Women who are recalled for further investigation for breast screening: psychological consequences 3 years after recall and factors affecting re-attendance

Tips for Addressing Screening Concerns: "Harms of Screening"

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

Supplemental Optoacoustic Imaging of Breast Masses: A Cost-Effectiveness Analysis

RATIONALE AND OBJECTIVES

To evaluate the cost-effectiveness of utilizing supplemental optoacoustic ultrasound (OA/US) versus gray-scale ultrasound (US) alone to differentiate benign and malignant breast masses in a diagnostic setting.

MATERIALS AND METHODS

We created a decision-tree model to compare the cost-effectiveness of OA/US and US from the perspective of the US healthcare system. We utilized diagnostic test performance parameters from the PIONEER-01(NCT01943916) clinical trial and cost parameters (USD) from the Truven Health MarketScan Databases. Utility (quality adjusted life year, QALY) values were determined following published patient-reported outcomes. Cost-effectiveness was calculated through incremental cost-effectiveness ratio (USD/QALY, ICER) and net monetary benefit (NMB) in a Markov chain model. Deterministic and probabilistic sensitivity analyses were performed to determine the significance of variation in input parameters. A willingness-to-pay (WTP) threshold of $100,000/QALY was used for the study.

RESULTS

OA/US had an estimated cumulative cost of $16,617.36 and the outcome of 16.85 QALYs in the 25-year period. The incremental NMB for OA/US was $1495.36, and the ICER was -$31,715.82/QALY, indicating that supplemental use of OA/US was more cost-effective than US alone. In the deterministic sensitivity analysis, when the cost of OA/US exceeded $1030.61 or the sensitivity of OA/US fell below 79.7%, or the specificity fell below 30.5%, the US alone strategy yielded higher NMB values compared to supplemental OA/US. According to probabilistic sensitivity analysis, OA/US was the better strategy in 98.69% of 10,000 iterations.

CONCLUSION

OA/US is more cost-effective than US to differentiate benign or malignant breast masses in the diagnostic setting. It can reduce costs while improving patients' quality of life, primarily by reducing false-positive results with consequent benign biopsies.

Timeliness of Breast Diagnostic Imaging and Biopsy in Practice: 15 Years of Collecting, Comparing, and Defining Quality Breast Cancer Care

BACKGROUND

The literature lacks well-established benchmarks for expected time between screening mammogram to diagnostic imaging and then to core needle breast biopsy.

METHODS

Timeliness of diagnostic imaging workup was evaluated using aggregate data from 2005 to 2019 submitted to The National Quality Measures for Breast Centers (NQMBC).

RESULTS

A total of 419 breast centers submitted data for 1,805,515 patients on the time from screening mammogram to diagnostic imaging. The overall time was 7 days with 75th, 25th, and 10th percentile values of 5, 10, and 13.5 days, respectively. The average time in business days decreased from 9.1 to 7.1 days (p < 0.001) over the study period with the greatest gains in poorest-performing quartiles. Screening centers and centers in the Midwest had significantly shorter time to diagnostic imaging. Time from diagnostic imaging to core needle biopsy was submitted by 406 facilities representing 386,077 patients. The average time was 6 business days, with 75th, 25th, and 10th percentiles of 4, 9, and 13.7 days, respectively. Time to biopsy improved from a mean of 9.0 to 6.3 days (p < 0.001) with the most improvement in the poorest-performing quartiles. Screening centers, centers in the Midwest, and centers in metropolitan areas had significantly shorter time to biopsy.

CONCLUSIONS

In a robust dataset, the time from screening mammogram to diagnostic imaging and from diagnostic imaging to biopsy decreased from 2005 to 2019. On average, patients could expect to have diagnostic imaging and biopsies within 1 week of abnormal results. Monitoring and comparing performance with reported data may improve quality in breast care.

Healthcare and Cancer Treatment Costs of Breast Screening Outcomes among Higher than Average Risk Women

Concurrent cohorts of 644,932 women aged 50-74 screened annually due to family history, dense breasts or biennially in the Ontario Breast Screening Program (OBSP) from 2011-2014 were linked to provincial administrative datasets to determine health system resource utilization and costs. Age-adjusted mean and median total healthcare costs (2018 CAD) and incremental cost differences were calculated by screening outcome and compared by recommendation using regression models. Healthcare costs were compared overall and 1 year after a false positive (n = 46,081) screening mammogram and 2 years after a breast cancer diagnosis (n = 6011). Mean overall healthcare costs by age were highest for those 60-74, particularly with annual screening for family/personal history (CAD 5425; 95% CI: 5308 to 5557) compared to biennial. Although the mean incremental cost difference was higher (23.4%) by CAD 10,235 (95% CI: 6141 to 14,329) per breast cancer for women screened annually for density ≥ 75% compared to biennially, the cost difference was 12.0% lower (-CAD 461; 95% CI: -777 to -114) per false positive result. In contrast, for women screened annually for family/personal history, the mean cost difference per false positive was 19.7% higher than for biennially (CAD 758; 95% CI: 404 to 1118); however, the cost difference per breast cancer was only slightly higher (2.5%) by CAD 1093 (95% CI: -1337 to CAD 3760). Understanding that associated costs of annual compared to biennial screening may balance out by age and outcome can assist decision-making regarding the use of limited healthcare resources.

Considerations for Evaluating the Introduction of New Cancer Screening Technology: Use of Interval Cancers to Assess Potential Benefits and Harms

This framework focuses on the importance of the consideration of the downstream intermediate and long-term health outcomes when a change to a screening program is introduced. The authors present a methodology for utilising the relationship between screen-detected and interval cancer rates to infer the benefits and harms associated with a change to the program. A review of the previous use of these measures in the literature is presented. The framework presents other aspects to consider when utilizing this methodology, and builds upon an existing framework that helps researchers, clinicians, and policy makers to consider the impacts of changes to screening programs on health outcomes. It is hoped that this research will inform future evaluative studies to assess the benefits and harms of changes to screening programs.

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

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Psychological distress and quality of life following provision of vascular imaging results of the coronary and carotid arteries to asymptomatic adults: a scoping review protocol

Background: Non-invasive screening for atherosclerosis or asymptomatic cardiovascular disease of the coronary and carotid arteries is commonly undertaken, and research has been focussed on how results from these screenings lead to behaviour change. However, no review has focused on the effects of these results on psychological distress and health-related quality of life (HRQoL). This protocol will outline how a scoping review will be conducted to map all available evidence on psychological distress and/or HRQoL outcomes following the provision of vascular imaging results of the coronary and carotid arteries.

