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.
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.
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.
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.
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.
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.
1. Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. GLOBOCAN 2008 v1.2, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 10 2010. http://globocan.iarc.fr
. Accessed December 20, 2011.
2. Dollinger M, Rosenbaum EH, Tempero M, Mulvihull SJ. Everyone’s Guide to Cancer Therapy: How Cancer is Diagnosed, Treated and Managed Day to Day. 4th ed. Kansas City, KS: Andrew McMeel Publishing; 2002.
3. Zabalegui A. Coping strategies and psychological distress in patients with advanced cancer. Oncol Nurs Forum. 1999; 26 (9): 1511–1518.
4. Khankari K, Eder M, Osborn CY, et al.. Improving colorectal cancer
screening among the medically underserved: a pilot study within a federally qualified health center. J Gen Intern Med. 2007; 22 (10): 1410–1414.
5. Ristvedt SL, Trinkaus KM. Psychological factors related to delay in consultation for cancer symptoms. Psychooncology. 2005; 14 (5): 339–350.
6. Manne S, Badr H, Zaider T, Nelson C, Kissane D. Cancer-related communication, relationship intimacy, and psychological distress among couples coping with localized prostate cancer. J Cancer Surviv. 2010; 4 (1): 74–85.
7. Ferrante JM, Chen P-H, Kim S. The effect of patient navigation on time to diagnosis, anxiety, and satisfaction in urban minority women with abnormal mammograms: a randomized controlled trial. J Urban Health. 2008; 85 (1): 114–124.
8. Hohneker J, Shah-Mehta S, Brandt PS. Perspectives on adherence and persistence with oral medications for cancer treatment. J Oncol Pract. 2011; 7 (1): 65–67.
9. Kronborg O, Fenger C, Olsen J, Jorgensen OD, Sondergaard O. Randomised study of screening for colorectal cancer
with faecal-occult-blood test. Lancet. 1996; 348 (9040): 1467–1471.
10. Richards MA, Smith P, Ramirez AJ, Fentiman IS, Rubens RD. The influence on survival of delay in the presentation and treatment of symptomatic breast cancer. Br J Cancer. 1999; 79 (5/6): 858–864.
11. Lohrisch C, Paltiel C, Gelmon K, et al.. Impact on survival of time from definitive surgery to initiation of adjuvant chemotherapy for early-stage breast cancer. J Clin Oncol. 2006; 24 (30): 4888–4894.
12. Kondryn HJ, Edmondson CL, Hill J, Eden TOB. Treatment non-adherence in teenage and young adult patients with cancer. Lancet Oncol. 2011; 12 (1): 100–108.
13. Consedine NS, Ladwig I, Reddig MK, Broadbent EA. The many faeces of colorectal cancer
screening embarrassment: preliminary psychometric development and links to screening outcome. Br J Health Psychol. 2011; 16 (3): 559–579.
14. Consedine NS, Magai C, Krivoshekova YS, Ryzewicz L, Neugut AI. Fear, anxiety, worry, and breast cancer screening
behavior: a critical review. Cancer Epidemiol Biomarkers Prev. 2004; 13 (4): 501–510.
15. Consedine NS, Moscowitz JT. The role of discrete emotions in health outcomes: a critical review. Appl Prev Psychol. 2007; 12 (2): 59–75.
16. Curtis V, Aunger R, Rabie T. Evidence that disgust
evolved to protect from risk of disease. Proc R Soc Lond B Biol Sci. 2004; 271 (suppl 4): S131–S133.
17. Davey GCL, Bond N. Using controlled comparisons in disgust
psychopathology research: the case of disgust
, hypochondriasis and health anxiety. J Behav Ther Exp Psychiatry. 2006; 37 (1): 4–15.
18. Angyal A. Disgust
and related aversions. J Abnorm Soc Psychol. 1941; 36 (3): 393–412.
19. Elfenbein HA, Ambady N. On the universality and cultural specificity of emotion recognition: a meta-analysis. Psychol Bull. 2002; 128 (2): 203–235.
20. Rozin P, Haidt J, McCauley CR. Disgust
. In: Lewis M, Haviland-Jones J, eds. Handbook of Emotions. 2nd ed. New York: Guilford; 2000: 637–653.
21. Berle D, Phillips ES. Disgust
and obsessive-compulsive disorder: an update. Psychiatry. 2006; 69 (3): 228–238.
22. Olatunji BO, Sawchuk CN. Disgust
: characteristic features, social manifestations, and clinical implications. J Soc Clin Psychol. 2005; 24 (7): 932–962.
23. Nemeroff CB, Rozin P. The contagion concept in adult thinking in the United States: transmission of germs and of interpersonal influence. Ethos. 1994; 22 (2): 158–186.
24. Neuberg SL, Kenrick DT, Schaller M. Human threat management systems: self-protection and disease avoidance
. Neurosci Biobehav Rev. 2011; 35 (4): 1042–1051.
25. Curtis V, de Barra M, Aunger R. Disgust
as an adaptive system for disease avoidance
behaviour. Philos Trans R Soc B. 2011; 366 (1563): 389–401.
26. Raman L, Gelman SA. Do children endorse psychosocial factors in the transmission of illness and disgust
? Dev Psychol. 2008; 44 (3): 801–813.
27. Navarrete CD, Fessler DMT. Disease avoidance
and ethnocentrism: the effects of disease vulnerability and disgust
sensitivity on intergroup attitudes. Evol Hum Behav. 2006; 27 (4): 270–282.
28. Park JH, Faulkner J, Schaller M. Evolved disease-avoidance
processes and contemporary anti-social behavior: prejudicial attitudes and avoidance
of people with physical disabilities. J Nonverbal Behav. 2003; 27 (2): 65.
29. Schnall S, Haidt J, Clore GL, Jordan AH. Disgust
as embodied moral judgment. Pers Soc Psychol B. 2008; 34 (8): 1096.
30. Inbar Y, Pizarro DA, Knobe J, Bloom P. Disgust
sensitivity predicts intuitive disapproval of gays. Emotion. 2009; 9 (3): 435–439.
31. Rozin P, Haidt J, McCauley CR, Dunlop L, Ashmore M. Individual differences in disgust
sensitivity: comparisons and evaluations of paper-and-pencil versus behavioral measures. J Res Pers. 1999; 33 (3): 330–351.
32. Sussner KM, Thompson HS, Jandorf L, et al.. The influence of acculturation and breast cancer-specific distress on perceived barriers to genetic testing for breast cancer among women of African descent. Psychooncology. 2009; 18 (9): 945–955.
33. Chapman GB, Coups EJ. Emotions and preventive behavior: worry, regret, and influenza vaccination. Health Psychol. 2006; 25 (1): 82–90.
34. Von Wagner C, Knight K, Halligan S, et al.. Patient experiences of colonoscopy, barium enema and CT colonography: a qualitative study. Br J Radiol. 2009; 82 (973): 13–19.
35. Brouse CH, Basch CE, Wolf RL, Shmukler C. Barriers to colorectal cancer
screening: an educational diagnosis. J Cancer Educ. 2004; 19 (3): 170–173.
36. Chapple A, Ziebland S, Hewitson P, McPherson A. What affects the uptake of screening for bowel cancer using a faecal occult blood test (FOBt): a qualitative study. Soc Sci Med. 2008; 66 (12): 2425–2435.
37. Deutekom M, Van Rossum LGM, Van Rijn AF, et al.. Comparison of guaiac and immunological fecal occult blood tests in colorectal cancer
screening: the patient perspective. Scand J Gastroenterol. 2010; 45 (11): 1345–1349.
38. Friedemann-Sanchez G, Griffin JM, Partin MR. Gender differences in colorectal cancer
screening barriers and information needs. Health Expect. 2007; 10 (2): 148–160.
39. Goldenberg JL, Arndt J, Hart J, Routledge C. Uncovering an existential barrier to breast self-exam behavior. J Exp Soc Psychol. 2008; 44 (2): 260–274.
40. Hillyer GC. Factors Related to Colorectal Cancer
Screening With the Fecal Immunochemical Test among Uninsured Hispanic Women in Upper Manhattan [dissertation]. New York: Teachers College, Columbia University; 2011.
41. O’Sullivan I, Orbell S. Self-sampling in screening to reduce mortality from colorectal cancer
: a qualitative exploration of the decision to complete a faecal occult blood test (FOBT). J Med Screen. 2004; 11 (1): 16–22.
42. Weitzman ER, Zapka J, Estabrook B, Goins KV. Risk and reluctance: understanding impediments to colorectal cancer
screening. Prev Med. 2001; 32 (6): 502–513.
43. Worthley DL, Cole SR, Esterman A, et al.. Screening for colorectal cancer
by faecal occult blood test: why people choose to refuse. Intern Med J. 2006; 36 (9): 607–610.
44. Akute OO. Colorectal carcinoma in Ibadan, Nigeria: a 20-year survey—1971 to 1990. Hepatogastroenterology. 2000; 47 (33): 709–713.
45. Carey CL, Harris LM. The origins of blood-injection fear/phobia in cancer patients undergoing intravenous chemotherapy. Behav Change. 2005; 22 (4): 212–219.
46. Hardy D. When We Dare Not Speak Its Name: Anal Taboo, Anal Health, and Affect Theory [dissertation]. Pennsylvania, PA: Widener University; 2010.
47. Harris LM, Jones MK, Carey CL. Characteristics of blood-injection-injury fears in people receiving intravenous chemotherapy. Curr Psychol. 2009; 28 (2): 124–132.
48. Gullo L, Tomassetti P, Migliori M, Casadei R, Marrano D. Do early symptoms of pancreatic cancer exist that can allow an earlier diagnosis? Pancreas. 2001; 22 (2): 210–213.
49. Rosman S. Cancer and stigma: experience of patients with chemotherapy-induced alopecia. Patient Educ Couns. 2004; 52 (3): 333–339.
50. Haidt J, McCauley C, Rozin P. Individual differences in sensitivity to disgust
: a scale sampling seven domains of disgust
elicitors. Pers Indiv Differ. 1994; 16: 701–713.
51. Consedine NS, Adjei BA, Ramirez PM, McKiernan J. An object lesson: differences in source determine the relations that trait anxiety, prostate cancer worry, and fear of screening hold with prostate screening frequency. Cancer Epidemiol Biomarkers. 2008; 17 (7): 1631–1639.
52. van Overveld M, de Jong PJ, Peters ML, Schouten E. The Disgust
Scale-R: a valid and reliable index to investigate separate disgust
domains? Pers Indiv Differ. 2011; 51 (3): 325–330.
53. Olatunji BO, Williams NL, Tolin DF, et al.. The Disgust
Scale: item analysis, factor structure, and suggestions for refinement. Psychol Assess. 2007; 19 (3): 281–297.
54. O’Malley AS, Kerner J, Johnson AE, Mandelblatt JS. Acculturation and breast cancer screening
among Hispanic women in New York city. Am J Public Health. 1999; 89 (2): 219–227.
55. Lyman GH, Dale DC, Crawford J. Incidence and predictors of low dose-intensity in adjuvant breast cancer chemotherapy: a nationwide study of community practices. J Clin Oncol. 2003; 21 (24): 4524–4531.
56. Tsunoda A, Yasuda N, Nakao K, et al.. Health-related quality of life in patients with advanced colorectal cancer
: results from a phase II study of S-1 combined with irinotecan (CPT-11). Int J Clin Oncol. 2010; 15 (3): 280–286.
57. Fessler DMT, Eng SJ, Navarrete CD. Elevated disgust
sensitivity in the first trimester of pregnancy: evidence supporting prophylaxis the compensatory hypothesis. Evol Hum Behav. 2005; 26 (4): 344–351.
58. Biron P, Fuhrmann C, Escande MC, et al.. Standards, options and recommendations (SOR) for the management of neutropenic cancer patients (excluding prolonged neutropenia). Bull. Cancer (Paris). 1998; 85 (8): 695–711.
59. Rubenstein EB, Rolston K. Outpatient management of febrile episodes in neutropenic cancer-patients. Support Care Cancer. 1994; 2 (6): 369–373.
60. Smith DM, Loewenstein G, Rozin P, Sherriff RL, Ubel PA. Sensitivity to disgust
, stigma, and adjustment to life with a colostomy. J Res Pers. 2007; 41 (4): 787–803.
61. Holmes S. Food avoidance
in patients undergoing cancer chemotherapy. Support Care Cancer. 1993; 1 (6): 326–330.
62. Cantora R, Lo´pez M, Aguado L, Rana S, Parker LA. Extinction of a saccharin-lithium association: assessment by consumption and taste reactivity. Learn Behav. 2006; 34 (1): 37–43.
63. McMullen CK, Hornbrook MC, Grant M, et al.. The greatest challenges reported by long-term colorectal cancer
survivors with stomas. J Support Oncol. 2008; 6 (4): 175–182.
64. Faulkner J, Schaller M, Park JH, Duncan LA. Evolved disease-avoidance
mechanisms and contemporary xenophobic attitudes. Group Proc Intergroup Relat. 2004; 7 (4): 333–353.
65. MacDonald LD, Anderson HR. Stigma in patients with rectal cancer: a community study. J Epidemiol Community Health. 1984; 38 (4): 284.
66. Olatunji BO, Haidt J, McKay D, David B. Core, animal reminder, and contamination disgust
: three kinds of disgust
with distinct personality, behavioral, physiological, and clinical correlates. J Res Pers. 2008; 42 (5): 1243–1259.
67. Sawchuk CN, Lohr JM, Westendorf DH, Meunier SA, Tolin DF. Emotional responding to fearful and disgusting stimuli in specific phobics. Behav Res Ther. 2002; 40 (9): 1031–1046.
68. Overton PG, Markland FE, Taggart HS, Bagshaw GL, Simpson J. Self-disgust
mediates the relationship between dysfunctional cognitions and depressive symptomatology. Emotion. 2008; 8 (3): 379–385.
69. de Jong PJ, van Lankveld J, Elgersma HJ, Borg C. Disgust
and sexual problems—theoretical conceptualization and case illustrations. Int J Cogn Ther. 2010; 3 (1): 23–39.
70. Franklin ME, Foa EB. Treatment of obsessive compulsive disorder. Annu Rev Clin Psycho. 2011; 7: 229–243.
71. Baer RA, Walsh E, Lykins ELB. Assessment of mindfulness. In: Didonna F, ed. Clinical Handbook of Mindfulness. New York: Springer; 2009: 153–168.