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Keywords:

  • Mammography;
  • decision making;
  • breast cancer screening;
  • breast screening;
  • breast cancer;
  • family history;
  • grounded theory;
  • qualitative research

Abstract

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Study Limitations
  7. Conclusions
  8. Acknowledgments
  9. Clinical Resources
  10. References

Purpose: This study's purpose is to describe and explain how women 55 years of age and older with a family history of breast cancer make screening mammography decisions.

Design: A qualitative design based on grounded theory. This purposeful sample consisted of 23 women 55 years of age or older with one more first-degree relatives diagnosed with breast cancer.

Method: Open-ended interviews were conducted with 23 women 55 years of age and older with a family history of breast cancer using a semistructured interview guide. Transcribed interview data were analyzed using constant comparative analysis to identify the conditions, actions, and consequences associated with participant's screening mammography decision making.

Findings: Women reported becoming aware of their breast cancer risk usually due to a triggering event such as having a family member diagnosed with breast cancer, resulting in women “guarding against cancer.” Women's actions included having mammograms, getting health check-ups, having healthy behaviors, and being optimistic. Most women reported extraordinary faith in mammography, often ignoring negative mammogram information. A negative mammogram gave women peace of mind and assurance that breast cancer was not present. Being called back for additional mammograms caused worry, especially with delayed results.

Conclusions: The “guarding against cancer” theory needs to be tested in other at-risk populations and ultimately used to test strategies that promote cancer screening decision making and the adoption of screening behaviors in those at increased risk for developing cancer.

Clinical Relevance: Women 55 years of age and older with a breast cancer family history need timely mammogram results, mammography reminders, and psychosocial support when undergoing a mammography recall or other follow-up tests.

Women 55 years of age and older account for over 65% of all breast cancers and more than 77% of breast cancer deaths (Ries et al., 2008). Breast cancer incidence increases with age until 80 years, where there is a slight decline, most likely due to incomplete detection (American Cancer Society [ACS], 2007); however, increased age is associated with decreased mammography use (Rawl, Champion, Menon, & Foster, 2000). In addition, having one first-degree relative diagnosed with breast cancer doubles a woman's risk for being diagnosed with breast cancer, compared to women without this family history. Breast cancer risk can quadruple with two or more first-degree relatives diagnosed with the disease (ACS).

Mammography is currently the most effective method for reducing breast cancer mortality and detecting the disease when cure is most likely (United States Preventative Services Task Force, 2002; Nystrom et al., 2002). Despite considerable research related to factors associated with mammography use and interventions to increase utilization, in a large study of women 40 years of age and older, 35% of women reported no mammogram in the past 2 years. In addition, there was an alarming 3.5% decline in mammography use from 2000 to 2005 (Slomiany, McMasters, & Chagpar, 2008). According to a meta-analysis, healthcare provider recommendation is consistently associated with increased mammography use (Schueler, Chu, & Smith-Bindman, 2008); however, as a woman's age increases, the likelihood that her physician will recommend mammography decreases (Hawley, Earp, O’Malley, & Ricketts, 2000; Lane, Zapka, Breen, Messina, & Fotheringham, 2000).

Having a family history of breast cancer impacts breast cancer risk perception, early detection beliefs, and mammography decisions, although study results are inconsistent. In women 40 years of age and older without breast cancer, those with a first-degree relative with the disease were more likely to believe breast cancer could be cured with early detection. They were also more likely to report a mammogram within the past year and rate their breast cancer risk higher than women without a family history (Tracy et al., 2008). In another study, however, 89% of women with a high breast cancer risk due to family history and other risk factors had an optimistic bias and underestimated their breast cancer risk. Level of perceived risk did not correlate with breast cancer screening in this study (Katapodi, Dodd, Lee, & Facione, 2009).

In a study of 41 women 27 to 84 years of age, 12 with a breast cancer family history, Silverman et al. (2001) explored women's beliefs about breast cancer and mammography. Almost all women viewed breast cancer as a progressive disease that begins in a silent curable form. Most believed that mammography had no down sides and could detect breast cancer early, and that breast cancers were seldom missed. Women believed even benign lesions had malignant potential.

A similar qualitative study of 50 women 36 to 83 years of age identified three approaches to mammography decision making (Lewis, Corcoran-Perry, Narayan, & Lally, 1999). Nearly half the women used “thoughtful consideration” considering age, family history, breast cancer risk factors, and mammography risks and benefits, with 57% having mammography. A third used “cursory consideration,” with 63% having mammography. Surprisingly, 25% used “little or no consideration,” with 92% having mammography and the physician usually making the decision.

A grounded theory study of 30 African American women 52 to 71 years of age found women who were “taking charge” (proactive) or “enduring” (reactive and passive) healthcare decision makers reported 100% mammography screening (Fowler, 2006). “Protesting” decision makers were more confrontational in attitudes about breast health, reported more fatalistic beliefs about breast cancer, and had skepticism of healthcare providers and screening procedures. Only 33% in this group reported any mammography screening. None of these studies addressed mammography decision-making processes in women with a family history of breast cancer.

A number of studies have found that tailored print and telephone interventions increased mammography screening in average-risk women (Sohl & Moyer, 2007); however, these studies rarely address whether or not these interventions are effective in women with a family history of breast cancer or how to tailor interventions to this population. Although having a family history of breast cancer impacts breast cancer risk awareness, mammography beliefs, and decision-making processes, decision-making studies of women with a breast cancer family history have largely focused on younger women who have undergone genetic testing for breast cancer predisposition.

In the mammography literature there are a range of ages used to define older women, ranging from 50 years of age and older to 65 years of age and older, depending on the study. In this study, older women are defined as 55 years of age and older since 65% of breast cancers occur in this age group.

This study's purpose was to describe and explain how women 55 years of age and older with at least one first-degree relative diagnosed with breast cancer make screening mammography decisions. Study aims were: (a) Generate a grounded theory that describes and explains participant's screening mammography decision-making processes. (b) Describe the conditions, actions, and consequences associated with participant's screening mammography decision making.

Methods

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Study Limitations
  7. Conclusions
  8. Acknowledgments
  9. Clinical Resources
  10. References

Design

Grounded theory methodologies guided this qualitative study. The study design was emergent, allowing the inquiry methods to be adapted based on what was learned in the ongoing data analysis. Using inductive analysis, concepts were identified from the text data, and categories of concepts were developed that explain the phenomenon of interest. Grounded theory focuses on how participants experience events and the meanings they assign to their behaviors and actions, which enhances understanding of human behavior (Strauss & Corbin, 2008).

After obtaining institutional review board approval for this study, women were recruited through fliers, newsletter advertisements, and presentations at events, including senior and community centers, medical offices, and senior living communities. Criteria for study inclusion were female gender; 55 years of age or older; having a first-degree relative with a breast cancer diagnosis; no personal history of breast cancer, ductal carcinoma in situ, breast implants, or mastectomy; and no cancer diagnosis (except nonmelanoma skin cancer) in the past 10 years. Women who met the study criteria and agreed to participate were interviewed in person at a private place of their choosing. Recruitment was discontinued when the analysis provided no new information contributing to the developing theory. The researcher conducted open-ended interviews using a semistructured interview guide. For the purpose of describing the participants, demographic data were collected at the end of the interview. Field notes were maintained to describe the environmental and emotional context of the interviews. Interviews were recorded and transcribed verbatim, with all personally identifying information deleted. QSR NVivo 2 software (2002, QSR International Pty. Ltd., Doncaster, Victoria, Australia) facilitated data management and analysis.

Sample

Twenty-three women 55 to 85 years of age (Table) living independently participated in this study. Ten of the women were married at the time of the interview, and all had at least a high school education, with 11 having some college. No participants used mobility aids. Participants had a total of 31 first-degree relatives with breast cancer (10 mothers, 15 sisters, and 6 daughters) and an average of 3.2 first- or second-degree relatives diagnosed with any cancer.

Table Table.  Sample Characteristics (N=23)
 n
Age ranges (56–85 years, mean age 71 years)
 55–59 2
 60–69 8
 70–79 8
 80 and older 5
Level of education
 High school graduate12
 4 or more years of college11
Marital status
 Currently married10
 Divorced 4
 Widowed 7
 Single 2
Summary of first-degree relatives with breast cancer (10 mothers,
   15 sisters, 6 daughters)
 Mother only 6
 Sister only 7
 Daughter only 3
 Mother and sister 3
 Mother and daughter 1
 Two sisters 1
 Sister and daughter 1
 Two sisters and one daughter 1

Data Analysis

Data collection and analysis occurred simultaneously since data analysis guided further data collection. Data were analyzed using text coding strategies common to grounded theory. Concepts were identified through open coding and organized into categories based on how well they explained mammography decision-making processes. Comparative analysis was used to identify patterns and variations in the data. Axial coding was conducted that identified conditions, actions, and consequences associated with the core category or main theme in the women's stories. Theoretical sampling was used to help develop the concepts and categories, for example, to gain understanding of how the two women who were not having mammograms guarded against cancer. Theoretical memos documented the researcher's thoughts and ideas during analysis. A theoretical model was developed that explains how older women with a family history of breast cancer make screening mammography decisions (Figure).

image

Figure Figure. Guarding against cancer.

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While the principal investigator conducted all of the interviews and did the preliminary analyses, three coinvestigators reviewed segments of the interview data, coding, and theoretical memos and provided critical feedback on how the data were conceptualized. Disagreements about the meanings of data or codes were resolved by reaching consensus in understanding the participants’ interview responses. Several research participants were interviewed a second time to answer additional questions to help refine the theory and to comment on whether the emerging theory and framework represented their experience, and changes were made based on this feedback. Trustworthiness of the grounded theory was verified by conducting multiple interviews with five participants, sharing and discussing the data and codes with coinvestigators, and using an audit trail for external review of field notes and theoretical memos.

Results

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Study Limitations
  7. Conclusions
  8. Acknowledgments
  9. Clinical Resources
  10. References

“Guarding Against Cancer” Grounded Theory

The “guarding against cancer” theory describes and explains the conditions, actions, and consequences involved when women 55 years of age and older with a family history of breast cancer make decisions about whether or not to have screening mammography. Guarding against cancer was the core process emerging from the data used to name the theory (Figure). Conditions associated with the decision-making process include triggering events, being aware of risk, and beliefs. Actions women took in guarding against cancer included taking charge of health and maintaining faith. The consequences or outcomes of guarding against cancer were how much peace of mind and assurance women had that cancer was not present and how much worry women had about cancer.

The process of guarding against cancer was usually the result of a “triggering event” that caused participants to become aware of their breast cancer risk. Women talked about their fear of getting breast cancer, dying of breast cancer, or having it and not knowing it. Women varied in how much they were guarding against cancer. As one woman put it, “you might sometimes be on real rigid, scared, on guard and other times you might be lightly on guard.” Triggering events usually caused women to increase or evaluate their level of guarding against cancer.

Conditions Associated With Guarding Against Cancer

Triggering event Triggering events are events that led to women being aware of their breast cancer risk. These events included having a friend or family member diagnosed with breast cancer, having a breast change discovered by themselves or their healthcare provider, reaching the age a close family member was diagnosed with cancer, the process of having a mammogram, or experiencing a mammogram recall (called back for additional mammogram views). Some triggering events were perceived by women as undesirable or negative, such as having a mammogram recall or a family member being diagnosed with breast cancer. Triggering events were also positive, such as having a negative mammogram result, or neutral, such as reminders.

Being aware of risk Women talked about having a family history of breast cancer making them more aware of their own cancer risk: “You hear about it but until it strikes your own family, I guess that's when it becomes important.” Having a family history of cancer was significant for the women in this study, and they often felt different from women without this history: “I realize that it doesn't happen to everyone else, it does happen in our family.”

Being aware of risk occurred as a result of a triggering event such as having a family member being diagnosed with breast cancer. Risk awareness often led to breast cancer screening or other health behaviors taking on a new level of importance. One woman's attitude toward mammography is illustrated by her comment, “I need it more than the average woman, because of this history we just talked about.” Most participants believed having a family history of breast cancer increased their own risk for the disease.

Having a family history of breast cancer, especially a mother, was often reported by women as influencing their awareness of risk and decision to have a mammogram. For example, “I knew because of my mother that I needed to have a mammogram, so it's never been a decision not to have it.”

A couple of women talked about their sister's diagnosis of breast cancer as being the influencing factor in their decision to have mammograms; however, none of the participants mentioned a daughter's diagnosis influencing their mammography decisions. All daughters were diagnosed in their forties or fifties. Women did not view having a daughter diagnosed with breast cancer as meaning they were at increased risk for breast cancer. They believed breast cancer was more likely in younger women and because they were past the age when their daughters were diagnosed, their risk of breast cancer had decreased. For example, “You know at my age [80], it isn't likely it really strikes … I thought about it when I was her age [daughter, age 54].”

Beliefs Women talked about beliefs they held that influenced whether or not they decided to have mammography or take other actions related to taking charge of health and guarding against cancer. The most common beliefs related to age, mammograms, and cancer susceptibility. Beliefs about age centered on whether or not a woman believed her breast cancer risk increased or decreased as she became older. Some women in their seventies or eighties believed that their increased age lowered their breast cancer risk because “I’ve lived this long and I don't have it” or that breast cancer was a disease of younger women, as illustrated by this quote: “I think [my risk is] very slim compared to someone in their fifties or in their forties.”

When comparing the nine women 75 years of age and older with the 14 participants 74 years of age and younger, women in the older age group tended to be less concerned about whether or not they were diagnosed with breast cancer and were more likely to underestimate their breast cancer risk. Women in the older age group receiving mammograms universally discussed keeping track of their mammograms using calendars and receiving reminders in the mail because “as you get older unless you keep a diary or a calendar, you don't remember.”

Women believed that mammograms would detect breast cancer early and that their “life may depend on it.” Mammography was viewed as very important and “you’re stupid not to do it.” Women saw mammography as a way to keep breast cancer from surprising them and preventing it from killing them. For example, “All I know is it's a fantastic technology. It's screening breasts for the beginnings of cancer and maybe even farther down the line,” and “It's the best thing I can do for right now.” Participants believed mammography was the best technology currently available and was better than either clinical breast examination or breast self-examination. Five participants receiving mammography who reported regular healthcare provider visits reported no recent clinical breast examination.

The two women who reported they were not receiving regular mammograms both believed mammograms were effective; however, they had different reasons for not having mammograms. Both were in their eighties and believed they were at risk for breast cancer, although they believed their risk was lower than it was 20 to 30 years ago. Both women had two first-degree relatives diagnosed with breast cancer, one of whom was a daughter. One woman guarded against cancer by avoiding mammograms because she believed they could actually cause her to have breast cancer. She had received painful mammograms in the past and reported telling a technician, “Every time you guys do this you press so hard, if I don't have cancer now, I will when you get through.” The other woman reported not having had a mammogram in at least 20 years because, although she reported receiving annual physical examinations, her doctor hadn't given her a breast examination in years or recommended a mammogram, so she believed she must not need them. She also believed her breast cancer risk was lower in her eighties because both her mother and daughter had been diagnosed with breast cancer in their fifties. She was guarding against breast cancer by checking her breasts several times a week in the shower, watching for any signs and symptoms, and being careful about her diet.

Actions Women Took in Guarding Against Cancer

Taking charge of health Women believed taking charge of their health by having mammograms, getting health check-ups, having healthy behaviors and being optimistic would lessen their chances of being diagnosed with or dying of breast and other cancers. Most women took action by having regular mammograms since they were seen as a way to “see inside” so breast cancer would not surprise them, as illustrated by, “I’m very dependent on my once a year mammogram. ‘Cause I feel I can touch myself forever, but the mammogram is really going to find something obvious like that, plus much more.” Some women scheduled their own mammograms, regardless of whether their providers had recommended them, to be sure they received them.

Maintaining faith Maintaining faith is the process women went through to maintain their belief that mammography is effective even in the presence of conflicting information. Faith in mammography's ability to detect breast cancer early appeared in all interviews regardless of whether or not women were having mammograms. Women talked about the pain of mammography and some women even dreaded the experience. Yet, they dared not miss their mammogram because breast cancer might go undetected. Even though mammography was painful, it was worth it. As one woman stated, “It hurts for a minute, maybe 2 minutes. You’ve got a whole year of reassurance after that, you know. And to me it's more than worth it.”

Some women's faith in mammography was so strong that information they received about mammography's limitations was often ignored or dismissed, even if mammography had missed a breast cancer in a close relative. For example, “Well, I’ve read some articles and every now and then there's a study that says that mammography's not as good as they thought it was and I just ignore them.”

Consequences of Guarding Against Cancer

Assurance and peace of mind Participants talked about the “assurance” and “peace of mind” conferred by a negative mammogram result. This peace of mind, however, was often time limited and only lasted until their next mammogram was due. “Well, you should have peace of mind, more peace of mind, afterwards, like you can just sigh this sigh of relief and say, ‘Wow, for another year I know I’m all right.’” Another participant talks about the assurance that cancer is not present. “Well, it's peace of mind that there's not a cancer that is lying undetected.”

Worry Women varied in whether or not they worried about getting breast cancer. Being called back for additional mammograms or follow-up tests often caused worry, anxiety, and breast cancer fear, especially when receiving test results was delayed. Worry was associated with losing peace of mind. Having a negative mammogram result helped women regain peace of mind and assurance. One participant who had several recalls described her experience.

You go through all this sleepless nights. Is it or isn't it, do I have this? I think about that because my mother had breast cancer and now my sister has been treated for breast cancer and she's younger than I am. So, the recalls are traumatic. I try to tell myself, “Look, you’ve been through this several times and it always has turned out okay, and after all, breast cancer is treatable, you know.” I try not to worry about it, but I still do.

Another woman described her recall experience as follows:

That is scary … I think that was the first time that they had to do more pictures—and then to be called back for an ultrasound. Then I had to wait for 3 or 4 days for the doctor … very scary.

One woman drove an hour to a breast center just so she would receive her mammogram results right away. Other women said they did not tend to worry in general and therefore they did not worry a lot about cancer: “If it happens then I’ll deal with it, but I don't focus on it.”

Discussion

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Study Limitations
  7. Conclusions
  8. Acknowledgments
  9. Clinical Resources
  10. References

In this study, conditions facilitating women's decisions to have mammography included having a family member diagnosed with breast cancer, believing that mammography detects breast cancer early, believing increased age increases breast cancer risk, receiving mammography reminders, and having a healthcare provider recommend a mammogram. Participants reported physician recommendation as influencing their decision to have a mammogram, which is consistent with the literature. What was not found in the literature was women being willing to defy their healthcare providers, if needed, to have their mammograms.

Although in this study participants described being actively involved in mammography decision making, in a study by Burack, George, and Gurney (2000), age was inversely related to active involvement in mammography decision making ranging from 48% in women 55 to 59 years of age to 19% in women 75 years of age and older. Perhaps women with a breast cancer family history are more likely to be actively involved because they are more aware of their breast cancer risk.

Not having insurance coverage has been associated with lower mammography rates, although, even with Medicare, older women are less likely to receive mammography (Schueler et al., 2008). All participants in this study had insurance coverage. Women on Medicare, however, reported needing to track their mammography dates in order for Medicare to cover the cost.

Increased age may be under recognized as a breast cancer risk factor in women with a breast cancer family history and patient education may be needed. Some women in this study believed as they got older breast cancer risk was reduced and screening was less important. In an earlier study, 12% of older women did not recognize increased age as a breast cancer risk factor (Thomas, Fox, Leake, & Roetzheim, 1996). More current studies related to whether or not women recognize age as a breast cancer risk factor were not found. However, a recent study found age was inversely related to women's level of perceived breast cancer risk regardless of family breast cancer history (Katapodi et al., 2009).

Individuals at increased risk for cancer may share core experiences related to undergoing cancer screening that are not experienced by individuals at average risk for cancer. This study has some similarities to another study of women with a family history of cancer being aware of their breast cancer risk. In a qualitative descriptive study of women 20 to 69 years of age with a family history of breast cancer, Chalmers and Thomson (1996, p. 261) explored the meaning of being at risk for breast cancer. “Living the breast cancer experience” of the relative led to “developing a risk perception,” which was sometimes complicated by emotions such as anxiety. Developing a risk perception involved the women articulating their personal vulnerability to breast cancer.

Similar to this study, women 22 to 60 years of age at high risk for breast cancer in another study went through a process called “seeking peace of mind,” which describes how they sought support and made healthcare decisions aimed at reducing their breast cancer risk to help them feel less vulnerable to breast cancer (Perry, 2004). In contrast, in two other studies of breast health practices, women at average risk for breast cancer viewed mammography as a routine health promotion activity without worrying about the outcome or needing a negative mammogram to achieve peace of mind (Canales & Wilkinson, 2002; Lewis et al., 1999).

Findings from this study are similar to those of Silverman et al. (2001) in that women almost universally believed that mammography could detect breast cancer early and cancers were seldom missed, with most believing that mammography had no down sides. The majority reported that if they were to receive an abnormal mammogram they would be fearful of the outcome.

Participant worry tended to be in response to a breast cancer threat such as having a mammogram recall or identifying a breast change. This is consistent with another study of younger women at hereditary risk for breast cancer, which found that family history did not predict cancer worry; however, clinical signs of breast cancer were significantly correlated (Loescher, 2003). Participants in this study who tended to worry reported more worry related to mammogram recalls and having to wait for test results. In another study, although women with high suspicion or abnormal mammograms often experienced mammography-related anxiety and breast cancer worries, immediate reading of screening mammograms decreased anxiety among women with false-positive results. Worry is complicated because while moderate worry has been associated with increased mammography use in women with a family history of breast cancer, mild or severe worry can decrease mammography use (Andersen, Smith, Meischke, Bowen, & Urban, 2003; Diefenbach, Miller, & Daly, 1999).

Study Limitations

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Study Limitations
  7. Conclusions
  8. Acknowledgments
  9. Clinical Resources
  10. References

All participants were White women. Most participants had multiple first-degree and second-degree relatives with breast and other cancers. Their mammography decision-making processes may be different from women with only one first-degree relative with breast cancer, or women from ethnically diverse backgrounds. The accuracy of self-reported mammograms could not be verified with medical records. Although efforts were made to recruit women not receiving regular mammograms, only two participants were not receiving regular mammograms.

Conclusions

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Study Limitations
  7. Conclusions
  8. Acknowledgments
  9. Clinical Resources
  10. References

Findings from this study indicate that primary care providers can facilitate women 55 years of age and older deciding to have mammograms by providing mammogram reminders, timely mammogram results, and psychosocial support for women undergoing a mammography recall or other follow-up tests such as ultrasound or breast biopsy. Healthcare providers also need to inform women that breast cancer risk increases with age because some women may believe as they get older their breast cancer risk lowers and breast cancer screening is not needed, especially if their relative was diagnosed with breast cancer at a younger age.

Studies are needed to identify support needs of women with a breast cancer family history undergoing mammography recall, the impact of delay in receiving mammography results, and to compare psychological and cost outcomes in women who receive care in centers where follow-up tests can be done the same day compared with settings where test results are delayed. Researchers need to explore older women's beliefs about age and breast cancer risk and the relationship to mammography behavior. Findings from this study need to be compared to a larger sample of older women not receiving regular mammography and to the mammography decision-making processes of different ethnic groups. The “guarding against cancer” theory needs to be tested in other at-risk populations such as those at increased risk for colorectal cancer. Developing a more generalizable theory can be used in future studies to test strategies that promote cancer screening decision making and the adoption of screening behaviors in those at increased risk for developing cancer.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Study Limitations
  7. Conclusions
  8. Acknowledgments
  9. Clinical Resources
  10. References

The primary author would like to acknowledge support from the following funding sources: John A. Hartford Foundation's Building Academic Geriatric Nursing Capacity 2002–2004 Pre-Doctoral Scholarship; National Institutes of Health National Research Service Award for Research Training: Nursing Care For Older Populations (T32 NR0007048); National Institutes of Health National Research Service Award for Research Training: Nursing Care For Older Populations (T32 NR7048-15); Oregon Health & Science University Dean's Scholarship; and Oncology Nursing Foundation 2002 Doctoral Scholarship. The authors would also like to acknowledge Richard J. Greco for his assistance with the “guarding against cancer” diagram in the Figure.

Clinical Resources

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Study Limitations
  7. Conclusions
  8. Acknowledgments
  9. Clinical Resources
  10. References

References

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Study Limitations
  7. Conclusions
  8. Acknowledgments
  9. Clinical Resources
  10. References
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