Methods: Arksey and O’Malley’s (2005) framework subsequently enhanced by Levac et al. (2010)  and Peters et al (2015, 2017) will guide the scoping review. Databases such as MEDLINE (Clarivate), APA PsychINFO, EMBASE, Social Work Abstracts, Psychology and Behavioural Sciences Collection, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) will be searched using MeSH terms  such as "Coronary stenosis", "Carotid Stenosis", "Psychological Distress" and "Quality of Life" and related terms. Two investigators will screen title and abstract and all articles meeting inclusion criteria will be extracted.  Data on authors, publication year, country of origin, aims/purpose, methodology, intervention, outcome measures as well as key findings that relate to the scoping review questions will be extracted for each included study. The findings will be presented using tables and thematic narrative synthesis. The scoping review will not produce a pooled estimate of the impact of vascular imaging results on psychological distress and HRQoL but will present information from the included studies related to psychological distress and HRQoL.

Conclusion:  The review will highlight and address gaps in knowledge and provide direction for future investigations.

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

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

Associations between breast cancer screening participation and residential area sociodemographic features, geographic accessibility, and features of screening venue location in Greater Sydney, Australia

Breast cancer screening (BCS) participation rates are often suboptimal and vary geographically. Environmental features may influence BCS participation, but few studies have assessed this relationship. This study assessed the associations between BCS participation, residential area sociodemographic characteristics, distance to BCS venue, and venue location attributes. Data for 384,433 women residing in Greater Sydney, Australia, invited to BCS during 2011-2014 were spatially joined to their state suburb (SSC) (n = 800). SSC sociodemographic measures included women's median age, proportion women speaking English at home, full-time employed, and university educated; and proportion dwellings with motor-vehicles. Road network distance was calculated to each BCS venue. BCS venues were coded as co-located with bus-stop, train-station, hospital, general practitioner (GP), and shop. Hot spots were calculated to quantify spatial clustering of BCS participation. Multilevel logistic models were used to estimate the associations between environmental predictors and BCS participation, accounting for SSC-level clustering. BCS participation was 53.9% and spatially clustered. BCS was positively associated with SSC-level median age for women, proportions women speaking English and university educated, and dwellings with motor-vehicles. Distance to venue was inversely associated with BCS. Venue co-location with GP was positively associated and co-location with bus-stop, train-station, and shop, hospital were negatively associated with BCS. Residential sociodemographic features, geographic access, and venue location attributes are associated with BCS participation. These findings implicate the relevance of social and built environmental factors to programmatic aims to raise BCS participation. Additional research on venue location features is required to understand where best to site BCS venues.

Artificial intelligence for the real world of breast screening

Breast cancer screening with mammography reduces mortality in the women who attend by detecting high risk cancer early. It is far from perfect with variations in both sensitivity for the detection of cancer and very wide variations in specificity, leading to unnecessary recalls and biopsies. Over the last 12 months several papers have reported on AI algorithms that perform as well as human readers on large well curated population data sets. The nature of the test sets, the way the gold standard has been calculated, the definition of a positive call, and the statistics used all influence the results. Historically retrospective studies have not predicted the real-life performance of radiologist plus machine. So, it is important to perform prospective studies before introducing Artificial intelligence into real world breast screening.

Breast Cancer Screening Recommendations Inclusive of All Women at Average Risk: Update from the ACR and Society of Breast Imaging

Breast cancer remains the most common nonskin cancer, the second leading cause of cancer deaths, and the leading cause of premature death in US women. Mammography screening has been proven effective in reducing breast cancer deaths in women age 40 years and older. A mortality reduction of 40% is possible with regular screening. Treatment advances cannot overcome the disadvantage of being diagnosed with an advanced-stage tumor. The ACR and Society of Breast Imaging recommend annual mammography screening beginning at age 40, which provides the greatest mortality reduction, diagnosis at earlier stage, better surgical options, and more effective chemotherapy. Annual screening results in more screening-detected tumors, tumors of smaller sizes, and fewer interval cancers than longer screening intervals. Screened women in their 40s are more likely to have early-stage disease, negative lymph nodes, and smaller tumors than unscreened women. Delaying screening until age 45 or 50 will result in an unnecessary loss of life to breast cancer and adversely affects minority women in particular. Screening should continue past age 74 years, without an upper age limit unless severe comorbidities limit life expectancy. Benefits of screening should be considered along with the possibilities of recall for additional imaging and benign biopsy and the less tangible risks of anxiety and overdiagnosis. Although recall and biopsy recommendations are higher with more frequent screening, so are life-years gained and breast cancer deaths averted. Women who wish to maximize benefit will choose annual screening starting at age 40 years and will not stop screening prematurely.

Anxiety and Its Association With Screening Mammography

Anxiety is often cited as a risk of screening mammography, and organizations such as the U.S. Preventive Services Task Force list anxiety as a screening-associated "harm" that should be mitigated. However, the level of mammography-related anxiety risk is difficult to assign clearly for myriad reasons, including the variability of individuals' baseline susceptibility to anxiety, the self-reported nature of subjective anxiety states, and the multiple sources of breast cancer screening-related anxiety. In addition, anxiety measures differ between studies and psychological responses to screening mammography vary across racial and ethnic groups. Nonetheless, breast radiology practices should acknowledge the existence of mammography-associated anxiety and consider strategies to decrease it. These strategies include immediate screening interpretations, patient education efforts, and relaxation techniques.

Subsequent attendance in a breast cancer screening program after a false-positive result in the Local Health Authority of Bologna (Italy)

We conducted a cross-sectional study to assess the likelihood of returning for routine breast cancer screening among women who have experienced a false-positive result (FPR) and to describe the possible individual and organizational factors that could influence subsequent attendance to the screening program. Several information were collected on demographic and clinical characteristics data. Electronic data from 2014 to 2016 related to breast screening program of the Local Health Authority (LHA) of Bologna (Italy) of women between 45 and 74 years old were reviewed. A total of 4847 women experienced an FPR during mammographic screening and were recalled to subsequent round; 80.2% adhered to the screening. Mean age was 54.2 ± 8.4 years old. Women resulted to be less likely to adhere to screening if they were not-Italian (p = 0.001), if they lived in the Bologna district (p < 0.001), if they had to wait more than 5 days from II level test to end of diagnostic procedures (p = 0.001), if the diagnostic tests were performed in a hospital with the less volume of activity and higher recall rate (RR) (p < 0.001) and if they had no previous participation to screening tests (p < 0.001). Our results are consistent with previous studies, and encourages the implementation and innovation of the organizational characteristics for breast cancer screening. The success of screening programs requires an efficient indicators monitoring strategy to develop and evaluate continuous improvement processes.

