Recall mammography and psychological distress

Impact of Interruptions During Screening Mammography on Physician Well-Being and Patient Care

OBJECTIVE

To assess the impact of interruptions on radiologists' efficiency, accuracy, and job satisfaction in interpreting screening mammograms.

METHODS

This institutional review board-approved retrospective reader study recruited nine breast radiologists from a single academic institution [name withheld] to interpret 150 screening mammograms performed between December 1, 2008, and December 31, 2015 under two different reading conditions, as follows: (1) uninterrupted batch reading and (2) interrupted reading. The 150 cases consisted of 125 normal mammograms and 25 mammograms with subtle breast cancers. Cases were divided into two groups of 75 cases each (cohort 1 and cohort 2), with a comparable distribution of cancer cases. Four rounds of 75 cases each were conducted with a 6-week washout period between rounds 2 and 3. After completing each interpretation session, readers completed a seven-question survey, assessing perceptions of mental and physical effort, level of frustration, and performance satisfaction. Clinical performance metrics (reading time, recall rate, sensitivity, specificity, accuracy, and positive predictive value 1) were calculated.

RESULTS

Recall rates were significantly (P = .04) higher during interrupted reading sessions (35.4%) than they were during uninterrupted batch reading sessions (31.4%). Accuracy was significantly (P = .049) worse in the interrupted reading sessions (69.5%), compared with uninterrupted sessions (73.6%). Differences in overall image interpretation times were not statistically significant (P = .065). Compared with uninterrupted batch reading sessions, readers during interrupted sessions reported feeling busier (P < .001), encountered higher levels of cognitive demand (P = .005), experienced elevated levels of physical fatigue (P = .004), and expressed lower levels of satisfaction with their performance (P = .041).

CONCLUSION

Interruptions during interpretation of screening mammography have deleterious effects on physician performance and their sense of well-being.

Tips for Addressing Screening Concerns: "Harms of Screening"

Early detection decreases deaths from breast cancer. Yet, there are conflicting recommendations about screening mammography by major professional medical organizations, including the age and frequency with which women should be screened. The controversy over breast cancer screening is centered on 3 main points: the impact on mortality, overdiagnosis, and false positive results. Some studies claim that adverse psychological effects such as anxiety or distress are caused by screening mammography. The purpose of this article is to address negative breast cancer screening concerns including overdiagnosis and overtreatment, effect on mortality, false positive results, mammography-related anxiety, and fear of radiation.

Strategies enhancing the patient experience in mammography: A scoping review

INTRODUCTION

A positive experience in mammography is essential for increasing patient attendance and reattendance at these examinations, whether conducted for diagnostic or screening purposes. Mammograms indeed facilitate early disease detection, enhance the potential for cure, and consequently reduce breast cancer mortality. The main objective of this review was to identify and map the strategies aiming to improve the patient experience in diagnostic and screening mammography.

METHODS

This scoping review was performed following the JBI methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Searches were performed through databases of MEDLINE, Embase.com, CINAHL, APA PsycINFO, Cochrane Central Register of Controlled Trials, Web of Science, ProQuest Dissertation and Theses, and three clinical trial registries. This review considered studies evaluating the effect of interventions, occurring within the mammography department, on the patient experience.

RESULTS

The literature search yielded 8113 citations of which 60, matching the inclusion criteria, were included. The strategies were classified into eight categories. The most represented one was breast compression and positioning, followed by relaxation techniques and analgesic care, communication and information, screening equipment, examination procedures, patient-related factors, physical environment, and finally staff characteristics. The studied outcomes related to patient experience were mainly pain, anxiety, comfort, and satisfaction. Other types of outcomes were also considered in the studies such as image quality, technical parameters, or radiation dose. Most studies were conducted by radiographers, on female patients, and none mentioned the inclusion of male or transgender patients.

CONCLUSION

This review outlined a diversity of strategies to improve patient experience, although technique-based interventions were predominant. Further research is warranted, notably on psychological strategies, and on men and transgender people.

IMPLICATIONS FOR PRACTICE

This scoping review provides guidance to healthcare providers and services for better patient/client-centered care.

