Cumulative false positive recall rate and association with participant related factors in a population based breast cancer screening programme

Long-term psychosocial consequences of false-positive screening mammography: a cohort study with follow-up of 12-14 years in Denmark

OBJECTIVE

To compare the long-term psychosocial consequences of mammography screening among women with breast cancer, normal results and false-positive results.

DESIGN

A matched cohort study with follow-up of 12-14 years.

SETTING

Denmark from 2004 to 2019.

PARTICIPANTS

1170 women who participated in the Danish mammography screening programme in 2004-2005.

INTERVENTION

Mammography screening for women aged 50-69 years.

OUTCOME MEASURES

We assessed the psychosocial consequences with the Consequences Of Screening-Breast Cancer, a condition-specific questionnaire that is psychometrically validated and encompasses 14 psychosocial dimensions.

RESULTS

Across all 14 psychosocial outcomes, women with false-positive results averagely reported higher psychosocial consequences compared with women with normal findings. Mean differences were statistically insignificant except for the existential values scale: 0.61 (95% CI (0.15 to 1.06), p=0.009). Additionally, women with false-positive results and women diagnosed with breast cancer were affected in a dose-response manner, where women diagnosed with breast cancer were more affected than women with false-positive results.

CONCLUSION

Our study suggests that a false-positive mammogram is associated with increased psychosocial consequences 12-14 years after the screening. This study adds to the harms of mammography screening. The findings should be used to inform decision-making among the invited women and political and governmental decisions about mammography screening programmes.

Mammographic Screening in Routine Practice: Multisite Study of Digital Breast Tomosynthesis and Digital Mammography Screenings

Background The use of digital breast tomosynthesis (DBT) is increasing over digital mammography (DM) following studies demonstrating lower recall rates (RRs) and higher cancer detection rates (CDRs). However, inconsistent interpretation of evidence on the risks and benefits of mammography has resulted in varying screening mammography recommendations. Purpose To evaluate screening outcomes among women in the United States who underwent routine DM or DBT mammographic screening. Materials and Methods This retrospective cohort study included women aged 40-79 years who underwent DM or DBT screening mammograms between January 2014 and December 2020. Outcomes of RR, CDR, positive predictive value of recall (PPV1), biopsy rate, and positive predictive value of biopsy (PPV3) were compared between DM and DBT with use of adjusted multivariable logistic regression models. Results A total of 2 528 063 screening mammograms from 1 100 447 women (mean age, 57 years ± 10 [SD]) were included. In crude analyses, DBT (1 693 727 screening mammograms vs 834 336 DM screening mammograms) demonstrated lower RR (10.3% [95% CI: 10.3, 10.4] for DM vs 8.9% [95% CI: 8.9, 9.0] for DBT; P < .001) and higher CDR (4.5 of 1000 screening mammograms [95% CI: 4.3, 4.6] vs 5.3 of 1000 [95% CI: 5.2, 5.5]; P < .001), PPV1 (4.3% [95% CI: 4.2, 4.5] vs 5.9% [95% CI: 5.7, 6.0]; P < .001), and biopsy rates (14.5 of 1000 screening mammograms [95% CI: 14.2, 14.7] vs 17.6 of 1000 [95% CI: 17.4, 17.8]; P < .001). PPV3 was similar between cohorts (30.0% [95% CI: 29.2, 30.9] for DM vs 29.3% [95% CI: 28.7, 29.9] for DBT; P = .16). After adjustment for age, breast density, site, and index year, associations remained stable with respect to statistical significance. Conclusion Women undergoing digital breast tomosynthesis had improved screening mammography outcomes compared with women who underwent digital mammography. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Bae and Seo in this issue.

AI-based Strategies to Reduce Workload in Breast Cancer Screening with Mammography and Tomosynthesis: A Retrospective Evaluation