The "Sweet Spot" Revisited: Optimal Recall Rates for Cancer Detection With 2D and 3D Digital Screening Mammography in the Metro Chicago Breast Cancer Registry

OBJECTIVE. One central question pertaining to mammography quality relates to discerning the optimal recall rate to maximize cancer detection while minimizing unnecessary downstream diagnostic imaging and breast biopsies. We examined the trade-offs for higher recall rates in terms of biopsy recommendations and cancer detection in a single large health care organization. MATERIALS AND METHODS. We included 2D analog, 2D digital, and 3D digital (tomosynthesis) screening mammography examinations among women 40-79 years old performed between January 1, 2005, and December 31, 2017, with cancer follow-up through 2018. There were 36, 67, and 38 radiologists who read at least 1000 2D analog examinations, 2D digital examinations, and 3D tomosynthesis examinations, respectively, who were included in these analyses. Using logistic regression with marginal standardization, we estimated radiologist-specific mean recall (abnormal interpretations/1000 mammograms), biopsy recommendation, cancer detection (screening-detected in situ and invasive cancers/1000 mammograms), and minimally invasive cancer detection rates while adjusting for differences in patient characteristics. RESULTS. Among 1,060,655 screening mammograms, the mean recall rate was 10.7%, the cancer detection rate was 4.0/1000 mammograms, and the biopsy recommendation rate was 1.60%. Recall rates between 7% and 9% appeared to maximize cancer detection while minimizing unnecessary biopsies. CONCLUSION. The results of this investigation are in contrast to those of a recent study suggesting appropriateness of higher recall rates. The "sweet spot" for optimal cancer detection appears to be in the recall rate range of 7-9% for both 2D digital mammography and 3D tomosynthesis. Too many women are being called back for diagnostic imaging, and new benchmarks could be set to reduce this burden.

Annual vs Biennial Screening: Diagnostic Accuracy Among Concurrent Cohorts Within the Ontario Breast Screening Program

BACKGROUND

The Ontario Breast Screening Program recommends annual mammography to women age 50-74 years at increased risk because of family history of breast or ovarian cancer or personal history of ovarian cancer or mammographic density 75% or greater. Few studies have examined the diagnostic accuracy of recommendations based on risk factors and included screen film as well as digital mammography.

METHODS

A retrospective design identified concurrent cohorts of women age 50-74 years screened annually or biennially with digital mammography only between 2011 and 2014 and followed until 2016 or breast cancer diagnosis. Diagnostic accuracy measures were compared between women screened annually because of first-degree relative of breast or ovarian cancer or personal history of ovarian cancer (n = 67 795 women), mammographic density 75% or greater (n = 51 956), or both (n = 3758) and those screened biennially (n = 526 815). The association between recommendation and sensitivity and specificity was assessed using generalized estimating equation models. All P values are two-sided.

RESULTS

For annual screening because of family or personal history vs biennial, sensitivity was statistically significantly higher (81.7% vs 70.6%; OR = 1.86, 95% CI = 1.48 to 2.34), particularly for invasive cancers and postmenopausal women. Although there was no statistically significant difference in sensitivity for annual screening for mammographic density 75% or greater, specificity was statistically significantly lower (91.3%; OR = 0.87, 95% CI = 0.80 to 0.96) vs biennial (92.3%), particularly for women age 50-59 years.

CONCLUSION

Compared with biennial screening, annual screening improved detection for women with a family or personal history of breast and/or ovarian cancer, supporting screening that is more frequent. The benefit for annual screening for women with higher mammographic density must be weighed against possible harms of increased false positives.

Dissemination of health technologies: Trends in the use of diagnostic test in breast cancer screening

OBJECTIVE

To analyse trends in the use of diagnostic test in breast cancer screening programs in Spain.

MATERIALS AND METHODS

Retrospective study of 542,695 women who had undergone at least one screening mammogram in any of the screening centres of three administrative regions in Spain, between 1996 and 2011. Process measures were: overall recall rate, overall invasive test rate, and rates of each type of invasive test (fine-needle aspiration biopsy, core-needle biopsy and surgical biopsy). As results measures were included detection of benign lesions rate, ductal in situ cancer rate and invasive cancer rate. Adjusted by age rates were estimated year by year for each measure and, also, the annual percent of change and its corresponding joint points.

RESULTS

Core-needle biopsy rates decreased between 1996 and 1999 and changed trends in 1999-2011 with an increase of 4.9% per year. Overall recall rate declined by 4.6% from 1999 to 2004, invasive test rate declined between 1996 and 2004 by 24.3%. Fine-needle aspiration biopsy rate changes were: a 22.4% declined per year (1996-1998), and 13.5% declined per year (1998-2005). Benign lesions rate decreased from 1996 to 2011, 21.4% per year (1996-2001) and 6.0% (2001-2011). Ductal carcinoma in situ and invasive cancer had no-statistically significant changes.

CONCLUSION

The introduction of core-needle biopsy was slow and not concurrent with the reduction in the use of other diagnostic tests, but also represented a reduction in the rate of overall diagnostic tests and in the detection rate of benigns lesions without affecting the cancer detection rates.

Postoperative Cancer Surveillance Following Oncoplastic Surgery with Latissimus Dorsi Flap: a Matched Case-Control Study

BACKGROUND

The latissimus dorsi (LD) myocutaneous flap is a widely used local option in oncoplastic surgery for avoiding breast deformities; however, concerns exist regarding its influence in monitoring recurrence. In this study, we evaluated the impact of this flap on postoperative cancer surveillance.

METHODS

Each patient receiving oncoplastic surgery with LD flap after partial mastectomy were matched in age, cancer stage, and body mass index with patients receiving partial mastectomy alone. Twenty-nine patients with the oncoplastic LD flap received 99 mammograms and 139 ultrasonograms, while 29 patients with partial mastectomy alone underwent 92 mammograms and 129 ultrasonograms. Mammographic and ultrasonographic findings were classified by Breast Imaging Reporting and Data System (BI-RADS) category and reviewed. Any recommendations for additional evaluation and recurrence were documented.

RESULTS

During an average follow-up period of 44 months, although the oncoplastic group demonstrated more newly developed benign calcifications (control 14% vs. oncoplastic 41%; p = 0.019) on mammography, the percentage of recall for additional imaging in category 0, and the short-interval follow-up in category 3, was not different between the control and oncoplastic group. Regarding ultrasonography, BI-RADS category was also not different between the two groups; however, the control group showed more fluid collections than the oncoplastic group (control 21% vs. oncoplastic 0%; p = 0.023). One case of local recurrence was observed in the control group.

CONCLUSION

Although there was an increase in benign calcifications in the oncoplastic group, there were no additional abnormal findings requiring further intervention. We concluded that the LD flap for oncoplastic surgery does not interfere with cancer surveillance, and even decreases the rate of fluid collection.

