues. In contrast t o these findings, Morris and her associates found marital adjustment largely unaffected by mastectomy [36]. There are few psychosocial studies reported on women with metastatic breast cancer. Interviews from an intensive case study of a forty-eight-year-old woman, her husband, and their twenty-year-old daughter revealed that the patient had infrequent visits from her children, family members hesitated to share feelings with each other, and the patient felt lonely, helpless and abandoned [61]. In addition to feeling lonely and anxious [62], the metastatic breast cancer patient may suffer from depression [61, 631. She may perceive few sources of emotional support for her deepest thoughts, feelings or fears [64]. In one study, patients experienced loneliness and isolation, and lacked family responsibilities [65] . There is a paucity of information on programmatic intervention with the

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metastatic patient. There is suggestive evidence that group therapy sessions may counteract the patient’s sense of powerlessness and uselessness [66]. Significant decreases in depression, anxiety, helplessness and powerlessness were found after three months in one group therapy program for the terminally ill [63]. THEME 6: THE ISOLATED WOMAN WITH BREAST CANCER IS THE PRIMARY TARGET FOR PSYCHOLOGICAL INTERVENTION

Treatment of a patient as an isolated individual is prevalent despite the increased emphasis on family-centered medcine. Primary or secondary intervention with spouse or family is an exception. Although the patient’s “significant others” are not ideologically forgot ten by the attending caregivers, designed or planned intervention with them is overlooked. This nonaction occurs despite evidence of acute family disruption resulting from family member illness [67, 681, and despite awareness that the family is the primary source of social interaction and support during adjustment to a stressful situation [69-711. There are a few reported attempts to integrate the husband or family of the breast cancer patient into a support program. They can be included in the actual decision-making of the medical treatment program, in counseling sessions designed to vent members’ feelings and fears, in information exchange sessions that include advice on sexual activity, and in general emotionally supportive consultative sessions 126, 68, 72-77] . Recently, two hospitals described the comprehensive support and rehabilitative services provided to breast cancer patients and their families by multidisciplinary teams [57, 781. Evaluation of each program, using a combination of behavioral and psychological measures, indicates its effectiveness. Descriptions of the services provided affirm the efficacy of the programs, although each is deficient in its evaluation design. THEME 7: A SUPPORTIVE INDIVIDUAL INTRODUCED EARLY I N THE DlAGNOSlS/TREATMENT PHASE OF BREAST CANCER APPEARS CRITICAL TO PSYCHOLOGICAL REHABILITATION

Social support for the breast cancer patient stems from three sources: her immediate family or husband, her friends, and her professional caregivers. Support consists of aiding in the patient’s emotional release, anticipatory problem-solving, and information exchange. Some physicians believe adjustment to breast cancer is facilitated by a thorough awareness of treatment options and outcomes, and by the patient’s involvement in related decisions [79-811. Early intervention seems critical for maximum psychological adjustment [82]. Coping responses to crisis, including maladaptive patterns, are solidified early, perhaps during the first month after the cancer diagnosis [83] . The focus

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in crisis intervention is to support appropriate coping patterns and to discourage inappropriate ones. Many clinicians advocate intervention as early as the first patient/provider encounter [84]. Early intervention for the husband, preferably during initial hospitalization, is also emphasized by clinicians [60, 851. The concept of “supportive individual” takes on multiple meanings in the literature, most of which are nonspecific and nonbehaviorally defined. The question of who this “supportive other” should be also remains unanswered. Numerous articles proclaim the value of an individual who has had breast surgery, such as the Reach to Recovery volunteer, but such patient contacts are now limited to one or two visits authorized only by the attending doctor [86]. Ervin reminds us that it is the husband, not the professional caregiver, who is the pivotal figure in psychological adjustment, and emphasizes the physician’s role in teaching the husband ways in which to be supportive [87]. Nurses have outlined their therapeutic role pre-, intra- and postoperatively [84, 85, 88-90]. In the acute care setting, the nurse may assume the role of coordinator for psychological and physical care [90, 911 ; may function as caregiver both preoperatively and postoperatively, thereby insuring continuity of psychological support [89] ; or may organize and direct small group therapy sessions [92]. Physicians describe their important contributions to the patient’s emotional adjustment. Anticipatory guidance for the woman with breast surgery is outlined, including goals related to functional, physical and cosmetic rehabilitation [93]. Many stress the importance of a semistructured or openended doctor/patient interview before breast surgery [50, 79, 87, 941. Articles underlining the importance of a supportive individual in the psychosocial rehabilitation of the woman with breast cancer raise a number of questions. Most of the reviewed articles are only exhortive and prescriptive. With few exceptions, they fail t o describe the services delivered by this individual t o the patient and leave unanswered the question of what level of credentialing, if any, is needed for this supportive other. The issue of who should serve as the supportive person is complicated by systematic evidence showing that providers may not be able to conceptualize from the patient’s point of view [95]. Even when a physician or nurse is open to dealing with the disease from the patient’s perspective, the provider/patient communication may not be synchronized; that is, the provider may be ready to listen when the patient is not ready to tell [96, 971. Maguire’s large-scale study indicates the high frequency with which patients display emotional responses but allow them to go undetected by both nurses and physicians [52]. Oppenheim and Rossman claim that the physician who ministers to the metastatic cancer patient is often inadequately prepared to take on such a long-term and demanding role [62]. Evaluation studies of the impact of current medical education in management of cancer care were not found.