Breast Cancer Screening and Diagnosis: Recent Advances in Imaging and Current Limitations

Breast cancer detection has a significant impact on population health. Although there are many breast imaging modalities, mammography is the predominant tool for breast cancer screening. The introduction of digital breast tomosynthesis to mammography has contributed to increased cancer detection rates and decreased recall rates. In average-risk women, starting annual screening mammography at age 40 years has demonstrated the highest mortality reduction. In intermediate- and high-risk women as well as in those with dense breasts, additional modalities, including MRI, ultrasound, and molecular breast imaging, can also be considered for adjunct screening to improve the detection of mammographically occult malignancy.

Racial Disparities in Breast Imaging Wait Times Before and After the Implementation of a Same-Day Biopsy Program

OBJECTIVE

To examine time from screening to diagnostic workup, biopsy, and surgery for non-Hispanic White (NHW) and Black women following implementation of a same-day biopsy program.

METHODS

All NHW and Black women with BI-RADS category 0 screening mammogram at Duke University Hospital were identified between August 1, 2020, and August 1, 2021. Patient characteristics were recorded. Time between screening mammogram, diagnostic workup, breast biopsy, surgical consultation, and surgery were recorded. Comparisons were made between NHW and Black women using a multivariable regression model. Diagnostic imaging to biopsy time interval was compared to historical averages before same-day biopsy implementation.

RESULTS

There were 2156 women: 69.9% NHW (1508/2156) and 30.1% Black (648/2156). Mean ± standard deviation time from screening to diagnostic imaging overall was 13.5 ± 32.5 days but longer for Black (18.0 ± 48.3 days) than for NHW women (11.5 ± 22.2 days) (P < 0.001). The mean time from diagnostic mammogram to biopsy was 5.9 ± 18.9 days, longer for Black (9.0 ± 27.9 days) than for NHW women (4.4 ± 11.8 days) (P = 0.017). The same-day biopsy program shortened the time from diagnostic imaging to biopsy overall (12.5 ± 12.4 days vs 5.9 ± 18.9 days; P < 0.001), with a significant reduction for NHW women (12.4 ± 11.7 days vs 4.4 ± 11.8 days) (P < 0.001) but not Black women (11.5 ± 9.9 days vs 9.0 ± 27.9 days) (P = 0.527).

CONCLUSION

Disparities exist along the breast imaging pathway. A same-day biopsy program benefited NHW women more than Black women.

Opting into breast screening over the age of 70 years: seeking evidence to support informed choice

AIM

To provide evidence specific to the Scottish population regarding the risk-benefit balance of women >70 years opting into continued breast screening, which may be used as a basis for patient information documentation.

MATERIALS AND METHODS

The present study consisted of a parallel, retrospective data analysis of breast cancer mortality data for breast cancer cases diagnosed between 2009 and 2013 (n=22,013) followed up to 31/12/18, and breast screening programme data from 2010 and 2015 (n=47,235). Screening outcome measures included recall for assessment, oncome of assessment, and tumour features. Tumours were classified as high, intermediate, or low risk according to grade and presence of invasion. Mortality data were linked to age at diagnosis and cause of death was recorded.

RESULTS

The proportion of all deaths due breast cancer is inversely related to age at diagnosis. From 77 years, women are more likely to die with breast cancer, than directly due to breast cancer. Mammographic screening accurately identifies breast cancer in older women; however, many of the cancers detected were considered intermediate or low risk.

CONCLUSIONS

Harms may outweigh the benefits of continued breast screening in older women. This information should be available to all older women.