Communicating benign biopsy results by telephone in the NHS Breast Screening Programme: a protocol for a cluster randomised crossover trial

INTRODUCTION

One of the main harms from breast cancer screening is the anxiety caused by false positive results. Various factors may be associated with false-positive anxiety. One modifiable factor may be the method of communication used to deliver results. The aim of this study is to measure the effect on anxiety of receiving benign biopsy results in-person or by telephone.

METHODS AND ANALYSIS

This is a multi-centre cluster randomised crossover trial in the English National Health Service Breast Screening Programme (NHSBSP) involving repeated survey measures at four time points. Participants will be women of screening age who have a biopsy following a suspicious mammography result, who ultimately receive a benign or normal (B1) result. Centres will trial both telephone and in-person results on a month-by-month basis, being randomised to which communication method will be trialled first. Women will be blinded to the method of communication they will receive. The analysis will compare women who have received telephone results and women who have received in-person results. The primary outcome measure will be anxiety (measured by the Psychological Consequences Questionnaire) after receiving results, while controlling for baseline anxiety. Secondary outcome measures will include anxiety at 3 and 6 months post-results, understanding of results and patient preferences for how results are communicated. Qualitative telephone interviews will also be conducted to further explore women's reasons for communication preferences. Qualitative and quantitative data will be integrated after initial separate analysis using the pillar integration process.

ETHICS AND DISSEMINATION

This study has been approved by the Public Health England Breast Screening Programme Research Advisory Committee, (BSPRAC_0013, ODR1718_040) and the National Health Service Health Research Authority (HRA) West Midlands-Coventry & Warwickshire Research Ethics Committee (17/WM/0313). The findings from this study will be disseminated to key stakeholders within the NHSBSP and via academic publications.

TRIAL REGISTRATION NUMBER

ISRCTN36997684 TRIAL SPONSOR: This research is part of a PhD award and is funded by the Economic and Social Research Council Doctoral Training Centre at the University of Warwick and Public Health England. The sponsor for this research is Jane Prewett (sponsorship@warwick.ac.uk).

How do women experience a false-positive test result from breast screening? A systematic review and thematic synthesis of qualitative studies

BACKGROUND

This is the first review to identify, appraise and synthesise women's experiences of having a false-positive breast screening test result.

METHODS

We systematically searched eight databases for qualitative research reporting women's experiences of receiving a false-positive screening test result. Two reviewers independently screened articles. Eight papers reporting seven studies were included. Study quality was appraised. Data were thematically synthesised.

RESULTS

Women passively attended screening in order to prove their perceived good health. Consequently, being recalled was unexpected, shocking and disempowering: women felt without options. They endured great uncertainty and stress and sought clarity about their health (e.g. by scrutinising the wording of recall letters and conversations with healthcare professionals). Their result was accompanied by relief and welcome feelings of certainty about their health, but some received unclear explanations of their result, contributing to lasting breast cancer-related worry and an ongoing need for further reassurance.

CONCLUSION

The organisation of breast screening programmes may constrain choice for women: they became passive recipients. The way healthcare professionals verbally communicate results to women may contribute to lasting breast cancer-related worry. Women need more reassurance, emotional support and answers to their questions before and during screening assessment, and after receiving their result.

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.

Genetic Testing to Guide Risk-Stratified Screens for Breast Cancer

Breast cancer screening modalities and guidelines continue to evolve and are increasingly based on risk factors, including genetic risk and a personal or family history of cancer. Here, we review genetic testing of high-penetrance hereditary breast and ovarian cancer genes, including BRCA1 and BRCA2, for the purpose of identifying high-risk individuals who would benefit from earlier screening and more sensitive methods such as magnetic resonance imaging. We also consider risk-based screening in the general population, including whether every woman should be genetically tested for high-risk genes and the potential use of polygenic risk scores. In addition to enabling early detection, the results of genetic screens of breast cancer susceptibility genes can be utilized to guide decision-making about when to elect prophylactic surgeries that reduce cancer risk and the choice of therapeutic options. Variants of uncertain significance, especially missense variants, are being identified during panel testing for hereditary breast and ovarian cancer. A finding of a variant of uncertain significance does not provide a basis for increased cancer surveillance or prophylactic procedures. Given that variant classification is often challenging, we also consider the role of multifactorial statistical analyses by large consortia and functional tests for this purpose.

Communication of cancer screening results by letter, telephone or in person: A mixed methods systematic review of the effect on attendee anxiety, understanding and preferences

Attending and receiving a result from screening can be an anxious process. Using an appropriate method to deliver screening results could improve communication and reduce negative outcomes for screening attendees. Screening programmes are increasingly communicating results by letter or telephone rather than in-person. We investigated the impact of communication methods on attendees.

We systematically reviewed the literature on the communication methods used to deliver results in cancer screening programmes for women, focusing on screening attendee anxiety, understanding of results and preferences for results communication. We included qualitative and quantitative research. We searched MEDLINE, PsycINFO, CINAHL, Cochrane Library and Embase. Results were analysed using framework synthesis. 10,558 papers were identified with seven studies meeting the inclusion criteria.

Several key ideas emerged from the synthesis including speed, accuracy of results, visual support, ability to ask questions, privacy of results location and managing expectations.

Verbal communication methods (telephone and in-person) were preferred and facilitated greater understanding than written methods, although there was considerable variability in attendee preferences. Findings for anxiety were mixed, with no clear consensus on which method of communication might minimise attendee anxiety.

The low number of identified studies and generally low quality evidence suggest we do not know the most appropriate communication methods in the delivery of cancer screening results. More research is needed to directly compare methods of results communication, focusing on what impact each method may have on screening attendees.

Measurement of breast-tissue x-ray attenuation by spectral imaging: fresh and fixed normal and malignant tissue

Knowledge of x-ray attenuation is essential for developing and evaluating x-ray imaging technologies. In mammography, measurement of breast density, dose estimation, and differentiation between cysts and solid tumours are example applications requiring accurate data on tissue attenuation. Published attenuation data are, however, sparse and cover a relatively wide range. To supplement available data we have previously measured the attenuation of cyst fluid and solid lesions using photon-counting spectral mammography. The present study aims to measure the attenuation of normal adipose and glandular tissue, and to measure the effect of formalin fixation, a major uncertainty in published data. A total of 27 tumour specimens, seven fibro-glandular tissue specimens, and 15 adipose tissue specimens were included. Spectral (energy-resolved) images of the samples were acquired and the image signal was mapped to equivalent thicknesses of two known reference materials, from which x-ray attenuation as a function of energy can be derived. The spread in attenuation between samples was relatively large, partly because of natural variation. The variation of malignant and glandular tissue was similar, whereas that of adipose tissue was lower. Formalin fixation slightly altered the attenuation of malignant and glandular tissue, whereas the attenuation of adipose tissue was not significantly affected. The difference in attenuation between fresh tumour tissue and cyst fluid was smaller than has previously been measured for fixed tissue, but the difference was still significant and discrimination of these two tissue types is still possible. The difference between glandular and malignant tissue was close-to significant; it is reasonable to expect a significant difference with a larger set of samples. We believe that our studies have contributed to lower the overall uncertainty of breast tissue attenuation in the literature due to the relatively large sample sets, the novel measurement method, and by clarifying the difference between fresh and fixed tissue.

Implications of false-positive results for future cancer screenings

BACKGROUND

False-positive cancer screening results may affect a patient's willingness to obtain future screening.

METHODS

The authors conducted logistic regression analysis of 450,484 person-years of electronic medical records (2006-2015) in 92,405 individuals aged 50 to 75 years. Exposures were false-positive breast, prostate, or colorectal cancer screening test results (repeat breast imaging or negative breast biopsy ≤3 months after screening mammography, repeat prostate-specific antigen [PSA] test ≤3 months after PSA test result ≥4.0 ng/mL or negative prostate biopsy ≤3 months after any PSA result, or negative colonoscopy [without biopsy/polypectomy] ≤6 months after a positive fecal occult blood test). Outcomes were up-to-date status with breast or colorectal cancer screening. Covariates included prior screening history, clinical information (eg, family history, obesity, and smoking status), comorbidity, and demographics.

RESULTS

Women were more likely to be up to date with breast cancer screening if they previously had false-positive mammography findings (adjusted odds ratio [AOR], 1.43 [95% confidence interval, 1.34-1.51] without breast biopsy and AOR, 2.02 [95% confidence interval, 1.56-2.62] with breast biopsy; both P<.001). The same women were more likely to be up to date with colorectal cancer screening (AOR range, 1.25-1.47 depending on breast biopsy; both P<.001). Men who previously had false-positive PSA testing were more likely to be up to date with colorectal cancer screening (AOR, 1.22 [P = .039] without prostate imaging/biopsy and AOR, 1.60 [P = .028] with imaging/biopsy). Results were stronger for individuals with more false-positive results (all P≤.005). However, women with previous false-positive colorectal cancer fecal occult blood test screening results were found to be less likely to be up to date with breast cancer screening (AOR, 0.73; P<.001).

CONCLUSIONS

Patients who previously had a false-positive breast or prostate cancer screening test were more likely to engage in future screening. Cancer 2018;124:2390-8. © 2018 American Cancer Society.

Patient Anxiety Before and Immediately After Imaging-Guided Breast Biopsy Procedures: Impact of Radiologist-Patient Communication

PURPOSE

The aim of this study was to evaluate patient anxiety and its association with perceived radiologist-patient communication in the setting of imaging-guided breast biopsy.

METHODS

After informed consent was obtained, 138 women recommended for imaging-guided breast procedures completed questionnaires immediately before and after biopsies, measuring state anxiety using the State-Trait Anxiety Inventory (range, 20-80). Before biopsies, women also completed questionnaires regarding their perceived communication with the radiologists recommending the procedures (modified Questionnaire on the Quality of Physician-Patient Interaction), demographic characteristics, and medical history; immediately after the biopsies, they completed a measure of perceived communication with the radiologists performing the biopsies. Experience levels (eg, attending radiologist, fellow) of the radiologists recommending and performing the biopsies were recorded. Data were analyzed using paired and independent t tests, one-way analysis of variance, Pearson's correlations, and multiple linear regression analyses.

RESULTS

Average prebiopsy anxiety was 44.5 ± 12.4 (range, 20-77) on a scale ranging from 20 to 80 points. Perceived communication with radiologists recommending biopsies averaged 52.4 ± 11.5 (range, 18-65). Better communication with radiologists recommending biopsies was significantly associated with lower levels of prebiopsy anxiety (r = -0.22, P = .01). After the biopsies, women's anxiety significantly decreased (paired t = -7.32, P < .001). Better communication with radiologists performing biopsies (mean, 57.8 ± 8.4; range, 32-65) was associated with lower postbiopsy anxiety after accounting for patients' baseline anxiety levels (β = -0.17, P = .04). White women reported higher prebiopsy and postbiopsy anxiety; nonwhite women reported poorer communication with recommending radiologists.

CONCLUSIONS

Patients' perceptions of better communication with radiologists were associated with lower levels of anxiety before and after biopsies. These results have implications for radiologist training and adherence to mammographic screening.

Time Spent by Breast Imaging Radiologists to Perform Value-Added Activities at an Academic Cancer Center

BACKGROUND

Health care reform in the United States has generated a paradigm shift in the practice of radiology aimed at increasing the degree of patient-centered care. We conducted a study to quantify the amount of time breast imaging radiologists spend on value-added activities at an academic comprehensive cancer center located in Miami, Florida, and accredited by the American College of Radiology as a Breast Imaging Center of Excellence.

METHODS

A prospective, observational study was conducted during a period of 20 consecutive workdays. Three participating breast imaging radiologists maintained a real-time log of each activity performed. A generalized linear model was used to perform a 1-way analysis of variance. An alpha level of .05 was used to determine statistical significance.

RESULTS

The average daily time dedicated to these activities was 92.1 minutes (range, 56.4-132.2). The amount of time significantly differed among breast imaging radiologists and correlated with their assigned daily role (P < .001 for both) but was independent of their years of experience. The daily role that required the most time was the interpretation of diagnostic imaging studies, which is when most interactions with patients, their relatives, and referring physicians occurred. The specific activity that required the most time was preparing for and participating in tumor boards.

CONCLUSIONS

Our findings suggest that the breast imaging radiologists who participated in this study dedicated a significant amount of their time to value-added activities to help improve patients' experience across the continuity of their care. We propose that similar studies be conducted at other institutions to better assess the magnitude of this finding across different breast imaging care settings.