Background The workflow of breast cancer screening programs could be improved given the high workload and the high number of false-positive and false-negative assessments. Purpose To evaluate if using an artificial intelligence (AI) system could reduce workload without reducing cancer detection in breast cancer screening with digital mammography (DM) or digital breast tomosynthesis (DBT). Materials and Methods Consecutive screening-paired and independently read DM and DBT images acquired from January 2015 to December 2016 were retrospectively collected from the Córdoba Tomosynthesis Screening Trial. The original reading settings were single or double reading of DM or DBT images. An AI system computed a cancer risk score for DM and DBT examinations independently. Each original setting was compared with a simulated autonomous AI triaging strategy (the least suspicious examinations for AI are not human-read; the rest are read in the same setting as the original, and examinations not recalled by radiologists but graded as very suspicious by AI are recalled) in terms of workload, sensitivity, and recall rate. The McNemar test with Bonferroni correction was used for statistical analysis. Results A total of 15 987 DM and DBT examinations (which included 98 screening-detected and 15 interval cancers) from 15 986 women (mean age ± standard deviation, 58 years ± 6) were evaluated. In comparison with double reading of DBT images (568 hours needed, 92 of 113 cancers detected, 706 recalls in 15 987 examinations), AI with DBT would result in 72.5% less workload (P < .001, 156 hours needed), noninferior sensitivity (95 of 113 cancers detected, P = .38), and 16.7% lower recall rate (P < .001, 588 recalls in 15 987 examinations). Similar results were obtained for AI with DM. In comparison with the original double reading of DM images (222 hours needed, 76 of 113 cancers detected, 807 recalls in 15 987 examinations), AI with DBT would result in 29.7% less workload (P < .001), 25.0% higher sensitivity (P < .001), and 27.1% lower recall rate (P < .001). Conclusion Digital mammography and digital breast tomosynthesis screening strategies based on artificial intelligence systems could reduce workload up to 70%. Published under a CC BY 4.0 license.

False-Positive Results in a Population-Based Colorectal Screening Program: Cumulative Risk from 2000 to 2017 with Biennial Screening

BACKGROUND

The aim of this study was to estimate the cumulative risk of a false-positive (FP) result in a fecal occult blood test (FOBT) through 7 screening rounds and to identify its associated factors in a population-based colorectal cancer screening program.

METHODS

Retrospective cohort study, which included participants ages 50 to 69 years of a colorectal cancer screening program in Catalonia, Spain. During this period, 2 FOBTs were used (guaiac and immunochemical). A discrete-time survival model was performed to identify risk factors of receiving a positive FOBT with no high-risk adenoma or colorectal cancer in the follow-up colonoscopy. We estimated the probability of having at least 1 FP over 7 screening rounds.

RESULTS

During the period of 2000 to 2017, the cumulative FP risk was 16.3% (IC_95%: 14.6%-18.3%), adjusted by age, sex, and type of test. The median number of screens was 2. Participants who began screening at age 50 years had a 7.3% [95% confidence interval (CI), 6.35-8.51] and a 12.4% (95% CI, 11.00-13.94) probability of an FP with 4 screening rounds of guaiac-based test and immunochemical test, respectively. Age, the fecal immunochemical test, first screening, and number of personal screens were factors associated with an FP result among screenees.

CONCLUSIONS

The cumulative risk of an FP in colorectal screening using FOBT seems acceptable as the colonoscopy, with its high accuracy, lengthens the time until additional colorectal screening is required, while complication rates remain low.

IMPACT

It is useful to determine the cumulative FP risk in cancer screening for both advising individuals and for health resources planning.

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.

Breast cancer risk is increased in the years following false-positive breast cancer screening

Supplemental Digital Content is available in the text.

A small number of studies have investigated breast cancer (BC) risk among women with a history of false-positive recall (FPR) in BC screening, but none of them has used time-to-event analysis while at the same time quantifying the effect of false-negative diagnostic assessment (FNDA). FNDA occurs when screening detects BC, but this BC is missed on diagnostic assessment (DA). As a result of FNDA, screenings that detected cancer are incorrectly classified as FPR. Our study linked data recorded in the Flemish BC screening program (women aged 50–69 years) to data from the national cancer registry. We used Cox proportional hazards models on a retrospective cohort of 298 738 women to assess the association between FPR and subsequent BC, while adjusting for potential confounders. The mean follow-up was 6.9 years. Compared with women without recall, women with a history of FPR were at an increased risk of developing BC [hazard ratio=2.10 (95% confidence interval: 1.92–2.31)]. However, 22% of BC after FPR was due to FNDA. The hazard ratio dropped to 1.69 (95% confidence interval: 1.52–1.87) when FNDA was excluded. Women with FPR have a subsequently increased BC risk compared with women without recall. The risk is higher for women who have a FPR BI-RADS 4 or 5 compared with FPR BI-RADS 3. There is room for improvement of diagnostic assessment: 41% of the excess risk is explained by FNDA after baseline screening.

Preliminary Results of a New Auxiliary Mechatronic Near-Field Radar System to 3D Mammography for Early Detection of Breast Cancer