Experiences of Women Who Refuse Recall for Further Investigation of Abnormal Screening Mammography: A Qualitative Study

Breast cancer has the highest incidence among all cancers for women in Taiwan. The current screening policy in Taiwan provides biennial mammogram tests for all women aged 45 to 69 years. A recommendation for further investigation is sent via post to women with a BI-RADS result of 0. The proportion of women who followed-up with a recall request for further investigation after an abnormal mammogram has been below 92.5% in recent years. Therefore, we aimed to explore the experiences of these women who refused recall for further investigation despite an abnormal mammogram. Purposive sampling was conducted on 13 women who refused recall for further examination of abnormal screening mammograms. Data collection included inductive, in-depth interviews or telephone interviews. A content analysis was applied. Three themes were identified: (1) negative screening experiences, (2) struggling with ’to go or not to go’, and (3) rationalizing without a follow-up examination. The first theme included three subthemes: (1) pain of examination, (2) the inconvenience of medical treatment; waiting, and (3) dissatisfaction with having to pay for further examination. The second major theme included three subthemes: (1) perceiving one’s susceptibility to breast cancer as very low, (2) questioning the accuracy of the results, and (3) procrastinating with a “head-in-the-sand” mentality. The third major theme included two subthemes: (1) fatalism and (2) paying attention to self-cultivation. In conclusion, the findings provide important information to healthcare providers involved in case management related to the actual living experiences of women with abnormal screening mammogram results and the additional education required to raise breast cancer awareness in the general public to achieve overall caring goals.

How to Minimize Patient Anxiety From Screening Mammography

Anxiety has been portrayed by the media and some organizations and societies as one of the harms of mammography. However, one experiences anxiety in multiple different medical tests that are undertaken, including screening examinations; it is not unique to mammography. Some may argue that because this anxiety is transient, the so-called harm is potentially overstated, but for some women the anxiety is significant. Anxiety can increase or decrease the likelihood of obtaining a screening mammogram. There are multiple ways that anxiety associated with screening mammography can be diminished, including before, during, and after the examination. These include simple measures such as patient education, improved communication, being aware of the patient's potential discomfort and addressing it, validating the patient's anxiety as well as providing the patient with positive factual data that can easily be implemented in every breast center. More complex interventions include altering the breast center environment with multisensory stimulation, reorganization of patient flow to minimize wait times, and relaxation techniques including complementary and alternative medicine. In this article we will review the literature on measures that can be taken to minimize anxiety that would maximize the likelihood of a woman obtaining an annual screening mammogram.

Improving Workflow Efficiency for Mammography Using Machine Learning

OBJECTIVE

The aim of this study was to determine whether machine learning could reduce the number of mammograms the radiologist must read by using a machine-learning classifier to correctly identify normal mammograms and to select the uncertain and abnormal examinations for radiological interpretation.

METHODS

Mammograms in a research data set from over 7,000 women who were recalled for assessment at six UK National Health Service Breast Screening Program centers were used. A convolutional neural network in conjunction with multitask learning was used to extract imaging features from mammograms that mimic the radiological assessment provided by a radiologist, the patient's nonimaging features, and pathology outcomes. A deep neural network was then used to concatenate and fuse multiple mammogram views to predict both a diagnosis and a recommendation of whether or not additional radiological assessment was needed.

RESULTS

Ten-fold cross-validation was used on 2,000 randomly selected patients from the data set; the remainder of the data set was used for convolutional neural network training. While maintaining an acceptable negative predictive value of 0.99, the proposed model was able to identify 34% (95% confidence interval, 25%-43%) and 91% (95% confidence interval: 88%-94%) of the negative mammograms for test sets with a cancer prevalence of 15% and 1%, respectively.

CONCLUSION

Machine learning was leveraged to successfully reduce the number of normal mammograms that radiologists need to read without degrading diagnostic accuracy.

Factors Impacting False Positive Recall in Screening Mammography

RATIONALE AND OBJECTIVES

Our objective was to identify factors impacting false positive recalls in screening mammography.

MATERIALS AND METHODS

We retrospectively reviewed our screening mammography database from August 31, 2015 to September 30, 2016, including full field digital mammograms (FFDM) and digital breast tomosynthesis (DBT) mammograms. False positive (FP) exams were defined as Breast Imaging-Reporting and Data System (BI-RADS) 1 or 2 assessments at diagnostic imaging with 1 year cancer-free follow-up, Breast Imaging-Reporting and Data System 3 assessment at diagnostic imaging with 2 years cancer free follow-up, or biopsy with benign pathology. True positives were defined as malignant pathology on biopsy or surgical excision. We evaluated the association of FP recalls with multiple patient-level factors and imaging features.

