Does biopsy, aspiration or six-month follow-up of a false-positive mammogram reduce future screening or have large psychosocial effects?

Consequences of false-positive screening mammograms

IMPORTANCE

False-positive mammograms, a common occurrence in breast cancer screening programs, represent a potential screening harm that is currently being evaluated by the US Preventive Services Task Force.

OBJECTIVE

To measure the effect of false-positive mammograms on quality of life by measuring personal anxiety, health utility, and attitudes toward future screening.

DESIGN, SETTING, AND PARTICIPANTS

The Digital Mammographic Imaging Screening Trial (DMIST) quality-of-life substudy telephone survey was performed shortly after screening and 1 year later at 22 DMIST sites and included randomly selected DMIST participants with positive and negative mammograms.

EXPOSURE

Mammogram requiring follow-up testing or referral without a cancer diagnosis.

MAIN OUTCOMES AND MEASURES

The 6-question short form of the Spielberger State-Trait Anxiety Inventory state scale (STAI-6) and the EuroQol EQ-5D instrument with US scoring. Attitudes toward future screening as measured by women's self-report of future intention to undergo mammographic screening and willingness to travel and stay overnight to undergo a hypothetical new type of mammography that would identify as many cancers with half the false-positive results.

RESULTS

Among 1450 eligible women invited to participate, 1226 (84.6%) were enrolled, with follow-up interviews obtained in 1028 (83.8%). Anxiety was significantly higher for women with false-positive mammograms (STAI-6, 35.2 vs 32.7), but health utility scores did not differ and there were no significant differences between groups at 1 year. Future screening intentions differed by group (25.7% vs 14.2% more likely in false-positive vs negative groups); willingness to travel and stay overnight did not (9.9% vs 10.5% in false-positive vs negative groups). Future screening intention was significantly increased among women with false-positive mammograms (odds ratio, 2.12; 95% CI, 1.54-2.93), younger age (2.78; 1.5-5.0), and poorer health (1.63; 1.09-2.43). Women's anticipated high-level anxiety regarding future false-positive mammograms was associated with willingness to travel overnight (odds ratio, 1.94; 95% CI, 1.28-2.95).

CONCLUSIONS AND RELEVANCE

False-positive mammograms were associated with increased short-term anxiety but not long-term anxiety, and there was no measurable health utility decrement. False-positive mammograms increased women's intention to undergo future breast cancer screening and did not increase their stated willingness to travel to avoid a false-positive result. Our finding of time-limited harm after false-positive screening mammograms is relevant for clinicians who counsel women on mammographic screening and for screening guideline development groups.

False-positive Mammographic Screening: Factors Influencing Re-attendance over a Decade of Screening

Introduction

International studies on the effect of false-positive mammographic screening results on subsequent re-attendance at screening are inconsistent.

Setting Breast

Check, the national breast screening programme for the Republic of Ireland, screens women two-yearly. Re-attendance for subsequent screening is approximately 90%.

Objectives and Methods

The aim of this research was to quantify the impact of false-positive mammographic screening results on subsequent re-attendance, using the BreastCheck clinical database with a decade of screening and to determine if age group, assessment procedure, initial or subsequent screening, location of appointment for next screening round and time from recall to non-malignant diagnosis predicted re-attendance.

Results

From programme commencement in 2000 to the end of 2007, 13,352 screening tests resulted in assessment; 11,765 participants were aged 50-62 years and of these 9746 received false-positive results (positive predictive value 17.2%). Following a false-positive recall to assessment, re-attendance at subsequent screening differed significantly by procedure type (open biopsy 80.3%; core biopsy only 90.2%; no tissue sampling 91.4%; P < 0.0001). Re-attendance differed significantly by timing of false-positive assessment in a woman's screening history (first versus subsequent screening, 89.5% versus 93.5%, P < 0.0001) and by location of next screening appointment (screening centre 89.8% versus mobile unit 91.3%, P < 0.01). The longer the period between recall to assessment and non-malignant diagnosis the less likely women were to re-attend. After logistic regression, first screening, older age, open surgical biopsy, re-invitation to screening centre and a longer period between recall and non-malignant diagnosis were significant negative predictors of re-attendance.

Conclusion

Since April 2008 BreastCheck has employed full field digital mammography throughout the programme, with a resulting increase in recalls; re-attendance will be closely monitored.

False-positive results in the randomized controlled trial of mammographic screening from age 40 ("Age" trial)

BACKGROUND

False-positive recall is a recognized disadvantage of mammographic breast screening, and the rate of such recalls may be higher in younger women, potentially limiting the value of screening below age 50.

