Does timely assessment affect the anxiety associated with an abnormal mammogram result?

Delayed or failure to follow-up abnormal breast cancer screening mammograms in primary care: a systematic review

Background

Successful breast cancer screening relies on timely follow-up of abnormal mammograms. Delayed or failure to follow-up abnormal mammograms undermines the potential benefits of screening and is associated with poorer outcomes. However, a comprehensive review of inadequate follow-up of abnormal mammograms in primary care has not previously been reported in the literature. This review could identify modifiable factors that influence follow-up, which if addressed, may lead to improved follow-up and patient outcomes.

Methods

A systematic literature review to determine the extent of inadequate follow-up of abnormal screening mammograms in primary care and identify factors impacting on follow-up was conducted. Relevant studies published between 1 January, 1990 and 29 October, 2020 were identified by searching MEDLINE®, Embase, CINAHL® and Cochrane Library, including reference and citation checking. Joanna Briggs Institute Critical Appraisal Checklists were used to assess the risk of bias of included studies according to study design.

Results

Eighteen publications reporting on 17 studies met inclusion criteria; 16 quantitative and two qualitative studies. All studies were conducted in the United States, except one study from the Netherlands. Failure to follow-up abnormal screening mammograms within 3 and at 6 months ranged from 7.2–33% and 27.3–71.6%, respectively. Women of ethnic minority and lower education attainment were more likely to have inadequate follow-up. Factors influencing follow-up included physician-patient miscommunication, information overload created by automated alerts, the absence of adequate retrieval systems to access patient’s results and a lack of coordination of patient records. Logistical barriers to follow-up included inconvenient clinic hours and inconsistent primary care providers. Patient navigation and case management with increased patient education and counselling by physicians was demonstrated to improve follow-up.

Conclusions

Follow-up of abnormal mammograms in primary care is suboptimal. However, interventions addressing amendable factors that negatively impact on follow-up have the potential to improve follow-up, especially for populations of women at risk of inadequate follow-up.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08100-3.

The Psychological Experience of Awaiting Breast Diagnosis

BACKGROUND

Each year, over 1 million women in the USA undergo diagnostic breast biopsies, many of which culminate in a benign outcome. However, for many patients, the experience of awaiting biopsy results is far from benign, instead provoking high levels of distress.

PURPOSE

To take a multifaceted approach to understanding the psychological experience of patients undergoing a breast biopsy.

METHOD

Female patients (N = 214) were interviewed at an appointment for a breast biopsy, just prior to undergoing the biopsy procedure. Pertinent to the current investigation, the interview assessed various patient characteristics, subjective health and cancer history, support availability, outcome expectations, distress, and coping strategies.

RESULTS

The findings revealed a complex set of interrelationships among patient characteristics, markers of distress, and use of coping strategies. Patients who were more distressed engaged in more avoidant coping strategies. Regarding the correlates of distress and coping, subjective health was more strongly associated with distress and coping than was cancer history; perceptions of support availability were also reliably associated with distress.

CONCLUSION

Taken together, the results suggest that patients focus on their immediate experience (e.g., subjective health, feelings of risk, perceptions of support) in the face of the acute moment of uncertainty prompted by a biopsy procedure, relative to more distal considerations such as cancer history and demographic characteristics. These findings can guide clinicians' interactions with patients at the biopsy appointment and can serve as a foundation for interventions designed to reduce distress in this context.

Mammography facilities serving vulnerable women have longer follow-up times

Objective

To investigate mammography facilities’ follow‐up times, population vulnerability, system‐based processes, and association with cancer stage at diagnosis.

Data Sources

Prospectively collected from San Francisco Mammography Registry (SFMR) 2005‐2011, California Cancer Registry 2005‐2012, SFMR facility survey 2012.

Study Design

We examined time to biopsy for 17 750 abnormal mammogram results (BI‐RADS 4/5), categorizing eight facilities as short or long follow‐up based on proportion of mammograms with biopsy at 30 days. We examined facility population vulnerability (race/ethnicity, language, education), and system processes. Among women with a cancer diagnosis, we modeled odds of advanced‐stage (≥IIb) cancer diagnosis by facility follow‐up group.

Data Extraction Methods

Merged SFMR, Cancer Registry and facility survey data.

Principal Findings

Facilities (N = 4) with short follow‐up completed biopsies by 30 days for 82% of mammograms compared with 62% for facilities with long follow‐up (N = 4) (P < 0.0001). All facilities serving high proportions of vulnerable women were long follow‐up facilities. The long follow‐up facilities had fewer radiologists, longer biopsy appointment wait times, and less communication directly with women. Having the index abnormal mammogram at a long follow‐up facility was associated with higher adjusted odds of advanced‐stage cancer (OR 1.45; 95% CI 1.10‐1.91).

Conclusions

Providing mammography facilities serving vulnerable women with appropriate resources may decrease disparities in abnormal mammogram follow‐up and cancer diagnosis stage.

Timely follow-up of positive cancer screening results: A systematic review and recommendations from the PROSPR Consortium

Timely follow-up for positive cancer screening results remains suboptimal, and the evidence base to inform decisions on optimizing the timeliness of diagnostic testing is unclear. This systematic review evaluated published studies regarding time to follow-up after a positive screening for breast, cervical, colorectal, and lung cancers. The quality of available evidence was very low or low across cancers, with potential attenuated or reversed associations from confounding by indication in most studies. Overall, evidence suggested that the risk for poorer cancer outcomes rises with longer wait times that vary within and across cancer types, which supports performing diagnostic testing as soon as feasible after the positive result, but evidence for specific time targets is limited. Within these limitations, we provide our opinion on cancer-specific recommendations for times to follow-up and how existing guidelines relate to the current evidence. Thresholds set should consider patient worry, potential for loss to follow-up with prolonged wait times, and available resources. Research is needed to better guide the timeliness of diagnostic follow-up, including considerations for patient preferences and existing barriers, while addressing methodological weaknesses. Research is also needed to identify effective interventions for reducing wait times for diagnostic testing, particularly in underserved or low-resource settings. CA Cancer J Clin 2018;68:199-216. © 2018 American Cancer Society.

Waiting time and the psychosocial consequences of false-positive mammography: cohort study

BACKGROUND

There is wide variation in the psychosocial response to false-positive mammography. We aimed to assess whether women having to wait longer to exclude cancer had increased psychosocial consequences that persisted after cancer was ruled out.

FINDINGS

We selected women with false-positive mammography (n = 272), screened for breast cancer in Copenhagen and Funen (Denmark) over a 1-year period. We measured psychosocial consequences immediately before women attended their recall visit and 1, 6, 18 and 36 months after women received their final diagnosis. After women were told that cancer had been ruled out, adverse psychosocial consequences decreased with time. We found no statistically significant differences between women who had cancer ruled out immediately at the recall visit (waiting time of 0) and women who had to wait longer before cancer was ruled out (waiting times 1-30, 30-120 and > 120 days), when psychosocial consequences were measured via a condition-specific questionnaire (Consequences of Screening in Breast Cancer) at 5 time points (0, 1, 6, 18 and 36 months after cancer exclusion).

CONCLUSION

We did not confirm that waiting time was associated with worse long-term psychosocial consequences but type II error (failure to detect a true difference) might be a plausible explanation for our results.

Incidence of distress and associated factors in women undergoing breast diagnostic evaluation

The purpose of this study was to identify the incidence of distress and factors associated with distress in women undergoing breast diagnostic evaluations. A total of 128 women undergoing a breast biopsy at three hospitals completed a set of nine standardized instruments. The presence of distress was identified with 14% having symptoms above the cutoff point for clinical anxiety. In multiple regression analyses, trait anxiety alone explained 71% of the State-Trait Anxiety Inventory State score. A model with trait anxiety, satisfaction with health care, meaning in life, and friend support accounted for 66% of the Hospital Anxiety and Depression Scale score for depression. It appears that when faced with a potential cancer diagnosis, distress levels are based on personality and self-evaluation of whether one has the resources to adapt to life with cancer. Distress screening protocols need to be routinely included in diagnostic radiology appointments. Nurses should implement interventions focusing on providing information, facilitating communication, and offering psychosocial support.

Language barriers, location of care, and delays in follow-up of abnormal mammograms

BACKGROUND

Breast cancer is frequently diagnosed after an abnormal mammography result. Language barriers can complicate communication of those results.

OBJECTIVES

We evaluated the association of non-English language with delay in follow-up.

METHODS

Retrospective cohort study of women at 3 mammography facilities participating in the San Francisco Mammography Registry with an abnormal mammogram result from 1997 to 2008. We measured median time from report of abnormal result to first follow-up test.

RESULTS

Of 13,014 women with 16,109 abnormal mammograms, 4027 (31%) had a non-English patient language. Clinical facilities differed in proportion of non-English speakers and in time to first follow-up test: facility A (38%; 25 d), facility B (18%; 14 d), and facility C (51%; 41 d). Most mammography examinations (67%) had breast imaging and reporting data system 0 (incomplete) assessment, requiring radiographic follow-up. At 30 days of follow-up, 67% of all English speakers with incomplete assessments had a follow-up examination compared with 50% of all non-English speakers (P<0.0001). The facility with the least delay and the lowest proportion of non-English speakers, had the biggest difference by language; compared with English speakers and adjusting for education, non-English speakers had twice the odds ratio of >30-day delay in follow-up (odds ratio=2.3; 95% confidence interval, 1.4-3.9).

CONCLUSIONS

There are considerable differences among facilities in delays in diagnostic follow-up of abnormal mammography results. More attention must be paid to understanding mammography facility factors, such as wait time to schedule diagnostic mammography and radiology workload, to improve rates of timely follow-up, particularly for those facilities disproportionately serving vulnerable non-English speaking patients.

Breast cancer worry in further examination of mammography screening--a systematic review

AIMS

In this systematic review, we explored which factors are associated with breast cancer (BC) worry in further examination (FE) of mammography screening and for how long women experience BC worry associated with FE.

METHODS

Medline, Cochrane, Cinahl and the International Network of Agencies for Health Technology Assessment databases were used in the search. In addition to this, reference lists of the selected articles were inspected. The subject headings and keywords searched included breast screening, mammography screening, BC worry, distress or anxiety, additional test, further examination and recall. These were used separately and in combination. The databases gave 598 references. From the selected titles, 83 abstracts were read; from these, 23 publications were selected for full-text review. On the basis of full texts, 15 articles were chosen.

FINDINGS

There were very few studies about the associations between FE and BC worry. In those found, the amount of measured variables was limited. BC worry in FE of breast screening was associated with several sociodemographic and psychosocial factors of recalled women, as well as those related to the FE process. About half of the recalled women were quite or very anxious in the prediagnostic phase.

CONCLUSIONS

The review gave implications for interventions in the FE process of mammography screening. These interventions should predominantly be made in the preclinical phase and should differ according to the type of recall visit and characteristics of recalled women. In communicating the diagnosis to the women, the time from the examination process to diagnosis should be as short as possible, and in addition to physicians being present, other health care professionals should also be there to ensure the necessary emotional and practical support a woman needs in such a situation.

Improving follow-up to abnormal breast cancer screening in an urban population

Delays in follow-up after cancer screening contribute to racial/ethnic disparities in cancer outcomes. We evaluated a patient navigator intervention among inner-city women with breast abnormalities. A full-time patient navigator supported patients using the care management model. Female patients 18 years and above, referred to an urban, hospital-based, diagnostic breast health practice from January to June 2000 (preintervention) and November 2001 to February 2003 (intervention), were studied. Timely follow-up was defined as arrival to diagnostic evaluation within 120 days from the date the original appointment was scheduled. Data were collected via computerized registration, medical records, and patient interview. Bivariate and multivariate logistic regression analyses were conducted, comparing preintervention and intervention groups, with propensity score analysis and time trend analysis to address the limitations of the pre-post design. 314 patients were scheduled preintervention; 1018, during the intervention. Overall, mean age was 44 years; 40% black, 36% non-Hispanic white, 14% Hispanic, 4% Asian, 5% other; 15% required an interpreter; 68% had no or only public insurance. Forty-four percent of referrals originated from a community health center, 34% from a hospital-based practice. During the intervention, 78% had timely follow-up versus 64% preintervention (P < .0001). In adjusted analyses, women in the intervention group had 39% greater odds of having timely follow-up (95% CI, 1.01-1.9). Timely follow-up in the adjusted model was associated with older age (P = .0003), having private insurance (P = .006), having an abnormal mammogram (P = .0001), and being referred from a hospital-based practice, as compared to a community health center (P = .003). Our data suggest a benefit of patient navigators in reducing delay in breast cancer care for poor and minority populations. Cancer 2007. (c) 2006 American Cancer Society.

Psychological Distress in U.S. Women Who Have Experienced False-Positive Mammograms

BACKGROUND

In the United States, approximately 10.7% of all screening mammograms lead to a false-positive result, but the overall impact of false-positives on psychological well-being is poorly understood.

MATERIALS AND METHODS

Data were analyzed from the 2000 U.S. National Health Interview Survey (NHIS), the most recent national survey that included a cancer control module. Study subjects were 9,755 women who ever had a mammogram, of which 1,450 had experienced a false-positive result. Psychological distress was assessed using the validated K6 questionnaire and logistic regression was used to discern any association with previous false-positive mammograms.

RESULTS

In a multivariate analysis, women who had indicated a previous false-positive mammogram were more likely to report feeling sad (OR = 1.18, 95% CI, 1.03-1.35), restless (OR = 1.23, 95% CI, 1.08-1.40), worthless (OR = 1.27, 95% CI, 1.04-1.54), and finding that everything was an effort (OR = 1.27, 95% CI, 1.10-1.47). These women were also more likely to have seen a mental health professional in the 12 months preceding the survey (OR = 1.28, 95% CI, 1.03-1.58) and had a higher composite score on all items of the K6 scale (P < 0.0001), a reflection of increased psychological distress. Analyses by age and race revealed that, among women who had experienced false-positives, younger women were more likely to feel that everything was an effort, and blacks were more likely to feel restless.

CONCLUSION

In a random sampling of the U.S. population, women who had previously experienced false-positive mammograms were more likely to report symptoms of anxiety and depression.

Breast cancer risk reduction options: awareness, discussion, and use among women from four ethnic groups

BACKGROUND

With recent advances in breast cancer risk reduction practices, it is increasingly important to assess both the breadth of and disparities in use across different racial/ethnic groups.

METHODS

We conducted telephone interviews with 1,700 women ages 40 to 74, from four racial/ethnic groups, without prior history of breast cancer, who received mammograms at one of five mammography facilities in San Francisco. Main outcomes measured included recognition of tamoxifen, raloxifene, genetic testing, and prophylactic surgery. Global indicators (recognition of any therapy, discussion of breast cancer risk) were developed from original outcome measures and analyzed using logistic regression.

RESULTS

Multivariate analyses indicate that race/ethnicity and interview language affected recognition of therapies and discussion of risk. White women were more likely than all other women to recognize any therapy and more likely than Asian-Americans to discuss risk. Women at high risk, who had a prior abnormal mammogram, who perceived themselves to be at high risk, or who were exposed to breast health information were more likely to discuss risk.

CONCLUSIONS

Women are aware of preventive therapies, although discussion and use is limited. Interventions to increase use of therapies should focus on those at high risk.

The psychological impact of mammographic screening. A systematic review

Concerns have been raised regarding the possible negative psychological impact of the cancer screening programmes offered in the UK. This review aims to assess the extent of and factors associated with the adverse psychological consequences of mammographic screening. Fifty-four papers from 13 countries were identified, a majority of which were published after 1990, coinciding more or less with the onset of routine mammographic screening. The results report that mammographic screening does not appear to create anxiety in women who are given a clear result after a mammogram and are subsequently placed on routine recall. However, women who have further investigations following their routine mammogram experience significant anxiety in the short term, and possibly in the long term. The nature and extent of the further investigation that women are exposed to during mammographic screening determines the intensity of the psychological impact. Factors associated with the adverse psychological impact of mammographic screening included: social demographic factors of younger age, lower education, living in urban areas, manual occupation, and one or no children; cancer screening factors of dissatisfaction with information and communication during screening process, waiting time between recall letter and recall appointment, pain experienced during the mammographic screening procedures, and previous false positive result; and cancer worry factors including fear of cancer and greater perceived risk of breast cancer. Difficulties in measuring the psychological impact of screening are discussed, and methods of alleviating the negative psychological outcomes are suggested.

Screening mammography: costs and use of screening-related services

PURPOSE

To determine the costs and screening-related services in women undergoing screening mammography.

MATERIALS AND METHODS

Study procedures were approved by the institutional committee for the protection of human subjects, and participants gave prior written consent. Data from a statewide mammography registry were used to identify imaging examinations, clinical consultations, interventional procedures, and pathology reports associated with screening mammography. The analysis included 99 064 women in the New Hampshire Mammography Network who underwent screening mammography between November 1, 1996, and March 31, 2000. Use of screening-related services in each case was tracked over an 18-month period, and procedure-specific national Medicare reimbursement rates from 2002 were applied for estimation of costs. Descriptive statistics (means, medians, standard deviations, 95% confidence intervals, frequencies, and percentages of resources and of costs) were calculated.

RESULTS

The majority of subjects (85 809, or 87%) underwent screening mammography only. Of the 13 255 (13%) who underwent diagnostic imaging, additional mammographic views were obtained in most at the time of screening, within days or weeks of screening, or at short-interval follow-up. The total cost was $12 287 739. Approximately 80% ($9 777 670) of the total cost was related to imaging, and 68% ($8 410 313), specifically to screening mammography. Twenty percent ($2 510 069) of the total cost was associated with consultation and interventional procedures in only 2942 (3%) of the women, primarily those who underwent biopsy. Procedures resulted in benign findings in 2247 (76%) of the 2942. Mean total direct medical costs per capita were low ($99) in women who underwent screening mammography only, moderate ($286) in women who also underwent diagnostic imaging, and substantially greater in women who underwent biopsy ($993).

CONCLUSION

While the largest component cost of screening mammography is that incurred in obtaining screening views alone, the highest costs per capita are associated with interventional procedures.

Decreasing Women's Anxieties After Abnormal Mammograms: A Controlled Trial

BACKGROUND

Few studies have evaluated interventions to decrease a woman's anxiety after she receives an abnormal mammogram (i.e., one with a recommendation for follow-up). We performed a controlled trial to compare the effects of both an immediate reading of mammograms (i.e., a radiology intervention) and of an educational intervention that taught skills to cope with anxiety on the psychological status of women whose mammograms were normal or abnormal.

METHODS

Eligible women (n = 8543) aged 39 years or older were recruited from seven mammography sites at the time of their scheduled mammography screening and assigned to receive no intervention, either the radiology or the educational intervention, or both interventions. We used the Impact of Events Scale (IES) and the Hopkins Symptom Checklist subscales for Anxiety (HSC-A) and Depression (HSC-D) in structured telephone interviews of 2844 women to assess the psychological status of all women with abnormal mammograms (excluding women diagnosed with breast cancer) and of a random sample of women with normal mammograms at 3 weeks and 3 months after their mammograms. All statistical tests were two-sided.

RESULTS

We obtained usable 3-week interviews for 2390 (84%) women. By the 3-week interview, 1037 (72.1%) of the 1439 interviewed women with abnormal mammograms had completed the recommended work-up and knew that their abnormal mammograms were false positives. Women with abnormal mammograms had higher IES and HSC-A scores (i.e., more anxiety) than women with normal mammograms (mean IES scores: 4.97 [95% confidence interval [CI] = 4.47 to 5.50] and 1.82 [95% CI = 1.51 to 2.14], respectively; P<.001; mean HSC-A scores: 1.14 [95% CI = 1.12 to 1.15] and 1.11 [95% CI = 1.09 to 1.13], respectively, P=.002). Among women with false-positive mammograms, those who had received the radiology intervention reported less anxiety than those who had not (mean IES scores: 4.42 [95% CI = 3.73 to 5.07] and 5.53 [95% CI = 4.82 to 6.28], respectively, P=.026). The educational intervention was not associated with any difference in psychological outcomes. Three months after the mammogram, by which time more than 80% of the women with abnormal results knew their mammograms to be false positives, anxiety levels of women with false-positive mammograms remained higher than those of women with normal mammograms (mean IES scores: 2.34 [95% CI = 1.99 to 2.69] and 1.15 [95% CI = 0.87 to 1.47], respectively, P<.001).

CONCLUSION

Immediate reading of screening mammograms, but not an educational intervention targeting coping skills, was associated with less anxiety among women with false-positive mammograms 3 weeks after mammography.

Factors Affecting Follow-up among Low-Income Women with Breast Abnormalities

PURPOSE

To assess factors affecting follow-up care among low-income women after identification of a breast abnormality.

METHODS

Women with a newly discovered breast abnormality were selected from one public hospital and two comprehensive health centers (CHCs) in Los Angeles county. Twelve months later, a telephone survey and medical chart review were conducted.

RESULTS

Of the 535 respondents, 8.6% received no follow-up care. Among those with follow-up care, 29.4% received inadequate care (did not initiate follow-up in a timely manner or did not complete all recommended procedures). Factors affecting receipt of any follow-up care included having the index visit at a CHC vs. a hospital (OR 2.79, CI 1.20-6.50), patient uncertainty about where to receive care (OR 0.24, CI 0.07-0.77), and recommendation of a clinical breast examination (CBE) (OR 0.12, CI 0.04-0.40) or 6-month mammogram (OR 0.11, CI 0.04-0.31) vs. a diagnostic mammogram as a first follow-up procedure. Factors affecting receipt of adequate follow-up care included index visit at a CHC vs. a hospital (OR 1.90, CI 1.13-3.20), being white/Asian Pacific Islander/other vs. Latina (OR 5.33, CI 1.71-16.68), recommendation of a 6-month mammogram vs. a diagnostic mammogram (OR 0.06, CI 0.02-0.14), and a family history of breast cancer (OR 0.44, CI 0.22-0.89).

CONCLUSIONS

To maximize return for follow-up among low-income women with a breast abnormality, clear information should be provided about where to obtain care, particularly to patients in hospital settings. The importance of complete and timely follow-up care should be emphasized, especially with referrals for clinical breast examinations or 6-month mammograms.