RESULTS

A total of 22,055 screening mammograms were performed, and 1887 patients were recalled (recall rate 8.6%). Recall rate was lower for DBT than full field digital mammograms (8.0% vs 10.6%, p < 0.001). FP results were lower if prior mammograms were available (90.8% vs 95.8%, p = 0.02), and if there was a previous benign breast biopsy (87.6% vs 92.9%, p = 0.01). Mean age for the FP group was lower than the true positive group (56.1 vs 62.9 years, p < 0.001). There were no significant differences in FP recalls based on history of high-risk lesions, family history of breast or ovarian cancer, hormone use, breast density, race, or body mass index.

CONCLUSION

FP recalls were significantly less likely with DBT, in older women, in patients with prior mammograms available for comparison, and in patients with histories of benign breast biopsy. This study supports the importance of using DBT in the screening setting and obtaining prior mammograms for comparison.

Factors associated with false-positive mammography at first screen in an Asian population

Introduction

False-positive recall is an issue in national screening programmes. The aim of this study is to investigate the recall rate at first screen and to identify potential predictors of false-positive recall in a multi-ethnic Asian population-based breast cancer screening programme.

Methods

Women aged 50–64 years attending screening mammography for the first time (n = 25,318) were included in this study. The associations between potential predictors (sociodemographic, lifestyle and reproductive) and false-positive recall were evaluated using multivariable logistic regression models.

Results

The recall rate was 7.6% (n = 1,923), of which with 93.8% were false-positive. Factors independently associated with higher false-positive recall included Indian ethnicity (odds ratio [95% confidence interval]: 1.52 [1.25 to 1.84]), premenopause (1.23 [1.04 to 1.44]), nulliparity (1.85 [1.57 to 2.17]), recent breast symptoms (1.72 [1.31 to 2.23]) and history of breast lump excision (1.87 [1.53 to 2.26]). Factors associated with lower risk of false-positive recall included older age at screen (0.84 [0.73 to 0.97]) and use of oral contraceptives (0.87 [0.78 to 0.97]). After further adjustment of percent mammographic density, associations with older age at screening (0.97 [0.84 to 1.11]) and menopausal status (1.12 [0.95 to 1.32]) were attenuated and no longer significant.

Conclusion

For every breast cancer identified, 15 women without cancer were subjected to further testing. Efforts to educate Asian women on what it means to be recalled will be useful in reducing unnecessary stress and anxiety.

Clinical Hypnosis and Music In Breast Biopsy:A Randomized Clinical Trial

A randomized clinical study was conducted to evaluate the effects on anxiety, depression, stress and optimism levels of an audio-recorded clinical hypnosis intervention and a music session and compare them with a control group in women scheduled for breast biopsy. We analyzed the data of 170 patients with an average age of 47 years, who were randomly assigned to each of the groups. The psychosocial variables were measured in three moments: baseline, which corresponds to the period before the intervention with hypnosis, music or waiting in the room before biopsy; a second measurement after the interventions and a third measurement after the breast biopsy procedure was finished. The results showed a statistically significant reduction in the stress (p < .001, η²p = .06); pain, (p < .01, η²p = .04); anxiety, (p < .001, ƞ²p = .07) and depression, (p < .001, ƞ²p = .05) in hypnosis and music groups compared with the control group. Before biopsy, hypnosis decrease significantly pain and depression levels compared with music, but after biopsy there were no differences between both groups. It is recommended to use audio-recorded hypnosis and music interventions to reduce physical and emotional discomfort during the biopsy procedure and to improve the quality of life of patients with suspected breast cancer.

Psychosocial consequences among women with false-positive results after mammography screening in Norway

BACKGROUND

Mammography screening may cause psychosocial harm for women experiencing a false-positive screening result. Previous studies suggest long-term consequences. The aim of the present study was to assess psychosocial consequences of false-positive findings on screening mammography within a six month follow-up.

