Effect of abnormal screening mammogram on quality of life

Contrast-enhanced mammography versus conventional imaging in women recalled from breast cancer screening (RACER trial): a multicentre, open-label, randomised controlled clinical trial

Background

Women recalled from breast cancer screening receive post-screening work-up in the hospital with conventional breast imaging. The RACER trial aimed to study whether contrast-enhanced mammography (CEM) as primary imaging instead of conventional imaging resulted in more accurate and efficient diagnostic work-up in recalled women.

Methods

In this randomised, controlled trial (registered under NL6413/NTR6589) participants were allocated using deterministic minimisation to CEM or conventional imaging as a primary work-up tool in two general and two academic hospitals. Predefined patients' factors were reason for recall, BI-RADS score, and study centre. Primary outcomes were sensitivity and specificity. Secondary outcomes were the proportion of women needing supplemental examinations, and number of days until diagnosis.

Findings

Between April, 2018, and September, 2021, 529 patients recalled from the Dutch screening program were randomised, 265 to conventional imaging and 264 to CEM. Three patients in the control arm had to be excluded from analysis due to a protocol breach. After the entire work-up, sensitivity was 98.0% (95% CI; 92.2-99.7%) in the intervention arm and 97.7% (91.8-99.6%) in the control arm (p = 1.0), and specificity was 75.6% (72.5-76.6%) and 75.4% (72.5-76.4%, p = 1.0), respectively. Based on only primary full-field digital mammography/digital breast tomosynthesis or CEM, final diagnosis was reached in 27.7% (73/264) in the intervention arm and 1.1% (3/262) in the control arm. The frequency of supplemental imaging was significantly higher in the control arm (p < 0.0001). Median time needed to reach final diagnosis was comparable: 1 day (control arm: IQR 0-4; intervention arm: IQR 0-3). Thirteen malignant occult lesions were detected using CEM, versus three using conventional imaging. No serious adverse events occurred.

Interpretation

Diagnostic accuracy of CEM in the work-up of recalled women is comparable with conventional imaging. However, work-up with CEM as primary imaging is a more efficient pathway.

Funding

ZonMw (grant number 843001801) and GE Healthcare.

Predictors of re-attendance at biennial screening mammography following a false positive referral: A study among women in the south of the Netherlands

AIM

A false positive (FP) referral after screening mammography may influence a woman's likelihood to re-attend the screening program. The impact of having a FP result in the first or subsequent screening round on re-attendance after a FP result was investigated. In addition, we aimed to study differences in re-attendance rates between women who underwent non-invasive and invasive additional examinations as part of the diagnostic work-up following a FP referral.

METHODS

A consecutive series of 13,597 women with a FP referral following biennial screening mammography in the south of the Netherlands between 2009 and 2019 was included.

RESULTS

The screening re-attendance rate was 81.2% after a FP referral, and 91.3% when also including women who had clinical mammographic follow-up. Women who received a FP referral in the first screening round were less likely to re-attend the screening programme in the following three years, compared to those with a FP test in any subsequent round (odds ratio (OR): 0.59, 95%-confidence interval (CI): 0.51-0.69). Women with a FP referral who underwent invasive examinations after referral were less likely to re-attend the screening programme than those who only received additional imaging (OR, 0.48; 95% CI 0.36-0.64).

CONCLUSION

Women with a FP referral are less likely to re-attend the screening programme if this referral occurs at their first screening round or when they undergo invasive diagnostic workup. Hospitals and screening organizations should prioritize informing women about the importance of re-attending the programme following a FP referral.

Breast Cancer After Reduction Mammoplasty: A Population-Based Analysis of Incidence, Treatment and Screening Patterns

Background

The risk of breast cancer may be decreased in women who undergo reduction mammoplasty. The purpose of this study was to describe the incidence and treatment of breast cancer after reduction mammoplasty and to better understand the use of breast cancer screening modalities in these patients.

Methods

This population-based retrospective analysis utilized the Discharge Abstract Database held by the Canadian Institute for Health Information and the National Ambulatory Care Reporting System to identify all women aged 20 years or older who underwent reduction mammoplasty in Alberta, Canada. The incidence and treatment of breast cancer were compared among patients who underwent reduction mammoplasty and age-sex-matched controls. Imaging utilization, including the use of mammography, ultrasound, and breast biopsy, was also compared.

Results

Between 2003 and 2007, 8021 patients over 20 years old underwent reduction mammoplasty in Alberta. Patients were followed for an average of 12.6 years. Eighty-nine (1.1%) patients who underwent reduction mammoplasty developed breast cancer after surgery, compared to 453 (1.9%) controls (P < 0.0001). Among patients diagnosed with breast cancer, there was no difference in patient and tumor characteristics. Women who underwent reduction mammoplasty were more likely to undergo mastectomy for cancer (41.6% vs 1.5%; P < 0.0001) and were more likely to undergo mammography (66.7% vs 58.7%; P < 0.0001), ultrasound (29.2% vs 26.2%; P < 0.0001) and biopsy for benign disease (7.2% vs 6%, P < 0.0001) compared to controls.

Conclusions

Despite an increased frequency of breast cancer screening, the incidence of breast cancer is lower after reduction mammoplasty compared with women who did not undergo breast reduction. After a diagnosis of breast cancer, surgical treatment patterns differ between groups, whereby mastectomy is more common after reduction mammoplasty.

