Studies Examining Disgust and Cancer Screening
Of the 9 studies relating to disgust and cancer screening, most posited a similar theme—that anticipated disgust was a key barrier to participation in CRC screening tests including fecal occult blood testing (FOBT), which requires individuals to collect a sample of their own feces, place in a sealed container, and then deliver to a health agency for analysis. One study contrasted participants and nonparticipants of an FOBT screening program and found that “disgust at the idea of handling stools” was a commonly cited reason for nonparticipation; some participants disliked the idea of things “rectal” or “fecal,” others refused because “it’s just not nice,” and others rejected the test because it was “pretty disgusting.”36 Other focus group studies similarly suggest that FOBT collection processes are seen as “disgusting” or “messy,”38,42 although there are exceptions.41 One study examining disgust and breast screening found that reluctance for breast self-examination was greater when participants were reminded of the physical nature of their bodies.39
Quantitative studies offered a similar theme. One study utilized a questionnaire based on health beliefs and focus group responses from nonparticipants of FOBT screening and found that 24.7% of people who had not taken part in a CRC screening program suggested that the test was “too unpleasant.”43 Another prospective study of 197 Hispanics found that those who engaged in CRC screening had lower disgust than those who did not participate as measured by a scale of perceived barriers to CRC screening, which included 5 disgust-specific items.40 Similarly, a randomized controlled trial examining whether a tailored telephone intervention would increase CRC screening found that 5% of people cited “beliefs” when asked open-ended questions about barriers to screening; beliefs included comments such as the tests “were gross” and “repugnant.”35
Taken together, 2 final studies provide some evidence that the specific stimuli encountered during screenings may be germane. A Dutch CRC screening trial of 20 623 participants found that those who received the guaiac FOBT were more likely to respond yes to “I found the test shameful” and “I found the test disgusting” and were less likely to take part in screening than those who received the immunological FOBT.37 These 2 tests primarily differ in terms of collection manner, with the guaiac FOBT requiring more handling of feces and potentially more opportunity for fecal contact. Similarly, Worthley et al43 found that the “degree of involvement” in the screening test made a difference to how unpleasant the process was rated, but noted that half of nonparticipants decided not to participate before they had considered collection methods.
Studies Examining Disgust and Cancer Treatment
Unlike studies investigating disgust and screening, the 6 studies relating to cancer treatment had no obvious themes (Table 2). Earliest was a retrospective analysis of Nigerian case notes of CRC patients between the years of 1971 and 1990.44 Most patients presented late with bowel symptoms, and 13% declined surgery to remove rectal tumors because of the required permanent colostomy; findings were taken as evidence that patients found the idea of colostomy “repugnant.” In contrast, another study identified disgust as a possible early indicator of pancreatic cancer, with a small proportion of patients reporting sudden-onset disgust for coffee, smoking, and/or wine.48
Three studies examined potential elicitors of disgust and cancer treatment including hair loss49 and investigation of blood-injection-injury (BII) concerns.45,47 In-depth qualitative interviews with lung and breast cancer patients found that “losing hair” through chemotherapy had the potential to elicit disgust because the treatment provided a physical reminder of the nature and consequences of being a cancer patient.49 In another work, Carey and Harris45 confirmed a link between disgust using a 16-item version of the Disgust Scale50 and BII in the cancer context and found that a “large minority” of chemotherapy patients (18.9%) experienced “strong feelings of fear, disgust, or discomfort” toward the sight of blood, receiving injections, or both. However, the link between elevated BII concern and disgust was attributed by the majority (52.8%) as a response to prior experiences rather to receiving chemotherapy per se. This finding is consistent with later research also identifying a relationship between BII and disgust (as measured by the Disgust Scale) in cancer patients.47 A final qualitative investigation conducted comparative analysis of interviews with anal healthcare workers and patients, finding that anal taboos and stigma permeated every aspect of anal healthcare delivery, with participants reporting shame, embarrassment, disgust, and fear.46
Discussion and Clinical Implications
Preliminary indications from this systematic review of disgust and CRC confirmed our impression that despite an intuitive link between disgust and avoidance dynamics in CRC contexts, empirical demonstrations of such a relationship are comparatively scant. Despite a lack of development, however, 2 broad findings emerged. First, disgust or disgust sensitivities appear likely to be promoting an aversion to (and avoidance of) CRC screening. Second, evidence suggests that several of the known elicitors of disgust are widely apparent in CRC contexts. In the following sections, we revisit these considerations in greater detail, structuring our discussion around key time points in the CRC trajectory; CRC screening, CRC decision making and treatment, and CRC posttreatment adaptation.