METHODS

A prospective matched cohort survey study using the questionnaire 'Consequences of Screening for Breast Cancer' (COS-BC), which was translated from Danish to Norwegian. Psychometric analyses investigated the measurement properties of the Norwegian version. Two screening clinics in Norway distributed the survey to 299 women with an abnormal mammogram and 541 women with a normal screen. Women received the questionnaire when receiving the screening result, and one and six months after screening.

RESULTS

At six months, statistically significant differences appeared in two scales: existential values and breast examination. At six-month follow-up, women with false-positive results showed no statistically significant differences from women diagnosed with breast cancer in three outcomes: sense of dejection, anxiety, and keeping my mind off things.

CONCLUSION

Our results indicate that the psychosocial consequences from having false-positive screening mammography results diminish after six months. The results support previous research describing breast-specific outcomes. However, our results indicate that Norwegian women are less frightened than other Scandinavian mammography screening participants.

Strategies for Decreasing Screening Mammography Recall Rates While Maintaining Performance Metrics

RATIONALE AND OBJECTIVE

This study aimed to determine the impact of interventions designed to reduce screening mammography recall rates on screening performance metrics.

MATERIALS AND METHODS

We assessed baseline performance for full-field digital mammography (FFDM) and digital breast tomosynthesis mammography (DBT) for a 3-year period before intervention. The first intervention sought to increase awareness of recalls from screening mammography. Breast imagers discussed their perceptions regarding screening recalls and were required to review their own recalled cases, including outcomes of diagnostic evaluation and biopsy. The second intervention implemented consensus double reading of all recalls, requiring two radiologists to agree if recall was necessary. Recall rates, cancer detection rates, and positive predictive value 1 (PPV1) were compared before and after each intervention.

RESULTS

The baseline recall rate, cancer detection rate, and PPV1 were 11.1%, 3.8/1000, and 3.4%, respectively, for FFDM, and 7.6%, 4.8/1000, and 6.0%, respectively, for DBT. Recall rates decreased significantly to 9.2% for FFDM and to 6.6% for DBT after the first intervention promoting awareness, as well as to 9.9% for FFDM after the second intervention implementing group consensus. PPV1 increased significantly to 5.7% for FFDM and to 9.0% for DBT after the second intervention. Cancer detection rate did not significantly change with the implementation of these interventions. An average of 2.3 minutes was spent consulting for each recall.

CONCLUSION

Reduction in recall rates is desirable, provided performance metrics remain favorable. Our interventions improved performance and could be implemented in other breast imaging settings.

The Effect of False-positive Mammograms on Antidepressant and Anxiolytic Initiation

BACKGROUND

Despite reported increases in anxiety following a false-positive mammogram, there is little evidence the effect rises to the clinical level of initiating medication.

OBJECTIVE

To analyze the effect of a false-positive mammogram on antidepressant or anxiolytic initiation and identify subpopulations most at risk.

SUBJECTS

MarketScan commercial and Medicaid claims databases used to identify women ages 40-64 undergoing screening mammography with no prior antidepressant or anxiolytic claims.

RESEARCH DESIGN

Using a retrospective cohort design, we estimated the effects of a false-positive relative to a negative mammogram on the likelihood of initiating antidepressants or anxiolytics using multivariate logistic models estimated separately by insurance type.

RESULTS

At 3 months after a false-positive mammogram, the relative risk (RR) for antidepressant or anxiolytic initiation was 1.19 [95% confidence interval (CI), 1.06-1.31] for the commercially insured and 1.13 (95% CI, 0.96-1.29) in the Medicaid population. In addition, 4 subgroups were at particularly elevated risk: commercially insured women ages 40-49 (RR=1.33; 95% CI, 1.13-1.54) or whose false-positive required multiple tests to resolve (RR=1.37; 95% CI, 1.17-1.57), included a biopsy (RR=1.68; 95% CI, 1.18-2.17), or whose resolution took >1 week (RR=1.21; 95% CI, 1.07-1.34).