Impact of a False-Positive Screening Mammogram on Subsequent Screening Behavior and Stage at Breast Cancer Diagnosis

Background: Experiencing a false positive (FP) screening mammogram is economically, physically, and emotionally burdensome, which may affect future screening behavior by delaying the next scheduled mammogram or by avoiding screening altogether. We sought to examine the impact of a FP screening mammogram on the subsequent screening mammography behavior.Methods: Delay in obtaining subsequent screening was defined as any mammogram performed more than 12 months from index mammogram. The Kaplan-Meier (product limit) estimator and Cox proportional hazards model were used to estimate the unadjusted delay and the hazard ratio (HR) of delay of the subsequent screening mammogram within the next 36 months from the index mammogram date.Results: A total of 650,232 true negative (TN) and 90,918 FP mammograms from 261,767 women were included. The likelihood of a subsequent mammogram was higher in women experiencing a TN result than women experiencing a FP result (85.0% vs. 77.9%, P < 0.001). The median delay in returning to screening was higher for FP versus TN (13 months vs. 3 months, P < 0.001). Women with TN result were 36% more likely to return to screening in the next 36 months compared with women with a FP result HR = 1.36 (95% CI, 1.35-1.37). Experiencing a FP mammogram increases the risk of late stage at diagnosis compared with prior TN mammogram (P < 0.001).Conclusions: Women with a FP mammogram were more likely to delay their subsequent screening compared with women with a TN mammogram.Impact: A prior FP experience may subsequently increase the 4-year cumulative risk of late stage at diagnosis. Cancer Epidemiol Biomarkers Prev; 26(3); 397-403. ©2017 AACR.

Positive and negative mood following imaging-guided core needle breast biopsy and receipt of biopsy results

Positive and negative mood are independent psychological responses to stressful events. Negative mood negatively impacts well-being and co-occurring positive mood leads to improved adjustment. Women undergoing core needle breast biopsies (CNB) experience distress during CNB and awaiting results; however, influences of mood are not well known. This longitudinal study examines psychosocial and biopsy- and spirituality-related factors associated with mood in patients day of CNB and one week after receiving results. Ninety women undergoing CNB completed questionnaires on psychosocial factors (chronic stress, social support), biopsy experiences (pain, radiologist communication), and spirituality (peace, meaning, faith) day of CNB. Measures of positive and negative mood were completed day of CNB and one week after receiving results (benign n = 50; abnormal n = 25). Multiple linear regression analyses were conducted. Greater positive mood correlated with greater peace (β = .25, p = .02) day of CNB. Lower negative mood correlated with greater peace (β = -.29, p = .004) and there was a trend for a relationship with less pain during CNB (β = .19, p = .07). For patients with benign results, day of CNB positive mood predicted positive mood post-results (β = .31, p = .03) and only chronic stress predicted negative mood (β = .33, p = .03). For women with abnormal results, greater meaning day of CNB predicted lower negative mood post-results (β = -.45, p = .03). Meaning and peace may be important for women undergoing CNB and receiving abnormal results.

Psychosocial Factors Associated With Withdrawal From the United Kingdom Collaborative Trial of Ovarian Cancer Screening After 1 Episode of Repeat Screening

OBJECTIVE

The United Kingdom Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) aims to establish the efficacy of 2 different ovarian cancer screening schedules. The psychosocial substudy examines the psychological factors associated with the screening program.

METHODS

Women aged 50 to 75 years from 16 UK gynecologic centers randomized to annual multimodal screening or ultrasound screening (US) groups were followed up for 7 years. Psychosocial data from women who withdrew from the study after a repeat screen were examined.

RESULTS

Sixteen percent (3499/21,733) of women requiring a repeat screening test in addition to annual screen withdrew from the study: 12.9% (1560/12,073) from the multimodal group and 20.1% (1939/9660) from the US group. An estimated relative risk of withdrawal is 1.46 (95% confidence interval, 1.36-1.56; P ≤ 0.001) for the US arm. High anxiety trait and increased psychological morbidity significantly influenced withdrawal, even when age, screening center, and group were taken into account (P < 0.001). The risk of withdrawal decreased significantly the longer a woman stayed in UKCTOCS, irrespective of the number of screens and intensity in the preceding year.

CONCLUSIONS

Withdrawal rate was greater in women undergoing US screening and in those who had repeats earlier in UKCTOCS. Having a high predisposition to anxiety, high current state anxiety, and above threshold general psychological morbidity all increased the withdrawal rate.

Association between Breast Parenchymal Complexity and False-Positive Recall From Digital Mammography Versus Breast Tomosynthesis: Preliminary Investigation in the ACRIN PA 4006 Trial

RATIONALE AND OBJECTIVES

We investigate associations between measures of mammographic parenchymal complexity and false-positive (FP) recall from screening with digital mammography (DM) versus digital breast tomosynthesis (DBT).

MATERIALS AND METHODS

We retrospectively analyzed data from 541 women recruited by the American College of Radiology Imaging Network 4006 trial, designed to evaluate callback and detection rates from screening with DM versus combined DM and DBT. Of these, 68 and 56 were FPs based on DM alone versus the combined DM/DBT readings, respectively. Mammographic complexity was quantified with computerized texture analysis and percent density. Logistic regression was performed to evaluate associations between extracted features and FP recall, after adjusting for age and number of previous benign biopsies. Odds ratios and area under the curve (AUC) of the receiver operating characteristic were used to assess association strength.

RESULTS

For DM, age, previous benign biopsies and texture features of correlation, inverse difference moment, sum average, and sum variance were deemed as significant predictors (P <.05) of FP recall, with an AUC = 0.77. For DBT, age was the only significant predictor of FP recall with AUC = 0.64. Using exploratory receiver operating characteristic thresholds for which no true-positives would be missed, a potential FP reduction of 23.5% and 8.9% was demonstrated, respectively, for DM alone versus DM/DBT.

CONCLUSION

Measures of breast complexity measured on 2D digital mammograms are indicative of the likelihood for FP recall from screening with DM, and could help identify women who could benefit from supplemental screening, including DBT.

False-Positive Result and Reattendance in the Ontario Breast Screening Program

Objective:

To determine the association between initial screen result and returning for a second screen in an organised breast screening programme for women with a biennial screening recommendation.

Setting:

Women who attended the Ontario Breast Screening Program (OBSP).

Methods:

A retrospective cohort study was conducted of 140,723 Ontario women aged 50 years ond older who had an initial screen at the OBSP between 1 July 1990 and 31 December 1995 and were followed until 30 June 1998. Rescreening rates at 36 months and risk ratio estimates were calculated using survival methods. Age of women, year of screen, region (within Ontario) and initial screen result were compared. For initial screen results, returning for a second screen was examined by integration of screening centre with an assessment programme and by modality of referral.

Results:

Women with a false-positive result were less likely to return for a second screen as were women aged 70 and older and those living in regions of Ontario with fewer OBSP screening centres. However, there were minimal differences in reattendance behaviour by initial screen result for women screened at the OBSP centre with an assessment programme.

Conclusions:

Integration of breast screening and assessment services improved reattendance of women with false-positive screen results within an organised screening programme.

The Adequacy of Measurement of Short and Long-Term Consequences of False-Positive Screening Mammography

Objectives:

The aim of this study is to review quantitative studies on women's experiences of consequences of false-positive screening mammography to assess the adequacy of the most frequently used instruments for measuring short-term and long-term psychological consequences.

Methods:

Relevant papers reporting quantitative studies on consequences of false-positive screening mammography were identified using MEDLlNE, CINAHL, EMBASE and PsycInfo databases. Articles citing development and psychometric properties of the most frequently used measures were also retrieved. Finally, the review focused on studies that had used at least one of the most frequently used measures.

Results:

Twenty-three relevant studies were identified. The most commonly used measures were the General Health Questionnaire (GHQ), the Hospital Anxiety and Depression Scale (HADS), the Psychological Consequences Questionnaire (PCQ) and the State-Trait Anxiety Inventory (STAI). One or more of these was used in 17 of the 23 studies.

Conclusions:

The GHQ, the HADS and the STAI have problems with language, content relevance, and content coverage in studies of false-positive screening mammography. These instruments should not be used to measure psychological consequences of any kind of cancer screening. The PCQ is an adequate questionnaire for measuring short-term consequences, and the PCQ is preferable to other measures because of its higher sensitivity. However, there is little evidence that the PCQ is able to adequately detect all long-term consequences of screening mammography. Given the inadequacy of the measurement instruments used, any current conclusions about the long-term consequences of false-positive results of screening mammography must remain tentative.

Response costs of mammography adherence: Iranian women's perceptions

Background: Mammography as the most common secondary prevention method has known to be helpful in detecting breast cancer at the early stages. Low level of participation among women toward mammography uptake due to cultural beliefs is a great concern. This study aimed at exploring the perceptions of women about response costs of mammography adherence (MA) in Yazd, Iran.

Methods: A qualitative study using semi-structured interviews was performed. Fourteen women,one oncology nurse, and a breast cancer survivor were purposefully interviewed. Interviews were transcribed verbatim and analyzed by directed content analysis method based on protection motivation theory (PMT).

Results: One main theme was emerged from the analysis namely called "response costs".Two main categories were also emerged from the data; (1) psychological barriers with six subcategories including "embarrassment," "worry about being diagnosed with cancer," "preoccupation with underlying disease," "misconception about mammography," "need for an accompanying person," and "internalizing the experiences of the others," and (2) maladaptive coping modes which encompassed three subcategories: "religious faith," "fatalism," and"avoidance and denial."

Conclusion: Useful information was provided about the response costs of mammography utilization based on the perceptions of women. Cognitive barriers may be decreased by conducting modifications in women’s awareness and attitude toward MA as well as changing the national health system infrastructures. Incorporating religious and cultural belief systems into MA educational programs through motivational messages is recommended.

Prevalence, Long-term Development, and Predictors of Psychosocial Consequences of False-Positive Mammography among Women Attending Population-Based Screening

BACKGROUND

Cancer screening aims to detect cancer at an asymptomatic stage, although side effects from screening also occur. We investigated the prevalence, longitudinal development, and predictors of psychosocial consequences of false-positive breast cancer screening.

METHODS

Three hundred ninety-nine women with false-positive screening mammography responded to the Consequences of Screening-Breast Cancer (COS-BC) questionnaire immediately after a negative diagnosis (free from breast cancer) following recall examination(s) (baseline), and 6 and 12 months later. Age-matched controls (n = 499) with a negative mammogram responded to the COS-BC at the same occasions. Five COS-BC scales (Sense of dejection, Anxiety, Behavioral, Sleep, and Existential values) were used as outcome measures.

RESULTS

Women with false-positive mammography had consistently higher prevalence of all five consequences compared with controls (P < 0.001). The prevalences decreased between baseline and 6 months (P < 0.001) but were stable between 6 and 12 months (P ≥ 0.136). Early recall profoundly predicted long-term consequences for all five outcomes (OR, 3.05-10.31), along with dissatisfaction with information at recall (OR, 2.28-2.56), being foreign-born (OR, 2.35-3.71), and lack of social support (OR, 1.13-1.25).

CONCLUSION

This 1-year longitudinal study shows that women experience psychosocial consequences of false-positive screening mammography. Early recall should be performed cautiously, and provision of information as well as social support may reduce psychosocial consequences.

IMPACT

Although delivery of population-based screening reduces breast cancer mortality, it also raises the issue of its impact on the psychosocial well-being of healthy women. Our findings identify predictors that can be targeted in future efforts to reduce the side effects of mammographic screening.

Measurement of breast-tissue x-ray attenuation by spectral mammography: solid lesions

Knowledge of x-ray attenuation is essential for developing and evaluating x-ray imaging technologies. For instance, techniques to distinguish between cysts and solid tumours at mammography screening would be highly desirable to reduce recalls, but the development requires knowledge of the x-ray attenuation for cysts and tumours. We have previously measured the attenuation of cyst fluid using photon-counting spectral mammography. Data on x-ray attenuation for solid breast lesions are available in the literature, but cover a relatively wide range, likely caused by natural spread between samples, random measurement errors, and different experimental conditions. In this study, we have adapted a previously developed spectral method to measure the linear attenuation of solid breast lesions. A total of 56 malignant and 5 benign lesions were included in the study. The samples were placed in a holder that allowed for thickness measurement. Spectral (energy-resolved) images of the samples were acquired and the image signal was mapped to equivalent thicknesses of two known reference materials, which can be used to derive the x-ray attenuation as a function of energy. The spread in equivalent material thicknesses was relatively large between samples, which is likely to be caused mainly by natural variation and only to a minor extent by random measurement errors and sample inhomogeneity. No significant difference in attenuation was found between benign and malignant solid lesions. The separation between cyst-fluid and tumour attenuation was, however, significant, which suggests it may be possible to distinguish cystic from solid breast lesions, and the results lay the groundwork for a clinical trial. In addition, the study adds a relatively large sample set to the published data and may contribute to a reduction in the overall uncertainty in the literature.

Patients' Knowledge, Beliefs, and Distress Associated with Detection and Evaluation of Incidental Pulmonary Nodules for Cancer: Results from a Multicenter Survey

INTRODUCTION

Pulmonary nodules are detected in more than 1 million Americans each year. Prior qualitative work suggests that the detection of incidental pulmonary nodules can be burdensome for patients, but whether these findings generalize to a broader sample of patients is unknown. We categorized patients' knowledge, beliefs, and distress associated with detection and evaluation of a pulmonary nodule, as well as their impressions of clinician communication.

METHODS

We administered a cross-sectional survey to adults with an incidental pulmonary nodule who were recruited from a rural medical center, an urban safety net hospital, and a Veterans Affairs hospital.

RESULTS

Of the 490 individuals mailed surveys, 244 (50%) responded. Median nodule size was 7 mm, mean patient age was 67 years, 29% of respondents were female, and 86% were white. A quarter of the respondents (26%) reported clinically significant distress related to their nodule, our primary outcome, as measured by the Impact of Event Scale. Patients reported multiple concerns, including uncertainty about the nodule's cause (78%), the possibility of cancer (73%), and the possible need for surgery (64%). Only 25% of patients accurately estimated their lung cancer risk (within 15% of their actual risk); overall, there was no correlation between perceived and actual risk (r = -0.007, p = 0.93). The 23% of patients who did receive information on cancer risk from their provider were more likely to find this information reassuring (16%) than scary (7%).

CONCLUSION

A quarter of patients with incidental pulmonary nodules experienced clinically significant distress. Knowledge about cancer risk and evaluation was poor. Clinician communication may help bridge knowledge gaps and alleviate distress in some patients.

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.

Recall Rate Reduction with Tomosynthesis During Baseline Screening Examinations: An Assessment From a Prospective Trial

RATIONALE AND OBJECTIVES

Assess results of a prospective, single-site clinical study evaluating digital breast tomosynthesis (DBT) during baseline screening mammography.

MATERIALS AND METHODS

Under an institutional review board-approved Health Insurance Portability and Accountability Act (HIPAA)-compliant protocol, consenting women between ages 34 and 56 years scheduled for their initial and/or baseline screening mammogram underwent both full field digital mammography (FFDM) and DBT. The FFDM and the FFDM plus DBT images were interpreted independently in a reader by mode balanced approach by two of 14 participating radiologists. A woman was recalled for a diagnostic work-up if either radiologist recommended a recall. We report overall recall rates and related diagnostic outcome from the 1080 participants. Proportion of recommended recalls (Breast Imaging Reporting and Data System 0) were compared using a generalized linear mixed model (SAS 9.3) with a significance level of P = .0294.

RESULTS

The fraction of women without breast cancer recommended for recall using FFDM alone and FFDM plus DBT were 412 of 1074 (38.4%) and 274 of 1074 (25.5%), respectively (P < .001). Large inter-reader variability in terms of recall reduction was observed among the 14 readers; however, 11 of 14 readers recalled fewer women using FFDM plus DBT (5 with P < .015). Six cancers (four ductal carcinomas in situ [DCIS] and two invasive ductal carcinomas [IDC]) were detected. One IDC was detected only on DBT and one DCIS cancer was detected only on FFDM, whereas the remaining cancers were detected on both modalities.

CONCLUSIONS

The use of FFDM plus DBT resulted in a significant decrease in recall rates during baseline screening mammography with no reduction in sensitivity.

Anxiety prior to breast biopsy: Relationships with length of time from breast biopsy recommendation to biopsy procedure and psychosocial factors

This study investigated how time from breast biopsy recommendation to biopsy procedure affected pre-biopsy anxiety ( N = 140 women), and whether the relationship between wait time and anxiety was affected by psychosocial factors (chronic life stress, traumatic events, social support). Analyses showed a significant interaction between wait time and chronic life stress. Increased time from biopsy recommendation was associated with greater anxiety in women with low levels of life stress. Women with high levels of life stress experienced increased anxiety regardless of wait time. These results suggest that women may benefit from shorter wait times and receiving strategies for managing anxiety.

MRI screening for breast cancer in women at high risk; is the Australian breast MRI screening access program addressing the needs of women at high risk of breast cancer?

Breast magnetic resonance imaging (MRI) screening of women under 50 years old at high familial risk of breast cancer was given interim funding by Medicare in 2009 on the basis that a review would be undertaken. An updated literature review has been undertaken by the Medical Services Advisory Committee but there has been no assessment of the quality of the screening or other screening outcomes. This review examines the evidence basis of breast MRI screening and how this fits within an Australian context with the purpose of informing future modifications to the provision of Medicare-funded breast MRI screening in Australia. Issues discussed will include selection of high-risk women, the options for MRI screening frequency and measuring the outcomes of screening.

Psychological impact of breast cancer screening in Japan

OBJECTIVE

The purpose of this study was to evaluate the psychological impact of breast cancer screening by use of mammography and/or ultrasound, and to reveal factors related to psychological distress.

METHODS

Three hundred and twenty women were recalled to our hospital because of suspicious malignant findings from breast cancer screening between March and November 2012. They were asked to complete three questionnaires: the Hospital Anxiety and Depression Scale (HADS) for anxiety and depression, the Brief Coping Orientations to Problems Experienced scale (Brief COPE) for coping styles, and an original questionnaire for personal information.

RESULTS

Complete data were available for 312 of 320 women (97.5 %). The median age was 45 years (range 23-73). The HADS revealed borderline or clinically significant anxiety for 70 % of the women. Family history of breast cancer, area of residence, number of times screened, number of recalls, and the period before the first visit were significantly related to psychological distress (p < 0.05). Brief COPE scores showed that self-blame, behavioral disengagement, self-distraction, use of emotional support, venting, denial, and less acceptance were related to increased anxiety.

CONCLUSION

Seventy percent of women who were recalled after breast cancer screening experienced psychological distress. Thus, negative psychological impact should be regarded as an adverse effect of breast cancer screening.

Diagnostic invasiveness and psychosocial consequences of false-positive mammography

PURPOSE

We undertook a study to assess whether women with false-positive mammography have worse psychosocial consequences if managed with a workup that involves a biopsy (invasive group) than if managed with only additional imaging (noninvasive group).

METHODS

We performed subgroup analysis of a cohort study of 454 women with abnormal screening mammography and 908 matched control women with normal results. Using a condition-specific questionnaire (Consequences of Screening in Breast Cancer), we assessed 12 psychosocial consequences at 5 time points (0, 1, 6, 18, and 36 months after final diagnosis) and compared the 2 groups of women with false-positives (invasive and noninvasive management groups).

RESULTS

Among the 252 women with false-positive mammography eligible for this study, psychosocial consequences were similar for those managed invasively and those managed noninvasively during the 36 months of follow-up. In 60 comparisons (12 scales and 5 time points), differences between the groups were never statistically significant (P <.01) and the point estimates for the differences were always close to zero. The psychosocial consequences of women with false-positive results, regardless of management, fell between those of women with normal mammography and those of women determined to have breast cancer.

CONCLUSIONS

We found no evidence that use of more invasive diagnostics was associated with worse psychosocial consequences. It is therefore reasonable to pool subgroups of women with false-positives in a single analysis. The invasiveness of subsequent diagnostic procedures does not help to identify women at higher risk for adverse psychosocial consequences of false-positive mammography.

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.