Accurate and early detection of breast cancer is of high importance, as it is directly associated with the patients’ overall well-being during treatment and their chances of survival. Uncertainties in current breast imaging methods can potentially cause two main problems: (1) missing newly formed or small tumors; and (2) false alarms, which could be a source of stress for patients. A recent study at the Massachusetts General Hospital (MGH) indicates that using Digital Breast Tomosynthesis (DBT) can reduce the number of false alarms, when compared to conventional mammography. Despite the image quality enhancement DBT provides, the accurate detection of cancerous masses is still limited by low radiological contrast (about 1%) between the fibro-glandular tissue and affected tissue at X-ray frequencies. In a lower frequency region, at microwave frequencies, the contrast is comparatively higher (about 10%) between the aforementioned tissues; yet, microwave imaging suffers from low spatial resolution. This work reviews conventional X-ray breast imaging and describes the preliminary results of a novel near-field radar imaging mechatronic system (NRIMS) that can be fused with the DBT, in a co-registered fashion, to combine the advantages of both modalities. The NRIMS consists of two antipodal Vivaldi antennas, an XY positioner, and an ethanol container, all of which are particularly designed based on the DBT physical specifications. In this paper, the independent performance of the NRIMS is assessed by (1) imaging a bearing ball immersed in sunflower oil and (2) computing the heat Specific Absorption Rate (SAR) due to the electromagnetic power transmitted into the breast. The preliminary results demonstrate that the system is capable of generating images of the ball. Furthermore, the SAR results show that the system complies with the standards set for human trials. As a result, a configuration based on this design might be suitable for use in realistic clinical applications.

The psychological impact of the rapid diagnostic centres in cancer screening: A systematic review

The purpose of this review is to assess the state of the literature and identify implications for nursing practice and future research on the psychological impact of rapid diagnostic centres (RDC) for women related to breast cancer. A systematic literature review was conducted on the topic and six studies were identified for data extraction and analysis. There is evidence that RDCs decrease short-term anxiety in women undergoing further cancer tests after cancer screening, and who receive a benign diagnosis. There is limited available research on the impact of anxiety on women who receive a diagnosis of cancer in RDCs, but some evidence showed that this sub-group had higher depression in the long term. Nurses need to be aware of the different needs of women undergoing further cancer screening tests after a cancer diagnosis and receiving these results in the same day.

Preliminary imaging results and SAR analysis of a microwave imaging system for early breast cancer detection

Currently X-ray-based imaging systems suffer from low contrast between malignant and healthy fibrous tissues in breast. Microwave Near-field Radar Imaging (NRI) shows a higher contrast between the aforementioned tissues and therefore can enhance tumor detection and diagnosis accuracy. In this work, we present the first imaging results of our developed NRI system that is equipped with a pair of Antipodal Vivaldi Antennas. We used a metal bearing ball immersed in oil as our object of interest, to keep the first measurement configuration simple. Moreover, to demonstrate the safety of our system for human subject tests, we simulated the Specific Absorption Rate (SAR) in a realistic breast tissue model and compared the resulted values with both the USA and Europe standards. The results show that firstly the imaging results from the measurements and simulations are comparable, and secondly the antennas radiations meet the SAR criteria.

Cumulative risk of false positive test in relation to breast symptoms in mammography screening: a historical prospective cohort study

Mammography has been found effective as the primary screening test for breast cancer. We estimated the cumulative probability of false positive screening test results with respect to symptom history reported at screen. A historical prospective cohort study was done using individual screening data from 413,611 women aged 50-69 years with 2,627,256 invitations for mammography screening between 1992 and 2012 in Finland. Symptoms (lump, retraction, and secretion) were reported at 56,805 visits, and 48,873 visits resulted in a false positive mammography result. Generalized linear models were used to estimate the probability of at least one false positive test and true positive at screening visits. The estimates were compared among women with and without symptoms history. The estimated cumulative probabilities were 18 and 6 % for false positive and true positive results, respectively. In women with a history of a lump, the cumulative probabilities of false positive test and true positive were 45 and 16 %, respectively, compared to 17 and 5 % with no reported lump. In women with a history of any given symptom, the cumulative probabilities of false positive test and true positive were 38 and 13 %, respectively. Likewise, women with a history of a 'lump and retraction' had the cumulative false positive probability of 56 %. The study showed higher cumulative risk of false positive tests and more cancers detected in women who reported symptoms compared to women who did not report symptoms at screen. The risk varies substantially, depending on symptom types and characteristics. Information on breast symptoms influences the balance of absolute benefits and harms of screening.

Statistical Methods for Estimating the Cumulative Risk of Screening Mammography Outcomes

BACKGROUND

This study illustrates alternative statistical methods for estimating cumulative risk of screening mammography outcomes in longitudinal studies.

METHODS

Data from the US Breast Cancer Surveillance Consortium (BCSC) and the Nijmegen Breast Cancer Screening Program in the Netherlands were used to compare four statistical approaches to estimating cumulative risk. We estimated cumulative risk of false-positive recall and screen-detected cancer after 10 screening rounds using data from 242,835 women ages 40 to 74 years screened at the BCSC facilities in 1993-2012 and from 17,297 women ages 50 to 74 years screened in Nijmegen in 1990-2012.

RESULTS

In the BCSC cohort, a censoring bias model estimated bounds of 53.8% to 59.3% for false-positive recall and 2.4% to 7.6% for screen-detected cancer, assuming 10% increased or decreased risk among women screened for one additional round. In the Nijmegen cohort, false-positive recall appeared to be associated with subsequent discontinuation of screening leading to overestimation of risk of a false-positive recall based on adjusted discrete-time survival models. Bounds estimated by the censoring bias model were 11.0% to 19.9% for false-positive recall and 4.2% to 9.7% for screen-detected cancer.

CONCLUSION

Choice of statistical methodology can substantially affect cumulative risk estimates. The censoring bias model is appropriate under a variety of censoring mechanisms and provides bounds for cumulative risk estimates under varying degrees of dependent censoring.

IMPACT

This article illustrates statistical methods for estimating cumulative risks of cancer screening outcomes, which will be increasingly important as screening test recommendations proliferate.

[An audit of breast cancer screening mammograms and the variability of radiological practice]

OBJECTIVE

To audit the breast cancer screening mammograms performed in a general hospital and to assess the variation in medical practice in the diagnostic process.

MATERIAL AND METHODS

A review was carried out on the screening mammograms performed between 1 May 2010 and 30 April 2011, with clinical follow up for two years, and a comparison with the published standards.

RESULTS

Of the 3,878 women examined, 368 (9.48%) were called back to complete the study (97 [16.1%] in the initial screening and 271 [8.2%] in revisions). Forty three biopsies (1.1%) were indicated, of which 24 were diagnosed with cancer. The positive predictive value (PPV) in screening studies (PPV1) was 6.52%. For the recommended biopsy (PPV2) it was 55%, with a sensitivity of 100%, a specificity of 91% and a cancer detection rate of 6.1/1,000. There were no false negatives. Twenty tumours were invasive; with no axillary lymph node infiltration was observed 15 of them. In 6 cases, the size of the tumour was less than or equal to 10mm, and in 17 it was less than 15mm. There were a higher percentage of new appointments by two radiologists (12% and 17.2% versus 7.3%) (P<.001). In 217 cases (58.96%; P<.001) only one radiologist indicated new appointments. Of this group, 73% were discharged in the first visit, compared to 47.6% in the non-discrepant group (P<.001). Four of the cancers were detected in these 217 patients.

CONCLUSIONS

The observed results are adjusted to the reference values. The discordant data are the new appointments rate, both in the initial screening and in the review, with a significant variation depending on the radiology reader.

Comparison of cumulative false-positive risk of screening mammography in the United States and Denmark

INTRODUCTION

In the United States (US), about one-half of women screened with annual mammography have at least one false-positive test after ten screens. The estimate for European women screened ten times biennially is much lower. We evaluate to what extent screening interval, mammogram type, and statistical methods, can explain the reported differences.

METHODS

We included all screens from women first screened at age 50-69 years in the US Breast Cancer Surveillance Consortium (BCSC) (n=99,455) between 1996-2010, and from two population-based mammography screening programs in Denmark (n=230,452 and n=400,204), between 1991-2012 and 1993-2013, respectively. Model-based cumulative false-positive risks were computed for the entire sample, using two statistical methods (Hubbard Njor) previously used to estimate false-positive risks in the US and Europe.

RESULTS

Empirical cumulative risk of at least one false-positive test after eight (annual or biennial) screens was 41.9% in BCSC, 16.1% in Copenhagen, and 7.4% in Funen. Variation in screening interval and mammogram type did not explain the differences by country. Using the Hubbard method, the model-based cumulative risks after eight screens was 45.1% in BCSC, 9.6% in Copenhagen, and 8.8% in Funen. Using the Njor method, these risks were estimated to be 43.6, 10.9 and 8.0%.

CONCLUSION

Choice of statistical method, screening interval and mammogram type does not explain the substantial differences in cumulative false-positive risk between the US and Europe.

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.

Screening for breast cancer with mammography

BACKGROUND

A variety of estimates of the benefits and harms of mammographic screening for breast cancer have been published and national policies vary.

OBJECTIVES

To assess the effect of screening for breast cancer with mammography on mortality and morbidity.

SEARCH METHODS

We searched PubMed (22 November 2012) and the World Health Organization's International Clinical Trials Registry Platform (22 November 2012).

SELECTION CRITERIA

Randomised trials comparing mammographic screening with no mammographic screening.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data. Study authors were contacted for additional information.