Assessment of Enhancement Kinetics Improves the Specificity of Abbreviated Breast MRI: Performance in an Enriched Cohort

Objective: To investigate the added value of kinetic information for breast lesion evaluation on abbreviated breast MRI (AB-MRI). Methods: This retrospective study analyzed 207 breast lesions with Breast Imaging Reporting and Data System categories 3, 4, or 5 on AB-MRI in 198 consecutive patients who had breast MRI for screening after breast cancer surgery between January 2017 and December 2019. All lesions were pathologically confirmed or stable on follow-up images for 2 years or more. Kinetic information of the lesions regarding the degree and rate of enhancement on the first post-contrast-enhanced image and the enhancement curve type from two post-contrast-enhanced images were analyzed on a commercially available computer-assisted diagnosis system. The diagnostic performances of AB-MRI with morphological analysis alone and with the addition of kinetic information were compared using the McNemar test. Results: Of 207 lesions, 59 (28.5%) were malignant and 148 (71.5%) were benign. The addition of an enhancement degree of ≥90% to the morphological analysis significantly increased the specificity of AB-MRI (29.7% vs. 52.7%, p < 0.001) without significantly reducing the sensitivity (94.9% vs. 89.8%, p = 0.083) compared to morphological analysis alone. Unnecessary biopsy could have been avoided in 34 benign lesions, although three malignant lesions could have been missed. For detecting invasive cancer, adding an enhancement degree ≥107% to the morphological analysis significantly increased the specificity (26.5% vs. 57.6%, p < 0.001) without significantly decreasing the sensitivity (94.6% vs. 86.5%, p = 0.083). Conclusion: Adding the degree of enhancement on the first post-contrast-enhanced image to the morphological analysis resulted in higher AB-MRI specificity without compromising its sensitivity.

A descriptive systematic review of the relationship between personality traits and quality of life of women with non-metastatic breast cancer

BACKGROUND

Quality of life (QoL) is an important patient-reported outcome that has been studied extensively as an endpoint. There is a growing interest in factors that may influence QoL, such as personality. This descriptive systematic review examined the relationship between personality and QoL in women with non-metastatic breast cancer.  METHODS: On November 24th, 2020, with a update on March 7th, 2022, PubMed, PsycINFO, CINAHL, Web of Science and Embase were systematically searched for studies that assessed the direct relationship between personality traits and QoL among adult women diagnosed with non-metastatic breast cancer. The National Institutes of Health Study Quality Assessment Tool was used to assess the quality and risk of bias of the included studies. Three reviewers independently extracted data regarding objectives, population, setting, design, method, outcome measurements and key results. The results are descriptively reported.

RESULTS

Twelve studies (6 cohort studies and 6 cross-sectional studies) were included. Three studies were rated as poor, one study was rated as good, and the remaining studies were rated as moderate. There was a small to moderate effect of personality on QoL as correlation coefficients ranged from 0.10 to 0.77, and the explained variance ranged from 4 to 43%. The (strength of the) relationship depended on the personality trait and QoL domain that was measured and was most apparent for the personality traits 'optimism' and 'trait anxiety' on psychosocial QoL domains. The results for the personality traits (unmitigated) agency, agreeableness, conscientiousness, novelty seeking, and self-efficacy indicated a smaller but statistically significant correlation between these personality traits and QoL.

CONCLUSIONS

The results confirm that personality affects QoL in women with non-metastatic breast cancer and thus provides evidence that personality traits are indeed important influential factors of QoL. It is therefore strongly recommended for all future QoL research to measure personality traits and use these variables as predictive factors, as they are needed to accurately interpret QoL. Information regarding personality traits provide physicians and patients with an interpretation of low or deterioration of QoL, which could guide physicians to improve their patients' health outcomes and subsequently QoL using psycho-oncological support or treatment.

Colorectal Cancer Screening - Approach, Evidence, and Future Directions

Colorectal Cancer ScreeningScreening for colorectal cancer is widespread and successful but screening programs across the globe differ in their recommendations. In this article, Helsingen and Kalager review the evidence for different approaches to colorectal cancer screening and propose a framework for the evaluation of screening programs going forward.

Patient-Reported Outcomes of Yearly Imaging Surveillance in Patients Following Endovascular Aortic Aneurysm Repair

Little is known about the impact of standardized imaging surveillance on anxiety levels and well-being of patients after endovascular aortic aneurysm repair (EVAR). We hypothesize that patient anxiety levels increase just before receiving the imaging results compared with standard anxiety levels.

METHODS

Prospective cohort study from November 2018 to May 2020 including post-EVAR patients visiting the outpatient clinics of 4 Dutch hospitals for imaging follow-up. The Patient-Reported Outcomes Measurement Information System (PROMIS) was used. Patients completed the PROMIS Anxiety v1.0 Short Form (SF) 4a, PROMIS-Global Health Scale v1.2, and PROMIS-Physical Function v1.2 SF8b at 2 time points: prior to the result of the imaging study (T1: pre-visit) and 6-8 months later (T2: reference measurement). Mean T-scores at T1 were compared to T2, and T2 to the general 65+ Dutch population.

RESULTS

Altogether 342 invited patients were eligible, 214 completed the first questionnaire, 189 returned 2 completed questionnaires and 128 patients did not participate. Out of 214 respondents, 195 were male (91.1%) and the mean (standard deviation) age was 75.2 (7.0) years. There were no significant differences between T1 and T2 in anxiety levels (0.48; 95% confidence interval[CI] -0.42-1.38), global mental health (0.27; 95% CI -0.79-0.84), global physical health (0.10; 95% CI -0.38-1.18) and physical function (0.53; 95% CI -0.26-1.32). Compared with the 65+ Dutch population, at T2 patients experienced more anxiety (3.8; 95% CI 2.96-5.54), had worse global physical health (-3.2; 95% CI -4.38 - -2.02) and physical function (-2.4; 95% CI -4.00 - -0.80). Global mental health was similar (-1.0; 95% CI -2.21 - 0.21).

CONCLUSIONS

Post-EVAR patients do not experience more anxiety just before receiving surveillance imaging results than outside this period, but do suffer from more anxiety and worse physical outcomes than the 65+ Dutch population.

Reducing False-Positive Screening MRI Rate in Women with Extremely Dense Breasts Using Prediction Models Based on Data from the DENSE Trial

Background High breast density increases breast cancer risk and lowers mammographic sensitivity. Supplemental MRI screening improves cancer detection but increases the number of false-positive screenings. Thus, methods to distinguish true-positive MRI screening results from false-positive ones are needed. Purpose To build prediction models based on clinical characteristics and MRI findings to reduce the rate of false-positive screening MRI findings in women with extremely dense breasts. Materials and Methods Clinical characteristics and MRI findings in Dutch breast cancer screening participants (age range, 50-75 years) with positive first-round MRI screening results (Breast Imaging Reporting and Data System 3, 4, or 5) after a normal screening mammography with extremely dense breasts (Volpara density category 4) were prospectively collected within the randomized controlled Dense Tissue and Early Breast Neoplasm Screening (DENSE) trial from December 2011 through November 2015. In this secondary analysis, prediction models were built using multivariable logistic regression analysis to distinguish true-positive MRI screening findings from false-positive ones. Results Among 454 women (median age, 52 years; interquartile range, 50-57 years) with a positive MRI result in a first supplemental MRI screening round, 79 were diagnosed with breast cancer (true-positive findings), and 375 had false-positive MRI results. The full prediction model (area under the receiver operating characteristics curve [AUC], 0.88; 95% CI: 0.84, 0.92), based on all collected clinical characteristics and MRI findings, could have prevented 45.5% (95% CI: 39.6, 51.5) of false-positive recalls and 21.3% (95% CI: 15.7, 28.3) of benign biopsies without missing any cancers. The model solely based on readily available MRI findings and age had a comparable performance (AUC, 0.84; 95% CI: 0.79, 0.88; P = .15) and could have prevented 35.5% (95% CI: 30.4, 41.1) of false-positive MRI screening results and 13.0% (95% CI: 8.8, 18.6) of benign biopsies. Conclusion Prediction models based on clinical characteristics and MRI findings may be useful to reduce the false-positive first-round screening MRI rate and benign biopsy rate in women with extremely dense breasts. Clinical trial registration no. NCT01315015 © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Imbriaco in this issue.

Prevalence and correlates of hopelessness in Tunisian women with benign breast disease and breast cancer

BACKGROUND

There is limited research suggesting that women with Benign Breast Disease (BBD) experience psychological distress similar to breast cancer (BC) women. We aimed to examine hopelessness and its related factors in BC and BBD women.

METHOD

This was a cross-sectional study. The Beck Hopelessness Scale and the Beck Depression Inventory were administered to 51 BBD and 52 BC women.

RESULTS

BC women had higher hopelessness scores as compared to those with BBD (6.9 ± 4.8 vs. 4.9 ± 3.6; p = .018). After controlling for confounding variables, depression and suicidal ideation/behavior were significantly associated with hopelessness in the BBD group, while only a lower socioeconomic status was associated with higher hopelessness scores in the BC group.

CONCLUSION

We found that not only BC but also BBD lead to a psychological burden. Early detection and handling of hopeless feelings and thoughts that may arise in this population are recommended.

Exploring the perceptions of advanced practitioner radiographers at a single breast screening unit in extending their role from delivering benign to malignant biopsy results; a preliminary study

OBJECTIVE

The study aims to explore the perceptions of advanced practice radiographers (APRs) currently giving benign biopsy results to extend their role to deliver NHS Breast Screening Programme (NHSBSP) malignant outcomes. In the UK, APRs are appropriately trained to deliver results, yet traditionally have been cultured not to. Increasing pressures on NHSBSP units are a key driver for APR evolvement. A significant lack of published research provides the rationale for the study, combined with an identified service need.

METHODS

Following ethical approval, a grounded theory design was applied to interview six APRs individually in a single breast screening unit. Extracted themes were considered during a subsequent focus group.

RESULTS

Five core themes identified; (i) role of the APR, (ii) patient experience, (iii) efficiency, (iv) role boundaries, and (v) delivering results.The findings indicate the ambiguity of radiographers delivering results within their profession, outlining the potential impact on themselves and patients. Mammography APRs are skilled to deliver results, and whilst enforced barriers may restrict extension a supportive environment can overcome these. Additional training is necessary to implement the role in the screening service.

CONCLUSION

Identified within their scope of practice; APRs have the ability with appropriate training and peer support to effectively deliver results with a patient-centred approach.

ADVANCES IN KNOWLEDGE

This study has identified important enabling factors and challenges concerning role extension in the delivery of breast biopsy results. The apparent suitability of APRs to communicate results may address breast service pressures, with benefit to patients and the radiology profession.

Older Women’s Perspectives Driving Mammography Screening Use and Overuse: a Narrative Review of Mixed-Methods Studies

Purpose of Review

Examining what older women know and perceive about mammography screening is critical for understanding patterns of under- and overuse, and concordance with screening mammography guidelines in the USA. This narrative review synthesizes qualitative and quantitative evidence around older women’s perspectives toward mammography screening.

Recent Findings

The majority of 43 identified studies focused on promoting mammography screening in women of different ages, with only four studies focusing on the overuse of mammography in women ≥ 70 years old. Older women hold positive attitudes around screening, perceive breast cancer as serious, believe the benefits outweigh the barriers, and are worried about undergoing treatment if diagnosed. Older women have limited knowledge of screening guidelines and potential harms of screening.

Summary

Efforts to address inequities in mammography access and underuse need to be supplemented by epidemiologic and interventional studies using mixed-methods approaches to improve awareness of benefits and harms of mammography screening in older racially and ethnically diverse women. As uncertainty around how best to approach mammography screening in older women remains, understanding women’s perspectives along with healthcare provider and system-level factors is critical for ensuring appropriate and equitable mammography screening use in older women.

Breast cancer risk, worry, and anxiety: Effect on patient perceptions of false-positive screening results

Objective

The impact of mammography screening recall on quality-of-life (QOL) has been studied in women at average risk for breast cancer, but it is unknown whether these effects differ by breast cancer risk level. We used a vignette-based survey to evaluate how women across the spectrum of breast cancer risk perceive the experience of screening recall.