METHODS

Attendance and screening outcome data for 53,884 women in the intervention arm of the U.K. Age trial were analyzed to report observed false-positive recall rates during 13 years of trial fieldwork. The Age trial was a randomized controlled trial of the effect of mammographic screening from age 40 on breast cancer mortality, conducted in 23 National Health Service screening centers between 1991 and 2004. Women randomized to the intervention arm were offered annual invitation to mammography from age 40 or 41 to age 48.

RESULTS

Overall, 7,893 women (14.6% of women the intervention arm and 18.1% of women attending at least one routine screen) experienced one or more false-positive screen during the trial. The rates of false-positive mammography at first and subsequent routine screens were 4.9% and 3.2%, respectively. The cumulative false-positive rate over seven screens was 20.5%. Eighty-nine percent of women who had a false-positive recall at their previous screen attended their next invitation to routine screening.

CONCLUSIONS

The rates of false-positive recall in the Age trial were comparable with the national screening program; however, the positive predictive value of referral was lower. Experiencing a false-positive screen did not seem to lessen the likelihood of re-attendance in the trial.

IMPACT

The question of greatly increased false-positive rates in this age group and of their compromising re-attendance is refuted by the findings of this study.

The use of patient-centered outcome measures in radiology: a systematic review

RATIONALE AND OBJECTIVES

To undertake a systematic review of literature on patient centred outcomes and explore the use of patient defined outcomes in radiology research.

MATERIALS AND METHODS

i)

DATA SOURCES

Published empirical studies in peer reviewed journals. ii)

STUDY SELECTION

Systematic search of English language radiology literature between 1990-2003, using four electronic databases, and reference lists of papers. Work relating to diagnostic or interventional imaging was included. Screening was excluded, together with articles based solely on the audit of patients' medical records. Patients needed to have inputted directly into the study, for example responding to questionnaires or participating in interviews. iii)

DATA EXTRACTION

Abstracts were retrieved and relevant full text articles obtained. Each paper was reviewed independently by two reviewers (research team members) using a data extraction form, developed by the authors. Categorisation of papers was undertaken at team meetings.

RESULTS

A total of 26 publications met the inclusion criteria for the review. Papers were placed within three categories: i) the primary aim of the study was investigate patient centred outcomes (n = 10); ii) the primary aim of the study was to describe the radiological procedure itself but patient contact was made post-procedure (n = 5) and iii) the primary aim of the study was to investigate patients' experiences during procedures (n = 11). Validated outcome measures were used in 10 studies. None of the outcome measures used were developed specifically for radiology. No papers were found where researchers had used patient defined outcomes.

CONCLUSION

The research highlighted difficulties relating to the review and reporting of outcomes research. The results indicated little patient engagement in outcome research in radiology.

Guidelines from the European Society of Breast Imaging for diagnostic interventional breast procedures

The aim of the breast team is to obtain a definitive, nonoperative diagnosis of all potential breast abnormalities in a timely and cost-effective way. Percutaneous needle biopsy with its high sensitivity and specificity should now be standard practice, removing the need for open surgical biopsy or frozen section. For patients with cancer, needle biopsy provides a cost-effective and rapid way of providing not only a definitive diagnosis but prognostic information, allowing prompt discussion of treatment options, be they surgical or medical. Early removal of uncertainty also allows better psychosocial adjustment to the disease. Patients with benign conditions found either by themselves or as a result of population or opportunistic screening can be promptly reassured and discharged, removing the health care and psychological costs of surgical biopsy or repeated follow-up. Radiologists involved in breast imaging should ensure that they have the necessary skills to carry out core biopsy and/or fine-needle aspiration (FNA) under all forms of image guidance. This paper provides guidelines on best practice for diagnostic interventional breast procedures and standards, against which all practitioners should audit themselves, from the European Society of Breast Imaging.

Mainstream breast cancer radiology perspective

Clinical breast-imaging tests must be fast, sensitive, specific, add information not otherwise available to clinicians at a reasonable cost, and be biopsy-capable. Mammography, breast ultrasound and imaging guided breast core biopsies and preoperative needle localizations are most often used in breast imaging facilities around the world. This article will describe mammography and breast ultrasound in current clinical practice for breast cancer detection, diagnosis, staging, image-guided biopsy, and for evaluation of response to neoadjuvant chemotherapy.

Adverse effects of screening mammography

The main risks and other adverse consequences from screening mammography include discomfort from breast compression, patient recall for additional imaging, and false positive biopsies. Although these risks affect a larger number of women than those who benefit from screening, the risks are less consequential than the life-sparing benefits from early detection. Radiation risk, even for multiple screenings, is negligible at current mammography doses. Anxiety before screening or resulting from supplementary imaging work-up, short-term follow-up, cyst aspiration, and biopsy has not dampened the enthusiasm of most women for the value of early detection.