False-positive mammography and depressed mood in a screening population: findings from the New Hampshire Mammography Network

Is the false-positive rate in mammography in North America too high?

The practice of investigating pathological abnormalities in the breasts of females who are asymptomatic is primarily employed using X-ray mammography. The importance of breast screening is reflected in the mortality-based benefits observed among females who are found to possess invasive breast carcinoma prior to the manifestation of clinical symptoms. It is estimated that population-based screening constitutes a 17% reduction in the breast cancer mortality rate among females affected by invasive breast carcinoma. In spite of the significant utility that screening confers in those affected by invasive cancer, limitations associated with screening manifest as potential harms affecting individuals who are free of invasive disease. Disease-free and benign tumour-bearing individuals who are subjected to diagnostic work-up following a screening examination constitute a population of cases referred to as false positives (FPs). This article discusses factors contributing to the FP rate in mammography and extends the discussion to an assessment of the consequences associated with FP reporting. We conclude that the mammography FP rate in North America is in excess based upon the observation of overtreatment of in situ lesions and the disproportionate distribution of detriment and benefit among the population of individuals recalled for diagnostic work-up subsequent to screening. To address the excessive incidence of FPs in mammography, we investigate solutions that may be employed to remediate the current status of the FP rate. Subsequently, it can be suggested that improvements in the breast-screening protocol, medical litigation risk, image interpretation software and the implementation of image acquisition modalities that overcome superimposition effects are promising solutions.

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.

Effects of false-positive results in a breast screening program on anxiety, depression and health-related quality of life

BACKGROUND

Decreased anxiety has been reported among women with false-positive results in mammography screening programs. No long-term effects have been fully demonstrated, and the findings for anxiety and depression are contradictory. Few studies have addressed changes in health-related quality of life (HRQOL).

OBJECTIVE

The objective was to study the short- and long-term effects such as changes in anxiety, depression, and HRQOL among women with false-positive results.

METHODS

With a longitudinal study design, data were collected on anxiety and depression (Hospital Anxiety and Depression Scale) and HRQOL (Short-Form 36 [SF-36] Health Survey) among women with false-positive results before screening, at recall, and at 3 and 6 months after screening. Controls (negative results in screening) were measured before screening and at 6 months after.

RESULTS

Women with false-positive results (n = 128) showed increased anxiety at recall (mean, 4.6 [SD, 3.7]) versus before screening (P = .04), but this decreased until 6 months after screening. Depression was increased until 6 months after screening (not statistically significant). Women with false-positive results scored lower than did control subjects on general health (P = .02) and mental health (P = .03) and higher on depression (P = .045) at 6 months after screening.

CONCLUSIONS

Efforts should be made to minimize anxiety at recall and depression after screening. Further research is needed on the long-term effects of recall and any effects on HRQOL.

IMPLICATIONS FOR PRACTICE

Information about the prevalence of false-positive results and time until unambiguous diagnostic results should be improved. Information leaflet based on evidence needs to be continually updated.