Methods

Women participating in mammography or breast MRI screening were recruited to complete a vignette-based survey. Using a numerical rating scale (0–100), women rated QOL for hypothetical scenarios of screening recall, both before and after benign results were known. Lifetime breast cancer risk was calculated using Gail and BRCAPRO risk models. Risk perception, trait anxiety, and breast cancer worry were assessed using validated instruments.

Results

The final study cohort included 162 women at low (n = 43, 26%), intermediate (n = 66, 41%), and high-risk (n = 53, 33%). Actual breast cancer risk was not a predictor of QOL for any of the presented scenarios. Across all risk levels, QOL ratings were significantly lower for the period during diagnostic uncertainty compared to after benign results were known (p < 0.05). In multivariable regression analyses, breast cancer worry was a significant predictor of decreased QoL for all screening scenarios while awaiting results, including scenarios with non-invasive imaging alone or with biopsy. High trait anxiety and family history predicted lower QOL scores after receipt of benign test results (p < 0.05).

Conclusions

Women with high trait anxiety and family history may particularly benefit from discussions about the risk of recall when choosing a screening regimen.

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Impact of screening recall on quality-of-life does not vary by breast cancer risk.

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Breast cancer worry predicts lower quality-of-life ratings while awaiting results.

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Quality-of-life ratings improve after receipt of benign results.

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High trait anxiety predicts lower quality-of-life after benign results are known.

Rapid Access to Contrast-Enhanced spectral mammogRaphy in women recalled from breast cancer screening: the RACER trial study design

BACKGROUND

In the Dutch breast cancer screening program, women recalled with a BI-RADS 0 score are referred for additional imaging, while those with BI-RADS 4/5 scores are also directed to an outpatient breast clinic. Approximately six out of ten women are recalled without being diagnosed with a malignancy. However, these recalls require additional imaging and doctor visits, which result in patient anxiety and increased health care costs. Conventional types of imaging used for additional imaging are full-field digital mammography and tomosynthesis. Contrast-enhanced spectral mammography has proved to have higher sensitivity and specificity than conventional imaging in women recalled from screening. Therefore, the aim is to study if CESM instead of conventional imaging is a more accurate, patient-friendly, and cost-effective strategy in the work-up of women recalled from breast cancer screening.

METHODS

This prospective, multicenter, randomized controlled trial will be conducted at four centers and will include 528 patients recalled for suspicious breast lesions from the Dutch breast cancer screening program. Participants are randomized in two groups: (1) standard care using conventional breast imaging techniques as initial imaging after recall versus (2) work-up primarily based on CESM. Written informed consent will be collected prior to study inclusion. The primary outcome is the diagnostic accuracy for detection of breast cancer. Secondary outcomes are numbers of additional diagnostic exams, days until final diagnosis, health care costs, and experienced patient anxiety.

DISCUSSION

Based on previously published retrospective studies, we expect to demonstrate in this prospective multicenter randomized controlled trial, that using CESM as a primary work-up tool in women recalled from breast cancer screening is a more accurate, cost-effective, and patient-friendly strategy.

TRIAL REGISTRATION

Netherlands Trial Register, NL6413/NTR6589. Registered on 6 July, 2017.

Systematic review on women's values and preferences concerning breast cancer screening and diagnostic services

BACKGROUND

There is still lack of consensus on the benefit-harm balance of breast cancer screening. In this scenario, women's values and preferences are crucial for developing health-related recommendations. In the context of the European Commission Initiative on Breast Cancer, we conducted a systematic review to inform the European Breast Guidelines.

METHODS

We searched Medline and included primary studies assessing women's values and preferences regarding breast cancer screening and diagnosis decision making. We used a thematic approach to synthesise relevant data. The quality of evidence was determined with GRADE, including GRADE CERQual for qualitative research.

RESULTS

We included 22 individual studies. Women were willing to accept the psychological and physical burden of breast cancer screening and a significant risk of overdiagnosis and false-positive mammography findings, in return for the benefit of earlier diagnosis. The anxiety engendered by the delay in getting results of diagnostic tests was highlighted as a significant burden, emphasising the need for rapid and efficient screening services, and clear and efficient communication. The confidence in the findings was low to moderate for screening and moderate for diagnosis, predominantly because of methodological limitations, lack of adequate understanding of the outcomes by participants, and indirectness.

CONCLUSIONS

Women value more the possibility of an earlier diagnosis over the risks of a false-positive result or overdiagnosis. Concerns remain that women may not understand the concept of overdiagnosis. Women highly value time efficient screening processes and rapid result delivery and will accept some discomfort for the peace of mind screening may provide.

The Economic and Social Value of an Image Exchange Network: A Case for the Cloud

As the health care environment continually changes, radiologists look to the ACR's Imaging 3.0^® initiative to guide the search for value. By leveraging new technology, a cloud-based image exchange network could provide secure universal access to prior images, which were previously siloed, to facilitate accurate interpretation, improved outcomes, and reduced costs. The breast imaging department represents a viable starting point given the robust data supporting the benefit of access to prior imaging studies, existing infrastructure for image sharing, and the current workflow reliance on prior images. This concept is scalable not only to the remainder of the radiology department but also to the broader medical record.

Scan-associated distress in lung cancer: Quantifying the impact of "scanxiety"

OBJECTIVES

Diagnostic imaging may be a major source of cancer-related distress, a condition known as "scanxiety". Scant scholarly work has been performed to evaluate scan-associated distress in cancer. We sought to characterize risk factors for scan-associated distress among patients with Non-Small Cell Lung Cancer (NSCLC), and to evaluate the impact of scan-associated distress on quality of life.

MATERIALS AND METHODS

We conducted a cross-sectional survey study of patients with recurrent/metastatic NSCLC treated at an academic medical center. Clinical and demographic variables were obtained through chart abstraction and patient self-report. We used a modified version of the Impact of Event Scale 6 (IES-6) to specifically assess distress associated with scans, and quality of life was measured using the Functional Assessment of Cancer Therapy - Lung (FACT-L).

RESULTS

Among 103 participants (survey response rate 76.3%), median age was 67, 61.2% were women, and 82.5% were white. At the study visit, 72.8% of subjects discussed a recent scan, and 83% reported some scan-associated distress. Scan-associated distress was not associated with whether the patient had a recent scan, progressive disease or time from diagnosis. Scan-associated distress was associated with impaired quality of life (p=0.004); each unit increase in IES-6 corresponded to an approximately one-unit decrease in FACT-L score.

CONCLUSION

Scan-associated distress is a common problem among patients with NSCLC, and is associated with impaired quality of life. Scan-associated distress severity was not associated with time since diagnosis or whether a recent scan was discussed at the study visit, which implies scan-associated distress may be a persistent problem.

Comparison of the diagnostic workup of women referred at non-blinded or blinded double reading in a population-based screening mammography programme in the south of the Netherlands

Background:

To determine whether referred women experience differences in diagnostic workup at non-blinded or blinded double reading of screening mammograms.

Methods:

We included a consecutive series of respectively 42.996 and 44.491 screens, double read either in a non-blinded or blinded manner between 2009 and 2011. This reading strategy was alternated on a monthly basis.

Results:

The overall ultrasound-guided core needle biopsy (CNB) rate and stereotactic CNB (SCNB) rate per 1000 screens were higher at blinded than at non-blinded reading (7.5 vs 6.0, P=0.008 and 8.1 vs 6.6, P=0.009). Among women with benign workup, these rates were higher at blinded reading (2.6 vs 1.4, P<0.001 and 5.9 vs 4.7, P=0.013). The benign biopsy rates were higher at blinded double reading (P<0.001), whereas the positive predictive value of biopsy did not differ (P=0.103).

Conclusions:

Blinded double-reading results in higher overall CNB and SCNB rates than non-blinded double reading, as well as a higher benign biopsy rate.

Taxonomy for complexity theory in the context of maternity care

BACKGROUND

The linear focus of 'normal science' is unable to adequately take account of the complex interactions that direct health care systems. There is a turn towards complexity theory as a more appropriate framework for understanding system behaviour. However, a comprehensive taxonomy for complexity theory in the context of health care is lacking.

OBJECTIVE

This paper aims to build a taxonomy based on the key complexity theory components that have been used in publications on complexity theory and health care, and to explore their explanatory power for health care system behaviour, specifically for maternity care.

METHOD

A search strategy was devised in PubMed and 31 papers were identified as relevant for the taxonomy.

FINDINGS

The final taxonomy for complexity theory included and defined 11 components. The use of waterbirth and the impact of the Term Breech trial showed that each of the components of our taxonomy has utility in helping to understand how these techniques became widely adopted. It is not just the components themselves that characterise a complex system but also the dynamics between them.

Benefits and harms of mammography screening

Mammography screening for breast cancer is widely available in many countries. Initially praised as a universal achievement to improve women's health and to reduce the burden of breast cancer, the benefits and harms of mammography screening have been debated heatedly in the past years. This review discusses the benefits and harms of mammography screening in light of findings from randomized trials and from more recent observational studies performed in the era of modern diagnostics and treatment. The main benefit of mammography screening is reduction of breast-cancer related death. Relative reductions vary from about 15 to 25% in randomized trials to more recent estimates of 13 to 17% in meta-analyses of observational studies. Using UK population data of 2007, for 1,000 women invited to biennial mammography screening for 20 years from age 50, 2 to 3 women are prevented from dying of breast cancer. All-cause mortality is unchanged. Overdiagnosis of breast cancer is the main harm of mammography screening. Based on recent estimates from the United States, the relative amount of overdiagnosis (including ductal carcinoma in situ and invasive cancer) is 31%. This results in 15 women overdiagnosed for every 1,000 women invited to biennial mammography screening for 20 years from age 50. Women should be unpassionately informed about the benefits and harms of mammography screening using absolute effect sizes in a comprehensible fashion. In an era of limited health care resources, screening services need to be scrutinized and compared with each other with regard to effectiveness, cost-effectiveness and harms.

Cancer or no cancer: the influence of trait anxiety and diagnosis on quality of life with breast cancer and benign disease: a prospective, longitudinal study

BACKGROUND

High trait anxiety (HTA) causes an impaired quality of life (QOL) and fatigue in women with breast cancer (BC) and benign breast disease (BBD). We examined whether the lowered QOL was determined solely by the personality characteristic HTA or by the combination of personality and diagnosis.

METHODS

In a prospective longitudinal study, women with BC (n = 152), BBD (n = 205), or gallstone disease (GD) before laparoscopic cholecystectomy (n = 128) were included. Questionnaires concerning trait anxiety (baseline), fatigue, and QOL were completed at baseline and at 6 months. Multivariate linear regression analysis was performed to analyze the predictors for QOL at 6 months.

RESULTS

At 6 months QOL scores were increased in the GD group, especially in women without HTA. For women without HTA, in the BBD group the scores for fatigue and physical QOL had improved at 6 months, whereas in the BC group physical QOL and fatigue was impaired. Women with HTA scored unfavorably on fatigue and QOL. HTA was the most important factor influencing QOL.

CONCLUSIONS

The course of QOL and fatigue during follow-up were significantly different for each diagnosis. Particularly HTA had a negative impact on QOL and fatigue. Especially the combination HTA and BC caused impaired QOL and fatigue. We recommend identifying women with BC and HTA and offer them a tailor-made follow-up protocol.

Psychological impact of male breast disorders: literature review and survey results

BACKGROUND

Referrals of men to breast assessment clinics are increasing. While most of the men will have benign disease, some of them will have breast cancer. Whichever pathology they have, men should be offered a service tailored to their needs, rather than being 'shoehorned' into a service designed to care for women. This paper explores the psychological impact on men of their condition and of attending a breast assessment clinic.

METHODS

The literature regarding male experience of breast problems is reviewed, and screening for psychological morbidity is discussed. Results of a survey regarding an all-male breast assessment clinic are reported, with a plan for future research.

RESULTS

Many of the 78 men surveyed described negative feelings relating to their condition although they did not want to be seen in an all-male breast assessment clinic if that meant a longer wait. Men reported feelings of anxiety, embarrassment, emasculation and even depression regarding their condition.

CONCLUSIONS

Men are distressed by gynaecomastia and need psychological support for any breast-related presentation. More formalised research into this area is needed, although the men's distress does not translate into the desire to attend an all-male assessment clinic if this means a longer wait before being seen.

Re-attendance after false-positive screening mammography: a population-based study in the Netherlands

Background:

In the current study, mammography adherence of women who had experienced a false-positive referral is evaluated, with emphasis on the probability of receiving surveillance mammography outside the national screening programme.

Methods:

We included 424 703 consecutive screens and collected imaging, biopsy and surgery reports of 3463 women who experienced a false-positive referral. Adherence to screening, both in and outside the screening programme, was evaluated.

Results:

Two years after the false-positive referral, overall screening adherence was 94.6%, with 64.7% of women returning to the national screening programme, compared with 94.9% of women re-attending the screening programme after a negative screen (P<0.0001). Four years after the false-positive screen, the overall adherence had decreased to 85.2% (P<0.0001) with a similar proportion of the women re-attending the screening programme (64.4%) and a lower proportion (20.8%) having clinical surveillance mammography. Women who had experienced a false-positive screen at their first screening round were less likely to adhere to mammography than women with an abnormal finding at one of the following screening rounds (92.4% vs 95.5%, P<0.0001).

Conclusion:

Overall screening adherence after previous false-positive referral was comparable to the re-attendance rate of women with a negative screen at 2-year follow-up. Overall adherence decreased 4 years after previous false-positive referral from 94.6% to 85.2%, with a relatively high estimate of women who continue with clinical surveillance mammography (20.8%). Women with false-positive screens should be made aware of the importance to re-attend future screening rounds, as a way to improve the effectiveness of the screening programme.

The effect of false positive breast screening examinations on subsequent attendance: retrospective cohort study

Objectives

To investigate the effect of false positive breast screening examination results on subsequent attendance in the UK National Health Service Breast Screening Programme.

Methods

253,017 previously screened women who were invited for rescreening were studied. Attendance rates of women who had received a normal result at the last (index) screen were compared with those of women who had received a false positive result. The effects of age, type of index screening examination (prevalent or incident) and tissue sampling at assessment were investigated.

Results

Women who had a false positive prevalent index screening examination were significantly more likely to reattend than those who had a normal prevalent index screening examination (87.7% vs. 86.0%). There was no significant difference in reattendance rates between women who had a false positive incident index screening examination and those with a normal incident index screening examination. However, women who underwent needle sampling or open biopsy following false positive incident index screening examinations were 12% and 60% less likely to reattend, respectively, than women whose index screening examinations were normal ( p < 0.001), although there was variation between centres. Increasing age significantly reduced the likelihood of reattendance. The overall reattendance of women who had been screened only once was six percentage points lower than that of women who had been screened more than once.

Conclusions

The findings suggest that most women who undergo the breast screening assessment process retain confidence in breast screening. Needle sampling and open biopsy should be used judiciously in the assessment of screen-detected abnormalities in view of the reduced reattendance that results from their use after incident screening examinations.

Impact of transition from analog screening mammography to digital screening mammography on screening outcome in The Netherlands: a population-based study

BACKGROUND

Full-field digital mammography (FFDM) has replaced screen-film mammography (SFM) in most breast screening programs. We analyzed the impact of this replacement on the screening outcome.

PATIENTS AND METHODS

The study population consisted of a consecutive series of 60 770 analog and 63 182 digital screens. During a 1-year follow-up, we collected breast imaging reports, biopsy results and surgical reports of all the referred women.

RESULTS

The referral rate and the cancer detection rate at FFDM were, respectively, 3.0% and 6,6‰, compared with 1.5% (P < 0.001) and 4.9‰ (P < 0.001) at SFM. Positive predictive values of referral and percutaneous biopsies were lower at FFDM, respectively, 21.9% versus 31.6% (P < 0.001) and 42.9% versus 62.8% (P < 0.001). Per 1000 screened women, there was a significant increase with FFDM versus SFM in the detection rate of low- and intermediate-grade ductal carcinoma in situ (DCIS) (+0.7), invasive T1a-c cancers (+0.9), invasive ductal cancers (+0.9), low-grade (+1.1), node-negative invasive cancers (+1.2), estrogen-receptor or progesterone-receptor-positive invasive cancers (respectively, +0.9 and +1.1) and Her2/Neu-negative (+0.8) invasive cancers. Mastectomy rates were stable at 1.1 per 1,000 screens.

CONCLUSIONS

FFDM significantly increased the referral rate and cancer detection rate, at the expense of a lower positive predictive value of referral and biopsy. Extra tumors detected at FFDM were mostly low-intermediate grade DCIS and smaller invasive tumors, of more favorable tumor characteristics. Mastectomy rates were not increased in the FFDM population, while increased over-diagnosis cannot be excluded.

An abnormal screening mammogram causes more anxiety than a palpable lump in benign breast disease

Being recalled for further diagnostic procedures after an abnormal screening mammogram (ASM) can evoke a high state anxiety with lowered quality of life (QoL). We examined whether these adverse psychological consequences are found in all women with benign breast disease (BBD) or are particular to women referred after ASM. In addition, the influence of the anxiety as a personality characteristic (trait anxiety) was studied. Between September 2002 and February 2010 we performed a prospective longitudinal study in six Dutch hospitals. Women referred after ASM or with a palpable lump in the breast (PL), who were subsequently diagnosed with BBD, were included. Before diagnosis (at referral) and during follow-up, questionnaires were completed examining trait anxiety (at referral), state anxiety, depressive symptoms (at referral, one, three and 6 months after diagnosis), and QoL (at referral and 12 months). Women referred after ASM (N=363) were compared with women with PL (N=401). A similar state anxiety score was found in both groups, but a lower psychological QoL score at 12 months was seen in the ASM group. In women with not-high trait anxiety those in the ASM group were more anxious with more depressive symptoms at referral, and reported impaired psychological QoL at referral and at 12 months compared with the PL group. No differences were found between ASM and PL in women with high trait anxiety, but this group scored unfavorably on anxiety, depressive symptoms and QoL compared with women with not-high trait anxiety. ASM evokes more anxiety and depressive symptoms and lowered QoL compared with women referred with PL, especially in women who are not prone to anxiety. Women should be fully informed properly about the risks and benefits of breast cancer screening programs. We recommend identifying women at risk of reduced QoL using a psychometric test.

Characteristics and screening outcome of women referred twice at screening mammography

OBJECTIVES

To determine the characteristics and screening outcome of women referred twice at screening mammography.

METHODS

We included 424,703 consecutive screening mammograms and collected imaging, biopsy and surgery reports of women with screen-detected breast cancer. Review of screening mammograms was performed to determine whether or not an initial and second referral comprised the same lesion.

RESULTS

The overall positive predictive value of referral for cancer was 38.6% (95% CI 37.3-39.8%). Of 147 (2.6%) women referred twice, 86 had been referred for a different lesion at second referral and 32 of these proved malignant (37.2%, 95% CI 27.0-47.4%). Sixty-one women had been referred twice for the same lesion, of which 22 proved malignant (36.1%, 95% CI 24.1-48.0%). Characteristics of these women were comparable to women with cancer diagnosed after first referral. Compared with women without cancer at second referral for the same lesion, women with cancer more frequently showed suspicious densities at screening mammography (86.4% vs 53.8%, P = 0.02) and work-up at first referral had less frequently included biopsy (22.7% vs 61.5%, P = 0.004).

CONCLUSIONS

Cancer risk in women referred twice for the same lesion is similar to that observed in women referred once, or referred for a second time but for a different lesion.

KEY POINTS

Cancer risk was 36% for lesions referred twice at screening mammography. The cancer risk was similar for lesions referred only once at screening. Densities at first referral were associated with increased cancer risk at second referral. No biopsy at first referral was associated with increased cancer risk at second referral. Patient and tumour characteristics were similar for women with and without diagnostic delay.

Lesions of uncertain malignant potential (B3) on core biopsy in the NHS Breast Screening Programme: is the screening round relevant?

INTRODUCTION

Most women who have screening mammography and undergo subsequent open biopsy following an indeterminate core biopsy result are eventually found to have benign disease. However, a significant number have malignant disease and the rate of malignancy in such cases may be influenced by various factors. This study examined the effect of the type of screening round (prevalent or incident) on the likelihood of breast cancer being present.

METHODS

A total of 199 women who had NHS breast screening mammograms and subsequent indeterminate (B3) core biopsy results followed by excision biopsy over an 11-year period in a single breast screening unit were reviewed.

RESULTS

The rate of malignancy following excision of a lesion graded as B3 on core biopsy was 21% for women in the prevalent screening round compared to 33% in subsequent rounds (Fisher's exact test, p=0.038).

CONCLUSIONS

The incidence of malignancy associated with a B3 core biopsy result appears to be related to the screening round in which the lesion is detected, being approximately 50% higher in the subsequent incident rounds compared to the initial prevalent round. This finding may be useful in formulating management plans for women who have an indeterminate biopsy result.

Risk of breast cancer after false-positive test results in screening mammography

BACKGROUND

Screening for disease in healthy people inevitably leads to some false-positive tests in disease-free individuals. Normally, women with false-positive screening tests for breast cancer are referred back to routine screening. However, the long-term outcome for women with false-positive tests is unknown.

METHODS

We used data from a long-standing population-based screening mammography program in Copenhagen, Denmark, to determine the long-term risk of breast cancer in women with false-positive tests. The age-adjusted relative risk (RR) of breast cancer for women with a false-positive test compared with women with only negative tests was estimated with Poisson regression, adjusted for age, and stratified by screening round and technology period. All statistical tests were two-sided.

RESULTS

A total of 58 003 women, aged 50-69 years, were included in the analysis. Women with negative tests had an absolute cancer rate of 339/100 000 person-years at risk, whereas women with a false-positive test had an absolute rate of 583/100 000 person-years at risk. The adjusted relative risk of breast cancer after a false-positive test was 1.67 (95% confidence interval [CI] 1.45 to 1.88). The relative risk remained statistically significantly increased 6 or more years after the false-positive test, with point estimates varying between 1.58 and 2.30. When stratified by assessment technology phase and using equal follow-up time, the false-positive group from the mid 1990s had a statistically significantly higher risk of breast cancer (RR = 1.65, 95% CI = 1.22 to 2.24) than the group with negative tests, whereas the false-positive group from the early 2000s was not statistically significantly different from the group testing negative.

CONCLUSIONS

The implementation of new assessment technology coincided with a decrease in the size of excess risk of breast cancer for women with false-positive screening results. However, it may be beneficial to actively encourage women with false-positive tests to continue to attend regular screening.

The Breast Imaging Reporting and Data System (BI-RADS) in the Dutch breast cancer screening programme: its role as an assessment and stratification tool

Objectives

To assess the suitability of the Breast Imaging Reporting and Data System (BI-RADS) as a quality assessment tool in the Dutch breast cancer screening programme.

Methods

The data of 93,793 screened women in the Amsterdam screening region (November 2005–July 2006) were reviewed. BI-RADS categories, work-up, age, final diagnosis and final TNM classification were available from the screening registry. Interval cancers were obtained through linkage with the cancer registry. BI-RADS was introduced as a pilot in the Amsterdam region before the nationwide introduction of digital mammography (2009–2010).

Results

A total of 1,559 women were referred to hospital (referral rate 1.7 %). Breast cancer was diagnosed in 485 women (detection rate 0.52 %); 253 interval cancers were reported, yielding a programme sensitivity of 66 % and specificity of 99 %. BI-RADS 0 had a lower positive predictive value (PPV, 14.1 %) than BI-RADS 4 (39.1 %) and BI-RADS 5 (92.9 %; P < 0.0001). The number of invasive procedures and tumour size also differed significantly between BI-RADS categories (P < 0.0001).

Conclusion

The significant differences in PPV, invasive procedures and tumour size match with stratification into BI-RADS categories. It revealed inter-observer variability between screening radiologists and can thus be used as a quality assessment tool in screening and as a stratification tool in diagnostic work-up.

Key Points

• The BI-RADS atlas is widely used in breast cancer screening programmes.

• There were significant differences in results amongst different BI-RADS categories.

• Those differences represented the radiologists’ degree of suspicion for malignancy, thus enabling stratification of referrals.

• BI-RADS can be used as a quality assessment tool in screening.

• Training should create more uniformity in applying the BI-RADS lexicon.

Malpractice claims following screening mammography in The Netherlands

Although malpractice lawsuits are frequently related to a delayed breast cancer diagnosis in symptomatic patients, information on claims at European screening mammography programs is lacking. We determined the type and frequency of malpractice claims at a Dutch breast cancer screening region. We included all 85,274 women (351,009 screens) who underwent biennial screening mammography at a southern breast screening region in The Netherlands between 1997 and 2009. Two screening radiologists reviewed the screening mammograms of all screen detected cancers and interval cancers and determined whether the cancer had been missed at the previous screen or at the latest screen, respectively. We analyzed all correspondence between the screening organization, clinicians and screened women, and collected complaints and claims until September 2011. At review, 20.9% (308/1,475) of screen detected cancers and 24.3% (163/670) of interval cancers were considered to be missed at a previous screen. A total of 19 women (of which 2, 6 and 11 women had been screened between 1997 and 2001 (102,439 screens), 2001 and 2005 (114,740 screens) and 2005 and 2009 (133,830 screens), respectively) had contacted the screening organization for additional information about their screen detected cancer or interval cancer, but filed no claim. Three other women directly initiated an insurance claim for financial compensation of their interval cancer without previously having contacted the screening organization. We conclude that screening-related claims were rarely encountered, although many screen detected cancers and interval cancers had been missed at a previous screen. A small but increasing proportion of women sought additional information about their breast cancer from the screening organization.

Trends in incidence and detection of advanced breast cancer at biennial screening mammography in The Netherlands: a population based study

Introduction

The aims of this study were to determine trends in the incidence of advanced breast cancer at screening mammography and the potential of screening to reduce it.

Methods

We included a consecutive series of 351,009 screening mammograms of 85,274 women aged 50-75 years, who underwent biennial screening at a Dutch breast screening region in the period 1997-2008. Two screening radiologists reviewed the screening mammograms of all advanced screen detected and advanced interval cancers and determined whether the advanced cancer (tumor > 20 mm and/or lymph node positive tumor) had been visible at a previous screen. Interval cancers were breast cancers diagnosed in women after a negative screening examination (defined as no recommendation for referral) and before any subsequent screen. Patient and tumor characteristics were compared between women with advanced cancer and women with non-advanced cancer, including ductal carcinoma in situ.

Results

A total of 1,771 screen detected cancers and 669 interval cancers were diagnosed in 2,440 women. Rates of advanced cancer remained stable over the 12-year period; the incidence of advanced screen-detected cancers fluctuated between 1.5 - 1.9 per 1,000 screened women (mean 1.6 per 1,000) and of advanced interval cancers between 0.8 - 1.6 per 1,000 screened women (mean 1.2 per 1,000). Of the 570 advanced screen-detected cancers, 106 (18.6%) were detected at initial screening; 265 (46.5%) cancers detected at subsequent screening had been radiologically occult at the previous screening mammogram, 88 (15.4%) had shown a minimal sign, and 111 (19.5%) had been missed. Corresponding figures for advanced interval cancers were 50.9% (216/424), 24.3% (103/424) and 25.1% (105/424), respectively. At multivariate analysis, women with a ≥ 30 months interval between the latest two screens had an increased risk of screen-detected advanced breast cancer (OR 1.63, 95%CI: 1.07-2.48) and hormone replacement therapy increased the risk of advanced disease among interval cancers (OR 3.04, 95%CI: 1.22-7.53).

Conclusion

We observed no decline in the risk of advanced breast cancer during 12 years of biennial screening mammography. The majority of these cancers could not have been prevented through earlier detection at screening.

Anxiety after an abnormal screening mammogram is a serious problem

PURPOSE

The aim of this study was to analyze the possible negative psychological consequences of a false positive screening mammogram (FPSM). We compared anxiety evoked by first (FSM) versus repeat screening mammogram (RSM). Questionnaires were completed prior to the diagnosis and during follow up.

RESULTS

No differences in anxiety, depressive symptoms, and Quality of Life (QoL) were found between FSM (N = 186) or RSM (N = 296) groups. All women experienced high anxiety before diagnosis was known. High trait anxiety was predictive for more anxiety, depressive symptoms, and lower QoL. Women with low score on trait anxiety were more momentary anxious in FSM group compared with RSM group (p = 0.048).

CONCLUSION

Negative psychological consequences after an FPSM are seen in all women. These effects are strengthened by personality and timing of the screening mammogram. All women should receive correct information concerning the negative psychological effects and should be offered psychosocial support if needed.