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THEME 8: ADAPTATION TO BREAST SURGERY OR CANCER IS FACILITATED BY TREATING THE PATIENT‘S FAMILY, NOT JUST THE PATIENT, AS THE “CLIENT“

The patient’s family and friends significantly affect, and are in turn affected, by the course of the disease. A recent investigation of the families of children with leukemia demonstrates that the majority suffer from resulting physical, psychological and social problems [71]. According to Olsen, it is the family, not the patient, who has the illness [67]. Not only the patient, but also the family members are thrown into a state of crisis and dysequilibrium. Their responses may include insomnia, panic, or excessive drinking. Children’s reactions to their mother’s illness depend on their ages, the obviousness of her symptoms, and the extent of her disability and final disease outcome [58]. Klein, Dean and Bogdonoff s study systematically documents spouses’ responses to patients’ illnesses [98]. Drawing from questionnaire data from 121 patients with chronic illness, the investigators found that a majority of the spouses showed an increase in symptomatic levels during illness. Nervousness and feelings of fatigue were the two most frequently reported symptoms. Most of the patients and spouses experienced an increase in role tension during illness. Role tension in the spouse correlated significantly with the number of symptoms reported in the patient. As the patient’s work activity declined, so did the spouse’s. Because of the problem of reestablishing sexual activity postsurgery, presurgical sex counseling is advocated by many clinicians [72-731. Such counseling attempts to minimize misunderstandings about postoperative sexuality [99] , to deal with husbands’ questions and concerns, and to ameliorate communication breakdown [75, 80, 1001. Although some clinicians defme an aggressive role for themselves in this area, others believe postoperative sexual adjustment is related primarily to the quality of the preoperative relationship, and as a result, they do not actively intervene [40, 1011. Data from a small interview study of husbands of Reach to Recovery volunteers reinforce this latter position [59]. When cancer patients are cared for at home, interview data from one study indicate that families expect the physician to give them information and provide emotional support [98]. Over half of the families interviewed state they were unable to obtain the medical assistance they felt was required. The most often-stated needs of these families deal with information about the patient’s status, help in giving psychological support to the patient, information on how to manage pain and discomfort, and the administration of medications. THEME 9: ONCE A CANCER DIAGNOSIS IS ATTACHED TO A WOMAN, MOST EMPLOYERS PERCEIVE HER AS AN EMPLOYMENT RISK

Financial recovery, including continuing occupational independence and insurability, needs to be part of cancer aftercare. Company group life