Disgust and Avoidance in CRC Screening
Although studies remain methodologically primitive (below), our review suggests that anticipated disgust contributes to the avoidance of CRC screening. Several considerations should, however, constrain our confidence at this point. First, it is worth noting that our understanding of the specific elicitors of disgust remains underdeveloped, with these early studies generally assessing impressions of screening as nasty, repulsive, or disgusting; standardized disgust and/or disgust sensitivity instrumentation is urgently needed in this context. Studies of emotion are increasingly demonstrating that specific stimuli are being avoided in screening contexts13,51; however, further research identifying the most salient disgust elicitors of distinct CRC screening methods is needed. In CRC screening, disgust generated by the idea of either fecal collection or regarding something being inserted into the anus may have distinct behavioral and psychological implications relative to disgust at the idea of a tumor growing inside the body. The former appears likely to generate behavioral avoidance, whereas the latter may well activate participation in screening. Research that identifies the specific elicitors of disgust has potential to inform communication and processes of CRC screening and potentially improve screening rates. Further to this goal is the need to develop tools specifically designed to measure disgust in CRC contexts. General measures of disgust propensity and sensitivity have been developed50,52,53; however, to our knowledge, apart from a recently developed CRC screening embarrassment measure,13 which assesses embarrassment regarding feces and the rectum as barriers to screening, there are no specific tools that measure disgust in the CRC screening context.
Second, whereas the majority of the studies reviewed here were qualitative and reference the “idea” of screenings being disgusting,36,41,42 quantitative and/or prospective data are few. Third, it is currently unclear whether it is dispositional disgust sensitivity, experienced or state disgust, or anticipated disgust that is most relevant at this juncture. Research investigating other emotions shows that anticipated emotion is often much worse than predicted,33 suggesting that nurse-led discussions of anticipated disgust may reassure potential screeners that experiences are often better than expected. Similarly, some cultural/ethnic groups have relatively low CRC screening rates,54 and it may be that differential sensitivity to disgust or culturally mediated sensitivities to disgust’s elicitors are playing a role. Research that identifies how communications and screening messages might be targeted to address anticipated disgust has potential to increase screening among these at-risk groups.
Disgust and Avoidance in CRC Treatment Decision Making
Although the majority of studies identified in this review focused on CRC screening, the cancer trajectory extends well beyond the decision to screen. Treatment delay and late presentation have significant implications for CRC prognosis, and disgust-generated avoidance appears likely to play a role in such delays. Despite noting this, our review identified no studies specifically addressing the possible impact of disgust on CRC decision-making processes. Clearly, blood sampling procedures can elicit disgust,45,47 and many CRC surgical treatments also require potentially disgust-generating invasions of the body envelope. Surgical access via the vagina, abdominal wall, or anus, which may involve the removal of tissue or entire organs, is likely to induce disgust and may sufficiently deter some people such that surgery is delayed, or even rejected, as a treatment option altogether. Again, we suggest that disgust is likely to form a core part of the affective substrate for these forms of avoidance and aversion.
Similarly, the adverse effect profiles that many treatments potentially create may also induce anticipated disgust in the CRC patient. One well-known downside to informed consent processes is that patients can develop a distorted picture of the likelihood of possible adverse effects. Upward of 15% of patients in other types of cancer fail to initiate chemotherapy,55 suggesting that there are clear barriers to certain types of treatment. Treatments for CRC can engender possible adverse effects including, but not limited to, vomiting, nausea, diarrhea, skin rashes, and gastrointestinal distress.56 To the extent that patients (a) are aware of these adverse effects and (b) anticipate being disgusted by them, we might expect anticipated disgust and/or a disgust sensitivity to predict delays in decision making and/or the uptake of recommended CRC treatment regimens. Both behavioral avoidance (eg, nonadherence, delay) and cognitive avoidance (eg, trying not to think about it) may play a role and potentially promote the search for alternative and perhaps clinically less efficacious options.
Provocatively, given the impact of many treatments on immune processes, disgust responses may become more common when immune functioning is impaired57—a protective mechanism in immunocompromised groups.24 Lowered immune function is well established in patients going through chemotherapy treatment and can lead to serious complications.58 Patients are routinely informed of their elevated risk of illness and infection and given guidelines on limiting exposure to pathogens.59 Such findings suggest that disgust sensitivity and/or anticipated disgust may increase among CRC patients being treated with immune-compromising agents. In this context, disgust-generated avoidance is potentially helpful if it promotes avoidance of potential contaminants or infectious agents. However, if disgust leads to restrictive dietary sensitivities or avoidance of the treatment itself, then it may ultimately lead to poorer outcomes. Clearly, such issues require further investigation.
Finally, many cancer treatments require that an individual engage repeatedly and/or over time in certain processes or behaviors. Given the issues with long-term treatment adherence noted above, the repeated nature of peoples’ experiences with treatment effects and adverse effects suggests that examinations of how people adapt or habituate to disgust-eliciting stimuli over time will be important. That such habituation occurs is evident anecdotally as well as in consideration of the fact that people are not normally troubled by the act of cleaning themselves after defecation, despite the necessary proximity to fecal matter. The rapidity with which people adapt to disgust-inducing stimuli may vary as a function of dispositional sensitivities60; thus, it may be clinically useful to target persons who have high disgust sensitivity with acknowledgement of the likelihood of disgust as a potential response to CRC treatment, but then to also reassure that generally people learn to live with, and adjust to, exposure to bodily function. Other than obsessive-compulsive and phobic clinical samples (see below), little is known about whether or how disgust sensitivities may habituate as a function of exposure to eliciting stimuli, and further work is needed.
Disgust and Avoidance in Posttreatment Adaptation
Beyond treatment, CRC can require considerable posttreatment adaptation to permanent changes to bodily function and other longer-term adverse effects. Although there is little evidence thus far, such processes also appear likely to be influenced by disgust. Enduring food aversions occur in up to 80% of cancer patients following treatment,61 and disgust may be an important factor in the development and maintenance of dietary restrictions. Animal work, in particular, suggests that conditioned food aversions endure well after the initial, conditioned disgust response has been extinguished.62 Future research is required to evaluate whether the food avoidance evident among CRC patients is similarly related to disgust and whether interventions designed to decouple disgust responses from specific foods will be of benefit.
Posttreatment adaptation to CRC will also often include a temporary or permanent stoma. Although physical functioning is generally unimpaired following stoma surgery, unpleasant noises, odors, and gas may occur, and stoma bags occasionally leak. Day-to-day management of stomas necessitates ongoing contact with fecal matter and is likely to elicit degrees of disgust in both patients and others. Patients with CRC often consider dealing with permanent stomas “their greatest challenge.”63 One recent study has shown that general disgust predicted poorer adjustment to colostomy, and colostomy-specific disgust predicted poorer adjustment to surgery.60 To date, however, there have been no studies of longer-term adjustment to disgust-eliciting stimuli in CRC. Although it is possible that habituation to fecal exposure occurs over time (with avoidant behavior and adjustment issues naturally resolving), this may not be the case for all patients.
