GERONTOLOGIC SERIES

Mammography Decision Making in Older Women With a Breast

Cancer Family History
Karen E. Greco, RN, PhD, ANP-BC1 , Lillian M. Nail, RN, PhD, FAAN2 , Judy Kendall, RN, PhD3 ,
Juliana Cartwright, RN, PhD4 , & Deborah C. Messecar, RN, PhD, MPH, CNS5
1
2
3
4
5

Beta Psi, Nurse Specialist (research), Contractor, Genetics Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD
Beta Psi, Dr. May Rawlinson Distinguished Professor & Senior Scientist, Oregon Health & Science University, School of Nursing, Portland, OR
Professor, Division of Child and Family Nursing, Oregon Health & Science University, School of Nursing, Portland, OR
Associate Professor, Oregon Health & Science University, School of Nursing, Portland, OR
Beta Psi, Associate Professor, Oregon Health & Science University, School of Nursing, Portland, OR

Key words
Mammography, decision making, breast cancer
screening, breast screening, breast cancer,
family history, grounded theory, qualitative
research
Correspondence
Dr. Karen E. Greco, 8901 Wisconsin Ave.,
Building 8, Room 5105, Bethesda,
MD 20889-5105. E-mail: karen.greco@nih.gov
Accepted: October 17, 2009
doi: 10.1111/j.1547-5069.2010.01335.x

Abstract
Purpose: This studys 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 participants 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. Womens 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 (Amer-

348

ican 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 womans risk for being diagnosed with

Journal of Nursing Scholarship, 2010; 42:3, 348356.

c 2010 Sigma Theta Tau International


Mammography Decisions in Older Women

Greco et al.

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 womans age increases, the likelihood that
her physician will recommend mammography decreases
(Hawley, Earp, OMalley, & 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 womens 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 consider-

ation, 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 studys 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
participants screening mammography decision-making
processes. (b) Describe the conditions, actions, and consequences associated with participants screening mammography decision making.

Methods
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
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Mammography Decisions in Older Women

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 firstdegree 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.

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
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Greco et al.

Table. Sample Characteristics (N=23)

n
Age ranges (5685 years, mean age 71 years)
5559
6069
7079
80 and older
Level of education
High school graduate
4 or more years of college
Marital status
Currently married
Divorced
Widowed
Single
Summary of rst-degree relatives with breast cancer (10 mothers,
15 sisters, 6 daughters)
Mother only
Sister only
Daughter only
Mother and sister
Mother and daughter
Two sisters
Sister and daughter
Two sisters and one daughter

2
8
8
5
12
11
10
4
7
2

6
7
3
3
1
1
1
1

that identified conditions, actions, and consequences associated with the core category or main theme in the
womens 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 researchers 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).
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.

Greco et al.

Mammography Decisions in Older Women

Figure. Guarding against cancer.

Results
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 mem-

ber 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 thats 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
doesnt 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 womans 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
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Mammography Decisions in Older Women

mother that I needed to have a mammogram, so its never

been a decision not to have it.
A couple of women talked about their sisters diagnosis of breast cancer as being the influencing factor in
their decision to have mammograms; however, none of
the participants mentioned a daughters 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 isnt 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 Ive lived this long
and I dont 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 dont
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
youre 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 its a fantastic technology. Its screening breasts for the
beginnings of cancer and maybe even farther down the
line, and Its 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
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Greco et al.

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 dont
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 hadnt
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, Im 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 mammographys 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

Mammography Decisions in Older Women

Greco et al.

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. Youve got a whole year
of reassurance after that, you know. And to me its more
than worth it.
Some womens faith in mammography was so strong
that information they received about mammographys
limitations was often ignored or dismissed, even if mammography had missed a breast cancer in a close relative.
For example, Well, Ive read some articles and every
now and then theres a study that says that mammographys 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 Im all right. Another participant talks
about the assurance that cancer is not present. Well,
its peace of mind that theres 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
isnt 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 shes younger than I am.
So, the recalls are traumatic. I try to tell myself, Look,
youve 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 picturesand 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 Ill deal with it, but I dont focus on it.

Discussion
In this study, conditions facilitating womens 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 womens 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
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Mammography Decisions in Older Women

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).
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Greco et al.

Study Limitations
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
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 womens 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 decisionmaking 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
The primary author would like to acknowledge support from the following funding sources: John A.

Greco et al.

Hartford Foundations Building Academic Geriatric Nursing Capacity 20022004 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 Deans
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
r National Cancer Institute Screening Mammograms.

http://www.cancer.gov/cancertopics/factsheet/
detection/screening-mammograms
National Comprehensive Cancer Network Guidelines for Breast Cancer Screening. http://www.
nccn.org/professionals/physician gls/f guidelines.
asp
Susan G. Komen for the Cure Breast Cancer
Screening and Mammography Resources. http://
ww5.komen.org/breastcancer/earlydetectionamp
screening.html
U.S. Surgeon Generals Family History Initiative
Resources and downloadable Pedigree Forms.
http://www.hhs.gov/familyhistory/respachealth.
html

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