MAIN RESULTS

Eight eligible trials were identified. We excluded a trial because the randomisation had failed to produce comparable groups.The eligible trials included 600,000 women in the analyses in the age range 39 to 74 years. Three trials with adequate randomisation did not show a statistically significant reduction in breast cancer mortality at 13 years (relative risk (RR) 0.90, 95% confidence interval (CI) 0.79 to 1.02); four trials with suboptimal randomisation showed a significant reduction in breast cancer mortality with an RR of 0.75 (95% CI 0.67 to 0.83). The RR for all seven trials combined was 0.81 (95% CI 0.74 to 0.87). We found that breast cancer mortality was an unreliable outcome that was biased in favour of screening, mainly because of differential misclassification of cause of death. The trials with adequate randomisation did not find an effect of screening on total cancer mortality, including breast cancer, after 10 years (RR 1.02, 95% CI 0.95 to 1.10) or on all-cause mortality after 13 years (RR 0.99, 95% CI 0.95 to 1.03).Total numbers of lumpectomies and mastectomies were significantly larger in the screened groups (RR 1.31, 95% CI 1.22 to 1.42), as were number of mastectomies (RR 1.20, 95% CI 1.08 to 1.32). The use of radiotherapy was similarly increased whereas there was no difference in the use of chemotherapy (data available in only two trials).

AUTHORS' CONCLUSIONS

If we assume that screening reduces breast cancer mortality by 15% and that overdiagnosis and overtreatment is at 30%, it means that for every 2000 women invited for screening throughout 10 years, one will avoid dying of breast cancer and 10 healthy women, who would not have been diagnosed if there had not been screening, will be treated unnecessarily. Furthermore, more than 200 women will experience important psychological distress including anxiety and uncertainty for years because of false positive findings. To help ensure that the women are fully informed before they decide whether or not to attend screening, we have written an evidence-based leaflet for lay people that is available in several languages on www.cochrane.dk. Because of substantial advances in treatment and greater breast cancer awareness since the trials were carried out, it is likely that the absolute effect of screening today is smaller than in the trials. Recent observational studies show more overdiagnosis than in the trials and very little or no reduction in the incidence of advanced cancers with screening.

Long-term psychosocial consequences of false-positive screening mammography

PURPOSE

Cancer screening programs have the potential of intended beneficial effects, but they also inevitably have unintended harmful effects. In the case of screening mammography, the most frequent harm is a false-positive result. Prior efforts to measure their psychosocial consequences have been limited by short-term follow-up, the use of generic survey instruments, and the lack of a relevant benchmark-women with breast cancer.

METHODS

In this cohort study with a 3-year follow-up, we recruited 454 women with abnormal findings in screening mammography over a 1-year period. For each woman with an abnormal finding on a screening mammogram (false and true positives), we recruited another 2 women with normal screening results who were screened the same day at the same clinic. These participants were asked to complete the Consequences of Screening in Breast Cancer-a validated questionnaire encompassing 12 psychosocial outcomes-at baseline, 1, 6, 18, and 36 months.

RESULTS

Six months after final diagnosis, women with false-positive findings reported changes in existential values and inner calmness as great as those reported by women with a diagnosis of breast cancer (Δ = 1.15; P = .015; and Δ = 0.13; P = .423, respectively). Three years after being declared free of cancer, women with false-positive results consistently reported greater negative psychosocial consequences compared with women who had normal findings in all 12 psychosocial outcomes (Δ >0 for 12 of 12 outcomes; P <.01 for 4 of 12 outcomes).

CONCLUSION

False-positive findings on screening mammography causes long-term psychosocial harm: 3 years after a false-positive finding, women experience psychosocial consequences that range between those experienced by women with a normal mammogram and those with a diagnosis of breast cancer.

The psychological impact of a false-positive screening mammogram in Barcelona

The purpose of this study was to ascertain the psychological impact of mammographic screening for women who receive negative results and for those who need additional non-invasive and invasive complementary investigations to exclude breast cancer (false positives). One hundred fifty women who attended a breast cancer screening programme in Barcelona, aged 50-69 years, were included in this study: 50 with negative results and 100 with false positive mammograms (50 underwent non-invasive and 50 underwent invasive complementary investigations). Participants worried little until they underwent mammography, but worries increased when a telephone call notified the women of the need for further testing. A substantial proportion of women requiring further assessment reported that they were at least somewhat worried about having breast cancer throughout the screening process (P < 0.0001). Nevertheless, levels of anxiety and depression, measured by the Hospital Anxiety and Depression Scale, showed no statistically significant differences among the three groups. In conclusion, although the women showed no psychological morbidity, there is a substantial psychological response in those with an abnormal screening mammogram.

False-positive results from colorectal cancer screening in Catalonia (Spain), 2000-2010

OBJECTIVE

To identify factors associated with a false-positive result in a population-based colorectal cancer (CRC) screening programme with the faecal occult blood test (FOBT) in Catalonia between 2000 and 2010.

METHODS

The study population consisted of participants of the Catalan CRC screening programme with a positive FOBT who underwent a colonoscopy for diagnostic confirmation from 2000 to 2010. A false-positive result was defined as having a positive test but detecting no high-risk adenoma or cancer in the follow-up colonoscopy. Multivariate logistic regression models were performed to identify sociodemographic and screening variables related to false-positive results. Adjusted odds ratios (OR) and their 95% confidence intervals (CI) were estimated.

RESULTS

Over the screening period, 1074 (1.7%) of the 63,332 screening tests had a positive result in the Catalan CRC screening programme. The false-positive proportion was 55.2% (n = 546). Women were more likely to have a positive FOBT in the absence of CRC neoplasia than men (adjusted OR = 2.91; 95% CI: 2.22-3.28). During the first prevalence round, the proportion of false-positive results was higher than in subsequent rounds (69.5% vs. 48.9%; P < 0.05). Re-screening and having a bleeding pathology such as haemorrhoids or anal fissures were also associated with a false-positive result.

CONCLUSION

The proportion of false-positive results and the associated risks should be estimated to provide an eligible population with more reliable information on the adverse effects of screening.

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.

Influence of false-positive mammography results on subsequent screening: do physician recommendations buffer negative effects?

OBJECTIVE

Cancer screening guidelines often include discussion about the unintended negative consequences of routine screening. This prospective study examined effects of false-positive mammography results on women's adherence to subsequent breast cancer screening and psychological well-being. We also assessed whether barriers to screening exacerbated the effects of false-positive results.

METHODS

We conducted secondary analyses of data from telephone interviews and medical claims records for 2406 insured women. The primary outcome was adherence to screening guidelines, defined as adherent (10-14 months), delayed (15-34 months), or no subsequent mammogram on record.

RESULTS

About 8% of women reported that their most recent screening mammograms produced false-positive results. In the absence of self-reported advice from their physicians to be screened, women were more likely to have no subsequent mammograms on record if they received false-positive results than if they received normal results (18% vs. 7%, OR = 3.17, 95% CI = 1.30, 7.70). Receipt of false-positive results was not associated with this outcome for women who said their physicians had advised regular screening in the past year (7% vs. 10%, OR = 0.74, 95% CI = 0.38, 1.45). False-positive results were associated with greater breast cancer worry (P < .01), thinking more about the benefits of screening (P < .001), and belief that abnormal test results do not mean women have cancer (P < .01), regardless of physicians' screening recommendations.

CONCLUSION

False-positive mammography results, coupled with reports that women's physicians did not advise regular screening, could lead to non-adherence to future screening. Abnormal mammograms that do not result in cancer diagnoses are opportunities for physicians to stress the importance of regular screening.

Effect of protocol-related variables and women's characteristics on the cumulative false-positive risk in breast cancer screening

BACKGROUND

Reducing the false-positive risk in breast cancer screening is important. We examined how the screening-protocol and women's characteristics affect the cumulative false-positive risk.

METHODS

This is a retrospective cohort study of 1,565,364 women aged 45-69 years who underwent 4,739,498 screening mammograms from 1990 to 2006. Multilevel discrete hazard models were used to estimate the cumulative false-positive risk over 10 sequential mammograms under different risk scenarios.

RESULTS

The factors affecting the false-positive risk for any procedure and for invasive procedures were double mammogram reading [odds ratio (OR)=2.06 and 4.44, respectively], two mammographic views (OR=0.77 and 1.56, respectively), digital mammography (OR=0.83 for invasive procedures), premenopausal status (OR=1.31 and 1.22, respectively), use of hormone replacement therapy (OR=1.03 and 0.84, respectively), previous invasive procedures (OR=1.52 and 2.00, respectively), and a familial history of breast cancer (OR=1.18 and 1.21, respectively). The cumulative false-positive risk for women who started screening at age 50-51 was 20.39% [95% confidence interval (CI) 20.02-20.76], ranging from 51.43% to 7.47% in the highest and lowest risk profiles, respectively. The cumulative risk for invasive procedures was 1.76% (95% CI 1.66-1.87), ranging from 12.02% to 1.58%.

CONCLUSIONS

The cumulative false-positive risk varied widely depending on the factors studied. These findings are relevant to provide women with accurate information and to improve the effectiveness of screening programs.

Effect of start age of breast cancer screening mammography on the risk of false-positive results

OBJECTIVE

To estimate the false-positive (FP) risk according to the start age of mammography screening (45-46 or 50-51 years).

METHOD

Data from eight regions of the Spanish breast cancer screening programme from 1990 to 2006 were included (1,565,364 women). Discrete time-hazard models were used to ascertain the effect of age and time-related, programme-related and personal variables on FP leading to any further procedure and to invasive procedures (FPI). In a subset we estimated the differential FP risk of starting screening at 45-46 years (175,656 women) or 50-51 (251,275).

RESULTS

A start age of 45-46 versus 50-51 years increased both FP (OR=1.20; 95%CI: 1.13-1.26) and FPI risks (OR=1.43 (95%CI: 1.18-1.73).Other factors increasing FP risk were premenopausal status (FP OR=1.26; 95%CI: 1.23-1.29 and FPI OR=1.22; 95%CI: 1.13-1.31), prior invasive procedures (FP OR=1.52; 95%CI: 1.47-1.57 and FPI (OR=2.08; 95%CI: 1.89-2.28) and family history (FP OR=1.16; 95%CI: 1.12-1.20 and FPI OR=1.26; 95%CI: 1.13-1.41). FP risk was increased by double reading (OR=1.36; 95%CI: 1.23-1.51) and FPI risk by double views (OR=1.34; 95%CI: 1.18-1.52). Both the cumulative FP and FPI risks were higher in women commencing screening at 45-46 years versus 50-51 years (33.30% versus 20.39% and 2.68% versus 1.76%).

CONCLUSIONS

Starting screening earlier increases the cumulative risk of FP and FPI.

Effect of radiologist experience on the risk of false-positive results in breast cancer screening programs

OBJECTIVES

To evaluate the effect of radiologist experience on the risk of false-positive results in population-based breast cancer screening programmes.

METHODS

We evaluated 1,440,384 single-read screening mammograms, corresponding to 471,112 women aged 45-69 years participating in four Spanish programmes between 1990 and 2006. The mammograms were interpreted by 72 radiologists.

RESULTS

The overall percentage of false-positive results was 5.85% and that for false-positives resulting in an invasive procedure was 0.38%. Both the risk of false-positives overall and of false-positives leading to an invasive procedure significantly decreased (p < 0.001) with greater reading volume in the previous year: OR 0.77 and OR 0.78, respectively, for a reading volume 500-1,999 mammograms and OR 0.59 and OR 0.60 for a reading volume of >14,999 mammograms with respect to the reference category (<500). The risk of both categories of false-positives was also significantly reduced (p < 0.001) as radiologists' years of experience increased: OR 0.96 and OR 0.84, respectively, for 1 year's experience and OR 0.72 and OR 0.73, respectively, for more than 4 years' experience with regard to the category of <1 year's experience.

CONCLUSION

Radiologist experience is a determining factor in the risk of a false-positive result in breast cancer screening.

Effect of false-positive results on reattendance at breast cancer screening programmes in Spain

BACKGROUND

Mammography is the only breast screening method, we are aware of today, which is able to reduce mortality from breast cancer. Nevertheless, this procedure carries an inherent risk of false-positive screening mammogram. The association between these results and reattendance at the next scheduled screening mammogram is controversial. The aim of this study was to examine the effect of a false-positive screening mammogram and women's characteristics on reattendance in eight regional population-based breast cancer screening programmes in Spain.

METHODS

This study included 1 383 032 women aged 44-67 years who were initially screened for breast cancer between 1990 and 2004. To investigate factors associated with reattendance, logistic regression models were used.

RESULTS

The mean age of women at first screening was 53.6 years (SD = 6.1 years). Of 120 800 women with a false-positive screening mammogram, 78.3% returned for a subsequent screening mammogram compared with 81.9% of those with a negative result (P < 0.001). Multivariate analysis showed that women with a false-positive result at first screening mammogram were less likely to reattend (OR = 0.71; 95% CI 0.70-0.73) and that the likelihood was lower in those who had undergone invasive additional tests (OR = 0.56; 95% CI 0.53-0.59).

CONCLUSION

A false-positive screening mammogram in the first screening negatively affected attendance at the subsequent screening. The results of this study could be useful to improve the screening process and to increase women's compliance.

Modelling the cumulative risk of a false-positive screening test

The goal of a screening test is to reduce morbidity and mortality through the early detection of disease; but the benefits of screening must be weighed against potential harms, such as false-positive (FP) results, which may lead to increased healthcare costs, patient anxiety, and other adverse outcomes associated with diagnostic follow-up procedures. Accurate estimation of the cumulative risk of an FP test after multiple screening rounds is important for program evaluation and goal setting, as well as informing individuals undergoing screening what they should expect from testing over time. Estimation of the cumulative FP risk is complicated by the existence of censoring and possible dependence of the censoring time on the event history. Current statistical methods for estimating the cumulative FP risk from censored data follow two distinct approaches, either conditioning on the number of screening tests observed or marginalizing over this random variable. We review these current methods, identify their limitations and possibly unrealistic assumptions, and propose simple extensions to address some of these limitations. We discuss areas where additional extensions may be useful. We illustrate methods for estimating the cumulative FP recall risk of screening mammography and investigate the appropriateness of modelling assumptions using 13 years of data collected by the Breast Cancer Surveillance Consortium (BCSC). In the BCSC data we found evidence of violations of modelling assumptions of both classes of statistical methods. The estimated risk of an FP recall after 10 screening mammograms varied between 58% and 77% depending on the approach used, with an estimate of 63% based on what we feel are the most reasonable modelling assumptions.

Effectiveness of early detection on breast cancer mortality reduction in Catalonia (Spain)

Background

At present, it is complicated to use screening trials to determine the optimal age intervals and periodicities of breast cancer early detection. Mathematical models are an alternative that has been widely used. The aim of this study was to estimate the effect of different breast cancer early detection strategies in Catalonia (Spain), in terms of breast cancer mortality reduction (MR) and years of life gained (YLG), using the stochastic models developed by Lee and Zelen (LZ).

Methods

We used the LZ model to estimate the cumulative probability of death for a cohort exposed to different screening strategies after T years of follow-up. We also obtained the cumulative probability of death for a cohort with no screening. These probabilities were used to estimate the possible breast cancer MR and YLG by age, period and cohort of birth. The inputs of the model were: incidence of, mortality from and survival after breast cancer, mortality from other causes, distribution of breast cancer stages at diagnosis and sensitivity of mammography. The outputs were relative breast cancer MR and YLG.

Results

Relative breast cancer MR varied from 20% for biennial exams in the 50 to 69 age interval to 30% for annual exams in the 40 to 74 age interval. When strategies differ in periodicity but not in the age interval of exams, biennial screening achieved almost 80% of the annual screening MR. In contrast to MR, the effect on YLG of extending screening from 69 to 74 years of age was smaller than the effect of extending the screening from 50 to 45 or 40 years.

Conclusion

In this study we have obtained a measure of the effect of breast cancer screening in terms of mortality and years of life gained. The Lee and Zelen mathematical models have been very useful for assessing the impact of different modalities of early detection on MR and YLG in Catalonia (Spain).

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

BACKGROUND

False positives occur in approximately 11% of screening mammographies in the USA and may be associated with psychologic sequelae.

METHODS

We sought to examine the association of false-positive mammography with depressed mood among women in a screening population. Using data from a state-based mammography registry, women who completed a standardized questionnaire between 7 May 2001 and 2 June 2003, a follow-up questionnaire between 19 June 2003 and 8 October 2004 and who received at least one screening mammogram during this interval were identified. False positives were examined in relation to depressed mood.

RESULTS

Eligibility criteria were met by 13 491 women with a median age of 63.9 (SD = 9.6). In the study population, 2107 (15.62%) experienced at least one false positive mammogram and 450 (3.34%) met criteria for depressed mood. Depressed mood was not significantly associated with false positives in the overall population [OR = 0.96; 95% confidence interval (CI) = 0.72-1.28], but this association was seen among Non-White women (OR = 3.23; 95% CI = 1.32-7.91).

CONCLUSION

Depressed mood may differentially affect some populations as a harm associated with screening mammography.

Implementation of digital mammography in a population-based breast cancer screening program: effect of screening round on recall rate and cancer detection

PURPOSE

To compare the effect of the introduction of digital mammography on the recall rate, detection rate, false-positive rate, and rates of invasive procedures performed in the first and successive rounds of a population-based breast cancer screening program with double reading in Barcelona, Spain.

MATERIALS AND METHODS

The study was approved by the ethics committee; informed consent was not required. Data were compared from 12,958 women aged 50-69 years old who participated in a screening round before the introduction of digital mammography (screen-film mammography group) with data from 6074 women who participated in another screening round after the introduction of digital mammography (digital mammography group). Groups were compared for recall rate and detection rate stratified according to first or successive screening rounds, and logistic regression analysis was performed.

RESULTS

Overall recall rates for screen-film and digital mammography groups were 5.5% and 4.2%, respectively (P < .001). The recall rate was higher in the first screening round (11.5% and 11.1% in the screen-film mammography and digital mammography groups, respectively; P = .68) than in successive screening rounds (3.6% and 2.4% in the screen-film mammography and digital mammography groups, respectively; P < .001). The main factors related to the risk of recall were screen-film mammography group (odds ratio = 1.28), first screening round (odds ratio = 3.53), menopausal status (odds ratio = 0.62), and history of personal benign breast disease (odds ratio = 2.26). No significant differences were found in the cancer detection rate between groups. In the first screening round, this rate was higher in the digital than in the screen-film mammography group (1.1% and 0.4%, respectively; P = .009). The invasive test rate was 2.6% and 1.3% in the screen-film and digital mammography groups, respectively (P < .001) and was lower with digital mammography than with screen-film mammography in both the first and successive screening rounds.

CONCLUSION

Digital mammography may reduce the adverse effects of screening programs if this technique is confirmed to have the same diagnostic accuracy as screen-film mammography.