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insurance programs can be a barrier to employment because the former cancer patient may be considered a financial risk. If the ex-cancer patient can get a job, she will automatically have any group health insurance coverage that it offers. Personal health insurance, however, is extremely difficult, if not impossible, to obtain without proof of total cancer arrest. Even then, a waiting period is still required before coverage is granted [102]. Only a few labor unions have met the challenge of these problems. In one systematic study, data on seventy-four employees with a history of cancer treatment were reviewed [ 1031. The majority of females had had breast cancer. Data showed that the turnover rate of employees with cancer was about the same as that for healthy employees, and attendance records of thirty-nine home-office employees revealed that absences for employees with cancer were only slightly greater. The major employment problem exists for cancer patients unable to return to their same jobs after treatment, or for those who attempt to change jobs [104]. This problem has been exacerbated in recent years because of increasing success in cancer treatment. Many employers react in the same way to all cancer patients, disregarding their individual medical histories. Yet, several studies indicate little difference exists be tween employability and dependability of persons with a history of cancer treatment and persons without cancer [105, 1061. Schottenfeld and Robbins did the most careful study on job performance status that the authors found [107]. A sample of 826 Caucasian women with primary operable breast cancer was studied to examine the quality of survival among radical mastectomy patients under sixty-five years of age. A crosssectional survey of the study sample was taken to determine the current performance status of 5, 10- and 15-year survivors. Fifty of the 316 five-year survivors were unable to work or perform daily activities. The performance of women with regional disease was significantly inferior to that of patients with localized disease. Of the ten-year survivors, a majority of the previously employed women continued to work, and only two patients attributed their lack of employment to breast cancer. Nine per cent were unable to work or perform daily activities. Of the 15-year survivors, only a small percentage lacked performance ability. The quality of survival at ten and fifteen years did not vary significantly with disease stage. Schonfield considered the psychological factors related to successful adaptation in breast cancer patients [108]. His indicator of successful adaptation was whether a sample of previously employed patients returned to work within nine months. He found that the reemployed patients showed significantly lower scores on the “morale loss scale” and significantly higher scores on the “well-being scale” than did those patients who did not return to work within nine months.

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THEME 10: FEW COMMUNITY-BASED OUTREACH PROGRAMS EXIST FOR CANCER PATIENTS

Compared to patients with coronary artery disease, stroke and other common chronic diseases, patients with cancer have fewer community-based support services. Reach to Recovery is one exception. Some isolated studies dealing with family-centered cancer treatment programs were located in the literature, but few outreach programs paralleling the “Coronary Clubs” or “Stroke Groups’’ were found. Family-centered posthospitalization programs at Memorial Sloan Kettering Hospital [74] and at Montefiore Hospital in New York City were exceptions [109]. Yalom describes a recent treatment innovation for patients and their families [ 6 6 ] .The most systematic survey of resources is that compiled by Fitzmaurice et al. for the San Francisco Bay area [110]. Generally speaking, the woman with breast cancer has only one major source of professional support-her physician. Once released to the communityat-large, her institutional sources of support are almost nonexistent.

Summary and Discussion The meanings attributed by the woman with breast cancer to her diagnosis and subsequent treatment are defined by society. First, cancer is defined as a fear word-one which is associated with death and decay. Second, to the degree that a woman has accepted a societal definition of herself as a sex object, she will attribute different meanings to the loss of her breast. Breast cancer may connote mutilation, decreased femininity and diminished sexual attractiveness. These conceptions are sources of stress that must be resolved by the patient during treatment and subsequent rehabilitation. Even with increasing emphasis on family-centered medicine, most intervention is targeted for the isolated patient with breast cancer. In light of findings which indicate serious family member problems and disruption to the family itself as a consequence of the mother’s illness, integration of the family members into support programs for the mastectomy patient seems critical. The few reported attempts to integrate the husband and family into a support program provide significant insights, although rigorous evaluation of these efforts is yet to come. Both physicians and nurses describe their important contributions to the patients’ emotional well-being through their educative and counseling efforts. Up to the present, these claims are unsubstantiated by systematic evidence and evaluation. Much of the literature reviewed focuses on the importance of providing emotional support to the woman with breast cancer. Despite the volume of work reported, however, it is evident that we know very little about how

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patients and families cope with the impact of the presenting diagnosis, the subsequent treatment, and the course of rehabilitation. Although there are multiple prescriptive papers, there is little systematic documentation of the problems of the breast cancer patient, when intervention should be offered, the length of time that it should encompass, its content, the appropriate individual to provide it, and-most important of all-if it makes any difference. Descriptive studies are clearly needed as a first stage in a needs assessment process geared to identifying and prioritizing the target intervention areas for the breast cancer patient. In designing these studies, care must be exercised in both the selection of sample inclusion criteria and choice of a control group so that psychological and social adjustment problems due to aging and life change are not erroneously attributed to breast cancer and its management. Much work needs to be done. First, the needs of the woman with breast cancer must be determined; second, intervention packages targeted for both the patient and her support system need t o be designed; and, finally, careful program evaluation to measure effectiveness needs to be established. Perhaps the value of thls review lies not only in its assessment of the previous body of work, but also in its directing attention toward neglected areas for future research.