CONCLUSIONS

False-positive mammograms were associated with significant increases in antidepressant or anxiolytic imitation among the commercially insured. Follow-up resources may be particularly beneficial for cases taking longer to resolve and involving biopsies or multiple tests. The results highlight the need to resolve false-positives quickly and effectively and to monitor depressive symptoms following a positive result.

A Simulation Screening Mammography Module Created for Instruction and Assessment: Radiology Residents vs National Benchmarks

RATIONALE AND OBJECTIVES

To improve mammographic screening training and breast cancer detection, radiology residents participated in a simulation screening mammography module in which they interpreted an enriched set of screening mammograms with known outcomes. This pilot research study evaluates the effectiveness of the simulation module while tracking the progress, efficiency, and accuracy of radiology resident interpretations and also compares their performance against national benchmarks.

MATERIALS AND METHODS

A simulation module was created with 266 digital screening mammograms enriched with high-risk breast lesions (seven cases) and breast malignancies (65 cases). Over a period of 27 months, 39 radiology residents participated in the simulation screening mammography module. Resident sensitivity and specificity were compared to Breast Cancer Surveillance Consortium (BCSC data through 2009) national benchmark and American College of Radiology (ACR) Breast Imaging Reporting and Data System (BI-RADS) acceptable screening mammography audit ranges.

RESULTS

The sensitivity, the percentage of cancers with an abnormal initial interpretation (BI-RADS 0), among residents was 84.5%, similar to the BCSC benchmark sensitivity of 84.9% (sensitivity for tissue diagnosis of cancer within 1 year following the initial examination) and within the acceptable ACR BI-RADS medical audit range of ≥75%. The specificity, the percentage of noncancers that had a negative image interpretation (BI-RADS 1 or 2), among residents was 83.2% compared to 90.3% reported in the BCSC benchmark data, but lower than the suggested ACR BI-RADS range of 88%-95%.

CONCLUSIONS

Using simulation modules for interpretation of screening mammograms is a promising method for training radiology residents to detect breast cancer and to help them achieve competence toward national benchmarks.

Harms of Breast Cancer Screening: Systematic Review to Update the 2009 U.S. Preventive Services Task Force Recommendation

BACKGROUND

In 2009, the U.S. Preventive Services Task Force recommended biennial mammography screening for women aged 50 to 74 years and selective screening for those aged 40 to 49 years.

PURPOSE

To review studies of screening in average-risk women with mammography, magnetic resonance imaging, or ultrasonography that reported on false-positive results, overdiagnosis, anxiety, pain, and radiation exposure.

DATA SOURCES

MEDLINE and Cochrane databases through December 2014.

STUDY SELECTION

English-language systematic reviews, randomized trials, and observational studies of screening.

DATA EXTRACTION

Investigators extracted and confirmed data from studies and dual-rated study quality. Discrepancies were resolved through consensus.

DATA SYNTHESIS

Based on 2 studies of U.S. data, 10-year cumulative rates of false-positive mammography results and biopsies were higher with annual than biennial screening (61% vs. 42% and 7% vs. 5%, respectively) and for women aged 40 to 49 years, those with dense breasts, and those using combination hormone therapy. Twenty-nine studies using different methods reported overdiagnosis rates of 0% to 54%; rates from randomized trials were 11% to 22%. Women with false-positive results reported more anxiety, distress, and breast cancer-specific worry, although results varied across 80 observational studies. Thirty-nine observational studies indicated that some women reported pain during mammography (1% to 77%); of these, 11% to 46% declined future screening. Models estimated 2 to 11 screening-related deaths from radiation-induced cancer per 100,000 women using digital mammography, depending on age and screening interval. Five observational studies of tomosynthesis and mammography indicated increased biopsies but reduced recalls compared with mammography alone.

LIMITATIONS

Studies of overdiagnosis were highly heterogeneous, and estimates varied depending on the analytic approach. Studies of anxiety and pain used different outcome measures. Radiation exposure was based on models.

CONCLUSION

False-positive results are common and are higher for annual screening, younger women, and women with dense breasts. Although overdiagnosis, anxiety, pain, and radiation exposure may cause harm, their effects on individual women are difficult to estimate and vary widely.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality.