Uncertainty During Breast Diagnostic Evaluation: State of the Science

Mariann Montgomery

uncertainty, breast cancer, breast neoplasms, breast cancer diagnosis, diagnosis, anxiety, systematic review
ONF 2009, 37(1), 77-83. DOI: 10.1188/10.ONF.77-83

Purpose/Objectives: To present the state of the science on uncertainty in relationship to the experiences of women undergoing diagnostic evaluation for suspected breast cancer.

Data Sources: Published articles from Medline®, CINAHL®, PubMED, and PsycINFO from 1983-2008 using the following key words: breast biopsy, mammography, uncertainty, reframing, inner strength, and disruption.

Data Synthesis: Fifty research studies were examined with all reporting the presence of anxiety persisting throughout the diagnostic evaluation until certitude is achieved through the establishment of a definitive diagnosis. Indirect determinants of uncertainty for women undergoing breast diagnostic evaluation include measures of anxiety, depression, social support, emotional responses, defense mechanisms, and the psychological impact of events.

Conclusions: Understanding and influencing the uncertainty experience have been suggested to be key in relieving psychosocial distress and positively influencing future screening behaviors. Several studies examine correlational relationships among anxiety, selection of coping methods, and demographic factors that influence uncertainty. A gap exists in the literature with regard to the relationship of inner strength and uncertainty.

Implications for Nursing: Nurses can be invaluable in assisting women in coping with the uncertainty experience by providing positive communication and support. Nursing interventions should be designed and tested for their effects on uncertainty experienced by women undergoing a breast diagnostic evaluation.

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    Allen, J.D., Shelton, R.C., Harden, E., & Goldman, R.E. (2008). Followup of abnormal screening mammograms among low-income ethnically diverse women: Findings from a qualitative study. Patient Education and Counseling, 72, 283-292. Retrieved from
    American Cancer Society. (2009). Breast cancer facts and figures, 2008. Atlanta, GA: Author.
    Andrykowski, M.A., Carpenter, J.S., Studts, J.L., Cordova, M.J., Cunningham, L.L. C., Beacham, A., … McGrath, P. (2002). Psychological impact of benign breast biopsy: A longitudinal, comparative study. Health Psychology, 21, 485-494. doi: 10.1037/0278-6133.21.5.485
    Arnsberger, P., Fox, P., Ryder, P., Nussey, B., Xiulan, Z., & Otero-Sabogal, R. (2006). Timely follow-up among multicultural women with abnormal mammograms. American Journal of Health Behavior, 30, 51-61. Retrieved from
    Aro, A.R., Pilvikki Absetz, S., van Elderen, T.M., van der Ploeg, E., & van der Kamp, L.J. (2000). False-positive findings in mammography screening induces short-term distress—Breast cancer-specific concern prevails longer. European Journal of Cancer, 36, 1089-1097. Retrieved from
    Baldacchino, D., & Draper, P. (2001). Spiritual coping strategies: A review of the nursing research literature. Journal of Advanced Nursing, 34, 833-841. doi: 10.1046/j.1365-2648.2001.01814.x
    Barton, M.B., Morley, D.S., Moore, S., Allen, J.D., Kleinman, K.P., Emmons, K.M., & Fletcher, S.W. (2004). Decreasing women's anxieties after abnormal mammograms: A controlled trial. Journal of the National Cancer Institute, 96, 529-538. doi: 10.1093/jnci/djh083
    Benedict, S., Williams, R.D., & Baron, P.L. (1994). Recalled anxiety: From discovery to diagnosis of a benign breast mass. Oncology Nursing Forum, 21, 1723-1727.
    Bradley, P.K., Berry, A., Lang, C., & Myers, R.E. (2006). Getting ready: developing an educational intervention to prepare African American women for breast biopsy. Association of Black Nursing Faculty Journal, 17, 15-19.
    Brett, J., Austoker, J., & Ong, G. (1998). Do women who undergo further investigation for breast screening suffer adverse psychological consequences? A multi-centre follow-up study comparing different breast screening result groups five months after their last breast screening appointment. Journal of Public Health Medicine, 20, 396-403. Retrieved from
    Bury, M. (1982). Chronic illness as biographical disruption. Sociology of Health and Illness, 4, 167-182.
    Chappy, S.L. (2004). Women's experience with breast biopsy. American Association of Operating Room Nurses Journal, 80, 885-901. Retrieved from
    Clutton, S., Buckley, B., & Pakenham, K.I. (1999). Predictors of emotional well-being following a false positive breast cancer screening result. Psychology and Health, 14, 263. Retrieved from
    Deane, K.A., & Degner, L.F. (1997). Determining the information needs of women after breast biopsy procedures. American Association of Operating Room Nurses Journal, 65, 767. Retrieved from
    Deane, K.A., & Degner, L.F. (1998). Information needs, uncertainty, and anxiety in women who had a breast biopsy with benign outcome. Cancer Nursing, 21, 117-126.
    De Grasse, C.E., Hugo, K., & Plotnikoff, R.C. (1997). Supporting women during breast diagnostics. Canadian Nurse, 93(9), 24-30.
    DeKeyser, F.G., Wainstock, J.M., Rose, L., Converse, P.J., & Dooley, W. (1998). Distress, symptom distress, and immune function in women with suspected breast cancer. Oncology Nursing Forum, 25, 1415-1422.
    Demir, F., Donmez, Y.C., Ozsaker, E., & Diramali, A. (2008). Patients' lived experiences of excisional breast biopsy: A phenomenological study. Journal of Clinical Nursing, 17, 744-751. doi: 10.1111/j.1365-2702.2007.02116.x
    Dingley, C.E., Bush, H.A., & Roux, G. (2000). Inner strength: A concept analysis. Journal of Theory Construction and Testing, 4(2), 30-35.
    Dingley, C.E., & Roux, G. (2003). Inner strength in older Hispanic women with chronic illness. Journal of Cultural Diversity, 10, 11-22.
    Drageset, S., & Lindstrom, T.C. (2003). The mental health of women with suspected breast cancer: The relationship between social support, anxiety, coping and defence in maintaining mental health. Journal of Psychiatric and Mental Health Nursing, 10, 401-409. doi: 10.1046/j.1365-2850.2003.00618.x
    Drageset, S., & Lindstrom, T.C. (2005). Coping with a possible breast cancer diagnosis: Demographic factors and social support. Journal of Advanced Nursing, 51, 217-226. doi: 10.1111/j.1365-2648.2005.03495.x
    Eriksen, H.R. (1997). The CODE: A revised battery for coping and defense and its relations to subjective help. Scandinavian Journal of Psychology, 38, 175-182.
    Ferrante, J.M., Chen, P.H., & Kim, S. (2008). The effect of patient navigation on time to diagnosis, anxiety, and satisfaction in urban minority women with abnormal mammograms: A randomized controlled trial. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 85, 114-124. doi: 10.1007/s11524-007-9228-9
    Fridfinnsdottir, E.B. (1997). Icelandic women's identifications of stressors and social support during the diagnostic phase of breast cancer. Journal of Advanced Nursing, 25, 526-531. doi: 10.1111/j.1365-2648.1997.tb03332.x
    Haas, J., Kaplan, C., McMillan, A., & Esserman, L.J. (2001). Does timely assessment affect the anxiety associated with an abnormal mammogram result? Journal of Women's Health and Gender-Based Medicine, 10, 599-605. doi: 10.1089/15246090152543184
    Harcourt, D., Rumsey, N., & Ambler, N. (1999). Same-day diagnosis of symptomatic breast problems: Psychological impact and coping strategies. Psychology, Health and Medicine, 4, 57-71. doi: 10.1080/135485099106405
    Heckman, B.D., Fisher, E.B., Monsees, B., Merbaum, M., Ristvedt, S., & Bishop, C. (2004). Coping and anxiety in women recalled for additional diagnostic procedures following an abnormal screening mammogram. Health Psychology, 23, 42-48. Retrieved from…
    Hislop, T.G., Harris, S.R., Jackson, J., Thorne, S.E., Rousseau, E.J., Coldman, A.J., … Olivotto, I.A. (2002). Satisfaction and anxiety for women during investigation of an abnormal screening mammogram. Breast Cancer Research and Treatment, 76, 245-254. doi: 10.1023/A:1020820103126
    Jordens, C.F., Little, M., Paul, K., & Sayers, E.J. (2001). Life disruption and generic complexity: A social linguistic analysis of narratives of cancer illness. Social Science Medicine, 53, 1227-1236. doi: 10.1016/S0277-9536(00)00422-6
    Lampic, C., Thurfjell, E., Bergh, J., & Sjoden, P.O. (2001). Short-and long-term anxiety and depression in women recalled after breast cancer screening. European Journal of Cancer, 37, 463-469. Retrieved from
    Lauver, D., & Tak, Y. (1995). Optimism and coping with a breast cancer symptom. Nursing Research, 44, 202-207.
    Lebel, S., Jakubovits, G., Rosberger, Z., Loiselle, C., Seguin, C., Cornaz, C., … Lisbona, A. (2003). Waiting for a breast biopsy: Psychosocial consequences and coping strategies. Journal of Psychosomatic Research, 55, 437. Retrieved from
    Liao, M., Chen, M., & Chen, S. (2008). Uncertainty and anxiety during the diagnostic period for women with suspected breast cancer. Cancer Nursing, 31, 274-283.
    Liao, M., Chen, M., Chen, S., & Chen, P. (2007). Healthcare and support needs of women with suspected breast cancer. Journal of Advanced Nursing, 60, 289-298. doi: 10.1111/j.1365-2648.2007.04410.x
    Logan, J., Hackbusch-Pinto, R., & De Grasse, C.E. (2006). Women undergoing breast diagnostics: The lived experience of spirituality. Oncology Nursing Forum, 33, 121-126. doi: 10.1188/06.ONF.121-126
    Lowe, J.B., Balanda, K.P., Del Mar, C., & Hawes, E. (1999). Psychologic distress in women with abnormal findings in mass mammography screening. Cancer, 85, 1114-1118. Retrieved from
    MacFarlane, M.E., & Sony, S.D. (1992). Women, breast lump discovery, and associated stress. Health Care for Women International, 13, 23-32.
    Maxwell, J.R., Bugbee, M.E., Wellisch, D., Shalmon, A., Sayre, J., & Bassett, L.W. (2000). Imaging-guided core needle biopsy of the breast: Study of psychological outcomes. Breast Journal, 6, 53-61. doi: 10.1046/j.1524-4741.2000.98079.x
    McCormick, K.M. (2002). A concept analysis of uncertainty in illness. Journal of Nursing Scholarship, 34, 127-131. doi: 10.1111/j.1547-5069.2002.00127.x
    Mishel, M.H. (1990). Reconceptualization of the uncertainty in illness theory. Image: The Journal of Nursing Scholarship, 22, 256-262.
    Mishel, M.H. (1997). Uncertainty in acute illness. Annual Review of Nursing Research, 15, 57-80.
    Mishel, M.H., & Braden, C.J. (1988). Finding meaning: Antecedents of uncertainty in illness. Nursing Research, 37, 98-103.
    Mishel, M.H., Germino, B.B., Gil, K.M., Belyea, M., Laney, I.C., Stewart, J., … Clayton, M. (2005). Benefits from an uncertainty management intervention for African-American and Caucasian older long-term breast cancer survivors. Psycho-Oncology, 14, 962-978. doi: 10.1002/pon.909
    Northouse, L.L., Jeffs, M., Cracchiolo-Caraway, A., Lampman, L., & Dorris, G. (1995). Emotional distress reported by women and husbands prior to a breast biopsy. Nursing Research, 44, 196-201.
    Northouse, L.L., Tocco, K.M., & West, P. (1997). Coping with a breast biopsy: How healthcare professionals can help women and their husbands. Oncology Nursing Forum, 24, 473-480.
    Novy, D.M., Price, M., Huynh, P.T., & Schuetz, A. (2001). Percutaneous core biopsy of the breast: Correlates of anxiety. Academic Radiology, 8, 467-472. Retrieved from
    Olsson, P., Armelius, K., Nordahl, G., Lenner, P., & Westman, G. (1999). Women with false positive screening mammograms: How do they cope? Journal of Medical Screening, 6, 89-93. Retrieved from
    O'Mahony, M. (2001). Women's lived experience of breast biopsy: A phenomenological study. Journal of Clinical Nursing, 10, 512-520 doi: 10.1046/j.1365-2702.2001.00493.x
    Ong, G., & Austoker, J. (1997). Recalling women for further investigation of breast screening: Women's experiences at the clinic and afterwards. Journal of Public Health Medicine, 19, 29-36. Retrieved from
    Owen, D.C. (1992). Emotional distress, coping behavior, and immunity in women undergoing breast biopsy. Unpublished doctoral dissertation. Case Western Reserve University: Health Sciences.
    Padgett, D.K., Yedidia, M.J., Kerner, J., & Mandelblatt, J. (2001). The emotional consequences of false positive mammography: African-American women's reactions in their own words. Women and Health, 33(3/4), 1-14.
    Penrod, J. (2007). Living with uncertainty: Concept advancement. Journal of Advanced Nursing, 57, 658-667. doi: 10.1111/j.1365-2648.2006.04008.x
    Pineault, P. (2007). Breast cancer screening: Women's experiences of waiting for further testing. Oncology Nursing Forum, 34, 847-853. doi: 10.1188/09.ONF.847-853
    Poole, K., Hood, K., Davis, B.D., Monypenny, I.J., Sweetland, H., Webster, D.J., … Mansel, R.E. (1999). Psychological distress associated with waiting for results of diagnostic investigations for breast disease. Breast (Edinburgh, Scotland), 8, 334-338. doi: 10.1054/brst.1999.0085
    Poole, K., & Lyne, P.A. (2000). The ‘cues’ to diagnosis: Describing the monitoring activities of women undergoing diagnostic investigations for breast cancer. Journal of Advanced Nursing, 31, 752-758. doi: 10.1046/j.1365-2648.2000.01345.x
    Potter, P.J. (2007). Breast biopsy and distress: Feasibility of testing a Reiki intervention. Journal of Holistic Nursing, 25, 238-248. Retrieved from
    Rehnberg, G., Absetz, P., & Aro, A.R. (2001). Women's satisfaction with information at breast biopsy in breast cancer screening. Patient Education and Counseling, 42, 1-8. Retrieved from
    Riese, S. (2001). Women's experiences with breast biopsy. Dissertation Abstracts International, 62(3), 194.
    Scott, D.W. (1983). Anxiety, critical thinking and information processing during and after breast biopsy. Nursing Research, 32, 24-28.
    Seckel, M.M., & Birney, M.H. (1996). Social support, stress, and age in women undergoing breast biopsies. Clinical Nurse Specialist: The Journal for Advanced Nursing Practice, 10, 137-143.
    Shaw, C.R., Wilson, S.A., & O'Brien, M.E. (1994). Information needs prior to breast biopsy. Clinical Nursing Research, 3, 119-131.
    Spielberger, C.D., Gorsuch, R.L., & Lushene, R. (1970). Test manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press.
    Thorne, S.E., Harris, S.R., Hislop, T.G., & Vestrup, J.A. (1999). The experience of waiting for diagnosis after an abnormal mammogram. Breast Journal, 5, 42. doi: 10.1046/j.1524-4741.1999.005001042.x
    Walter, J.M. (2005). Psychoneuroimmunological manifestations of stress in women undergoing breast biopsy. Dissertation Abstracts International, 66(11), 164.
    Wilson, S. (2007). ‘When you have children, you're obliged to live’: Motherhood, chronic illness and biographical disruption. Sociology of Health and Illness, 29, 610-626. doi: 10.1111/j.1467-9566.2007.01008.x