ACKNOWLEDGEMENTS We thank Frank Stockdale, M.D., Muriel Jeffrey, and our anonymous reviewers for their comments on a previous version of this paper. REFERENCES

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8. H. T. Lynch and A. J. Krush, Heredity and Breast Cancer: Implications for Cancer Control, Med. Times, 94, pp. 599-605, 1966. 9. H. T. Lynch and A. J. Krush, Heredity, Emotions and Cancer Control, Postgrad. Med., 43, pp. 134-138, 1968a. 10. H. C. Shands, J. E. Finesinger, S. Cobb and R. D. Abrams, Psychological Mechanisms in Patients with Cancer, Cancer, 4, pp. 1159-1 170, 1951. 11. B. Cobb, R. L. Clark, Jr., C. McGuire and C. D. Howe, Patient-Responsible Delay of Treatment in Cancer, Cancer, 7r5, pp. 920-926, 1954. 12. B. Kutner, H. B. Makover and A. Oppenheim, Delay in the Diagnosis and Treatment of Cancer: A Critical Analysis of the Literature, J. Chronic Dis., 7, pp. 95-120, 1958. 13. M. G. Drellich, I. Bieber and A. M. Sutherland, The Psychological Impact of Cancer and Cancer Surgery. VI. Adaptation t o Hysterectomy, Cancer, 9, pp. 1120-1 126, 1956. 14. N. Kline and J. Sobin, The Psychological Management of Cancer Cases, J.A.M.A., 146r17,pp. 1547-1551, 1951. 15. Gallup Organization, Inc., Women’s Attitudes Regarding Breast Cancer, J. Med. Assoc. State Ala., 44, pp. 419-429, 1975. 16. C. J. Magarey, P. B. Todd and P. J. Blizard, Measurement of Women’s Attitudes t o Breast Cancer, Aus. NZ J. Surg., 45, p. 112, 1975. 17. S. Fisher, Motivation for Patient Delay, Arch. Gen. Psychiat., 16. pp. 676678, 1967. 18. C. A. Hammerschlag, S. Fisher, J. DeCosse and E. Kaplan, Breast Symptoms and Patient Delay: Psychological Variables Involved, Cancer, 17, pp. 14801485, 1964. 19. T. P. Hackett, N. H. Cassem and J. W. Raker, Patient Delay in Cancer,New Engl. J. Med., 289, pp. 14-20, 1973. 20. H. T. Lynch and A. J. Krush, Attitudes and Delay in Cancer Detection, Cancer, 18, pp. 287-293, 1968b. 21. H. T. Lynch, A. J. Krush and M. Lipp, The Delay Problem in Cancer, Med. Times, 100,pp. 77-87, 1972. 22. G. Rosemond and W. Maier, Postoperative Care and Rehabilitation in Breast Cancer Surgery, Cancer, 24, pp. 1307-1309, 1969. 23. H. S . Goldsmith and E. S. Alday, Role of the Surgeon in the Rehabilitation of the Breast Cancer Patient,Cancer, 28, pp. 1672-1675, 1971. 24. R. C. Mastrovito, Emotional Considerations in Cancer, N Y State J. Med., 72, pp. 2874-2877, 1972. 25. E. Day, The Patient with Cancer and the Family, New Engl. J. Med., 274, pp. 883-886, 1966. 26. V. Ventafridda, G. Martino and M. Del Vecchio, Rehabilitation of the Mastectomy Patient, Proceedings, XI Int’l Cancer Congress, V. 4, Cancer Campaigns, Detection, Rehabilitation, Clinical Classification, Florence, 1974, Excerpta Med, Amsterdam, pp. 225-228, 1975. 27. K. A. Menninger, Somatic Correlations With the Unconscious Repudiation of Femininity in Women,J. N e w . Ment. Dis., 89, pp. 514-527, 1939. 28. R. Renneker and M. Cutler, Psychological Problems of Adjustment t o Cancer of the Breast, J.A.M.A., 148, pp. 833-838, 1952.

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