To this point, we have focused on disgust in the cancer patient. However, patients are diagnosed and treated and return to life in social contexts, creating the possibility that the real (or perceived) disgust responses of intimate partners, caregivers, nursing staff, other health professionals, and broader support networks may be important. Disgust responses play a key role in the stigmatization (and avoidance) of “out-group” persons, particularly among those with a detectable disease or disability,28,64 and another work suggests that both patients and health professionals alike are affected by the stigma of anal disgust.46 It may be that, in these broader networks, the (imagined) threat of contagion creates disgust-generated stigmatization of patients, particularly when overt disease cues (eg, odors, hair loss, disfigurement, wounds) are exhibited. Within closer relationships, these same disease cues may trigger a disgust response in both patients and their loved ones, potentially impacting on the quality of intimacy and relationship connections.
Colostomy patients report high stigmatization, feelings that promote greater utilization of medical services, poorer health, more emotional difficulty, and social withdrawal,65 and those patients with higher disgust sensitivity report greater stigmatization, assuming others will also be disgusted by their colostomy.60 In terms of posttreatment adaptation then, the anticipation of disgust-driven stigmatization may promote social avoidance because patients anticipate disgust reactions and stigmatization from others. The quality-of-life implications of social isolation, withdrawal from existing relationships, and a reluctance to form new bonds are enormous for both CRC patients and those around them.
The clinical implications of disgust in the CRC context are extensive, with preliminary evidence suggesting that disgust may promote avoidance behaviors across the spectrum of the CRC trajectory. Evidence in other populations suggests that disgust promotes avoidance in nonclinical samples66 and has been shown to feature anxiety disorders,21,67 depression,68 and sexual dysfunction69; however, the role that disgust takes in shaping maladaptive outcomes in physical health outcomes is yet to be determined. Early identification of those at risk of struggling with disgust in CRC contexts has the potential to lessen the negative impact of diagnosis and treatment through the informed channeling of individuals to appropriate interventions. Specific recommendations on the form that these interventions might take are difficult at this stage, given the very limited research in the area. However, therapeutic work conducted with other populations suggests that 2 classes of approach might be appropriate: exposure-based therapy and mindfulness training. Exposure therapy using gradual or abrupt exposure to problematic stimuli has good empirical support in the treatment of anxiety disorders70 and has been used specifically where disgust is a factor in sexual problems.69 Such an approach may well translate to the habituation and desensitization of stimuli perceived as disgusting in CRC contexts. Therapeutic work utilizing a mindfulness approach also shows promise, with its inherent focus on present-moment acceptance that is fundamentally in contrast to avoidance. Training in mindfulness aims to counter avoidant mental and behavioral processes by encouraging the acceptance of a wide range of experiences including bodily sensations, thoughts, and emotions without trying to avoid or suppress them, even when they are unpleasant.71 A mindfulness approach may be suited to CRC treatment and adaptation contexts when acceptance of current physical status and disgust-eliciting stimuli is more feasible than change.
Our systematic review of research examining disgust and cancer has confirmed that research investigating disgust and avoidance in cancer contexts remains in its infancy, with few data suited to the provision of guidance for nursing staff and other health professionals working in this context. Above, we have suggested that disgust may represent one of the primary emotional substrates of avoidance behaviors among both CRC patients and those around them. Delay and nonadherence have significant implications in the CRC context; understanding the mechanisms that might be driving avoidance has potential to inform potential interventions, with oncology nurses uniquely positioned to guide and facilitate these interventions. However, there is still much we do not know. Of the available studies, designs are almost exclusively cross-sectional, small-scale, and convenience based. Instrumentation has typically been weak in early work, and more robust measurement is also called for. These limits noted, preliminary data indicate that the careful study of disgust may extend our understanding of avoidance in the CRC trajectory. However, future research is required that both investigates the specific mechanisms driving disgust-generated avoidance in CRC screening and treatment and develops tools specifically designed to identify triggers of disgust and barriers to appropriate behaviors in CRC contexts. Research and development in these areas will enable guidance into communication, medical practice, and clinical interventions in the CRC context.
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Keywords:© 2013 Lippincott Williams & Wilkins, Inc.
Avoidance; Cancer screening; Colorectal cancer; Disgust; Emotional barriers; Systematic review